Greetings from
Southampton
Introduction
• We are entering a period in which the occupational therapy
curriculum worldwide is undergoing dramatic transformation
and experiencing significant structural changes.
• The role of curriculum design is one of the focal issues in this
transformation and clinical reasoning is the core of
occupational therapy practice. With evolving theories, rapidly
developing technology, and expanding practice areas,
occupational therapy educators have been challenged to
determine the necessary course content to prepare students
for entry-level practice and as a consequence different models
of fieldwork are presently being proposed.
Aims of this Study
• The study examined implications for curriculum design
resulting from a two-year longitudinal study of a cohort of 80
Occupational therapy students, which explored their
development of learning from novice to beginning therapist
using a range of measures and
• Show what evidence is there for the progressive development
of clinical reasoning skills in trainee occupational therapy
students of the Hong Kong Polytechnic University?
Methodology & Design of Study
Research Design
• This study adopted a mixed method study design
(Longitudinal), which followed over two years and performed
repeated measurements at different stages of their clinical
reasoning development.
Sample Population
• The student cohort of the study composed of a class of 80
Hong Kong OT students enrolled into the study at the end of
their first year of the three-year BSc (Hons) Degree in
Occupational Therapy programme.
Methodology & Design of Study
• Test Instrument used:
• The Self-Assessment of Clinical Reflection and
Reasoning (SACRR): Consists of two sections:
– The first section contains demographic information.
– The second section contains 26 close-ended questions that
evaluate different aspects of clinical reflection and reasoning.
– These questions use a 5-point Likert scale from “strongly
agree”(5) to “strongly disagree” (1).
• Reliability of SACRR:
– Cronbach’s alpha for pre-test was 0.87 and for the post-test
was 0.92 suggesting a high internal consistency.
Organisation of Academic & Clinical Education - BSc (Hons) in Occupational Therapy
Integration between Academic subjects
and Clinical Education Subjects
Clinical Education I (CE I):
– CE IA (2 weeks) takes place at the beginning of Year I
summer vacation whilst Clinical Education IB (3 weeks)
takes place after the first semester of Year 2.
– CE I provides students with the opportunity to identify
functional problems encountered by people with
disabilities, and the roles and functions of an occupational
therapist, as well as observe the occupational therapy
intervention process within various clinical settings.
Clinical Education II (CE II):
– CEII takes place during Year II summer term. This 8-week
clinical placement provides students with the opportunity
to participate as contributing members of a
multidisciplinary/rehabilitation team and to enhance their
experience in adopting a holistic approach to client care.
Integration between Academic subjects
and Clinical Education Subjects
Clinical Education III (CE III) & Clinical
Education IV (CE IV):
– CE III & CE IV takes place in the middle of first semester
(8 weeks) and the beginning of second semester (8
weeks) of final year respectively.
– These two subjects provide students with the opportunity
to consolidate, integrate, and apply knowledge, skills and
attitudes learned at the University to occupational therapy
practice.
– Students are expected to take responsibilities to seek
guidance, to update their knowledge and skills, as well as
to evaluate their own practice independently.
Results
Factor loading of the 26 items of Self-Assessment of Clinical Reflection
and Reasoning (SACRR) after maximum likelihood varimax rotation
Factor Loadings
Items
CEIV10
CEIV8
CEIV7
CEIV9
CEIV26
CEIV3
CEIV25
CEIV1
CEIV4
CEIV5
CEIV2
CEIV20
CEIV18
CEIV24
CEIV11
CEIV16
CEIV15
CEIV14
CEIV6
CEIV13
CEIV19
CEIV22
CEIV17
CEIV21
CEIV23
CEIV12
Factor
1
0.81
0.74
0.72
0.70
0.69
-0.11
0.11
0.35
0.13
-0.09
0.50
0.23
0.31
0.33
0.14
0.30
0.28
0.19
0.13
-0.25
0.03
0.12
0.10
0.20
0.08
0.31
Factor
2
0.02
0.19
0.02
0.02
0.30
0.66
0.65
0.62
0.59
0.54
0.50
0.46
0.37
0.34
0.33
0.19
0.19
0.14
-0.12
0.33
0.22
0.31
0.07
0.11
0.03
0.35
Factor
3
0.26
0.09
0.13
0.19
0.08
0.02
-0.03
0.00
0.31
0.37
-0.20
-0.10
0.10
0.03
0.26
0.76
0.73
0.63
0.50
0.48
0.44
0.43
0.14
0.44
0.44
0.22
Factor
4
-0.02
-0.17
0.20
-0.12
0.25
0.11
0.07
0.17
-0.09
-0.11
0.07
-0.23
-0.08
0.15
0.28
-0.10
-0.10
-0.03
0.08
0.10
0.17
0.27
-0.77
0.54
0.49
0.39
Results
Results of factor analysis and thematic analysis showing
groupings and internal consistency coefficients
Proposed Themes/Concepts
Factor
Groupings
Question no.
Cronbach’s
alpha
Knowledge/Theory application
1
7, 8, 9, 10, 26
0.83
Decision making based on
experience and evidence
2
1, 2, 3, 4, 5, 11,18, 20, 24,
25
0.75
Dealing with uncertainty
3
6, 13, 14, 15, 16, 19, 22
0.74
Self-reflection and reasoning
4
12, 17, 21, 23
0.52
Results
Mean subscale scores for SACRR
3.90
3.80
3.70
Knowledge
Decision making
3.60
Uncertainty
Self-reflection
3.50
Total score
3.40
3.30
CEII (pre)
CEII (post)
CEIII (post)
CEIV (post)
Results (Summary)
• Mean of total scores increased gradually over 4 periods (CEII
to CEIV) of clinical education placements indicating that the
gradual change over time in both dimension of students’
reasoning and reflection which is presumed to be due to
exposure to different learning experiences in a variety of
clinical settings.
• The overall change in students’ development of contextual
learning of specific reasoning occurred at the end of year 2
(CEII-post-test) and not at the beginning of year 2 (CEII-pretest). This finding is important as it suggests that it is
reflection, or the processing of experiences and the search for
meaning within them, which promotes learning (Boud &
Walker, 1991; Schön, 1987).
Discussion
Knowledge/Theory Application:
– Students during focus group interview rated “integration of
theory to practice” as one of the four most important things
that they learned in their clinical education placements.
Based on this evidence, it is seen that clinical reasoning has
become yet another “skill” to be taught among other skills
and that it has been interpreted as having a reason for
connecting a particular treatment decision to a particular
frame of reference or a theory.
Discussion
Decision making based on experience and
evidence:
– The results of mean scores in this Grouping clearly
indicated a greater change in students’ clinical decisionmaking skills after CEII (post) placement, which took
place at the end of their second year of study.
– This is a significant curricular implication, which clearly
recognises the fact that subjects in Year 1 appeared to be
not directly contributing to patient treatment and
unresolved clinical problems but also acknowledge that
Year 1 is mainly a foundation year in which students
expected to learn theoretical knowledge from Biological,
Behavioural and OT Theory and Process subjects.
Discussion
Dealing with uncertainty:
– The findings confirmed that exposure to the uncertainty of an
unstructured methodology might foster more active
participation by the students in clinical education placements
and thus facilitate the transition from one mode or level of
critical thinking to a higher order for better planning of clinical
interventions.
– Based on this study, it is important to point out that most
occupational therapy curricula teach students only the most
popular theories, how to apply them to straightforward cases
and fails to equip students with the skills that they need to deal
with the unstructured methodology and ill-defined problems.
Discussion
• Self-reflection and reasoning:
– During supervision and integration with students, clinical
educators begin to explicit explanations of their reasoning
process. This kind of interchange can facilitate
communication and self-reflection by both therapist and
student. This view is clearly substantiated in this
research; when students asked “what you think you are
better at as a result of the course?”
Conclusions and Recommendations
• This study offers the resolution of one of the most crucial and
baffling problem encountered in the field of clinical reasoning,
namely the extent to which clinical reasoning can be
articulated and explained to beginning practitioners in their
undergraduate curriculum.
• The findings also point out the need to identify and
understand that a `new’ epistemology fundamentally
characterizes professional practice as judgment and wise
action in complex, unique, and uncertain situations with
conflicting values and ethical stances in a social and cultural
context.
Conclusions and Recommendations
• Many other valuable considerations such as the teaching of
different modes of reasoning, the learning of patterns and
processes of reasoning both to give meaning to clinical decisions
and to explain action, and the teaching of appropriate
techniques for accessing encrypted knowledge fall within the
ambit of a thinking curriculum.
• Clinical reasoning as an area of advanced specialism, it is now in
the forefront of professional practice. As such it needs to be
accorded a special place in the undergraduate curriculum.
Similarly, because of the cognitive complexity inherent in the
clinical reasoning it seems evident that this area of practice
provides an advanced knowledge-base for the teaching and
learning of clinical reasoning skills in preparation for complex
practice.
Conclusions and Recommendations
• A high percentage of what has been researched concerns
with models of clinical reasoning rather than clinical practice.
This study has only been able to report on one area of
interest in the development of clinical reasoning skills as a
novice-expert continuum in the undergraduate curriculum
but it also had the effect of drawing attention to the need for
further research into many facets of the client-therapist
relationship.
Acknowledgements
My sincere gratitude goes to the following people
without their support, this study would not have
been possible:
– Former students and staff of the Department of
Rehabilitation Sciences at the Hong Kong Polytechnic
University, particularly Dr Kit Sinclair for constructive
comments and Mr. Peggo Lam for statistical advice.
– Mr Kevin Durkin, IT Technical Assistant, School of Health
Professions and Rehabilitation Sciences at the University
of Southampton for multi-media support and design
contribution.
Thank you.