PTJ 0312
PTJ 0312
PTJ 0312
Research Report
Key Words: Clinical practice, Clinical reasoning strategies, Decision making, Dialectical reasoning,
Knowledge.
Ian Edwards, Mark Jones, Judi Carr, Annette Braunack-Mayer, Gail M Jensen
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I Edwards, PhD, Grad Dip Physio (Ortho), MAPA, is Physiotherapist, The Brian Burdekin Clinic, Adelaide, South Australia, Australia, and Lecturer,
School of Health Sciences, University of South Australia. Address all correspondence to Dr Edwards at School of Health Sciences, University of
South Australia, North Terrace, Adelaide, South Australia, Australia 5000 (ian.edwards@unisa.edu.au).
M Jones, MAppSc (Manip Ther), Cert Phys Ther, Grad Dip Advan Manip Ther, MMPA, MAPA, is Senior Lecturer and Director, Graduate Programs
in Musculoskeletal and Sports Physiotherapy, School of Health Sciences, University of South Australia.
J Carr, Dip Physio, Grad Dip F Ed, is Physiotherapist, Murray Mallee Community Health Service, Murray Bridge, South Australia, Australia.
GM Jensen, PT, PhD, FAPTA, is Professor of Physical Therapy, Associate Dean for Faculty Development and Assessment, and Faculty Associate,
Center for Health Policy and Ethics, School of Pharmacy and Allied Health, Creighton University, Omaha, Neb.
All authors provided concept/idea/research design. Dr Edwards, Mr Jones, and Dr Braunack-Mayer provided writing and project management.
Dr Edwards provided data collection, and Dr Edwards, Mr Jones, and Ms Carr provided data analysis. Dr Edwards provided fund procurement. The
authors thank Dr Marie Williams, Associate Professor, School of Health Sciences, University of South Australia, for her helpful comments in
reviewing the manuscript.
This study was approved by the Human Research Ethics Committee of the University of South Australia and supported by a grant from the South
Australian branch of the Australian Physiotherapy Association.
This article was received September 20, 2002, and was accepted October 17, 2003.
Years Since
Graduation Work Setting Teaching Experience Qualifications
Data Collection
their current standing and expertise in their respective Data collection took place, in the manner of grounded
fields. The APA consultants for each field were con- theory, in 3 “waves” over the course of approximately 1
tacted and asked to nominate, based on criteria of year. The first data collection consisted of observation of
expertise (Fig. 1), a short list of physical therapists treatment sessions and semistructured and unstructured
regarded by their peers as experts in their particular interviews (see Fig. 2 for sample questions). Each phys-
fields. Not all of the characteristics described in Figure 1, ical therapist was “shadowed”51 over the course of 2 or 3
however, are operationally defined. The consultants days of their usual work. The orthopedic and neurolog-
were asked to nominate only physical therapists whom ical physical therapists were all observed in the rooms of
they felt possessed at least 5 of the 7 criteria. Two their private practices. The domiciliary care (home
physical therapists from each list were selected at ran-
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Edwards et al . 321
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sample, together with the views of the second sample of • Ethical reasoning includes the apprehension of ethi-
therapists (incorporated in the composite case studies) cal and practical dilemmas that impinge on both
were all compared with existing models of reasoning the conduct of intervention and its desired goals,
from the relevant literature. and the resultant action toward their resolution.
My hands can actually do more than just about anything, Neve: I had a guy who was a plasterer, and he had terrible
and sometimes . . . most times they’re more powerful than headaches, and I said to him, “What do you notice happen-
what you can say anyway . . . putting hands on someone can ing?” . . . and he really didn’t notice very much. But he
speak enormous amounts. asked the people whom he worked with, and he said, “Well,
how do I look when I’ve got a headache?” and they said,
The following example was taken from field notes writ- “You smile all the time,” and he realized he was clenching
ten while observing neurological therapist Narelle at his teeth, trying to look like he wasn’t in pain . . . but teeth
work. Her patient, N, had a particularly aggressive form clenching was really perpetuating the headaches. So it’s not
the whole story of headaches, but sometimes the teeth
of multiple sclerosis. She was attending the treatment
clenching can be a problem, especially if there is a lot to do
session with her caregiver and friend H. It was not long
and not a lot of time to do it in. Sometimes we get into the
since N ceased being able to look after herself and was habit of just gritting our teeth and . . . keeping going when
forced to go into a nursing home. She was not an old we’re in pain. It’s sort of a chicken and egg thing. I don’t
woman, yet she gave an impression of feeling it to be so. know what comes first, whether the teeth clenching comes
N was depressed and, understandably, experienced first or the headache.
mood swings. Narelle, in the session, had been working
on tightness in N’s foot. The treatment atmosphere had A strong theme in the earlier part of this initial session
been loud (particularly on Narelle’s part) and also had been M’s poor coping mechanisms and unresolved
action filled. At one point, Narelle was called to the conflict with other family members. Some of this conflict
telephone. While she was away (no more than 2 min- had derived from M’s inability to keep her house main-
utes), N began to cry. When Narelle returned, she got in tained to the standards that she would like. Having a
very close, softened her voice, and cradled N’s left arm 2-year-old son was not helping her in this endeavor and
without speaking further for a short time. This was neither were the high expectations of her mother-in-law.
despite the fact that prior to the telephone call, she had The story that Neve told M regarding the plasterer with
been working on N’s foot. After a silent moment, N headaches appeared to have the aim of providing her
uttered, in response to Narelle’s proximity rather than to with the insight that people sometimes may be unaware
any question: “God, it’s heavy!” The session then slowly that their own responses, or coping behaviors can con-
resumed its course. tribute to the production or perpetuation of symptoms.
Thus, the plasterer, who in response to Neve’s question,
The Clinical Reasoning Strategy—Teaching “What do you notice happening?” (when he had these
Teaching was a ubiquitous activity in the practice of all of headaches), asked his workmates what he looked like
the physical therapists in our study. The scope of teach- and was told that he “smiled all the time.” The plasterer
ing included information provision, instruction, advice then realized that he was clenching his teeth, trying to
(including informal counseling), and explanation. look like he was not in pain, but in doing so was
contributing to further headache symptoms.
Examples of instrumental teaching were numerous.
Domiciliary care therapist Denise taught Mr H, who had Neve’s purpose in telling this story had been to encour-
a stroke, how to get up and down off a chair indepen- age M to reflect less on the “outcome” of her stressors
dently. The maneuver—rising from a sitting position to and more toward her own responses to these stressors as
The kind of communicative teaching used was accompa- A communicative approach to collaboration emphasizes
nied in the same session by Neve’s teaching M, in a more the plurality of choices and the necessity of “means to
instrumental way, how to recognize increased tension in ends” approaches to problem solving that relate to a
her temporalis and masseter muscles and to then be able person’s values and beliefs. It is not only this transfer of
to use relaxation techniques to decrease these factors. meaning (ie, where the intentions of the therapist and
Thus, we considered both forms of teaching, the instru- the perspectives of the patient are communicated and
mental and the communicative, essential components of mutually understood) but also the transfer of power
sound management of M’s headaches. We believe there (ie, the therapist’s letting go of a professional “right” to
be right in favor of the patient’s assumption of a greater
Just try and drop that wrist down . . . slowly! Don’t push The Clinical Reasoning Strategy—Ethics
down at your shoulder! Don’t push down at your shoulder! Ethical problems were seen to take various forms within
Just relax it. Just think about rotating at the elbow. the 3 fields. A major source of ethical dilemmas in
clinical practice revolved around problems associated
and, with resource allocation. These problems took different
expressions according to setting. For example, in domi-
Lift those toes right up for me and let them down . . . and ciliary care, these problems often involved access issues
lift them up, right up . . . c’mon, c’mon . . . c’mon toes get such as waiting lists and availability of equipment,
moving . . . and drop down. And lift them up and drop. And whereas, in manual therapy, these problems took the
lift them up. Alright? form of determining adequate and fair treatment times
and billing issues. Ethical dilemmas arose from complex
Communicative approaches to collaboration were situations within therapy encounters as the following
observed in all settings, but were particularly found in example illustrates.
the domiciliary care (home health) setting. Danielle
spoke positively of a power shift from therapist to Neurological therapist Narelle works with J, who had
patient: hemiplegia and was introduced in the collaborative
reasoning section. J’s husband, Bob, is in attendance. As
The power difference is not the same as in the hospital. Narelle works with J to alleviate stiffness and abnormal
There’s none of this, “Do this because I say so.” People say
reflex activity in the lower limb, the conversation takes a
“no” to you more often in this setting than they ever would,
turn, one that reaches a point of unexpected intensity. It
Narelle: But the statistics, J, are that 1 in 4 of us have some Narelle has just had to pilot her way through a situation
kind of malformation to our brains because it’s such an where, she needed to acknowledge J’s disappointment
incredibly intricate structure. and Bob’s burning anger toward the surgeon and surgi-
cal management of J’s aneurism. She also needed to
J: But when it happens to you . . . express another perspective about outcomes in such
cases. Working with neurologists and neurosurgeons on
Narelle: But a lot of people never have problems, but just a regular basis, Narelle is aware of some of their realities.
occasionally people will. There’s not a lot you can do. In J’s situation, Narelle decides not to make any defini-
tive comments about whether or not she would have
J: I never heard of it until it happened to me, and then been better not to have had the surgery. She mildly
everyone you speak to. . . . I spoke to someone yesterday. corroborates J’s own statement that “it needed to be
done straightaway.” Interestingly, she does not “toe” any
Bob: What gets me is that they know what the side effects professional line as such, feeling content to contradict
are, but they still go ahead and do the operation.
“Dr Squirrel’s” alleged remark that “there’s always some-
thing goes wrong” with the contrasting example of her
Narelle: The side effects of the operation?
own sister. Narelle apparently decides that there is
Bob: h-uh. . . . They still go ahead and do the operation,
nothing further she can add to the present conversation
they just chalk up: “Huh, there’s another life I’ve saved.” and returns the focus, through her “cutting off the big
toe” remark, to the foot that is being mobilized.
J: Bob’s a bit bitter about it.
The ethical reasoning that has taken place exhibits
Bob: Oh bitter? I’d cut the bastard’s hands off if I could. recognition of the particular faces (patterns) of patient
or caregiver anger. Although not necessarily evoking
J: That’s because I was told that I would have—might ready-made or protocol-based solutions to such dilem-
have—a minor stroke, and I don’t think this is . . . mas, nevertheless some elements of Narelle’s learned
experience are brought into action at these times: the
Bob: Might have a slight little bit of paralysis that’ll only last imperative to listen carefully to and take seriously the
a few weeks. patient’s or caregiver’s feelings or complaints; the
importance of determining perspective and the “com-
J: But I mean if I had the ultimatum, what do I do? Do I have pleteness” of the story; and the knowledge that her
the operation to cut the aneurism off? response is not only sought by the patient or caregiver
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