Factors That Influence the Clinical Decision-Making of Rehabilitation Professionals in Long-Term Care Settings
Wainwright, Susan Flannery, McGinnis, Patricia Quinn, Journal of Allied Health
The purpose of this qualitative research was to evaluate the reasoning of clinicians practicing in long-term care facilities and to explore factors influencing their professional development. Eighteen participants were recruited from eight clinical sites and included seven occupational therapists, eight physical therapists, and three speech therapists distributed across three groups relative to experience. Nonparticipant observation and videotape of therapist-patient interactions were used in semi-structured interviews with each participant. Qualitative data analysis software was used during a process of open and axial coding, followed by thematic analysis. The facilitory and inhibitory factors that affect clinical reasoning and professional development were identified. Rehabilitation professionals in long-term care demonstrated clinical reasoning within the context of patient-centered goals. Well-developed and explicit programs for mentorship, professional development, and continuing education fostered their clinical reasoning abilities. Participants perceived that these factors were vital to achieving optimal patient outcomes. J Allied Health 2009; 38:143-151.
CONTEMPORARY LITERATURE indicates that effective clinical decision-making is the foundation of optimal patient management. While it is known that decision- making is shaped by prior experience,1"6 little is known about the type and scope of experiences that are most facil- itory in developing the abilities and attributes consistent with expert decision-making. Through study of the prior experiences of rehabilitation professionals, it is possible to gain insight into how their clinical decision-making thought processes develop. Knowledge of facilitory experiences identified by clinicians can be used to guide the professional development of rehabilitation professionals.
This succinct definition of clinical decision-making, "reasoning that results in action,"7 captures the factors that contribute to the decision-making process. Three important premises are assumed in this definition: 1) thought that leads to action requires deliberation about an appropriate course(s) of action; 2) reasoning occurs within a specific context; and 3) there is an anticipated outcome. Across the disciplines of medicine, nursing, occupational therapy, and physical therapy, there are differences in the way that clinical decision-making has been studied. For example, the research on clinical decision-making in medicine has focused on reasoning processes and decisionmaking models used by practitioners.1,2,8 Study within the nursing field has focused on quantifying the use of clinical decision-making,9-13 the field of physical therapy has focused on behavioral attributes demonstrated by the clinicians,14-17 and the occupational therapy literature has described models of clinical reasoning during initial assessment18 as well as clinical reasoning across therapist-patient interactions throughout the episode of care.19-21
Contemporary clinical practice incorporates evidencebased practice to direct the best practice for patient management and attainment of optimal patient outcomes. Evidence-based practice integrates clinical expertise, best available evidence, and patient values.22 Clinical judgment includes declarative and tacit knowledge. Declarative knowledge is based on formal education and research, while tacit knowledge is the intuitive way in which clinicians think about and organize information that is gained through practice.23 Clinical judgment develops through observation and practice of these tasks and activities. The tacit elements are the personal and professional experiences that provide the framework used for thinking about and judging information to develop an appropriate plan of action. While these clinical reasoning processes, abilities, and behavioral attributes have been described in the literature, this has not been explored within the context of the long-term care setting. …