Clinical reasoning focused on clients’ behaviour change in physiotherapy : Development and evaluation of the Reasoning 4 Change instrument

Abstract: With the recognition of the impact of lifestyle behaviours on health and the evidence of incorporating behavioural considerations in physiotherapy, there is a need to advance the clinical reasoning of physiotherapists. Clinical reasoning encompasses the thinking and decision-making processes guiding client management and is a core competency of physiotherapists. Enabling clinical reasoning advancements requires investigations in practice and education, which in turn require robust assessments. The overall aim of this thesis was to develop and evaluate an instrument to study physiotherapy students’ clinical reasoning focused on clients’ activity-related behaviour and behaviour change.In study I, a conceptual model was developed based on exploration of existing research, theory and views of physiotherapists and students. The data resulted in the clinical reasoning model focused on clients’ behaviour change with reference to physiotherapists (CRBC-PT). Studies II and III included instrument development and evaluation in four phases. Phase 1 included determination of the instrument structure and item generation based on the CRBC-PT model, evidence in clinical reasoning assessment and existing measures. Phase 2 included cognitive interviews with students to assess item understanding and resulted in revisions of item problems and approval of feasibility. Phase 3 included a Delphi study with physiotherapists with expertise in behavioural medicine to evaluate item relevance. The findings demonstrated a high level of consensus regarding content relevance. The final version of the Reasoning 4 Change (R4C) instrument included four domains, namely, Physiotherapist, Input from client, Functional behavioural analysis, and Strategies for behaviour change. In phase 4, the reliability and validity of the instrument were evaluated. Physiotherapists with expertise in behavioural medicine and students responded to the web-based R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists. The analyses showed excellent inter-rater reliability, satisfactory construct validity, internal consistency and test-retest reliability. In study IV, final-semester students (n=151) from all physiotherapy programmes in Sweden completed the R4C instrument. Hierarchical multiple regression analyses were conducted with three dependent variables, namely, input from client, functional behavioural analysis, and strategies for behaviour change. All included independent variables explained 37% of the variance in input from client. Cognitive and metacognitive skills explained 22%, attitudes 15% and curriculum with behavioural medicine competencies 3%. Only the variable curriculum with behavioural medicine competencies explained the variance in functional behavioural analysis (4%) and strategies for behaviour change (5%).In conclusion, the in-depth description of clinical reasoning focused on clients’ behaviour change may contribute to expanded understanding of the complexity and multidimensionality in reasoning processes that incorporate factors related to human behaviours, analyses of what factors motivate or hinder behaviours, and interventions to support behaviour change. Such knowledge is valuable for the teaching of and learning clinical reasoning. The R4C instrument helps fill the need for well-tested instruments and can support investigations and evaluations in physiotherapy education and research. To develop students’ clinical reasoning competence, cognitive and metacognitive skills, positive attitudes and the incorporation of behavioural medicine competencies into physiotherapy curricula should be targeted. Further attention to complex reasoning, including analysis and intervention, is warranted.