天美影视传媒

Clinical Reasoning

When a student is having difficulties with clinical reasoning, they are having trouble synthesizing information. This means they cannot sort through all the information, select relevant details, and use their knowledge to guide them in making an appropriate decision. The breakdown could be in any of these components. Most often, these deficits can be improved when the student can identify what pieces of information they are not considering in the process. A review of that content can often help the student go back and rethink the case with a different perspective. Fieldwork supervisors should ask the student many why questions about a case. Think about how you would logically analyze the information provided. What factors guided you in your reasoning process? We often must simultaneously consider the following information:

• client鈥檚 diagnosis ( most recent and past relevant problems)
• expected outcomes for this diagnosis
• client鈥檚 age, gender, education, and resources (family, financial, and environmental)
• current context for OT service (out-patient, acute care, SNF, school, etc..)
• relevant past medical history
• prior level of function
• current medications and side effects
• behaviors demonstrated by the client

We then attempt to analyze this information and synthesize it with the observation and data collection from an evaluation process or treatment session. This leads us to draw conclusions based on knowledge and experience. When we must make choices, there are questions we ask ourselves in the process. If you can identify the step in the process when your thinking diverged from the student鈥檚 thinking, this will help guide the student to review some specific content.

Activities to help improve clinical reasoning include asking the student to:

1. Search the literature to find evidence about effectiveness of a specific intervention(s) and outcomes. Create an annotated reference list with this information.
2. Make a one page diagnostic summary of the disease or condition.
3. Write out treatment activities prior to a therapy session and match which objectives from the client鈥檚 chart are addressed by each activity. Specify how to grade each step to make it easier and harder. FW Supervisors can review this before treatment to make suggestions or ask questions. This should help the treatment session go more smoothly.
4. Ask the student to give a rationale for choosing certain interventions. Can the student clearly articulate their rationale? If not, ask them to look up supporting information to discuss the next day.
5. If students have trouble selecting appropriate assessment tools, ask students to compare and contrast two or three different tools. They will need time to look at and review the tools. You can ask them to provide a written typed summary format for this compare/contrast task.
6. Develop a list of possible courses of action in an emergency situation.
7. Have the student monitor and direct their own learning using learning objectives written related to clinical reasoning.
8. Allow the student to watch a videotape of a patient assessment or treatment and ask them to analyze the procedure and write a brief summary of decisions made during the process and other possibilities to consider
9. Arrange for student to observe another therapist who can provide some role modeling of the reasoning process with some talking aloud to help student follow the process
10. Ask the student to review patient charts and identify decision making of other therapists and document clues or specific details that influenced the decision
11. Given a potential problem determine three possible solutions and pros and cons for each solution
12. Utilize a case the student is familiar with. Now make some hypothetical changes in the case-(age, gender, phase of recovery, context for delivery of OT services, roles and previous leisure interests, etc) and ask the student to redesign components of the treatment plan with this new information. Can he/she shift their thinking process to include this new information and come out with a reasonable plan?

Intervention Deficits

Your departmental policy and procedure manual may contain specific performance criteria for conducting some evaluations or treatments. The student could possibly use these to conduct a self-evaluation of the task. Feedback during the process (specifically if it is therapeutic handling) provided by a more experienced therapist may be necessary to correct errors and prevent the student from developing bad habits. A review of relevant content about a process can often help students revise their own performance.

Fieldwork supervisors should ask the student to demonstrate or show how to accurately conduct something when discussing interventions. Think about how you would perform the task. What factors guided you in refining your procedures? We often revise our procedures during a task, based on the performance of the client. There are observations we make and expectations we have about process. More experienced therapists begin to make some of these adjustments about therapeutic handling and patient positioning without much conscious effort, but students must learn to attend to and adjust these procedures while engaged in the therapeutic activity.

Activities to help improve interventions include asking the student to:

1. Practice specific tasks until a certain level of competency is reached
2. Allow student to watch a videotape of a role model conducting this task. Have them record their observations about the role model鈥檚 performance. Ask them to identify steps of the task with an asterisk (*) that the role model does much more proficiently or accurately than they do. Now they know what to practice. Have student create a procedural checklist of the task for themselves and others. Ask them to list the performance steps on the left side of the form and include a checklist and comments column on the right side. See example below: 
         
    
   Procedural Analysis for
   __________________________
   
   

   Task Steps	Accuracy  Check 鉁�	Comments:
   1.
   2.
   3.
   4. (or more)

   
   
   Could they use this form now and observe someone and evaluate their proficiency with the task based on this checklist? Have them ask a peer or other therapist to observe them perform the task and utilize the checklist and complete the comments sections to help them further define their need to practice.
3. Ask the student to videotape themselves performing specific tasks. Ask them to critique themselves. Students can use the newly created checklist form (see suggestion 3) to critique their own performance on the videotape.
4. Ask the student to role-play the procedure with another student or therapist. If it is an assessment tool, have the subjects try to role-play a variety of responses during testing so the student learns to grade or score a variety of      responses or learns when to discontinue or re-instruct according to the test manual. If it is a treatment technique, have the subjects show a variety of responses so the student learns to respond to different scenarios.
5. Ask the student to write their own personal learning objective to measure improvements in performance. Be sure it includes measurable criteria, conditions, and timelines.
6. Ask the student to provide evidence-based research in order to explain why they choose certain interventions.

Professional Behaviors

When a student is having difficulties with professional behaviors, they are having trouble with their interpersonal communication. This means they may be conveying an inappropriate attitude such as aggression, helplessness, intolerance, or stubbornness as examples. They may not be able to see it in themselves.

Most often, these deficits can be improved when the student becomes aware, makes a conscious effort to change, and deals with his/her stress or issues. Fieldwork supervisors may be uncomfortable with providing feedback about this component, but really it does need to be addressed. Often students are stressed when on clinical fieldwork and it may bring out the worst in them as the stress builds, rather than the best of them. Sometimes students get frustrated with themselves. Begin to write down observations of the student鈥檚 attitude in terms of objective behaviors and communication and what the student did that was not appropriate.

Make an appointment with the student and choose someplace that is quiet and distraction free. Try to provide some private space to have a frank conversation about these behaviors with the student. Be supportive but also be firm about what are acceptable and not acceptable behaviors in the clinic. Let them know you are interested in helping them change to show more acceptable communication. If you discover the student has problems that require professional counseling, contact the USA Academic Fieldwork Coordinator as soon as possible. Counseling services are available to USA students on campus.

Activities to help improve attitude include asking the student to:

1. Read the book FISH by Stephen Lundin. ISBN 0-7868-6602-0-51995
2. Write a list of professional behaviors (not skills) that are expected from therapists.  Ask them to review the list and choose areas they feel they need to work on.  Identify resources and develop strategies to help improve this area.
3. Read an article on stress management and implement some strategies.
4. Make a one page list of positive affirmations and post them where they can see them.
5. Think of a role model they admire and list specific professional behaviors this person possesses.  Think of a specific incident in which this person handled a difficult situation very well.  Describe in writing how the role model handled the situation and what was most impressive.  What did the student learn from this model?
6. Request opportunities to see role models of positive attitude in action.  Next, journal a reflection of this experience and what they learned from this observation.
7. Describe typical behaviors of a student that takes responsibility for his/her own learning.  What would the responsible student do to demonstrate a positive attitude about learning and improving themselves?  Now examine this list.  Have the student underline those that they have demonstrated.  Place a star next to those they need to improve on.
8. Make an outcomes list of what will happen if the student makes him/herself more positive in attitude and what would happen if the student continues to hold on to his/her old behaviors.  Now place a star next to the outcome you want.  Ask the student to reflect on the Who Moved My Cheese book and their current status.
9. Write a personal objective that identifies the changes he/she wants to make that is measurable and includes timelines and resources to accomplish it.  Now have him/her track their progress towards this goal.
10. Make a list of feedback you have received over the last two-three weeks.  Make a two-column sheet with positive feedback on the left and negative feedback on the right. This should include feedback from your fieldwork supervisor,  other therapists, patients, peers, and your family.  Now examine your sheet.  What conclusions can you draw about this information?  Are you ready to change yet?
11. If he/she has difficulty accepting feedback, he/she probably goes quickly into one of our many defense mechanisms (denial, regression, rationalization, etc).  Constructive criticism is an effort to help the student identify what needs to change. The speaker is trying to help.  Ask the student to listen intently to the speaker and thank the speaker for providing this information.  The student should paraphrase the issues presented to them about what others are telling them.  Ask the student to check in with others about what others opinions are of them.  Make every effort to learn from this situation, do not ignore it.
12. Keep a feedback log (See Weekly Feedback log). Have the student track the feedback he/she receives and review it weekly with the supervisor to see if he/she is making progress.
13. Keep a journal. Use the journal to express yourself and your response to a variety of situations.

Observation

When a student is having difficulties with interpreting observations, they are missing valuable information and cues from the client and environment that the more skilled clinician recognizes. This missed information may be vital to making adaptations and changes in the therapeutic process. Most often these deficits can be improved when the student can learn to watch more carefully and write concisely about what they are observing.

Fieldwork supervisors should ask the student to observe closely and record their observations of a particular treatment or assessment process. This can be done regularly so the student practices and improves. Think about what you, the fieldwork supervisor, notice the student is missing when observing. Therapists often revise their procedures during a task, based on their observation of the process. Students who miss the clues will not make the necessary adjustment. Sometimes the students are so focused on what they should be doing, they forget to attend to the client and the environment. More experienced therapists are more attune to these and are more comfortable with their own roles.

This deficit can usually be remediated with more opportunities to observe and reflect on their observation skills.

Grading Activities

When a student has difficulty with grading activities, he/she has difficulty adapting the task to make it a just right challenge for the client. He/she may make the task too easy and boring or too hard and frustrating for the patient. Either way, the client is not experiencing success with the activity.

First ask the student to identify the rationale behind selecting this particular activity. Have the student consider these:

• Is this activity an appropriate one for this client given the information you have?
• Is it culturally appropriate? Age appropriate? Gender appropriate?
• Is the client intrinsically motivated to do it?
• Can the task be adapted easily?

If the student answered the above questions and the activity has met this criteria, then move to the task analysis.

Next, have student list each step of the activity, the assistance or cues to provide, how to gradually increase or decrease performance demands. You can make a chart similar to this one.



The student should consider the task demands and possible changes such as positioning the client, positioning of the materials, size of materials, type of tools needed, type of cues provided, amount of assistance provided, etc. The student can change the environment, the task, or the person. Have the student write this out ahead of the treatment so the thought process is in place.

Sometimes the student can do the task analysis component well, but has difficulty with the synthesis. This is the part when the task demands are changed to match the client鈥檚 abilities. This is the essence of grading a task. If this is the problem, have the student analyze the same task with two very different patients (i.e. a five year old with CP and an adult with TBI). This may help illustrate the synthesis component. Discuss the analysis and synthesis components with the student.

Therapeutic Handling

When a student is having difficulty with therapeutic handling, he/she is not effectively using his/her hands to guide the client鈥檚 motor control. The student may not be sure of what to do with his/her hands, where to place the hands, how to normalize the tone with the hands, or how to change the response the client is showing to him/her. This is a skill that requires much guided practice to comprehend and master. Most likely the student has practiced most of these techniques on primarily normal bodies (their classmates and family members). This may be the first time he/she really feels spasticity or flaccidity. There are many things the fieldwork supervisor can do to help the student reason through the process and practice it.

1. Have the student write up a plan on paper with specifics about what they need to do. Have the student list muscle groups or specific muscles that have abnormal tone. Next identify the type of abnormal tone. Next identify specific handling techniques to use to normalize the tone. Lastly identify positions to do these techniques in.  Review the table with the student before the session begins and provide feedback.

    

   Muscles	Type of Tone	Handling technique to normalize tone	Positions to consider

    

2. Have the student practice the procedure on another person with a normal body. Have the student identify bony landmarks, palpation of muscle bellies, place his/her hands in manner to facilitate movement. You may have the 鈥渃lient鈥� move in specific ways such as reaching in various planes and ask the student to identify the changes he/she feels in specific muscles when the patient actively moves.
3. Have the student practice some techniques on you. Provide immediate feedback during the process and identify what the student is doing correctly and incorrectly. Factors to consider are the weight of the hand on you, the amount of pressure, the gliding of his/her hands to promote your movement, and the support provided proximally to help      maintain balance when needed. Some describe this process as a dance. The student must provide the right cues to help you gently move.
4. Role model specific techniques on a client and ask the student questions during the process. It鈥檚 best if you tell the student about this activity ahead of time to ease anxiety. You can ask him/her to identify where your hand it placed, which techniques you are implementing, which muscles show a change in tone, why you moved your hand to a new  location or changed your technique.
5. Refer them back to the textbooks to review the motor control theories (Bobath, Brunnstrom, Rood, PNF) and be prepared to discuss these as a compare and contrast question.
6. When the student verbalizes the information correctly but seems impatient with the techniques, he/she may be under the impression it is an all or nothing concept. Explain that relaxation may take twenty minutes or longer in some patients. Relaxation may occur in stages for some patients as you work your way proximally to distally. Review the benefits of slow steady stretching to elongate muscles to prepare them to move.
7. Have the student practice with you a variety of clients with various stages of recovery and different types of abnormal tone. The more the student feels, the more he/she will understand the normal movement process.
8. There are some commercially available videos of therapists demonstrating handling techniques on a client. Have the student watch the video and describe what they see and what they learned. If you do not have any available in your department, consider making one or call the Academic Fieldwork Coordinator at the 天美影视传媒 to request to borrow one.

Accepting Feedback

A student who is not accepting of feedback often has a defense mechanism blocking his/her ability to actively listen. The student may be denying it is his/her responsibility to change. The student could be defensive. The student could be withdrawn. The student could appear stubborn and resistive to change. The student may be tired of hearing the same feedback. The student may be down and not sure what else to do. Either way, you are both probably uncomfortable with the situation at the present time.

Make an appointment to meet with the student daily if possible, if not daily, then at least twice weekly. This will eliminate the possibility of avoiding each other and set the stage to make the meetings gradually more comfortable.

1. Each of you should prepare a list of experiences or learning opportunities provided to the student that day or week ( i.e. evaluations conducted, client treatments, etc..). Now identify your reflection of how the student performed during each experience. Each statement on the list must begin with 鈥淚鈥� not 鈥測ou鈥�. The fieldwork supervisor鈥檚 list may have beginning statements such as I observed 鈥�, I noted.. , I saw the client do this.., I heard the nurse say鈥�. The student should make his/her list of experiences and identify his/her reflection of the process.
2. Begin your meeting dialogue by comparing the positives.  Discuss the diversity of responses between the student and yourself.  Summarize what you both perceive as going well.
3. Next, ask the student to identify their perceptions of the negatives for the day. Listen carefully. Discuss your perceptions of the negatives and dialogue about the differences. Be an active listener.  Make eye contact. Allow the student time to speak their perceptions. Summarize what both of you perceive as not going well.
4. Conclude with the student formulating an action plan that includes what experiences they want and what they will do differently to promote a different outcome.
5. Try to identify ways in which the student can learn to critique him/ herself or be observed by someone else and get feedback. This will provide multiple sources of feedback to the student. Often when a student reviews his/her own work at a later date the perception is different. Have student watching a videotape of him/herself performing a specific procedure and ask him/her to evaluate the performance. Can the student now identify their weaknesses?
6. Ask the student to start a personal journal where they reflect at the end of each day on the positive and negative experiences. This can be just for the student him/herself to read. Encourage the student to vent and write freely and then reflect back to see if they identify changes in him/herself.

Helpful suggestions for providing feedback:

• Be very specific when giving feedback in regards to each situation
• Give feedback in a private area not in front of others
• Be honest
• Provide suggestions for improvement
• Provide feedback on a situation as quickly as possible
• Always make sure the student understands the feedback given
• Focus your feedback on the behavior
• Base your feedback on first hand experience
• Be mindful of self-esteem
• Allow the student time to respond
• Relate feedback to learning goals
• Be nonjudgmental
• Avoid assumptions

If this plan is not helping, contact the Academic Fieldwork Coordinator for further suggestions.

Help When a Student is Failing

Failing a student is a very stressful experience for both the supervisor and the student. Often fieldwork supervisors report they are torn between their commitment to the student and their commitment to the clients. Supervisors want the student to be successful, however, they cannot pass a student who is not showing entry-level competencies. Students must take responsibility to change in order to meet the requirements for each fieldwork site. Supervisors should immediately take action when a student鈥檚 performance is not up to acceptable levels. Provide feedback regularly, as early as possible during the rotation, and in writing.

Kramer and Stern (1995) suggest that three things be done when a student is having difficulty:

1. Supervisors should provide students with specific and direct feedback that can be used in systematic, goal directed way.
2. Supervisors should describe why these actions or behaviors interfere with development and are not conducive to meeting performance expectations.
3. If problems do not improve after the above two suggestions are implemented, contact the Academic Fieldwork Coordinator.

Mc Creedy & Graham (1997) identify a five-step process for dealing with students with problem behaviors. They suggest the following:

1. Identify student problems and discuss with colleagues. Initiate the use of weekly feedback logs with the student.
2. Try to resolve the problem. Meet with student and articulate concerns clearly and with examples. Keep notes of your meeting with the student and have both of you sign and date your summary of the meeting. Do not focus on student鈥檚 personal issues but focus on performance problems. Conclude with developing a plan of action that identifies what the student will do to remediate the deficit. Set measurable objectives for student performance. Utilize the weekly feedback logs with the student. Both the supervisor and the student should keep copies of these forms.
3. Collaborate with school. Call the Academic Fieldwork Coordinator and discuss the situation. The Academic Fieldwork Coordinator may decide to make a site visit to sit down with the fieldwork supervisor and the student to review the action plans and progress to date. You may collectively complete a behavioral contract at this time. Provide copies      of weekly feedback forms. Don鈥檛 wait too long to make this call. The longer you wait, the more likely the student will not be successful within the time designated for completing level II fieldwork.
4. Follow up meetings between supervisor and student. Meet regularly, preferably weekly or twice weekly to measure progress towards goals and to provide further feedback to student about performance. Keep accurate notes regarding these meetings.
5. If the student is not making sufficient progress, a meeting between the fieldwork supervisor, the student, and the Academic Fieldwork Coordinator is warranted. Decisions may need to be made about the possibilities of success or failure for the student. Options to consider include extending the fieldwork time if student can make progress or termination of the fieldwork with a failing grade. These decisions will be made collaboratively between the school, the fieldwork site and the student.

Creating the Paper Trail

It can not be emphasized enough the importance of accurate and adequate documentation when a clinical rotation site may be failing a student The weekly feedback forms and behavioral contracts are the written documents providing evidence about the quality of the supervision and feedback provided to the student. It provides evidence that the student was informed early of the need to improve and provides objective measures of the student performance. Sites may want to save examples of the written work the student completed that was unacceptable. Also, you should add any written observations about the student鈥檚 performance. If you receive feedback from other departments, make a written note that includes the behaviors noted, the date and place they occurred, the person who witnessed the behaviors, and the outcomes. Be sure to follow up with the student on the weekly feedback logs and behavior contracts when warranted.

Look at your facilities employee handbook and identify policies about consequences of unprofessional behaviors. How would this employer handle similar behaviors in an employee? Use that as a guide. Any inappropriate and unprofessional behaviors that jeopardize a client鈥檚 safety or confidentiality should be immediately noted and dealt with. You may utilize the AOTA professional Code of Ethics and Standards of Practice as guides for writing up infractions. Any infractions of this nature should be reported immediately to the USA Academic Fieldwork Coordinator. Students should be asked to sign and date forms written about infractions to avoid the student denying that they received the information.

Academic Fieldwork Clinical Coordinator

Do not feel that you are alone in the process. The Academic Fieldwork Coordinator will guide you through the process of providing adequate supervision for the OT student. When things are going well, little intervention is warranted. However, when issues arise and the student does not make changes in performance, the AFC should be called immediately to help you both work through the issues, assure objective measures are being utilized, and provide resources for both of you. This mediation is absolutely necessary and should be utilized whenever needed.