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The clinical reasoning process as an educational strategy for entry-level physical therapy professionals

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The clinical reasoning process as an educational strategy for entry-level physical therapy professionals
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DuPont, Blanche Burt
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English
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xi, 186 leaves : ill. ; 28 cm.

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College students ( jstor )
Control groups ( jstor )
Educational research ( jstor )
Gene therapy ( jstor )
Movement therapy ( jstor )
Pediatrics ( jstor )
Physical examinations ( jstor )
Physical therapy ( jstor )
Problem solving ( jstor )
Reasoning ( jstor )
Dissertations, Academic -- Educational Leadership -- UF
Educational Leadership thesis Ph. D
Medical logic -- Study and teaching ( lcsh )
Physical therapy -- Study and teaching ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (Ph. D.)--University of Florida, 1990.
Bibliography:
Includes bibliographical references (leaves 176-183)
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Blanche Burt DuPont.

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THE CLINICAL REASONING PROCESS AS AN EDUCATIONAL STRATEGY
FOR ENTRY-LEVEL PHYSICAL THERAPY PROFESSIONALS











By

BLANCHE BURT DUPONT


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


1990























This dissertation is

dedicated to my parents

Mary Lee and John Burt, II

and to

Professor Emeritus, Martha Wroe















ACKNOWLEDGEMENTS


The completion of this dissertation was made possible by the assistance and support of many individuals. My committee chairman, Dr. James Hensel, has been a constant source of encouragement. he has given me the continuing incentive I have needed to complete a Ph.D. while owning and directing a private practice in pediatric physical therapy and being a mother of two.

Dr. Gordon Lawrence helped me to focus my ideas for

the dissertation. He provided inspiration and guidance up through the proposal stages of my dissertation.

My committee members, Dr. Mary Kay Dykes and Dr.

Martha Clendenin, have been helpful in narrowing my focus, editing, and advising me as to the problems and merits in my dissertation project.

My loyal staff member, Cheryl Riehl, contributed to both my personal and professional growth. I thank Leila Cantara for her tolerance, advice, speed in typing, and ability to organize a dissertation.

In particular there has been an empathetic, adept

physical therapist, a spirit filled with love--Martha Wroe


iii









who has been my mentor. Because of my admiration and respect for her ability to communicate with student physical therapists, I have continued to teach in clinical physical therapy and to hope for a full-time academic career someday.

My husband and children were helpful and supportive

during my study. To my parents, my best friends, Mary Lee and John, I owe more than I can express. In everything they do, they always strive for success, and they have instilled this drive in me. My appreciation, my love, and all my good works are dedicated to them, and especially to Martha Wroe, Professor Emeritus, University of Florida.


iv

















TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS ..................................... iii

LIST OF TABLES ........................................ vii

LIST OF FIGURES .................................... viii

ABSTRACT .............................................. ix

CHAPTERS

I INTRODUCTION .................................... 1

Significance of the Study ...................... 3
Physical Therapy .............................. 4
Traditional Programs .......................... 5
Clinical Reasoning in Physical Therapy ..... 7
Statement of the Problem ........................ 10
Purpose of the Study ........................... 11
The Study .................................... 12
Justification of the Study Methodology ..... 12
Subjects .... ................................. 13
Control/Experimental Groups .................. 14
Research Questions ........................... 14
Assumptions . .................................. 15
Definition of Terms ............................ 16
Limitations ................................... 19
Summary . .... .................................. 21

II REVIEW OF THE LITERATURE ....................... 22

Objectives ............ ....................... 22
Ability to Solve Problems ...................... 24
Problem Solving in Medicine .................... 25
Clinical Reasoning and the Physical Therapy
Student .............. ..................... 37
Presentation by Using Videotape Patient Cases. 40
Studies Relating Problem Solving to MyersBriggs Personality Dimensions ............ 43
Summary .................-- -..................... 51


v









III METHODOLOGY ..................................


Statement of the Hypothesis .................... 54
Instrumentation ................................. 55
The Videos .................................. 55
Development of the Scoring Key ............ 57
The Myers-Briggs Type Indicator ........... 61
The Pilot Study ................................. 63
Subjects for the Pilot Study .............. 63
Method of the Pilot Study ................... 64
Results of the Pilot Study .................. 65
The Study .................................... 66
Subjects .... ................................ 66
Method .................................... 67
Data and Recording Analysis .................... 69
Recording ................................... 69
Analysis .... ................................ 70
Summary ......................................... 72

IV RESULTS ......................................... 74

Objectives of the Study ......................... 74
Research Questions .......................... 75
Hypotheses .... .............................. 76
Objectives ..................................... 77
Research Questions and Hypotheses ............ 78
Development of the Scoring Key ................. 78
Occasion One: Experts ....................... 78
Occasion Two: Experts ....................... 79
Accuracy/Problem Statement Form ........... 80
Pilot and Experimental study Groups ....... 80
Myers-Briggs Type Indicator .................... 98
Results: Accuracy Scores ....................... 102
Results: Research Questions 1 and 2 and Test
of Hypotheses 1 and 2 ....................... 104
Results: Research Question 3 and Test of
Hypothesis 3 ................................ 106
Summary ...................................... 107

V DISCUSSION ................................... 110

Discussion of the Study ......................... 110
Summary of the Procedures ................... 113
Summary of the Findings ...................... 115
Implications ... . ............................. 115
Directions for Future Research ................. 117
Research on Instructional Use of CRP ......... 119 Summary and Conclusions ........................ 120


vi


53









APPENDICES


A LITERATURE REVIEW TABLES OF STUDIES OF PROBLEM
SOLVING AND MYERS-BRIGGS TYPE INDICATOR ....... 123


B FORMAT AND PRESENTATION OF THE MODEL OF VIDEO
INSTRUCTION FOLLOWING THE CLINICAL REASONING
PROCESS ...................................... 134

C THE VIDEO MODEL .............................. 140

D RATING AND STATEMENT FORMS AND STEPS IN CRP
SHEETS USED WITH EXPERTS, PILOT STUDY GROUP,
EXPERIMENTAL AND CONTROL GROUPS ................. 158

E DATA RECORDING FORMS ......................... 174

REFERENCES ......................................... 176

BIOGRAPHICAL SKETCH ................................ 184


vii
















LIST OF TABLES


Table Page

1 Behaviors of Problem Solver ..................... 32

2 Experts' Agreement Scores Based on Cues
Generated from the Work of Harris (1987) ...... 79

3 Results: Expert Panel's Problem Statements ... 81 4 Homogeneity of Slopes ........................... 87

5 Efficiency Score 1--Patient History Adjusted
Means and Standard Deviations by Group,
Personality Dimension, and School for Posttest. 88

6 Efficiency Score 2--Physical Examination
Adjusted Means and Standard Deviations by
Group, Personality Dimension, and School for
Posttest ......................................... 89

7 Efficiency Score 3--Volitional Movement
Adjusted Means and Standard Deviations by
Group, Personality Dimension, and School for
Posttest ...... ................................ 90

8 Student MBTI Profile Table ...................... 99

9 Group SN by Number of Subjects Per Cell and by
Percent of Subjects in Cell .................... 102

10 Group JP by Number of Subjects Per Cell and by Percent of Subjects in Cell .................... 103

11 Frequency Distribution for Control and Experimental Groups ........................... 103

12 2 X 2 X 2 MANCOVA Table ....................... 105

13 Chi Square Analysis ........................... 108


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LIST OF FIGURES


Figure Page

1 The problem-solving mode........................ 34

2 Hypothesis-oriented algorithm for clinicians.. 35

3 Video structure and model....................... 42

4 Experimental design............................. 71

5 Scatterplot for efficiency score--patient
history ......................................... 83

6 Scatterplot for efficiency score--physical
examination ..................................... 84

7 Scatterplot for efficiency score--volitional
movement ........................................ 86

8 Patient History--Experimental Group.
Frequency distribution bar graph of pretest/
posttest scores on efficiency score (1) ...... 92

9 Patient History--Control Group. Frequency
distribution bar graph of pretest/posttest
scores on efficiency score (1) ................. 93

10 Physical Exam--Experimental Group. Frequency distribution bar graph of pretest/posttest
scores on efficiency score (2) ................ 94

11 Physical Exam--Control Group. Frequency
distribution bar graph of pretest/posttest
scores on efficiency score (2) ............... 95

12 Volitional Movement--Experimental Group.
Frequency distribution bar graph of pretest/
posttest scores on efficiency score (3) ...... 96

13 Volitional Movement--Control Group. Frequency
distribution bar graph of pretest/posttest
scores on efficiency score (3) ............... 97


ix
















Abstract of Dissertation Presented to the
Graduate School of the University of Florida in
Partial Fulfillment of the Requirements for
the Degree of Doctor of Philosophy

THE CLINICAL REASONING PROCESS AS AN EDUCATIONAL STRATEGY
FOR ENTRY-LEVEL PHYSICAL THERAPY PROFESSIONALS By

Blanche Burt DuPont

May 1990

Chairperson: James W. Hensel Major Department: Educational Leadership

The purpose of this study was to determine the

effects of using the clinical reasoning process as an educational strategy for preparing physical therapy students entering the profession. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the clinical reasoning process (CRP).

Ten expert pediatric physical therapists created two scoring keys for two measures used in the study: diagnostic efficiency and diagnostic accuracy. Two videos were formatted to present a pediatric patient evaluation, one video was structured to include the rules of the CRP.


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Subjects were 75 volunteer, entry-level physical therapists graduating from four Florida education programs. Subjects completed the Myers-Briggs Type Indicator to determine personality characteristics. Subjects were randomly assigned to experimental or control groups. Both groups viewed the unstructured video and completed a critical cues rating list and a problem statement form. The list was used to assess efficiency in rating diagnostic cues, the form to assess accuracy in diagnosis. The control group again viewed the unstructured video while the experimental group viewed the structured version. Both groups completed a cues rating list and problem statement form.

Efficiency and accuracy measures were evaluated with a MANCOVA and a chi square, respectively. Subjects did not improve in diagnostic efficiency (F = .89, p > .35; F = .04; p > .8441; F = .31, p > .5785). There was no significant relationship between efficiency and personality characteristics. Subjects did improve in ability to accurately diagnose a pediatric movement
2
dysfunction (X2= 9.13, p < .0025). Indications are that there is merit in incorporating use of CRP strategies for the purpose of training physical therapists to accurately diagnose movement dysfunction.


xi














CHAPTER I
INTRODUCTION



Educators have been concerned with the need to

provide instructional programs that enable students who will work at professional decision-making levels to acquire critical thinking skills. These students will need to act as experts, persons who have demonstrated their ability in problem solving. The Education Commission of the United States, in 1982, called critical thinking, problem solving, and decision making the basic subjects for the future. In recent years researchers have been examining how students develop higher order critical thinking skills (Feely, 1976; Knight, 1987). Educational researchers, working within the problem-solving paradigm in cognitive psychology, have looked at the critical thinking skills that experts bring to problem solving and decision making (Bruner, Goodnow, & Austin, 1956; John & Miller, 1957). By investigating the problem-solving behaviors of experts, persons with highly developed knowledge and years of experience in a particular discipline, researchers have determined that there are sets of strategies that are considered critical thinking


1








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skills. Within a given discipline, such as medicine or law, a specific set of strategies employed in assessing the problem or problems of a patient is termed diagnosis (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980; Elstein, Shulman, & Sprafka, 1979). Diagnosis is an essential tool in the work of physicians, who are responsible for identification of a patient's primary problem and who are also responsible for the decision in regard to appropriate treatment. Researchers have studied the specific set of strategies physicians employ in diagnosis, and have looked at how to assist student physicians to acquire and develop diagnostic skills (Barrows & Tamblyn, 1980; Ben Bassat, 1986; Einhorn, 1986). The need to diagnose is found in other areas of the medical field. Physicians refer patients to a health related group of practitioners for forms of treatment not administered by themselves. one of these groups of practitioners to which patients are referred is physical therapists (Echternach & Rothstein, 1986, 1989).

Physical therapy as a profession in the health care industry encompasses the treatment of patients who have orthopedic or neurological dysfunctions as sequelae of illness, accident, injury, or congenital malformations. Before treatment strategies can be used the physical therapist must assess the specific problem of the patient. Traditionally, the attending physician had the








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responsibility for determining that a patient needed physical therapy (Echternach & Rothstein, 1986, 1989).

The first physical therapy evaluations were carried out when a physician ordered specific tests for the patient (i.e., manual muscle test, range of motion test). The physician would take the information from these tests and diagnose the patient's movement dysfunction after which he or she would tell the therapist how to treat and manage the patient. At the present time, the situation with physician referral is often different.

Significance of the Study

About 48% of the states have granted physical therapists the right to practice without referral (Pickard, 1989). While Florida has not yet legislated this right to physical therapists, the trend in Florida that is similar to a national trend is the one in which physical therapy practitioners are now practicing away from institutional settings in private practices. This delegates to the physical therapy practitioners complete responsibility for the management of patient progress. The movement toward more autonomy for the physical therapists, with the corresponding increase in responsibility, is expected to continue. It is important to note that these impending changes can only occur via changes in state licensing processes and that the changes were not self-initiated changes. Not only are physical









4


therapists often working more independently, but also there are increasing case loads of complex problem patients. For example, in one specialty area of physical therapy--pediatrics--the medical profession is continually developing ways to prevent infant mortality. Many of these at-risk neonates ultimately require some type of therapeutic intervention. Entry-level physical therapists, those who have completed their studies and are ready to practice on a professional level, are expected not only to diagnose movement problems of all varieties, but to recognize whether as practitioners they personally can manage such complex cases. Expert physical therapists possess sophisticated evaluation skills to meet the challenges of practice in today's society and today's entry-level professionals need to know as much about acquiring those sophisticated skills as possible. Physical Therapy

Educators who educate students to become physical therapists have recognized the increasing complexity of patient problems and the responsibility of the practitioner. The faculties of numerous programs in physical therapy have planned to require a master's degree before licensing can be applied for by a candidate wishing to enter practice. Although the American Physical Therapy Association cannot mandate this plan, the Association has recommended it. The master's degree may ensure that









5


students would have more time to acquire diagnostic skills. More time spent in course work does not, however, assist students in developing the set of strategies that will enable them to make accurate diagnoses unless instructional programs provide information to students on how to acquire and use critical thinking skills in diagnosis. Traditional programs in physical therapy may not facilitate the students' development of the particular set of problem-solving strategies needed to identify patient problems (May, 1977; May & Newman, 1980; Slaughter, Brown, Gardner, & Perritt, 1989). Traditional Programs

Traditionally, instructional programs in physical therapy, like medicine, have emphasized a stepwise approach to the study of a patient case (Barrows & Bennett, 1972; Gordon, 1973). In this approach, emphasis has been placed on development of observational skills and collection of data (Arand & Harding, 1987; May, 1977; May & Newman, 1980; Olsen, 1983).

This traditional approach has been a two-step

process: (a) identifying the problem through emphasis on all the data one could find about a patient and (b) eliminating and rejecting possible causes. Symptoms or signs that could not be accounted for if certain causes for the problem were accepted by the physical therapist would be referred back to the physician. Researchers have









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determined that there is a set of problem-solving strategies that have served to speed up certain channels of thought and weaken others (Barrows & Bennett, 1972). Use of these strategies by the physical therapist could quicken the diagnostic process of movement dysfunction that the therapist can no longer leave primarily to the physician. This set of strategies eliminates certain data collection steps and hones observational skills (Barrows & Feltovich, 1987; Barrows & Tamblyn, 1980; Elstein et al., 1979; Gordon, 1973; Helfer & Slater, 1971). These researchers sought to understand clinical problem-solving strategies in patient diagnosis by investigating the method that experts use to diagnose patient disorders. From this research they developed a set of rules that could be used to teach student physicians to proceed successfully through patient diagnosis (Barrows, 1983, 1986; Barrows & Bennett, 1972; Barrows & Feltovich, 1987; Barrows & Tamblyn, 1980; Cutler, 1985; Elstein et al., 1972; Gordon, 1973). This set of training rules or strategies in diagnostic problem solving was labeled the clinical reasoning process (CRP). The CRP has been studied for over 15 years in medicine. In addition, Payton (1985) found that experts in physical therapy also used the same set of strategies or rules.








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Clinical Reasoning in Physical Therapy

The clinical diagnostic problem-solving strategies

used by experts in physical therapy were similar to those used by the physician experts in Barrows' and others (1972, 1980, 1983, 1986, 1987) studies. The training of students in the use of the specific set of rules known as the clinical reasoning process (CRP) has not been investigated in physical therapy. Two studies of facilitating clinical problem solving by teaching students strategies have been carried out, but these researchers in physical therapy education were not employing the clinical reasoning process (CRP). The researchers could not demonstrate a significant improvement in student performance, although many subjects in both studies reported that the strategies they learned helped them to organize their approach to patient diagnosis (Burnett & Pierson, 1988; Slaughter, Brown, Gardner, & Perritt, 1989).

While many students indicated that they benefited

from learning to use strategies for diagnosis, it was not clear whether there was any way to predict which students needed such instruction. In 1983 it was reported that some students in medical school, even when not taught clinical reasoning strategies, automatically adopted and began to use these rules when they moved into practice. Others never appeared to develop the skills on their own;








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they had to receive instruction (Barrows & Tamblyn, 1980; Kern & Doherty, 1982; Margolis, Barnoon, & Barok, 1982). Students entering medical school have personal problemsolving strategies; not all these strategies appeared to be effective in clinical settings. The authors of studies on student physicians hypothesized that differences in certain personality characteristics might enable some graduating physicians, who had not received direct instruction in clinical reasoning skills, to be effective in diagnoses upon entering practice while others with different personality characteristics could not be successful without this instruction (Barrows & Tamblyn, 1980; Elstein et al., 1979).

Observers have not considered that entry-level

physical therapists possess clinical reasoning skills that enable them to be uniformly effective in diagnosis (May, 1977; May & Newman, 1980; Olsen, 1983). They were not reported to have the skills that lead to efficient, accurate diagnosis of movement dysfunction, especially in a specialty area of practice like pediatrics. Educators in general, however, have assumed that experience and native intelligence, along with accumulation of knowledge in school would produce in their students the ability to analyze, synthesize, and ultimately make sound clinical judgments (May, 1977; May & Newman, 1980; Rothstein & Echternach, 1986, 1989). This has not been demonstrated








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in research and it should not be assumed that all physical therapists develop critical thinking skills and strategies that allow them to make patient diagnoses. It has been hypothesized that personality differences may underlie the varying abilities in clinical reasoning strategies of physical therapists (Burnett & Pierson, 1988; Burnett, Mahoney, & Chidley, 1986). Identifying students who may be in need of training in acquisition and use of these skills would assist educators interested in developing instructional programs that would include education in clinical reasoning strategies. Such research has not been undertaken.

Two directions in research directed toward improving instructional programs in physical therapy are indicated: one is a demonstration that students provided with a set of training strategies in clinical reasoning do become skilled in diagnosis, and the other is identification of those students who need such training in order to become experts. Physical therapy is, however, an expanding field. Many specialty areas now exist within the profession of physical therapy. This researcher is a practitioner in the area of neurological pediatrics and therefore familiar with the critical needs of these patients. Researchers have pointed out that diagnostic needs are critical in this specialty (Bobath, 1967; Illingworth, 1965; Kong, 1966; Quinton, 1986).









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Neurological movement disorders such as cerebral palsy have been the most common diagnostic movement problems seen by the pediatric physical therapist. Experts in the field have applied problem-solving techniques to these complex pediatric cases. In many instances of early neurological dysfunction, the patient's functional outcome can be changed with early appropriate treatment. Entrylevel practitioners in this specialty have needed to know how to diagnose in the manner of experts. The study of an instructional approach aimed toward improving successful clinical reasoning in an area of diagnostic physical therapy would be an important area of research (Campbell, Anderson, & Gardner, 1989). Given the importance of early identification of the problem and treatment in neurological pediatrics, and given the researcher's expertise in the area, it seemed most appropriate to carry out a study in this specialty area.

Statement of the Problem

Practitioners in physical therapy need to make

efficient, accurate diagnoses of movement dysfunction. Due to the increasing complexities in physical therapy, practitioners are specializing; one such specialty is pediatrics. Not all entry-level physical therapy students have demonstrated that they possess clinical reasoning strategies that can lead to efficient, accurate diagnosis of movement dysfunction in the pediatric patient. Through








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observation of expert physicians and physical therapists, researchers have identified the problem-solving strategies that make up the effective clinical reasoning process (CRP) (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980; Elstein et al., 1972; Elstein et al., 1979; Payton, 1985). Traditional instructional programs, however, have not included training in the CRP. To date there have not been studies investigating whether training in the CRP would benefit students, enabling them to become accurate, efficient diagnosticians upon entering the field. There also have not been studies that aimed at determining which students would need such training. While some physical therapists without specific training have been shown to have developed automatically the use of CRP, others without training have not become efficient, accurate clinicians. It was hypothesized that personality characteristics might influence development of this type of problem solving in individuals. Educators who would like to implement training did not have a basis for determining if CRP training is effective as a teaching tool nor did they have a means of determining which students would benefit from such training.

Purpose of the Study

The purpose of this study was to determine the effects of using the clinical reasoning process as a training strategy for physical therapy students entering








12

the profession. The relationship between two personality dimensions and successful use of this problem-solving tool was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the CRP.

The Study

In this study the effectiveness of using what is described in the literature as the clinical reasoning process as a teaching tool for entry-level physical therapy professionals was investigated. The study was carried out in the state of Florida from October 1988 through August 1989. Subjects were 75 graduating students from the four physical therapy training programs in the state. The investigation proceeded in the following steps: development of the instructional video, development of the scoring key by a panel of experts, administration of the Myers Briggs Type Indicator to volunteer subjects, viewing of the video learning experiment by a pilot group followed by the same with a control and experimental group. Before proceeding to carry out the steps in the study, the work of major researchers was reviewed to justify the methodology, that is, the CRP and the video.

Justification of the Study Methodology

This study was designed to test the effectiveness of the CRP in teaching patient evaluation. Barrows and








13

Tamblyn (1980) noted that the two major justifications for using the CRP in teaching patient evaluation included efficiency and accuracy in diagnosis. Efficiency indicated that a medical expert was able to perceive critical patient cues while eliminating unimportant cues in order to test more thoroughly and to observe the patient more carefully. Accuracy scores were indicative that the expert knew when he or she had enough information to make a correct diagnostic and treatment decision. At that point the expert stopped collecting data and closed the problem-solving process. The accurate diagnostician arrived at a diagnosis that replicated what other experts would state (Barrows & Tamblyn, 1980; Helfer & Slater, 1971; Marshall, 1983). In this study efficiency and accuracy of problem solving during the CRP were evaluated by asking subjects to carry out two tasks during and after viewing a video presentation of a case. These were (a) complete a critical cues list with three subsections to determine efficiency, and (b) write a primary problem statement to determine accuracy in the diagnosis of movement dysfunction (Barrows & Tamblyn, 1980). Subjects

Subjects were 75 volunteer graduating students from the four physical therapy training programs in Florida (N = 75). All subjects completed the Myers-Briggs Type Indicator (MBTI) for use in identifying differences in two









14

personality dimensions. Students were randomly placed in experimental or control groups, and both groups received a pretest. A posttest was administered after subjects completed the list necessary for the pretest in the study. Control/Experimental Groups

The subjects viewed the instructional video of a patient evaluation task. The video that experimental subjects viewed was the video structured to include the steps in the clinical reasoning process. Student subjects were tested as to their clinical reasoning efficiency skills by matching their critical cues ratings with those of experts. Accuracy was analyzed by key phrase agreement with experts on the primary problem statement. Subjects wrote primary problem statements in order to record a movement diagnosis. This movement diagnosis was matched with those of experts. The data were then analyzed to complete the study. This study was designed to enable the researcher to formulate responses to the following research questions.

Research Questions

1. Can instruction in the method known as the

clinical reasoning process that experts use to diagnose patient movement dysfunction affect entry-level physical therapy students' ability to rate patient movement behaviors efficiently?









15

2. Will there be an affect of students' personality dimensions or characteristics and instruction in the use of the CRP on the way students efficiently rate patient cues?

3. Can instruction in the method of experts (CRP)

assist entry-level (preservice) physical therapy students to accurately diagnose a patient's primary problem with movement, so that students' key words/phrases agree with those of experts?

Assumptions

1. It was assumed based on research that students can learn to use the experimental CRP to solve more complex problems at this level in their professional education (entry level) (Ben Bassat, 1986; Burnett & Pierson, 1988; Groen & Patel, 1985; Watts, 1985).

2. It was assumed that application of this problemsolving method is relevant to different types of clinical evaluation problems (Ben Bassat, 1986; Burnett & Pierson, 1988; Groen & Patel, 1985; Watts, 1985).

3. It was assumed that the success of using the CRP might differ when comparing individuals with differences in personality dimensions (Hunter & Levy, 1982; Lawrence, 1984a, 1984b; McCaulley & Natter, 1974).

4. It was assumed that the 75 graduating physical therapists who volunteered for the study were









16


representative of graduating (entry level) physical therapy professionals in the state of Florida.

5. It was assumed that regardless of whether the subject was a master's degree entry-level student or a bachelor's degree entry-level student, they were all novice learners.

Definition of Terms

Accuracy is the ability to quickly make an

appropriate summation of the patient's movement problems (Barrows & Tamblyn, 1980). This ability was evaluated on the basis of agreement of key words/phrases between subjects' primary problem statements and experts' primary problem statements (Ben Bassat, 1986; Helfer & Slater, 1971; Marshall, 1983; McGuire, 1985).

Clinical reasoning process (CRP) is a set of problemsolving strategies used by experts in medicine and physical therapy to arrive at clinical patient problem solutions or diagnoses. It is also termed problem solving in clinical medicine or the method of experts (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980). For the purpose of this study it is termed CRP.

Cues are those test behaviors which experts report as essential for arriving at the primary problem statement. The relevance of cues is important in excluding an alternative hypothesis or problem statement so that one








17


can establish a finite movement diagnosis or primary problem statement (Marshall, 1983).

Diagnosis of movement dysfunction (or movement

diagnosis) was used in the context of this study to mean that the entry-level professional must know how to determine the patient's primary problem with movement. The primary problem is, in effect, the movement diagnosis and at the same time it is the primary problem which must be approached by the physical therapist in treatment.

Efficiency is the ability to observe and rate

critically important cues as demonstrated by the patient and patient's family in the instructional video. These cues allow the expert to formulate appropriate problem statements (Barrows & Tamblyn, 1980). Efficiency was evaluated by comparing the student and expert ratings of critical cues as observed during each of three video components (Helfer & Slater, 1971; Marshall, 1983).

Entry level is used to define a student in physical therapy who is ready to enter into the practice of physical therapy subsequent to completing all the didactic and clinical components of their educational program in the discipline. It is used here interchangeably with "graduating."

Information-processing theory is essentially a theory of communication systems developed in the context of telephone engineering. It was introduced into cognitive








18

psychology primarily by Miller (1956) and Bruner, Goodnow, and Austin (1956).

Intuitive (intuition) is one of the poles of the MBTI. There are four poles or two sets of dimensions relevant to this dissertation: (a) intuition and sensing and (b) judging and perceiving. Intuition is the ability to perceive potentialities in both external and internal events. An intuitive person is one who can perceive "meaning in relationships and associations that are not directly presented to the senses" (Myers & McCaulley, 1987, p. 12). Its polar opposite is sensing.

Judging (judgment) is one of the poles of the MBTI. It is characterized by a person who prefers to "live life in a self-regimented, purposeful, and exacting way" (Myers & McCaulley, 1987, p. 13). Its polar opposite is perceiving. Judging people are closure oriented. They make decisions as soon as they have enough information.

Perceiving (perception) is one of the poles of the MBTI. It is characterized by a person with a preference to "live life in a flexible, adaptable, and tolerant way" (Myers & McCaulley, 1987, p. 13). Its polar opposite is judging. Perceiving people dislike closure and enjoy investigating all possibilities.

Sensing (sensation) is one of the poles of the MBTI. It is characterized by a person who prefers the immediate, real, and practical side of life that can be gained









19


through use of one's senses (Myers & McCaulley, 1987, p. 12). Its opposite pole is intuitive or intuition.

Limitations

Seven specific limitations have been described that

have a direct impact on this study. They were as follows:

1. The sample of professionals used in the study was limited to physical therapy students from educational programs in Florida. Their performance may not be representative of that of the general population of entrylevel physical therapy professionals. The use of all possible schools of physical therapy in Florida limited generalization of the results to those entry-level physical therapy professionals in Florida.

2. Subjects may not indicate their true preferences on the MBTI. As Myers and McCaulley (1987) explained,

as with any self-report instrument, the
correctness of the results depends in part on
how well the questions have been answered. If
people answering the MBTI feel that they have
nothing to gain, they may answer carelessly or
even at random. If they fear they have
something to lose, they may answer as they
assume they should. But if they understand
before answering, that they will be told how they score and will be invited to confirm or
correct the report of their dimensions, their
answers are more likely to be genuine. (p. 53)

3. Clinical reasoning or clinical problem solving is a complex cognitive skill which does not lend itself to easy measurement or discovery of ideal strategies. The instructional video was limited to only a small portion of









20

this particular cognitive domain. In addition, there was no exploration of the psychomotor domain, that is, of the physical handling skills used to conduct pediatric evaluation (Berner, 1984).

4. The definitions of efficiency and accuracy are narrow and may not apply to all types of clinical reasoning behaviors.

5. Data gathering was not done in a typical or

normal clinical practice manner; it was done based upon students' rating of cues, and the writing of a problem statement during and subsequent to viewing a video (Berner, 1984). This is not the most frequently used method of data gathering in physical therapy programs.

6. The test behaviors included in the pediatric

video case evaluation were limited to those established by research. The video may not have shown all the behaviors that either all experts or all student subjects would have considered relevant (Harris, 1987; Ross, Lipper, & Auld, 1986; Georgieff, Bernbaum, Hoffman-Williamson, & Daft, 1986; Gorga, Stern, & Ross, 1985; Stanley & English, 1986) (see Appendix A).

7. All experts did not agree 100% on critical cue ratings or problem statement key words/phrases. Researchers in physical therapy have demonstrated that if there are more than three experts who are to agree on a









21


subject, then to some degree disagreement among experts should be expected (Delitto, Shulman, & Rose, 1989).

Summary

Empirical studies have shown that when solving

complex clinical problems, expert physical therapists demonstrated systematic patterns in behavior. These patterns followed a set of rules termed the clinical reasoning process. A systematic review of the literature indicated that even if they are not trained in the CRP, some professionals immediately upon entry into practice employed these rules of the CRP. Certain personality dimensions or characteristics of some professionals are related to how well they solve problems once they enter practice. These dimensions of personality were thought to be relevant to the determination of whether a student needed to receive structured training in the CRP.

The purpose of this study was to determine the effects of using the CRP as a training strategy for physical therapy students entering the profession. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the CRP.















CHAPTER II
REVIEW OF THE LITERATURE



The literature reviewed for this research covered the topics relevant to the three objectives and the three research questions. Each of the three objectives, along with the relevant topics, are presented. The literature reviewed for each topic was found to be relevant to the study.

objectives

The first objective was to investigate whether

experimental and control groups differed in their ability to rate cues efficiently and, if they differ, whether the differences were based on watching a video edited to facilitate use of the CRP. Determining critical cues is an essential step in problem solving. Discussion of the first objective encompasses a review of the large bank of information about the CRP as part of the problem-solving paradigm. Problem solving has received greater emphasis in educational programs for physical therapists because of the movement toward autonomy in the practice of physical therapy (Echternach & Rothstein, 1989). Due to the necessity for precision in the practice of physical


22








23


therapy, this researcher identified a precise set of strategies that was mentioned in the literature as being applicable to the area of clinical problem solving in patient diagnosis. The literature review includes discussion of the studies of problem solving in diagnosis. Instruction through the use of video case presentations as a method of assisting students to become expert problem solvers was also reviewed.

The second objective was to investigate whether there was a relationship between two personality dimensions and successful use of the problem-solving paradigm known as CRP. Personality characteristics or dimensions, as they related to problem solving, have been mentioned in studies involving the Myers-Briggs Type Indicator. A review of the relevant literature on the MBTI and its applicability to studies such as this research is included in this chapter.

The third objective was to investigate the subjects' ability to accurately diagnose a pediatric patient movement dysfunction, and to determine if experimental subjects differed as a result of viewing a structured instructional video that included the rules of the clinical reasoning process. The authors of the literature on problem solving in medicine indicated that there were two variables related to clinical diagnostic success: (a) efficiency in diagnosing a patient's dysfunction; and (b)








24

accuracy in diagnosing a patient's primary dysfunction or problem. Literature relevant to the topics of efficiency and accuracy was reviewed in relationship to this objective.

The literature reviewed for this study was related to the topics found relevant to the objectives of the research. The topics are: problem-solving paradigm; problem solving in medicine, problem solving in physical therapy; clinical reasoning and the physical therapy student; patient case presentation videos; and studies relating problem solving to personality dimensions or characteristics. The literature is discussed next in the order of the topics mentioned.

Ability to Solve Problems

Problem solving as a mental exercise has long

attracted the attention of researchers (Feely, 1976; Greeno, 1978; Norman, 1976). Problem solving was described by Bloom as an evaluative and decision-making process represented by the evaluation stage of his taxonomy (Feely, 1976). As a higher order mental effort, problem solving was further investigated by cognitive psychologists. A problem-solving paradigm was developed, in which a person was viewed as an information channel, receiving information from the environment and acting adaptively on it (Greeno, 1978). In order to analyze the processes involved in problem solving, information channel








25

theorists followed the information as it entered the human nervous system and was processed (Norman, 1976). In further studies Greeno (1978) found that there was not a single homogeneous set of problem-solving processing skills that could be identified as the essential skills involved in all types of problem solving. Greeno found, however, that the human system seemed to function on two basic principles: (a) individual bits of information can be chunked together and eventually one symbol comes to represent larger pieces of experience; and (b) redundant data are eliminated to conserve the limited time, space, and energy required by the human system to process essential information. Another way of saying this is that the efficient human system selects data that convey maximum information. Cognitive psychologists began to explore these principles as they related to problem solving within specific disciplines such as medicine. Their research involved studies of the strategies employed by expert practitioners in solving medically related diagnostic problems.

Problem Solving in Medicine

The strategies used by physician experts were found to be consistent and sequential (Barrows & Bennett, 1972). Elstein, Schulman, and Sprafka (1979) began structuring the problem-solving activities of medical students to follow these strategies used by experts.








26


These authors agreed on certain consistently used cognitive strategies, such as the number of hypotheses experts generate early in the diagnostic process and the steps they follow to hone these hypotheses and eliminate irrelevant cues. Barrows and Bennett (1972) also found that the expert started with very general hypotheses and progressed to a specific hypothesis or problem statement. Medical students eventually were able to apply these hypotheses generating processes in interviewing and examining actual patients. In Barrow's original studies, medical students learned the rules initially by practicing with simulated video and written patient case presentations (Barrows & Tamblyn, 1980; Gordon, 1973;

Miller, 1956).

The rules for the clinical reasoning process (CRP)

were stated by Barrows and Tamblyn (1980). These rules or strategies represent one set of strategies used for problem solving in clinical medicine. These are the set of strategies used in this study.

Step I "Cue Phase": Studies in clinical
reasoning show that the expert assembles an
initial concept of a patient's problems with lightning speed from critical cues
inherent in the first encounter.
Step II "Hypothesis Phase": Within moments
after the first encounter, almost
simultaneously with the initial concept,
the expert in medicine generates 2-5
hypotheses or problem statements that
literally "pop" into mind. Hypotheses or problem statements can be ideas, hunches, guesses, or impressions that can explain
causes for the patient's problems.









27


Step III "Maximization Phase": Experts process
all of their hypotheses (problem
statements) in parallel manner; then they stop and deduce which hypotheses (problem
statements) are most likely responsible for
the patient problem. They then rank order
their hypotheses (problem statements).
Step IV "Case Building Phase": Experts search
the data again, modifying their problem
formulations, altering, rejecting, and
revising any hypotheses (problem
statements) that need it.
Step V "Closure Phase": Experts stop when they
have just enough data to formulate a final hypothesis or problem statement. (pp. 2230)

Barrows and Bennett (1972) and Barrows and Tamblyn

(1980) worked primarily with medical students, while

Elstein et al. (1979) further clarified the hypotheses

generating activities of the CRP as used by experts.

Elstein et al. found that three phases of hypothesesgeneration were being used by experts.

Phases in the hypotheses generation activity (Elstein

et al., 1972) are as follows:

1. Generate a list of alternative hypotheses or
actions
a. Multiple competing hypotheses
b. Probability (consider the most common
diagnosis first)
c. Utility (consider seriously those
diagnoses for which effective therapies
are available and in which failure to
treat would be a serious omission)
2. Gather data
a. Form a reasoned plan for listing
hypotheses (problem statements)
(1) Relate diagnostic decisions to
treatment alternatives
(2) Every datum gathered must have a
reason
b. Branch and screen: history taking and
physical examination should be branching
procedures; develop adequate screening









28


tactics to help make overly detailed
examinations unnecessary
c. Cost-benefit calculation; estimate
whether seeing other specialists and
performing other medical tests are
beneficial and cost effective
d. Precision; strive for the degree of
reliability needed for the decision at
hand; more is not necessary
3. Aggregating data, evaluating hypotheses, and
selecting a course of action
a. Actively seek out and evaluate evidence
that tends to rule out any hypothesis
(problem statement) or action
alternative as well as evidence that tends to confirm it; be aware of the
tendency to discount or disregard
evidence likely to disconfirm your
favorite hypothesis (problem statement)
b. Multiple diagnosis; consider the
possibility that a patient with multiple problems or complaints has more than one disorder (or more than one etiology for
abnormal movement)
c. Bayes' theorem; revise probabilities
after collecting data
1. In assessing problems, give special
weight to a particular dysfunction
if it is a commonly found
dysfunction
2. If clinical findings are relatively
more likely in problem A than in B,
revise opinion in favor of A
3. If hard data are presented, weight
each finding as at least confirming, disconfirming, or not changing one's
prior belief
4. If problems are rank ordered on the
basis of predominance of findings in
their support, this ranking will
correspond roughly to a probability
scale
d. Probability and utility should guide
action
1. Consider clustering problems that
would be treated identically; this
nesting effectively reduces the
number of alternatives to be
evaluated
2. Among the benefits and penalties
of medical action, consider quality
of life. (p. 297)









29


Watts (1985) described clinical reasoning as it related to physical therapy. She combined all of the steps used by Barrows and Tamblyn (1980) and Elstein et al. (1979) into two steps. The first, a global step, was oriented toward identification of the patient's primary problem with movement. It should be noted that in physical therapy literature the words "patient problem" were sometimes substituted for the word hypotheses. The primary movement problem in physical therapy would be the same as primary diagnosis in medicine (Olsen, 1983; Echternach & Rothstein, 1986; Watts, 1985). In addition to the problem identification step, Watts designated a second step that she termed the "decision tree" (p. 15). This second part of Watts' model was mentioned here for the purpose of completeness, however, the focus of the current study was Watts' global step one. A description of the Watts model follows:

Step I Narrow and delineate the problem focus
by
1. specifying type of patients to which
this problem focus can be applied;
2. listing characteristics of the
patient's disorder that are of
greatest interest; and
3. noting the specific action decision
to be addressed.
Step II Structure the decision process over time
and diagram it. (p. 15)

Others in physical therapy have described clinical reasoning analyses and designated them as models of









30

clinical decision making (May & Newman, 1980; Olsen, 1983; Rothstein & Echternach, 1986). May and Newman (1980) created a behavioral model for facilitating clinical problem-solving strategies. The model was adapted to and used in a physical therapy program. May and Newman found it necessary to define the students' progress by documenting the students' completion of problem-solving skills in the cognitive, affective, and psychomotor domains. May and Newman, like Barrows and Bennett (1972), Elstein et al. (1972), and Watts (1985), saw the need to avoid an excess of facts and data that may be related to a problem but would not be essential in solving that problem. May (1977) reported that the traditional approach to training physical therapists led her to observe that the development of problem-solving skills occurred inconsistently when instructors followed the stepwise or textbook approach to data collection. She explained in a later article (May & Newman, 1980) that not telling the students all the facts may be difficult for the traditional instructor to accept, but that effective clinical problem solving skills were "best learned in an environment in which the student is free to test thinking skills, explore alternatives, and discover solutions" (p. 1140). May's Behavioral Model is depicted in Table 1.

Olsen (1983) and Echternach and Rothstein (1986)

refined and delimited two problem-solving models for use









31


in patient diagnosis and treatment planning. Both schematic representations closely follow the clinical diagnostic steps set forth in the clinical reasoning process devised by Elstein et al. (1972) and Barrows and Bennett (1972) except that Olsen did not use branching. (See Figures 1 and 2.) Watts (1985) and Echternach and Rothstein (1986) stated that the further sophistication of the overall problem-solving model or paradigm in clinical practice must include a part two, or "branching program." Both physical therapy models, therefore, included problem identification and treatment management phases, whereas Barrows and Tamblyn's medical model differed in that it emphasized primary problem identification or diagnosis (see Figures 1 and 2).

Terminology employed by researchers in medicine and in physical therapy differed. Watts (1985, p. 15) used the words "decision analysis" and "clinical decision making," while Barrows and Tamblyn (1980) retained the wording more popularly used in medicine in the 1970s and early 1980s, i.e., clinical reasoning. Gordon (1973) and Elstein et al. (1972, 1979) coined the phrase hypothetico-deductive reasoning. Suchman (1980), an educator, termed a teaching model with similar characteristics "inquiry training" (Joyce & Weil, 1980, p. 61); while Delitto, Shulman, and Rose (1989), in the










Table 1

Behaviors of Problem Bolver


Process Cognitive Domain Affective Domain Psychomotor Domain


PROBLEM RECOGNITION


PROBLEM! DEFINITION


PROBLEM ANALYST IS







DATA HANAgEHENT Data-collection methods


SOLUTION DEVELOPMENT Data Analysis





ALTERNATIVE SOLUTION
DETERM[NATION


Realise that there is a
problem


Translate and interpret all
input received
Establils problem boundary

Break down the cognitive.
affective, and psychomotor components of the problem Determine the relationships
between elements
Organise ihe principles
involved
Determine desired outcomes

Identify data needed Relate data to data-collection
methods
Select data-collection methods

Organism data collected Classify data collected Relate data collected to
problem components and
desired outcomes



Bynthesise data into a series
of alternatives related to
desired outcome


Be aware of own feelings of unease (constructive discontent)

Be aware of response sets Be willing to defer judgment


Be willing to defer judgment Be receptive to new
relationships
Be aware of own response sets Feel satisfaction




Be receptive to new approaches Be aware of response mets ae willing to use creative
abilities

Be aware of own response set Be willing to defer judgment Be willing to use creative
abilities
Be receptive to new
relationships Feel satisfaction

leek out new Ideas se
beneficial to self
Be willing to use creative
abilities


Perceive sensory stimuli
(auditory, visual, taste,
tactile, smell, kinesthesia)

Perceive sensory stimuli and
environmental impact


Perform habitual tasks related
to thinking (write, pace,
chew, read)






Perform habitual toks related
to thinking (listen, read,
write)


Perform habitual tasks related
to thinking ('ead, pace,
write)





Perform habitual'tesks related
to thinking (listen, pace,
chew)


U)











Table 1--Continued


Process Cognitive Domain Affective Domain Psychomotor Domain


SOLUTION SELECTION



SOLUTION IMPLEMENTATION







OUTCOME EVALUATION


Evaluate all solutions and place in priority order Hake judgment in terms of desired outcome

Apply solution to problem








Relate actual outcomes to
desired outcome


Be willing to make a decision Be aware of own ago Desire to be creative Peel satisfaction

Respond positively to
risk-takinB
Exhibit self-confidence Respond to internal/external
cues
Be willing to use creative
abilities
Feel satisfaction

Be aware of own ego Be aware of own response set Be willing to respond
objectively


Perform habitual teaks related thinking (read, observe. pace)


Perform appropriate complex overt responses







Perform habitual tasks related
to thinking (observe.
listen. road)


Adapted from: May, B. J., & Newman, J. (1980). Developing competence i problem solving: A behavioral model. Physical TheraDy, _U(9), p. 1142.


C.-)











Cause

" What tissue is.involveda " What in the patholop' that .sauges Nos probim live ident fled? " What a the nature of the
haulo ogy? " What a the satent of the


to em

* What is the
patient's comlaintl
" at objective
finding do I
note on
evaluation
" What problem
could result
from this person's condition.


---or ----------


Hathod

e What method
might I use to influence this
problem?







- .....--- .- ...


/


Solutis" Now will the method Linflanee the
ausag " What maeanisme are involved?


6lo


Goal Not Net

s Reassess







Goal

U weaetly what
do I hops to
achieve?






Goal Net-s Discontinue
or progress
treatment


FIgurxi. The problem-solving mode. The heavy, solid lines indicate progression through the model. The broken lines indicate when the user should check back to previous components (Olsen, 1982, p. 527).


eModalitv

a of all the ways of delivering the methodd" which one is Most. sppro!Eiate? Why? a 1ow will I
deliver the.
mathed? Now '
many time/
day, how many
days, duration* intensi ete.1 o lhat activities,
techniques
and elements
_will. I.. Vj _....


. neow will the method influene the pro b laI-.


It-


---------------


I








35


Referral to other - 4.
practitioner (if no hypotheses can be generated)


PART ONE

Collect initial data (ea. interview. history.
:nart review. subiective information)



2. Generate a problem statement Establish goals (measurable and functional with a temporal element)



3. Examination (collection of data)


'I


Generate working hypotheses about why goals are or cannot be met at the present time (establish testing criteria for each hypothesis)


/


Ask whether goals are viable
" if no. modify e if yes, proceed


5. Plan reevaluation methodology (schedule dates for reevaluations)



Consultation, if : : 6. Plan treatment strategy based on needed hypotheses (overall treatment approach)



7. Plan tactics to implement strategy (specifics of treatment plan)



8. Implement tactics (treatment)


Figure 2.
Part One: planning


Hypothesis-oriented algorithm for clinicians.
Guidelines for evaluation and treatment (Echternach & Rothstein, 1986, p. 1389).









36


PART TWO


Yes/


Discharge pa


9. Reassessment Have goals been met?



e No i ent


Are tactics being implemented correctly?
(is treatment being implemented as planned?)


Yes Improve ipe


nentation-Go to 8


Are tactics appropriate?

Y es

Is strategy correct? tactics-Go to 7



Are hypotheses viable? Change strategy-Go to 6
(Qe. if testing criteria have been met and goals are not met, new hypotheses are needed)
No


generate new hypotheses-Go to 4










Figure 2--continued. Part Two: Branching program. All
numbers less than 9 refer to the steps in part one of figure (Echternach & Rothstein, 1986, p. 1390).









37

physical therapy literature, termed the process or set of strategies "the method of experts" (p. 554). The processes described were consistent across authors, despite the differences in the names given to the process. In this study the term clinical reasoning process (CRP) was chosen. The set of strategies used in this study was the steps in the CRP as described by Barrows and Tamblyn 1980).

Clinical Reasoning and the Physical Therapy Student

May (1977) reported that "Students enter physical

therapy with a developed approach to solving problems" (p. 807). However, their problem-solving techniques as applied to patient-related problems may or may not be successful because May (1977) noted that there are as many ways to solve problems as there are categories of problems. May saw that patient problems may require a problem-solving methodology that was not within a student's initial repertoire, either because the student lacked understanding of the basic knowledge structure of the discipline, or because the student for some reason did not begin processing like experts (Boshuizen & Claessen, 1982). May, like Elstein et al. (1972, 1979) in medicine, found that many physical therapy entry-level professionals did not have medical problem-solving skills after they had graduated despite the fact they possessed the basic content knowledge of the discipline. Some of these entry-









38


level therapists never seemed to become good diagnosticians, whereas others, whether taught or not, automatically began using clinical reasoning to solve patient problems.

Burnett and Pierson (1988) explained that encouraging physical therapy students to practice problem solving was not without difficulties. Learning situations that demanded multiplicity in thinking and that required students to use limited experience and information met with varying degrees of student responsiveness. Burnett and Pierson (1988) developed a group of problem-solving activities for the classroom that included written patient case scenarios that were presented to first-year physical therapy students. The ultimate goal of the activities was to have students complete a problem-oriented patientstatus written note. Evaluation of the activities and problem-solving course work was carried out based on students' evaluations. Students believed the course helped in developing problem-solving skills, but only 31% reported that the course was important. The majority of students saw the course as boring but this may have been due to the fact that they were first year students and could not see the relevance of the activities so early in their training.

Slaughter, Brown, Gardner, and Perritt (1989) studied 31 first-year physical therapy students. The researchers








39


used prepared written case studies. The Slaughter et al. students discussed these prepared cases with their clinical instructors by asking a set sequence of questions termed "the analytical questioning sequence" (p. 28, 444). Pretest and posttest evaluation of the learning experience was done by administering the Watson Glaser Critical Thinking Appraisal (CTA) (Slaughter et al., 1989). The authors found no significant results and attributed the lack of significance to inadequacies in the CTA. Beginning CTA scores for these first year students had a percentile rank of 97% to 99% so that with high initial scores it would have been very difficult to show improvement.

In summary, the Burnett and Pierson (1988) and

Slaughter et al. (1989) studies demonstrated that the development of problem-solving abilities in physical therapy students is a relevant topic in physical therapy education. Prior to this time, traditional physical therapy textbooks, case study techniques, and faculty instructional approaches demonstrated a step-by-step method of mastery of content by encouraging data-gathering habits. This data-gathering method has been relevant early in physical therapy instructional programs because beginning students have needed to acquire a basic knowledge structure. Without basic knowledge the students lacked the basis for generating hypotheses or problem









40


statements. For this reason Burnett and Pierson and Slaughter et al. anticipated that the first-year students would have an inability to recognize the importance of learning problem-solving techniques. It appears from this study and others that, as the students mature, exposure to an approach used by experts may help physical therapy students in the transition from compulsive data gathering to focusing on relevant cues and to analyzing and synthesizing data with greater accuracy and efficiency (Barrows, 1983; Barrows & Tamblyn, 1980; Burnett & Pierson, 1988; Delitto, Shulman, & Rose, 1989; Glaser, 1984, 1985; Groen & Patel, 1985; Payton, 1985). One way that has been shown to be an effective way to provide exposure to the strategies of expert clinicians is the presentation of a patient case by video.

Presentation by Using Videotape Patient Cases

In order to present the instructional structure that revolved around a patient case evaluation a video format was used to package the program for easy, reliable use with students. Vander Sijde et al. (1987) described the development of audiovisuals for problem solving in physical therapy education. The authors developed the audiovisuals to assist students with patient diagnosis and management. Although the videos did not include the steps in the clinical reasoning process, a simple, easily









41


reproduced format for patient evaluation was included. The authors explained their work as follows:

In an attempt to close the gap between acquiring
theoretical knowledge and learning through
experience to solve patients' problems which we
consider the major objective of physical therapy
education, we started to record patient case histories on videotape with the intention of
giving students the opportunity of practicing
problem-solving skills. . . . The following
steps in the development of those case histories
are described as
1. choosing a model for videotaped case
histories;
2. implementing the model;
3. structuring the videotape;
4. using the videotaped case histories.
(p. 555)

The objective of the Vander Sijde project was to develop a series of videotapes for training physical therapy students. These video tapes were based on proper theoretical constructs relating to what the students needed to know about their patients and what procedures students needed to use. The authors did not determine whether students could actually make decisions and solve problems better after exposure to the videos, nor did they ascertain which processes were used by students to make their decisions. These authors did present the first formal attempts at video formatting for case evaluations and they also added a problem-solving questioning protocol to the video (see Figure 3). It remained to be determined whether students improved in their skills after watching








42


MODEL OF VIDEO INSTRUCTION


Medical infar=:..=-- t---e Parien=


QUESTION: What do you want to ask in the medical history-taking process?


History-taking process


QUESTION: Were the questions asked useful?

Did you miss any questions?

What do you do next?


Inspection of the patient


QUESTION: What did you observe?

What are your next steps in examining the patient?



Examination of the patient QUESTION: Did differences exist between your examination proposal and the one you saw? What is your conclusion?



Evaluation of the case by a physical therapist






Figure 3. Video structure and model (Vander Sijde et al., 1987, p. 556).


I


I








43


videos and if so, if these students had identifying personality characteristics.

Studies Relating Problem Solving to Myers-Briggs Personality Dimensions

There were many studies in the literature relating one particular personality indicator entitled the Myers Briggs Type Indicator to problem-solving abilities. It was decided for the purpose of clarity and expediency that the studies should be put into a table format (see Appendix A, Table A-3).

The Myers Briggs Types Indicator (MBTI) was chosen for this study due to the large data bank of studies relating it to problem solving. (A description of the MBTI is also included in Appendix A.) The MBTI was developed in 1962 to identify personality type differences. The indicator was based upon Carl Jung's theory of psychological type. The essence of Jung's theory was that seemingly random variations in behavior were actually quite orderly and that differences between people in their behavior were basically differences in the way that people used perception and judgment. Perceptions are the ways people become aware of environmental happenings, ideas, etc. while judgments are the ways that people come to conclusions about what they perceived (Myers & McCaulley, 1962, 1985, 1987). The MBTI was based on identifying these ideas of Jung about perception and








44


judgment. The test author, Isabel Briggs Myers, characterized 16 psychological types based upon a person's perception and judgment preferences in four polar dimensions: extraversion (E) versus introversion (I), sensing (S) versus intuition (N) thinking (T) versus feeling (F) and judging (J) versus perceiving (P). The dimensions of sensing versus intuition and judging versus perceiving have been found by various researchers to be the most relevant to problem-solving ability (Myers & McCaulley, 1962, 1985, 1987). Consequently, these two dimensions were considered for inclusion in the analysis for this study (Myers & Myers, 1980). In Table A-2 personality problem-solving dimensions as they were related to instructional models, media, and methods in past studies were presented. In addition, Table A-3 contains further information about the characteristics frequently associated with each type, definitions of the four dimensions, and an exploration of how student motivation effects personality type. Burnett and Pierson (1988) in the physical therapy literature alluded to the role personality characteristics play in developing a student's abilities to problem solve in clinical practice. Following the contents of Table A-2 a full description of the studies was included herein for the reader.

Eggins (1979), in a classical aptitude-treatmentinteraction (ATI) study reported in Myers and McCaulley









45


(1987), combined the idea of a structured learning model with personality characteristic information that facilitated problem solving at three different levels. She reported on the effects of three models of instruction on 350 sixth-grade students who were asked to do an animal classification task. The teaching models that Eggins used were three concept attainment models: (a) the inductive reasoning model based on the ideas of Bruner, Goodrow, and Austin (1967) (moderate structure, moderate conceptual level); (b) a didactive approach based on Ausubel's (1963) advanced organizer (high structure, low conceptual level); and (c) the concrete examples approach of Gagne (1965) (high structure, low conceptual level). The Bruner et. al (1967) model imposed the least structure on learners by providing an opportunity for them to see common characteristics and relationships for themselves. The Bruner approach was helpful to intuitive types.

Ausubel's (1963) model presented facts in a

structured way like Gagne's approach, but the advanced organizer was designed to help students relate facts to concepts. The Ausubel model bridged the gap for both sensing and intuitive types (Myers & McCaulley, 1987). Gagne's (1965) model presented a linear structure that was useful for sensing types. Eggins randomized her subjects to one of the three methods. The subjects were tested immediately and again after 10 days. Key findings were








46


that (a) students classified as intuitive benefited most from Bruner's inductive, less-structured approach; (b) students classified as sensing types learned better with the highly structured Gagne method; (c) students classified as judging types with high intelligence did best with Ausubel's didactic approach or Bruner's inductive approach; (d) students classified as perceptive types with high intelligence did best with Gagne's highly structured design; sensing judging (SJ) and intuitive judging (NJ) types succeeded with all three models; and sensing perceptive (SP) and intuitive perceptive (NP) types were significantly affected by the level of structure in their instruction. The SP types did best with a highly structured model, i.e., the Gagne method. Eggins (1979) also mentioned a difference in learning based only upon the judging perceptive (JP) dimension. High intelligence Js (those with moderate to high conceptual levels) preferred the instructional model of Bruner because it facilitated inductive (creative) reasoning. The high intelligence Ps, however, preferred the highly structured, step-by-step Gagne model.

McCaulley's (1981) general summary of research on the MBTI identified a number of studies that are indirectly related to the learning aspects of sensing/intuitive differences. Sensing types did well in tasks related to practical skills and were motivated to learn if they saw









47


the practical usefulness of the task. Intuitive types prevailed in mental tasks that required manipulation of symbols and verbal reasoning. Sensing students preferred televised instruction with orderly, sequenced steps aimed toward the accomplishment of preset goals. They did not like dealing with analogies, recognizing figurative and symbolic language, or establishing relationships and alternatives. They failed to get involved in classroom discussions and resisted instructional models that attempted to facilitate such interaction (Carskadon, 1978; Nisbet, Ruble, & Schurr, 1981). Intuitive types liked instructional models that required self-instruction, reading, drawing analogies, group discussion, manipulation of symbols and verbal reasoning. They wanted to deal with alternatives and the relationships between them (Carskadon, 1978; Kilmann & Taylor, 1974; Nisbet et al., 1981).

Griesen (1972) studied beginning medical students who were given a choice between a traditional program or a new independent study program; judging types chose the former, whereas perceiving types wanted to try the new independent program of study. The two instructional programs were very different: the traditional approach had high structure, whereas the independent approach had low structure.









48


John and Miller (1957) investigated the problemsolving behaviors of 59 students from various class levels of the University of Chicago as they completed electronically operated logic exercises on the Problem Solving and Information (PSI) apparatus. The PSI determined the proper logical sequence of pushing buttons on the apparatus to illuminate a central panel light. When John and Miller (1957) graphed the number of tests versus time, they found a regularity of processes involved in the solution and stated, "It appears that individuals display different but highly characteristic rates of making decisions based on the evaluation of a body of data" (p. 296). They attempted to correlate a number of psychological measures with performance and concluded that "correlation of certain of the variables with other available measures show that personality factors such as anxiety, perceptual factors such as speed and flexibility of closure (Thurstone's Primary Mental Abilities), and cognitive factors, were all involved in problem-solving performance" (p. 229).

Ross et al. (1986) intercorrelated the four MBTI scales with 15 ability tests, 7 experimental interest tests, and 10 scales from the Personality Research Inventory. Five hundred and seventy-one high-school students were tested. Through a factor analysis it was determined that, for males, intuition was associated with









49

structure in general problem solving, whereas slowness or carefulness in problem solving was associated with sensing. McCaulley and Natter (1974), using a sample of 521 secondary school students, agreed that the choice of learning tools and strategies of sensing versus intuitive types differed drastically. Hoy and Vaught (1981), in a study of the relationships between problem-solving personality characteristics and problem-solving skills among 39 entrepreneurs, found that of the four MBTI scales, only sensing/intuition correlated with problemsolving skills. The authors reported that high scores were correlated with intuitive types (N). Lewis (1976) studied 85 psychology students. Intuitive types tended to be associated with efficiency on an intuitive problemsolving scale.

Hunter and Levy (1982) studied the relationships

between problem-solving behaviors and Jungian personality types. They presented two problem-solving exercises to 80 subjects from Howard University. They grouped students by SJ, SP, NP, and NJ, thus using only two of the four MBTI dimensions to form four possible dimension combinations. On one exercise, the Embedded Figures Test, intuitive perceptive types (NP) attempted more problems and solved them correctly more often then sensing judging (SJ) types. Sensing judging (SJ) types had a greater tendency to adhere to the concrete aspects of stimuli. Intuitive









50


judging (NJ) types saw beyond the literal aspects of stimuli and tended to be orderly, systematic, and persistent in tedious tasks. The NJs were able to list significantly more possible solutions to the box problem.

Westcott (1968) gave subjects verbal and numerical series problems and analogy problems. Information as to problem solution was given in small amounts in a fixed sequence. Westcott hypothesized that intuitive (N) people would need less information to solve the same problems. He identified four categories based on the amount of information and time needed for solution: intuitive thinkers (little information, high success); wild guessers (low information, low success); careful guessers (high information, high success); and careful failures (high information, low success). Westcott also found that "subjects who relate to stimuli by perceptual responses rather than by judgmental responses, regardless of whether one perceives details or implications, are more successful on intuitive problem solving [p < .05]" (p. 22).

Weber (1975) again investigated problem-solving skills, this time based on results from the Embedded Figures Test and the MBTI. His results supported two of his hypotheses. Intuitive types performed better than sensing types (p < 0.01 for timed tests, p < 0.05 for untimed tests). Male perceiving types produced more correct responses than did judging males, perceiving








51


females, or judging females. He also found that sensing types produced more incorrect responses than intuitive (p < 0.01). Lastly, intuitive perceiving (NP) types produced more correct responses overall on untimed tests (p <

0.01).

Summary

This review of literature provided support for the

use of the medical problem solving set of strategies known as the CRP that was used in this study. These strategies, although varying in descriptions, are similar in concept across numerous researchers.

In the review of the literature it has been noted also that there are general patterns of problem-solving performance exhibited among persons who belong to the two MBTI dimensions of sensing versus intuition (S/N) and perceiving versus judging (J/P). Persons with sensing type personalities preferred to solve problems in standard, practical ways, contrary to intuitive type persons, who preferred to apply imagination in finding new problem-solving methods. Judging type people strive for closure, acting quicker and with less information than perceptive type people, who generally spent more time and acquired more information before moving toward a solution. Researchers have noted that the consistencies in type of behavior exhibited by a certain person were combined with certain regularities in the process used to solve









52


problems. Indications were that some variation in problem-solving behavior could be attributed to personality dimensions (see Appendix A). Some studies found the sensing versus intuitive dimension (S/N) to be the most significant variable, whereas others chose from the four possible combinations: SP, NP, SP, NJ. (See Table A-3 in Appendix A.) All studies found significant relationships between these dimensions and the problemsolving model, the environment, and the task which the learner was given. A summary of the models of problem solving and MBTI related problem solving studies mentioned in this chapter are included in Appendix A-3. In the next chapter the methodology of the study will be discussed.















CHAPTER III
METHODOLOGY





In this chapter the methodology of the study is

presented. The purpose of the study was to determine the effects of using the clinical reasoning process (CRP) as a teaching tool for entry-level physical therapy professionals. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the clinical reasoning process.

The investigation was conducted by means of an

experimental study. Seventy-five entry-level physical therapy students from Florida institutions volunteered to participate. These students were randomly assigned to either the control or experimental groups. All students participated in the learning experience that involved the students' ability to use the clinical reasoning process (CRP) in identifying the problems of a patient in a case portrayed in a video. The methodology of the study has


53









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been included here in the order followed by the researcher in setting up the experimental study: statement of the hypotheses, instrumentation, pilot study, experimental study, and data collection and analysis.

Statement of the Hypotheses

The three hypotheses tested (stated in null form) were as follows:

Hypothesis 1: There will be no significant

difference at the .05 level between the mean scores of the experimental group and the control group on diagnostic efficiency (critical cues list) based on: efficiency score 1--patient history, efficiency score 2--physical examination, or efficiency score 3--volitional movement.

Hypothesis 2: There will be no affect at the .05 level of personality dimensions or structure in instruction on diagnostic efficiency scores in three areas: patient history, physical examination, or volitional movement.

Hypothesis 3: There will be no significant

difference at the .05 level between the mean scores of the experimental and the control group between key phrase agreement of students and experts on a primary problem statement. The primary problem statement was used to represent the diagnosis of the patient's primary movement dysfunction.









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Instrumentation

The Videos

The instructional video model was designed to encompass three basic instructional components: (a) pediatric physical examination items (explicit cues from Harris (1987), (b) video patient evaluation design (Vander Sijde et al., 1987), and (c) rules and strategies of the CRP (Barrows & Tamblyn, 1980). Two separate videos were produced. Both depicted the physical examination tests (Harris, 1987) and the patient evaluation design (Vender Sijde et al., 1987). One video was edited to include the structured instructional rules and contextualized implicit cues considered to represent the clinical reasoning process used by experts in medicine and physical therapy (Barrows, 1983, 1986; Barrows & Bennett, 1972; Barrows & Tamblyn, 1980) (see Appendix C).

A pediatric patient case vignette was chosen as the

sample content for the video instruction because pediatric diagnosis is a complex diagnostic problem in physical therapy. The 2 year old patient had cerebral palsy; this neurological deficit represents a group of disabilities that frequently remain undiagnosed until well into the first or second year of life (Campbell et al., 1989; Illingworth, 1965). The developmental milestones such as crawling and walking are the cues that most physicians use to evaluate normal development in infants; however, these








56


cues are sometimes not present until the last quarter of the infant's first year. Physical therapists have learned to look at other cues and to look for these cues earlier than the second year of life. The importance of early physical therapy to minimize later motor handicaps has been emphasized by the proponents of early intervention (Bobath, 1967; Kong, 1966; Quintin, 1986). Data have been conflicting on the effectiveness of early therapy, but the variance may be partially due to failure on the part of physical therapists to make reliable movement diagnoses, to use precise and quantifiable measures and to implement effective treatment management strategies within the child's first two years. The test items termed "cues selected for the physical examination" part of the video presentation were taken from the work of Harris (1987), who conducted comprehensive longitudinal research concerning the early abnormal movement signs of cerebral palsy. (See Appendix B.) There are elements from four relevant movement variables shown in the video: muscle tone, primitive reflexes, automatic reactions, and volitional movement (Chandler, Andrews, & Swanson, 1980). In addition, the video began with a patient/parent interview that included the patient history. Physicians indicated that the patient/parent interview was considered critical to early diagnosis in pediatric physical therapy and therefore the video included three related sections:








57


patient history, physical examination, and volitional movement (Georgieff, Bernbaum, Hoffman-Williamson, & Daft, 1986; Gorga, Stern, & Ross, 1985; Ross, Lipper, & Auld, 1986; Stanley & English, 1986).

To establish the validity of the critical cues lists and of the primary problem statement, 10 experts in pediatric physical therapy were asked to participate in identifying key behaviors and in writing problem statements. These results were necessary to obtain in order to compare students' abilities to identify cues and to write primary problem statements with the abilities of the experts in those areas.

Development of the Scoring Key

Experts were chosen on the basis of the definition

offered by Delitto, Shulman, & Rose (1989). An expert is one who is well informed, highly skilled, and recognized by colleagues in physical therapy as possessing efficient, accurate clinical judgment in a particular specialty area. The expert's judgment should be consistent with the judgment of other experts on similar patient cases.

Ten expert licensed physical therapists agreed to assist in the development of the scoring keys for the critical cues list and for the primary problem statement. All were certified in the neurodevelopmental treatment approach to pediatrics. These same 10 therapists were recommended by knowledgeable University of Florida faculty








58


members in physical therapy. They were also all working full-time as pediatrics practitioners, and two were assistant instructors in the neurodevelopmental treatment approach to enhance the practicing therapists' ability to diagnose and treat pediatric patients. These experts met on two separate occasions.

First occasion. On the first occasion experts were shown the video presentation of the pediatric patient evaluation. The same patient and same evaluation procedures were portrayed in the two videos shown to subjects throughout the study. There were two steps taken on this first occasion.

1. The critical cues list.

The panel of experts were given a blank form that was headed critical cues list. (See Appendix D.) They were told to write in every cue that they observed while watching the video. After the video was shown, they were asked to review their list of cues and score the cues by placing a (+) by cues that were somewhat important, a (++) by those that were important, and a (+++) by cues that were critically important for one to observe in diagnosing the patient's primary movement dysfunction. There was no opportunity for collaboration among the experts. Nine out of ten experts listed the same eight critical cues. This list of eight expert-generated critical cues was used









59


ultimately in the critical cues rating lists for experimental study subjects.

2. The primary problem statement.

On this same first occasion of the experts

participation, the experts were presented with a problem statement form (see Appendix D). They were asked to each write one statement that indicated the patient's primary problem with movement. Nine out of ten experts wrote contextually similar primary problem statements. Their key words and phrases were used as the basis of the scoring key for the problem statement form. A list of all key words/phrases was developed. The primary problem statement forms of the experts provided the basis for comparison with primary problem statements developed by students later in the course of the study when they watched the video.

The researcher questioned the experts about that point in time during the video viewing when they had formulated their original idea about the patient's primary problem. The experts reported that they had formulated their idea almost immediately upon viewing the patient during the patient history segment of the video. This concurred with Barrows and Tamblyn (1980) who reported that experts in medicine stated that they had an immediate idea about the patient's primary problems. The experts formulated their diagnosis within the first seconds of the








60


doctor-patient encounter. The experts were apparently relying on implicit cues that their knowledge and experience taught them to identify as critical in identifying patient problems. Because the implicit cues list was generated by experts on the critical cues rating list in the patient history section, and because these explicit cues helped the experts write their final problem statements, this list was presented later to the experimental group subjects.

Second occasion. On the second occasion, when the experts met they were given another cues form. On this occasion the cues that the patient case video had been formatted to include were contained on a rating list. The cues were drawn from the work of Harris (1987) on physical examination for early identification of cerebral palsy and from the two sections (patient history and volitional movement) recommended by physicians in the literature review. The cues from Harris' work were labeled on the video to avoid confusion. The experts were asked to view the video and to rate the cues using a system developed by Fleisher (1972): (+) if the cue was somewhat important,

(++) if the cue was important, and (+++) if the cue was critically important in determining this child's primary problem. The experts placed a +++ score or "critical" score by an average of nine cues on the rating list. Again, this result was in agreement with the finding of








61


Barrows and Tamblyn (1980) who reported that experts in medicine usually rated between 9 and 13 cues as being critically important. Of the 10 experts, 90% agreed on eight of these nine cues.

After the second occasion, each of the three

subsections of the critical cues rating lists was compared across all 10 experts, and cue scores by each of three subsections were averaged by section to form a scoring key. This list was the scoring key against which subjects' ratings were compared. The experts after the two meetings had generated the scoring keys for the two dependent measures in this study. The dependent measures consisted of (a) Critical Cues Rating List with three dimensions, and consequently, three separate scores, and

(b) a problem statement list (see Appendix C).

Before student subjects were asked to carry out tasks similar to those asked of experts, the students were given the Myers-Briggs Type Inventory. This measure was used to determine whether personality type influenced students' ability to advantageously use the clinical reasoning process or to recognize certain types of cues. The Myers BriQs Type Indicator

The MBTI, a 126 item, dual-response inventory, measures personal preferences along four dimensions. First published in 1962 by the Educational Testing Service, the MBTI consists of the scales which can be used








62


to determine how an individual uses one, two, or more of the four dimensions in relating to his or her environment. The Indicator was designed "explicitly to make it possible to test C. J. Jung's theory of psychological types" (Myers & McCaulley, 1987, p. 11). There is a large data bank indicating that MBTI measures are consistent with Jung's theory. The theory was explained in the statement that "random variation in behavior is actually quite orderly and consistent. It is based upon differences in four dimensions" (Myers & McCaulley, 1987, p. 1). Since its publication, the Indicator has been used in various capacities to assist in explaining personality and behavioral characteristics. over 250,000 completed protocols to the MBTI have been studied and evaluated by Myers and McCaulley (1985, 1987).

The MBTI has been shown to have reliability and validity. Reliability evidence includes internal consistency, test-retest, and continuous score correlations for each preference type. The validation evidence includes correlation with other instruments measuring similar psychological constructs, some of which are much longer than the MBTI.

For the research project in clinical reasoning two mental processes, sensing and intuition, and two styles, judging and perceiving, were supported by the literature as having bearing on individuals' abilities to problem








63


solve (Burnett & Pierson, 1988; Hunter & Levy, 1982; Lawrence, 1984a, 1984b; Lewis, 1976; McCaulley, 1981; Myers & McCaulley, 1985, 1987; Myers & Myers, 1980). These dimensions were chosen for data collection.

The data consisted of responses from each subject for the pilot study, and for the experimental study. Each subject completed the entire Indicator. The MBTI protocol was scored by the Center for Application of Psychological Type. Each subject received a complimentary personality profile compiled by the Center. From each subject's total score the S/N and J/P dimension scores were used in data recording. The first subjects to complete this process were those who participated in the pilot study.

The Pilot Study

In the time period immediately after the expert panel met on the first occasion, the researcher was informed that the 1988 graduating class of physical therapy students at the University of Florida had agreed to participate in a pilot study. The researcher obtained permission to proceed from the Human Subjects Review Board, University of Florida. Subjects for the Pilot Study

The pilot study group consisted of 27 graduating

physical therapy students. In order to be considered for the study, students had to be able to complete the video learning experience after they had completed all didactic









64

and clinical components of their training and before they graduated. The time, consequently, for administering the study was limited to less than one week for all subjects.

To make the administration of the MBTI more

complicated for the researcher in the pilot study, the availability of the subjects was realized less than three months before they graduated. Since students were away from the University on clinical rotations. Therefore, the MBTI was mailed to participants. All subjects completed and returned the MBTI prior to returning to their university for graduation and viewing of the video. Through the administration of this pilot study the researcher learned how to sequence these tasks of MBTI administration and video viewing cost effectively. Method of the Pilot Study

Subjects were randomly assigned to the experimental or control group using a coin toss per name on a list. The experimental group watched the video structured to include the rules of CRP. The control group saw the unstructured pediatric case evaluation. The subjects were given critical cues forms and asked to write in the cues they observed in the video. After completing the writing assignment, they were given time to review the video and rate each cue as: somewhat important (+), important (++), or critically important (+++). The subjects consistently listed the cues that were labeled on the video screen.









65


They rarely listed the implicit or expert-generated cues, possibly because these were not labeled on either video, but also because they apparently were at a professional level where cues of this nature may have been truly implicit. Such implicit cues may be noticed only by experts.

Analyzing the critical cues list from the pilot study group proved to be difficult due to the number of inconsistencies on student forms. It appeared that a scoring key would not relate to the forms. A rating sheet was generated from the list of explicit cues labeled in the video. When the panel of experts met on the second occasion, they established the scoring key by rating each cue (see Appendix D).

The subjects of the pilot study also completed a

problem statement form. When key word/phrase agreement on the problem statement form was analyzed visually, comparison could be made easily with the forms filled out by experts. The problem statement form remained unchanged and was later used with subjects in the experimental study. (See Appendix D.)

Results of the Pilot Study

Subjects who viewed the structured video performed better on problem statement agreement with greater than 75% (N = 10 of 13) of the pilot subjects achieving agreement with the experts. Less than 10% (N = 2 of 14)








66


of those viewing the unstructured video achieved this level of agreement.

In summary, from analysis of the findings, it was determined that score form changes needed to be made on the critical cues list to increase clarity and ease of administration. It was also determined from the same analysis of findings that the problem statement format was functional for the purposes of the study and did not require changes. In addition, it was also determined that the two independent measures of the study, the instructional videos and the MBTI were acceptable without further change.

The Study

Implications from the pilot study were that the researcher could continue with the study after making changes in the critical cues history. Therefore, educational program chairman were contacted to make the final arrangements with graduating students in physical therapy in Florida. The student subjects were asked to volunteer to participate in the study and to do so within two to three days of their anticipated date of graduation. Subjects

The subjects for the study were volunteers,

graduating students from four university physical therapy education programs in Florida. The four programs in physical therapy were located at Florida A&M University









67


(1), Tallahasse; Florida International University (2), Miami; University of Florida (3), Gainesville; and the University of Miami (4), Miami. Only the University of Miami graduates were entry-level master's degree students. The other graduates were entry-level bachelor's degree students. University of Miami students graduated in December, 1988, while students from the other three schools graduated in August, 1989. There were 107 graduating students in the Florida physical therapy programs; 90 volunteered; however, 15 were unable to participate at the last minute. A total of 75 volunteers participated.

Method

A table of random numbers was used to assigned

subjects to the experimental or to the control group. Each subject completed the MBTI. The personality dimension scores for all subjects were recorded on the data recording forms. To begin the learning experiment, all subjects in both experimental and control groups were pretested. Each of the four subject groups at the Florida educational programs in physical therapy had a designated date and time for viewing the video instructional models as a group. In the pretest subjects viewed the unstructured video and completed the critical cues rating list (without implicit cues) and problem statement form.








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The experimental group reviewed a short instructional sheet that explained the steps in the CRP. Subjects were told to note changes in their critical cues rating list and that the new list included implicit cues generated by experts. They were also told to note the implicit cues and to rate them along with rating the explicit cues. The implicit cues were not included in the data analysis. It was thought that asking subjects to rate these cues would focus student attention on the implicit cues. After they received the instructions, the experimental group subjects were shown the structured video.

The control group again viewed the unstructured

video. They completed the same answer sheets that were used in the pretests for both groups and waited in their classroom until experimental subjects completed the study. Along with randomization of subjects to control and experimental groups, the pretesting was carried out to eliminate the effects of differences in the prior knowledge and experience of subjects. Pretest scores were used as the covariable in analysis of efficiency measures. The problem statement measure with scores of 0 or +1 could have indicated a +1 when subjects were guessing about patient diagnosis so a pretest covariable was not used in the accuracy analysis. (See Appendix D.)









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Data and Recording Analysis

Recording

After completion of the pretest and posttest

viewings, each subject's efficiency scores were recorded next to his or her group and personality dimension variables. Scores for efficiency were divided into three sections. A section score was given for patient history, physical examination, and volitional movement ratings. Each subsection rating was recorded then compared with the experts' ratings to obtain a disagreement point score for the pretest and the posttest. The pretest scores were used as the covariable in a multiple analysis of covariance (MANCOVA 2 X 2 X 2).

The primary problem statements from the problem

statement forms of each subject were analyzed visually for key word/phrase agreement with experts and a score of "0" indicating no agreement or a score of +1 indicating agreement was put into the data recording forms. Problem statement forms were the same for experimental and control groups. In addition to scores from the rating list and problem statement form a student's MBTI S/N and J/P dimension scores were recorded along with each subject's group (experimental or control) and School (i.e., FAMU, UF, FIU, UM). (See Appendix E for data recording forms.)









70


Analysis

The video structure in CRP represented the

categorical independent variable group: E/C, and the personality dimensions represented two additional categorical independent variables: SN and JP. There were three dependent variables represented by the three efficiency scores. These were the variables used in a 2 X

2 X 2 multiple analysis of covariance to determine the significance of the structured learning experience had on students' efficiency in diagnosing a pediatric patient's movement dysfunction. (See Figure 4.)

The problem statement form dichotomous scores of 0 or +1 were analyzed on posttest scores only. A chi-square analysis for nonparametric data was conducted. Personality dimension scores could not be added to the chi-square analysis because a subject sample of 500 or more would have been needed to perform a three-way log linear analysis on nonparametric data. When the study was conceived subject sample considerations were made and it was determined that a subject sample of 500 entry-level physical therapy professionals (or greater than 25% of all physical therapy programs) would not be within the scope of this researcher's capabilities; however, if personality characteristics were normally distributed it was determined that log linear analysis would be valid.












(a)


Group


Personality SN


E / / / /
C /
/ / /


S

I I I I'

N

J P

Personality
JP


Experimental


Subjects to


/


\ Control


E
Group


C

0 1

Posttest Accuracy


Figure 4. Experimental design. (a) 2 X 2 X 2 MANCOVA with pretest scores as covariable and efficiency scores 1, 2, 3 as dependent variables; (b) Chi square table (personality dimensions not included due to insufficient N).


71


(b)









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Summary

The purpose of this study was to determine the

effects of using the CRP as a teaching tool for entrylevel physical therapy professionals. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use explicitly structured rules of the clinical reasoning process. To do so, two instructional videos were generated. one included an explicitly structured analysis of a patient evaluation according to the rules of the CRP, and the other showed the same evaluation without rules (unstructured). In the unstructured video there were no cues given to the viewer to help in organizing problem solving strategies along a specific path.

Seventy-five subjects from the four Florida programs in physical therapy volunteered to participate. They were given the MBTI, and two dimension scores were recorded for each subject on the data recording forms. Subjects were pooled across all four programs and then randomized to an experimental or a control group using a table of random numbers. All subjects participated in a pretest and a posttest experience and generated scores for: (a) a critical cues rating list and (b) a problem statements form. Scores from the list and the form were recorded in









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the data-recording forms along with the subjects' personality dimension scores (see Appendix E).

Data on efficiency scores were analyzed using a 2 X 2 X 2 multiple analysis of covariance while analysis of accuracy scores was done using the chi-square technique for nonparametric data. Results obtained through the analysis are reported in the next chapter.















CHAPTER IV
RESULTS



Objectives of the Study

The results reported in this chapter were obtained from a research study carried out from October 1988 through August 1989 and based on a pilot study done in August 1988. There were three objectives of the study. The first objective was to investigate whether experimental and control groups differed in their ability to rate efficiently cues that experts verified as being observable in the video and important to patient diagnosis. If they did differ, an investigation was conducted to determine whether the differences were based on watching a video edited to facilitate use of the clinical reasoning process. The second objective was to investigate whether there was a relationship between two personality dimensions and successful use of this problemsolving paradigm known as CRP. The third objective was to investigate the subjects' ability to accurately diagnose a pediatric patient movement dysfunction, and to determine if experimental subjects differed as a result of viewing a


74








75


video edited to facilitate use of the clinical reasoning process.

The study was conducted out in five steps: (a)

statement of the hypotheses, (b) instrumentation including development of the videos and the scoring keys, (c) administration and scoring of the MBTI, (d) conducting the learning experiment, and (e) data analysis. There were three research questions and consequently three hypotheses generated to satisfy the objectives of the study. Data analyses were performed to answer the research questions and to establish rejection or acceptance of each of the three hypotheses.

Research Questions

1. Can instruction in the method known as the

clinical reasoning process that experts use to diagnose patient movement dysfunction affect entry-level physical therapy students' ability to rate patient movement behaviors efficiently?

2. Will there be an affect of students' personality dimensions or characteristics and instruction in the use of the CRP on the way students efficiently rate patient cues?

3. Can instruction in the method of experts (CRP)

assist entry-level (preservice) physical therapy students to accurately diagnose a patient's primary problem with









76


movement, so that student's key words/phrases agree with those of experts?

Hypotheses

The three hypotheses tested (stated in null form) were as follows:

Hypothesis 1: There will be no significant

difference at the .05 level between the mean scores of the experimental group and the control group on diagnostic efficiency (Critical Cues Rating List) based on: efficiency score 1--patient history, efficiency score 2-physical examination, or efficiency score 3--volitional movement.

Hypothesis 2: There will be no affect at the .05 level of personality dimensions or structure in instruction on diagnostic efficiency scores in three areas: patient history, physical examination, or volitional movement.

Hypothesis 3: There will be no significant

difference at the .05 level between the mean scores of the experimental and the control group between key phrase agreement of students and experts on a primary problem statement. The primary problem statement was used to represent the diagnosis of the patient's primary movement dysfunction.








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Findings are discussed as they relate to the

objectives, research questions, and hypotheses of this study.

Obiectives

To fulfill objective one, an experimental and a control study group of volunteer graduating physical therapy professionals viewed the videos. Half of all subjects (control group) viewed the unstructured video and the other half (experimental group) viewed the structured video. The experimental study group responded to one of two critical cues lists and those responses were analyzed to establish an efficiency score for each subject. (See score forms in Appendices C and D.)

To fulfill objective two, each subject completed the Myers Briggs Type Indicator prior to the video learning experiment. Their preferences on the S/N dimension and the J/P dimension were recorded (see Appendix A). These scores were entered in to a multiple analysis of covariance with the efficiency scores in order to satisfy objective two. (See data recording forms in Appendix E.)

To fulfill objective three, subjects from the pilot study and the experimental study groups completed the problem statement form. The primary problem statement on these completed forms was compared for key word/phrase agreement with experts.









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Research Questions and Hypotheses

To answer research questions one and two a 2X2X2 MANCOVA was used and two personality dimension scores along with pretest scores (covariables) were entered into this analysis. Results of the analysis established that the answers to research questions 1 and 2 were "no" and that null hypotheses 1 and 2 continued to be accepted.

To answer research question 3 and hypothesis 3 a chisquare analysis was performed on posttest only scores from the problem statement scores. Results of this analysis related to question 3 and established that null hypothesis 3 should be rejected. Expanded results from the work with the panel of experts and formal experimental study groups are presented here. Both pilot and major study findings appear in relation to each question.

Development of the Scoring Key Occasion One: Experts

On occasion one, experts listed all the cues that

they observed in the video. An implicit list of cues was generated from the cues consistently listed. Eight cues were consistent across 90% of the 10 experts. These eight cues were considered implicit. (See Appendix D for the Critical Cues Rating List for the experimental group subjects.)









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Occasion Two: Experts

There were three sections to both video patient evaluations. Experts rated each subsection as to the importance of each individual cue that they saw in the video. Cues were rated as (1) somewhat important, (2) important, (3) critically important, or (4) don't know (if it is important). There were no (4) ratings among the experts but it was anticipated that some students may want to use this category if they could not see the relevance of a cue and its' importance in making a patient diagnosis. Therefore, the category was inserted in the Rating List prior to the experts' ratings.

Experts rated the critical cues list by subsection and a subsection score was obtained by averaging the experts' scores to obtain a mean score per subsection (see Table 2).


Table 2

Experts' Agreement Scores Based on Cues Generated from the Work of Harris (1987)



Efficiency Score Subsection Label Experts' Mean Score


1 Patient History 16.2
(8 cues)

2 Physical Examination 35.5
(16 cues)

3 Volitional Movement 5.7
(2 cues)









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Accuracy/Problem Statement Form

Occasion one: Experts. After viewing the video

experts were asked to fill in the problem statement form. The video screen contained instruction on filling in the form. Experts completed the problem statement form. Conceptual agreement about the primary movement dysfunction was obtained across 9 of the 10 experts (see Table 3). Key words/phrases were taken from the statements of the nine experts who were in agreement.

Occasion two: Experts. The problem statement form generated from occasion one were sufficient for development of the key for accuracy. There was no need to again elicit responses from the experts on occasion two. Pilot and Experimental Study Groups

Efficiency scores: Pilot study group. Results from the original pilot study group were explained in Chapter III because these results were used to further develop the critical cues rating list (efficiency score form) and should be considered as part of the methodology of the study (see Chapter III).

Efficiency scores: Experimental study group.

Scatter plots were generated from the efficiency scores on each of the three subsections: 1--patient history, 2-physical examination, and 3--volitional movement.









81

Table 3

Results: Expert Panel's Problem Statements



Expert's
Number Expert's Problem Statement


1* The child has a problem with movement
coordination showing fluctuations in tone,
but more on spastic side.

2 This child's main problem is with trunk
postural tone.

3 This child's main problem is with proximal
strength and control.

4 Underlying low tone.

5 This child's primary problem with movement
is her increased tone in extremities,
decreased tone in trunk.

6 Poor trunk control with associated pelvic
instability.

7 Linden has low trunk tone.

8 The patient exhibits primarily low-tone
characteristics.

9 Primary problem is lack of trunk and lower
extremity control.
-----------------------------------------------------10 Linden has a low tone base.


*Only one of the 10 experts did not agree that the primary movement problem is based upon one of these key phrases:
(1) trunk postural tone, (2) proximal strength and control, (3) underlying low tone, (4) decreased tone in trunk, (5) poor trunk control, (6) lack of trunk control,
(7) low trunk tone, (8) low tone characteristics, and (9) low tone base.








82


Efficiency score--patient history. There were four outliers, that is, subjects who had statistically significant differences between their pretest and posttest scores because their change or difference scores were more than two standard errors away from the group mean. Of these subjects, three were from the experimental group and one was from the control group. Two experimental group subjects and one control group subject increased their disagreement with experts, while one experimental subject made a drastic improvement and improved the agreement with experts (decreasing from a disagreement point score of 6.8 to a score of 1.0). Interestingly, all four outliers on efficiency score--patient history were students from the same program in physical therapy at School (1). See Figure 5.

Efficiency score--physical examination. There were three outliers and all were experimental group subjects. One subject significantly improved in agreement with experts, while two significantly increased their disagreement scores. This means that the improved student had pretest scores of more than two standard errors away from the mean and decreased the error to within one standard error of the mean. Two outliers (one who improved and one who regressed) were students from School

(2), while the other subject who regressed attended School

(1). See Figure 6.













0 @ 0 0 0


0 0 0 0 0

0


0 .0 0


0 .


0 0 000


0
0


0


0 0 0 6


0

G0 0 0 S00
o0 0


Pretest Efficiency Score


Figure 5. Scatter plot for efficiency score--patient history; 9 indicates experimental group scores, o indicates control group scores, and a circle around the dot indicates an outlier score.


7


61-


83


51-


0 00


4 -


0

1
0
C







o


0
OC


3


21-


1



0


0 b0


-
































0 0


0


0


0


0
0


* 00
* 0
0
0 0


0
0
00 0 0


0 0


0 0
0


0 0 '0


0


0
0 *


2.5 5.0 7.5


12.0 15.0


17.5 20.0 22.5


Pretest Efficiency Score









Figure 6. Scatter plot for efficiency score--physical examination; * indicates experimental group scores, o indicates control group scores, and a circle around the dot indicates an outlier score.


21.5 18.5


84


15.5 1-


0


0 0


0


*
0
0 12.5
C

CD
9.5

U)

a) 6.5 a.5

0
I
3.5


0.5


0 0


e
0


0


0
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0 0


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0
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0


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85


Efficiency score--volitional movement. There were two outliers who increased in their disagreement with experts between pretest and posttest situations. These students had functioned on the posttest with scores that were greater than two standard errors away from the mean. Both were control group subjects from School (1). See Figure 7.

With the outlier scores included, the variances

remained homogeneous. The slopes for all three efficiency scores were also homogeneous. See Table 4. Adjusted means and standard deviation scores were generated by group, by personality dimensions and by school. The posttest scores were adjusted relative to pretest scores on each efficiency measure. See Tables 5, 6, and 7.

Frequency distribution bar graphs provided a better

visual comparison of the data between pretest and posttest for the experimental and the control group subjects, because actual pretest versus posttest score averaging, that is adjusted means and standard deviations, masked some differences between groups.

Efficiency score--patient history. Experimental

group posttest scores were in greater disagreement with experts, while the control group improved in ability to observe cues, agreeing more with the experts. The normally distributed graph of pretest scores became















2.3


2.1


1.9


1.7

0
o 1.5C 1.3C)

1.1

4.
0




0~0
0.7
o 0 0

0.5


0.3


I I I I I
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8

Pretest Efficiency Score





Figure 7. Scatter plot for efficiency score--volitional
movement. There was more than one subject in the
experimental group indicated by the e, however, this
single dot represents the scores of this group. As can be
seen control group (o) subjects varied widely and two
subjects were outlier (circle around the dot).









87


Table 4

Homogeneity of Slopes


Source DF F PR > F


a. EFFICIENCY--Patient History Pretest Efficiency Score 1 * Group Pretest Efficiency Score 2 * Group Pretest Efficiency Score 3 * Group b. EFFICIENCY--Physical Examination Pretest Efficiency Score 1 * Group Pretest Efficiency Score 2 * Group Pretest Efficiency Score 3 * Group c. EFFICIENCY--Volitional Movement Pretest Efficiency Score 1 * Group Pretest Efficiency Score 2 * Group Pretest Efficiency Score 3 * Group


1,62 1,62 1,62


1,62 1,62 1,62




1,62 1,62 1,62


.89

.04

.31


0.00

1.21 .34




1.20 .75 .09


.3485

.8441 .5785


.9948 .2749 .5629




.2766 .3901 .7630









88


Table 5

Efficiency Score 1--Patient History Adiusted Means and Standard Deviation Disagreement Scores by Group, Personality Dimension, and School for Posttest


Posttest Mean


Control


Experimental


2.43 3.02


Standard Deviation


.299 .311


Personality Dimensions:

Intuitive

Sensing Judging Perceiving Schools:

(1)

(2) (3)

(4)


Note. Lower scores indicate experts.


higher agreement with


Groups:


2.91

2.54 3.02

2.45


.279 .335 .269 .357


3.13 2.95 2.15 2.69


.351

.455 .356 .603









89


Table 6

Efficiency Score 2--Physical Examination Adiusted Means and Standard Deviation Disagreement Scores by Group, Personality Dimension, and School for Posttest



Posttest Mean Standard Deviation Groups:

Control 5.53 .596

Experimental 5.98 .621


Personality Dimensions:

Intuitive 6.06 .559

Sensing 5.45 .669

Judging 6.19 .538

Perceiving 5.33 .714


Schools:

(1) 5.07 .703

(2) 6.13 .910

(3) 4.54 .712

(4) 7.30 1.210


Note. Lower scores indicate higher agreement with experts.




Full Text

PAGE 1

THE CLINICAL REASONING PROCESS AS AN EDUCATIONAL STRATEGY FOR ENTRY-LEVEL PHYSICAL THERAPY PROFESSIONALS By BLANCHE BURT DUPONT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1990

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This dissertation is dedicated to my parents Mary Lee and John Burt, II and to Professor Emeritus, Martha Wroe

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ACKNOWLEDGEMENTS The completion of this dissertation was made possible by the assistance and support of many individuals. My committee chairman, Dr. James Hensel, has been a constant source of encouragement, he has given me the continuing incentive I have needed to complete a Ph.D. while owning and directing a private practice in pediatric physical therapy and being a mother of two. Dr. Gordon Lawrence helped me to focus my ideas for the dissertation. He provided inspiration and guidance up through the proposal stages of my dissertation. My committee members, Dr. Mary Kay Dykes and Dr. Martha Clendenin, have been helpful in narrowing my focus, editing, and advising me as to the problems and merits in my dissertation project. My loyal staff member, Cheryl Riehl, contributed to both my personal and professional growth. I thank Leila Cantara for her tolerance, advice, speed in typing, and ability to organize a dissertation. In particular there has been an empathetic, adept physical therapist, a spirit filled with love — Martha Wroe iii

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who has been my mentor. Because of my admiration and respect for her ability to communicate v/ith student physical therapists, I have continued to teach in clinical physical therapy and to hope for a full-time academic career someday. My husband and children were helpful and supportive during my study. To my parents, my best friends, Mary Lee and John, I owe more than I can express. In everything they do, they always strive for success, and they have instilled this drive in me. My appreciation, my love, and all my good works are dedicated to them, and especially to Martha Wroe, Professor Emeritus, University of Florida. iv

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i TABLE OF CONTENTS Page ACKNOWLEDGEMENTS iii LIST OF TABLES vii LIST OF FIGURES viii ABSTRACT ix CHAPTERS I INTRODUCTION 1 Significance of the Study 3 Physical Therapy 4 Traditional Programs 5 Clinical Reasoning in Physical Therapy 7 Statement of the Problem 10 Purpose of the Study 11 The Study 12 Justification of the Study Methodology 12 Subjects 13 Control/Experimental Groups 14 Research Questions 14 Assumptions 15 Definition of Terms 16 Limitations 19 Summary 21 II REVIEW OF THE LITERATURE 22 Objectives 22 Ability to Solve Problems 24 Problem Solving in Medicine 25 Clinical Reasoning and the Physical Therapy Student 37 Presentation by Using Videotape Patient Cases. 40 Studies Relating Problem Solving to MyersBriggs Personality Dimensions 43 Summary 51 V

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Ill METHODOLOGY 53 Statement of the Hypothesis 54 Instrumentation 55 The Videos 55 Development of the Scoring Key 57 The Myers-Briggs Type Indicator 61 The Pilot Study 63 Subjects for the Pilot Study 63 Method of the Pilot Study 64 Results of the Pilot Study 65 The Study 66 Subjects 66 Method 67 Data and Recording Analysis 69 Recording 69 Analysis 70 Summary 72 IV RESULTS 74 Objectives of the Study 74 Research Questions 75 Hypotheses 76 Objectives 77 Research Questions and Hypotheses 78 Development of the Scoring Key 78 Occasion One: Experts 78 Occasion Two: Experts 79 Accuracy/ Problem Statement Form 80 Pilot and Experimental study Groups 80 Myers-Briggs Type Indicator 98 Results: Accuracy Scores 102 Results: Research Questions 1 and 2 and Test of Hypotheses 1 and 2 104 Results: Research Question 3 and Test of Hypothesis 3 106 Summary 107 V DISCUSSION 110 Discussion of the Study 110 Summary of the Procedures 113 Summary of the Findings 115 Implications 115 Directions for Future Research 117 Research on Instructional Use of CRP 119 Summary and Conclusions 120 vi

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APPENDICES A LITERATURE REVIEW TABLES OF STUDIES OF PROBLEM SOLVING AND MYERS-BRIGGS TYPE INDICATOR 123 B FORMAT AND PRESENTATION OF THE MODEL OF VIDEO INSTRUCTION FOLLOWING THE CLINICAL REASONING PROCESS 134 C THE VIDEO MODEL 140 D RATING AND STATEMENT FORMS AND STEPS IN CRP SHEETS USED WITH EXPERTS, PILOT STUDY GROUP, EXPERIMENTAL AND CONTROL GROUPS 158 E DATA RECORDING FORMS 174 REFERENCES 176 BIOGRAPHICAL SKETCH 184 vii

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LIST OF TABLES Table Page 1 Behaviors of Problem Solver 32 2 Experts' Agreement Scores Based on Cues Generated from the Work of Harris (1987) 79 3 Results: Expert Panel's Problem Statements ... 81 4 Homogeneity of Slopes 87 5 Efficiency Score 1 — Patient History Adjusted Means and Standard Deviations by Group, Personality Dimension, and School for Posttest. 88 6 Efficiency Score 2 — Physical Examination Adjusted Means and Standard Deviations by Group, Personality Dimension, and School for Posttest 89 7 Efficiency Score 3 — Volitional Movement Adjusted Means and Standard Deviations by Group, Personality Dimension, and School for Posttest 90 8 Student MBTI Profile Table 99 9 Group SN by Number of Subjects Per Cell and by Percent of Subjects in Cell 102 10 Group JP by Number of Subjects Per Cell and by Percent of Subjects in Cell 103 11 Frequency Distribution for Control and Experimental Groups 103 12 2X2X2 MANCOVA Table 105 13 Chi Square Analysis 108 viii

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LIST OF FIGURES Figure Page 1 The problem-solving mode 34 2 Hypothesis-oriented algorithm for clinicians.. 35 3 Video structure and model 42 4 Experimental design 71 5 Scatterplot for efficiency score — patient history 83 6 Scatterplot for efficiency score — physical examination 84 7 Scatterplot for efficiency score — volitional movement 86 8 Patient History — Experimental Group. Frequency distribution bar graph of pretest/ posttest scores on efficiency score (1) 92 9 Patient History — Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (1) 93 10 Physical Exam — Experimental Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (2) 94 11 Physical Exam — Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (2) 95 12 Volitional Movement — Experimental Group. Frequency distribution bar graph of pretest/ posttest scores on efficiency score (3) 96 13 Volitional Movement — Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (3) 97 ix

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE CLINICAL REASONING PROCESS AS AN EDUCATIONAL STRATEGY FOR ENTRY-LEVEL PHYSICAL THERAPY PROFESSIONALS By Blanche Burt DuPont May 1990 Chairperson: James W. Hensel Major Department: Educational Leadership The purpose of this study was to determine the effects of using the clinical reasoning process as an educational strategy for preparing physical therapy students entering the profession. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the clinical reasoning process (CRP) . Ten expert pediatric physical therapists created two scoring keys for two measures used in the study: diagnostic efficiency and diagnostic accuracy. Two videos were formatted to present a pediatric patient evaluation, one video was structured to include the rules of the CRP. X

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Subjects were 75 volunteer, entry-level physical therapists graduating from four Florida education programs. Subjects completed the Myers-Briggs Type Indicator to determine personality characteristics. Subjects were randomly assigned to experimental or control groups. Both groups viewed the unstructured video and completed a critical cues rating list and a problem statement form. The list was used to assess efficiency in rating diagnostic cues, the form to assess accuracy in diagnosis. The control group again viewed the unstructured video while the experimental group viewed the structured version. Both groups completed a cues rating list and problem statement form. Efficiency and accuracy measures were evaluated with a MANCOVA and a chi square, respectively. Subjects did not improve in diagnostic efficiency (F = .89, p > .35; F = .04; p > .8441; F = .31, p > .5785). There was no significant relationship between efficiency and personality characteristics. Subjects did improve in ability to accurately diagnose a pediatric movement dysfunction (X^= 9.13, p < .0025). Indications are that there is merit in incorporating use of CRP strategies for the purpose of training physical therapists to accurately diagnose movement dysfunction. xi

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CHAPTER I INTRODUCTION Educators have been concerned with the need to provide instructional programs that enable students who will work at professional decision-making levels to acquire critical thinking skills. These students will need to act as experts, persons who have demonstrated their ability in problem solving. The Education Commission of the United States, in 1982, called critical thinking, problem solving, and decision making the basic subjects for the future. In recent years researchers have been examining how students develop higher order critical thinking skills (Feely, 1976; Knight, 1987). Educational researchers, working within the problem-solving paradigm in cognitive psychology, have looked at the critical thinking skills that experts bring to problem solving and decision making (Bruner, Goodnow, & Austin, 1956; John & Miller, 1957) . By investigating the problem-solving behaviors of experts, persons with highly developed knowledge and years of experience in a particular discipline, researchers have determined that there are sets of strategies that are considered critical thinking 1

PAGE 13

2 skills. Within a given discipline, such as medicine or law, a specific set of strategies employed in assessing the problem or problems of a patient is termed diagnosis (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980; Elstein, Shulman, & Sprafka, 1979) . Diagnosis is an essential tool in the work of physicians, who are responsible for identification of a patient's primary problem and who are also responsible for the decision in regard to appropriate treatment. Researchers have studied the specific set of strategies physicians employ in diagnosis, and have looked at how to assist student physicians to acquire and develop diagnostic skills (Barrows & Tamblyn, 1980; Ben Bassat, 1986; Einhorn, 1986) . The need to diagnose is found in other areas of the medical field. Physicians refer patients to a health related group of practitioners for forms of treatment not administered by themselves. One of these groups of practitioners to which patients are referred is physical therapists (Echternach 6e Rothstein, 1986, 1989) . Physical therapy as a profession in the health care industry encompasses the treatment of patients who have orthopedic or neurological dysfunctions as sequelae of illness, accident, injury, or congenital malformations. Before treatment strategies can be used the physical therapist must assess the specific problem of the patient. Traditionally, the attending physician had the

PAGE 14

3 responsibility for determining that a patient needed physical therapy (Echternach & Rothstein, 1986, 1989) . The first physical therapy evaluations were carried out when a physician ordered specific tests for the patient (i.e., manual muscle test, range of motion test). The physician would take the information from these tests and diagnose the patient's movement dysfunction after which he or she would tell the therapist how to treat and manage the patient. At the present time, the situation with physician referral is often different. Significance of the Study About 48% of the states have granted physical therapists the right to practice without referral (Pickard, 1989) . While Florida has not yet legislated this right to physical therapists, the trend in Florida that is similar to a national trend is the one in which physical therapy practitioners are now practicing away from institutional settings in private practices. This delegates to the physical therapy practitioners complete responsibility for the management of patient progress. The movement toward more autonomy for the physical therapists, with the corresponding increase in responsibility, is expected to continue. It is important to note that these impending changes can only occur via changes in state licensing processes and that the changes were not self-initiated changes. Not only are physical

PAGE 15

4 therapists often working more independently, but also there are increasing case loads of complex problem patients. For example, in one specialty area of physical therapy — pediatrics — the medical profession is continually developing ways to prevent infant mortality. Many of these at-risk neonates ultimately require some type of therapeutic intervention. Entry-level physical therapists, those who have completed their studies and are ready to practice on a professional level, are expected not only to diagnose movement problems of all varieties, but to recognize whether as practitioners they personally can manage such complex cases. Expert physical therapists possess sophisticated evaluation skills to meet the challenges of practice in today's society and today's entry-level professionals need to know as much about acquiring those sophisticated skills as possible. Physical Therapy Educators who educate students to become physical therapists have recognized the increasing complexity of patient problems and the responsibility of the practitioner. The faculties of numerous programs in physical therapy have planned to require a master's degree before licensing can be applied for by a candidate wishing to enter practice. Although the American Physical Therapy Association cannot mandate this plan, the Association has recommended it. The master's degree may ensure that

PAGE 16

5 students would have more time to acquire diagnostic skills. More time spent in course work does not, however, assist students in developing the set of strategies that will enable them to make accurate diagnoses unless instructional programs provide information to students on how to acquire and use critical thinking skills in diagnosis. Traditional programs in physical therapy may not facilitate the students' development of the particular set of problem-solving strategies needed to identify patient problems (May, 1977; May & Newman, 1980; Slaughter, Brown, Gardner, & Perritt, 1989) . Traditional Programs Traditionally, instructional programs in physical therapy, like medicine, have emphasized a stepwise approach to the study of a patient case (Barrows & Bennett, 1972; Gordon, 1973). In this approach, emphasis has been placed on development of observational skills and collection of data (Arand & Harding, 1987; May, 1977; May & Newman, 1980; Olsen, 1983). This traditional approach has been a two-step process: (a) identifying the problem through emphasis on all the data one could find about a patient and (b) eliminating and rejecting possible causes. Symptoms or signs that could not be accounted for if certain causes for the problem were accepted by the physical therapist would be referred back to the physician. Researchers have

PAGE 17

6 determined that there is a set of problem-solving strategies that have served to speed up certain channels of thought and weaken others (Barrows & Bennett, 1972) . Use of these strategies by the physical therapist could quicken the diagnostic process of movement dysfunction that the therapist can no longer leave primarily to the physician. This set of strategies eliminates certain data collection steps and hones observational skills (Barrows & Feltovich, 1987; Barrows & Tamblyn, 1980; Elstein et al., 1979; Gordon, 1973; Heifer & Slater, 1971). These researchers sought to understand clinical problem-solving strategies in patient diagnosis by investigating the method that experts use to diagnose patient disorders. From this research they developed a set of rules that could be used to teach student physicians to proceed successfully through patient diagnosis (Barrows, 1983, 1986; Barrows & Bennett, 1972; Barrows & Feltovich, 1987; Barrows & Tamblyn, 1980; Cutler, 1985; Elstein et al., 1972; Gordon, 1973). This set of training rules or strategies in diagnostic problem solving was labeled the clinical reasoning process (CRP) . The CRP has been studied for over 15 years in medicine. In addition, Payton (1985) found that experts in physical therapy also used the same set of strategies or rules.

PAGE 18

7 Clinical Reasoning in Physical Therapy The clinical diagnostic problem-solving strategies used by experts in physical therapy were similar to those used by the physician experts in Barrows' and others (1972, 1980, 1983, 1986, 1987) studies. The training of students in the use of the specific set of rules known as the clinical reasoning process (CRP) has not been investigated in physical therapy. Two studies of facilitating clinical problem solving by teaching students strategies have been carried out, but these researchers in physical therapy education were not employing the clinical reasoning process (CRP) . The researchers could not demonstrate a significant improvement in student performance, although many subjects in both studies reported that the strategies they learned helped them to organize their approach to patient diagnosis (Burnett & Pierson, 1988; Slaughter, Brown, Gardner, & Perritt, 1989) . While many students indicated that they benefited from learning to use strategies for diagnosis, it was not clear whether there was any way to predict which students needed such instruction. In 1983 it was reported that some students in medical school, even when not taught clinical reasoning strategies, automatically adopted and began to use these rules when they moved into practice. Others never appeared to develop the skills on their own;

PAGE 19

8 they had to receive instruction (Barrows & Tamblyn, 1980; Kern & Doherty, 1982; Margolis, Barnoon, St Barok, 1982). Students entering medical school have personal problemsolving strategies; not all these strategies appeared to be effective in clinical settings. The authors of studies on student physicians hypothesized that differences in certain personality characteristics might enable some graduating physicians, who had not received direct instruction in clinical reasoning skills, to be effective in diagnoses upon entering practice while others with different personality characteristics could not be successful without this instruction (Barrows & Tamblyn, 1980; Elstein et al., 1979). Observers have not considered that entry-level physical therapists possess clinical reasoning skills that enable them to be uniformly effective in diagnosis (May, 1977; May St Newman, 1980; Olsen, 1983). They were not reported to have the skills that lead to efficient, accurate diagnosis of movement dysfunction, especially in a specialty area of practice like pediatrics. Educators in general, however, have assumed that experience and native intelligence, along with accumulation of knowledge in school would produce in their students the ability to analyze, synthesize, and ultimately make sound clinical judgments (May, 1977; May & Newman, 1980; Rothstein & Echternach, 1986, 1989). This has not been demonstrated

PAGE 20

in research and it should not be assumed that all physical therapists develop critical thinking skills and strategies that allow them to make patient diagnoses. It has been hypothesized that personality differences may underlie the varying abilities in clinical reasoning strategies of physical therapists (Burnett & Pierson, 1988; Burnett, Mahoney, & Chidley, 1986) . Identifying students who may be in need of training in acquisition and use of these skills would assist educators interested in developing instructional programs that would include education in clinical reasoning strategies. Such research has not been undertaken. Two directions in research directed toward improving instructional programs in physical therapy are indicated: one is a demonstration that students provided with a set of training strategies in clinical reasoning do become skilled in diagnosis, and the other is identification of those students who need such training in order to become experts. Physical therapy is, however, an expanding field. Many specialty areas now exist within the profession of physical therapy. This researcher is a practitioner in the area of neurological pediatrics and therefore familiar with the critical needs of these patients. Researchers have pointed out that diagnostic needs are critical in this specialty (Bobath, 1967; Illingworth, 1965; Kong, 1966; Quinton, 1986).

PAGE 21

10 Neurological movement disorders such as cerebral palsy have been the most common diagnostic movement problems seen by the pediatric physical therapist. Experts in the field have applied problem-solving techniques to these complex pediatric cases. In many instances of early neurological dysfunction, the patient's functional outcome can be changed with early appropriate treatment. Entrylevel practitioners in this specialty have needed to know how to diagnose in the manner of experts. The study of an instructional approach aimed toward improving successful clinical reasoning in an area of diagnostic physical therapy would be an important area of research (Campbell, Anderson, & Gardner, 1989) . Given the importance of early identification of the problem and treatment in neurological pediatrics, and given the researcher's expertise in the area, it seemed most appropriate to carry out a study in this specialty area. Statement of the Problem Practitioners in physical therapy need to make efficient, accurate diagnoses of movement dysfunction. Due to the increasing complexities in physical therapy, practitioners are specializing; one such specialty is pediatrics. Not all entry-level physical therapy students have demonstrated that they possess clinical reasoning strategies that can lead to efficient, accurate diagnosis of movement dysfunction in the pediatric patient. Through

PAGE 22

11 observation of expert physicians and physical therapists, researchers have identified the problem-solving strategies that make up the effective clinical reasoning process (CRP) (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980; Elstein et al., 1972; Elstein et al., 1979; Payton, 1985). Traditional instructional programs, however, have not included training in the CRP. To date there have not been studies investigating whether training in the CRP would benefit students, enabling them to become accurate, efficient diagnosticians upon entering the field. There also have not been studies that aimed at determining which students would need such training. While some physical therapists without specific training have been shown to have developed automatically the use of CRP, others without training have not become efficient, accurate clinicians. It was hypothesized that personality characteristics might influence development of this type of problem solving in individuals. Educators who would like to implement training did not have a basis for determining if CRP training is effective as a teaching tool nor did they have a means of determining which students would benefit from such training. Purpose of the Study The purpose of this study was to determine the effects of using the clinical reasoning process as a training strategy for physical therapy students entering

PAGE 23

12 the profession. The relationship between two personality dimensions and successful use of this problem-solving tool was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the GRP. The Study In this study the effectiveness of using what is described in the literature as the clinical reasoning process as a teaching tool for entry-level physical therapy professionals was investigated. The study was carried out in the state of Florida from October 1988 through August 1989. Subjects were 75 graduating students from the four physical therapy training programs in the state. The investigation proceeded in the following steps: development of the instructional video, development of the scoring key by a panel of experts, administration of the Myers Briggs Type Indicator to volunteer subjects, viewing of the video learning experiment by a pilot group followed by the same with a control and experimental group. Before proceeding to carry out the steps in the study, the work of major researchers was reviewed to justify the methodology, that is, the CRP and the video. Justification of the Study Methodology This study was designed to test the effectiveness of the CRP in teaching patient evaluation. Barrows and

PAGE 24

13 Tamblyn (1980) noted that the two major justifications for using the CRP in teaching patient evaluation included efficiency and accuracy in diagnosis. Efficiency indicated that a medical expert was able to perceive critical patient cues while eliminating unimportant cues in order to test more thoroughly and to observe the patient more carefully. Accuracy scores were indicative that the expert knew when he or she had enough information to make a correct diagnostic and treatment decision. At that point the expert stopped collecting data and closed the problem-solving process. The accurate diagnostician arrived at a diagnosis that replicated what other experts would state (Barrows & Tamblyn, 1980; Heifer & Slater, 1971; Marshall, 1983). In this study efficiency and accuracy of problem solving during the CRP were evaluated by asking subjects to carry out two tasks during and after viewing a video presentation of a case. These were (a) complete a critical cues list with three subsections to determine efficiency, and (b) write a primary problem statement to determine accuracy in the diagnosis of movement dysfunction (Barrows & Tamblyn, 1980) . Subi ects Subjects were 75 volunteer graduating students from the four physical therapy training programs in Florida (N = 75) . All subjects completed the Myers-Briggs Type Indicator (MBTI) for use in identifying differences in two

PAGE 25

14 personality dimensions. Students were randomly placed in experimental or control groups, and both groups received a pretest. A posttest was administered after subjects completed the list necessary for the pretest in the study. Control/Experimental Groups The subjects viewed the instructional video of a patient evaluation task. The video that experimental subjects viewed was the video structured to include the steps in the clinical reasoning process. Student subjects were tested as to their clinical reasoning efficiency skills by matching their critical cues ratings with those of experts. Accuracy was analyzed by key phrase agreement with experts on the primary problem statement. Subjects wrote primary problem statements in order to record a movement diagnosis. This movement diagnosis was matched with those of experts. The data were then analyzed to complete the study. This study was designed to enable the researcher to formulate responses to the following research questions. Research Questions 1. Can instruction in the method known as the clinical reasoning process that experts use to diagnose patient movement dysfunction affect entry-level physical therapy students' ability to rate patient movement behaviors efficiently?

PAGE 26

15 2. Will there be an affect of students' personality dimensions or characteristics and instruction in the use of the CRP on the way students efficiently rate patient cues? 3. Can instruction in the method of experts (CRP) assist entry-level (preservice) physical therapy students to accurately diagnose a patient's primary problem with movement, so that students' key words/phrases agree with those of experts? Assumptions 1. It was assumed based on research that students can learn to use the experimental CRP to solve more complex problems at this level in their professional education (entry level) (Ben Bassat, 1986; Burnett & Pierson, 1988; Groen & Patel, 1985; Watts, 1985). 2. It was assumed that application of this problemsolving method is relevant to different types of clinical evaluation problems (Ben Bassat, 1986; Burnett & Pierson, 1988; Groen & Patel, 1985; Watts, 1985). 3. It was assumed that the success of using the CRP might differ when comparing individuals with differences in personality dimensions (Hunter & Levy, 1982; Lawrence, 1984a, 1984b; McCaulley & Natter, 1974). 4. It was assumed that the 75 graduating physical therapists who volunteered for the study were

PAGE 27

16 representative of graduating (entry level) physical therapy professionals in the state of Florida. 5. It was assumed that regardless of whether the subject was a master's degree entry-level student or a bachelor's degree entry-level student, they were all novice learners. Definition of Terms Accuracy is the ability to quickly make an appropriate summation of the patient's movement problems (Barrows & Tamblyn, 1980) . This ability was evaluated on the basis of agreement of key words/phrases between subjects' primary problem statements and experts' primary problem statements (Ben Bassat, 1986; Heifer & Slater, 1971; Marshall, 1983; McGuire, 1985). Clinical reasoning process (CRP) is a set of problemsolving strategies used by experts in medicine and physical therapy to arrive at clinical patient problem solutions or diagnoses. It is also termed problem solving in clinical medicine or the method of experts (Barrows & Bennett, 1972; Barrows & Tamblyn, 1980). For the purpose of this study it is termed CRP. Cues are those test behaviors which experts report as essential for arriving at the primary problem statement. The relevance of cues is important in excluding an alternative hypothesis or problem statement so that one

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17 can establish a finite movement diagnosis or primary problem statement (Marshall, 1983) . Diagnosis of movement dysfunction for movement diagnosis) was used in the context of this study to mean that the entry-level professional must know how to determine the patient's primary problem with movement. The primary problem is, in effect, the movement diagnosis and at the same time it is the primary problem which must be approached by the physical therapist in treatment. Efficiency is the ability to observe and rate critically important cues as demonstrated by the patient and patient's family in the instructional video. These cues allow the expert to formulate appropriate problem statements (Barrows & Tamblyn, 1980) . Efficiency was evaluated by comparing the student and expert ratings of critical cues as observed during each of three video components (Heifer & Slater, 1971; Marshall, 1983). Entry level is used to define a student in physical therapy who is ready to enter into the practice of physical therapy subsequent to completing all the didactic and clinical components of their educational program in the discipline. It is used here interchangeably with "graduating. " Informa tion-processing theory is essentially a theory of communication systems developed in the context of telephone engineering. It was introduced into cognitive

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18 psychology primarily by Miller (1956) and Bruner, Goodnow, and Austin (1956) . Intuitive (intuition) is one of the poles of the MBTI. There are four poles or two sets of dimensions relevant to this dissertation: (a) intuition and sensing and (b) judging and perceiving. Intuition is the ability to perceive potentialities in both external and internal events. An intuitive person is one who can perceive "meaning in relationships and associations that are not directly presented to the senses" (Myers & McCaulley, 1987, p. 12). Its polar opposite is sensing. Judging (judgment) is one of the poles of the MBTI. It is characterized by a person who prefers to "live life in a self -regimented, purposeful, and exacting way" (Myers & McCaulley, 1987, p. 13). Its polar opposite is perceiving. Judging people are closure oriented. They make decisions as soon as they have enough information. Perceiving (perception) is one of the poles of the MBTI. It is characterized by a person with a preference to "live life in a flexible, adaptable, and tolerant way" (Myers & McCaulley, 1987, p. 13). Its polar opposite is judging. Perceiving people dislike closure and enjoy investigating all possibilities. Sensing (sensation) is one of the poles of the MBTI. It is characterized by a person who prefers the immediate, real, and practical side of life that can be gained

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19 through use of one's senses (Myers & McCaulley, 1987, p. 12) . Its opposite pole is intuitive or intuition. Limitations Seven specific limitations have been described that have a direct impact on this study. They were as follows: 1. The sample of professionals used in the study was limited to physical therapy students from educational programs in Florida. Their performance may not be representative of that of the general population of entrylevel physical therapy professionals. The use of all possible schools of physical therapy in Florida limited generalization of the results to those entry-level physical therapy professionals in Florida. 2. Subjects may not indicate their true preferences on the MBTI. As Myers and McCaulley (1987) explained, as with any self -report instrument, the correctness of the results depends in part on how well the questions have been answered. If people answering the MBTI feel that they have nothing to gain, they may answer carelessly or even at random. If they fear they have something to lose, they may answer as they assume they should. But if they understand before answering, that they will be told how they score and will be invited to confirm or correct the report of their dimensions, their answers are more likely to be genuine. (p. 53) 3. Clinical reasoning or clinical problem solving is a complex cognitive skill which does not lend itself to easy measurement or discovery of ideal strategies. The instructional video was limited to only a small portion of

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20 this particular cognitive domain. In addition, there was no exploration of the psychomotor domain, that is, of the physical handling skills used to conduct pediatric evaluation (Berner, 1984) . 4. The definitions of efficiency and accuracy are narrow and may not apply to all types of clinical reasoning behaviors. 5. Data gathering was not done in a typical or normal clinical practice manner; it was done based upon students' rating of cues, and the writing of a problem statement during and subsequent to viewing a video (Berner, 1984) . This is not the most frequently used method of data gathering in physical therapy programs. 6. The test behaviors included in the pediatric video case evaluation were limited to those established by research. The video may not have shown all the behaviors that either all experts or all student subjects would have considered relevant (Harris, 1987; Ross, Lipper, & Auld, 1986; Georgieff, Bernbaum, Hoffman-Williamson, & Daft, 1986; Gorga, Stern, & Ross, 1985; Stanley & English, 1986) (see Appendix A) . 7. All experts did not agree 100% on critical cue ratings or problem statement key words/phrases. Researchers in physical therapy have demonstrated that if there are more than three experts who are to agree on a

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21 subject, then to some degree disagreement among experts should be expected (Delitto, Shulman, & Rose, 1989) . Summary Empirical studies have shown that when solving complex clinical problems, expert physical therapists demonstrated systematic patterns in behavior. These patterns followed a set of rules termed the clinical reasoning process. A systematic review of the literature indicated that even if they are not trained in the CRP, some professionals immediately upon entry into practice employed these rules of the CRP. Certain personality dimensions or characteristics of some professionals are related to how well they solve problems once they enter practice. These dimensions of personality were thought to be relevant to the determination of whether a student needed to receive structured training in the CRP. The purpose of this study was to determine the effects of using the CRP as a training strategy for physical therapy students entering the profession. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the CRP.

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CHAPTER II REVIEW OF THE LITERATURE The literature reviewed for this research covered the topics relevant to the three objectives and the three research questions. Each of the three objectives, along with the relevant topics, are presented. The literature reviewed for each topic was found to be relevant to the study . Objectives The first objective was to investigate whether experimental and control groups differed in their ability to rate cues efficiently and, if they differ, whether the differences were based on watching a video edited to facilitate use of the GRP. Determining critical cues is an essential step in problem solving. Discussion of the first objective encompasses a review of the large bank of information about the CRP as part of the problem-solving paradigm. Problem solving has received greater emphasis in educational programs for physical therapists because of the movement toward autonomy in the practice of physical therapy (Echternach & Rothstein, 1989) . Due to the necessity for precision in the practice of physical 22

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23 therapy, this researcher identified a precise set of strategies that was mentioned in the literature as being applicable to the area of clinical problem solving in patient diagnosis. The literature review includes discussion of the studies of problem solving in diagnosis. Instruction through the use of video case presentations as a method of assisting students to become expert problem solvers was also reviewed. The second objective was to investigate whether there was a relationship between two personality dimensions and successful use of the problem-solving paradigm known as GRP. Personality characteristics or dimensions, as they related to problem solving, have been mentioned in studies involving the Myers-Briggs Type Indicator. A review of the relevant literature on the MBTI and its applicability to studies such as this research is included in this chapter. The third objective was to investigate the subjects' ability to accurately diagnose a pediatric patient movement dysfunction, and to determine if experimental subjects differed as a result of viewing a structured instructional video that included the rules of the clinical reasoning process. The authors of the literature on problem solving in medicine indicated that there were two variables related to clinical diagnostic success: (a) efficiency in diagnosing a patient's dysfunction; and (b)

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accuracy in diagnosing a patient's primary dysfunction or problem. Literature relevant to the topics of efficiency and accuracy was reviewed in relationship to this objective. The literature reviewed for this study was related to the topics found relevant to the objectives of the research. The topics are: problem-solving paradigm; problem solving in medicine, problem solving in physical therapy; clinical reasoning and the physical therapy student; patient case presentation videos; and studies relating problem solving to personality dimensions or characteristics. The literature is discussed next in the order of the topics mentioned. Abilitv to Solve Problems Problem solving as a mental exercise has long attracted the attention of researchers (Feely, 1976; Greeno, 1978; Norman, 1976). Problem solving was described by Bloom as an evaluative and decision-making process represented by the evaluation stage of his taxonomy (Feely, 1976) . As a higher order mental effort, problem solving was further investigated by cognitive psychologists. A problem-solving paradigm was developed, in which a person was viewed as an information channel, receiving information from the environment and acting adaptively on it (Greeno, 1978). In order to analyze the processes involved in problem solving, information channel

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theorists followed the information as it entered the human nervous system and was processed (Norman, 1976) . In further studies Greeno (1978) found that there was not a single homogeneous set of problem-solving processing skills that could be identified as the essential skills involved in all types of problem solving. Greeno found, however, that the human system seemed to function on two basic principles: (a) individual bits of information can be chunked together and eventually one symbol comes to represent larger pieces of experience; and (b) redundant data are eliminated to conserve the limited time, space, and energy reguired by the human system to process essential information. Another way of saying this is that the efficient human system selects data that convey maximum information. Cognitive psychologists began to explore these principles as they related to problem solving within specific disciplines such as medicine. Their research involved studies of the strategies employed by expert practitioners in solving medically related diagnostic problems. Problem Solving in Medicine The strategies used by physician experts were found to be consistent and sequential (Barrows & Bennett, 1972) . Elstein, Schulman, and Sprafka (1979) began structuring the problem-solving activities of medical students to follow these strategies used by experts.

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26 These authors agreed on certain consistently used cognitive strategies, such as the number of hypotheses experts generate early in the diagnostic process and the steps they follow to hone these hypotheses and eliminate irrelevant cues. Barrows and Bennett (1972) also found that the expert started with very general hypotheses and progressed to a specific hypothesis or problem statement. Medical students eventually were able to apply these hypotheses generating processes in interviewing and examining actual patients. In Barrow's original studies, medical students learned the rules initially by practicing with simulated video and written patient case presentations (Barrows & Tamblyn, 1980; Gordon, 1973; Miller, 1956) . The rules for the clinical reasoning process (CRP) were stated by Barrows and Tamblyn (1980) . These rules or strategies represent one set of strategies used for problem solving in clinical medicine. These are the set of strategies used in this study. Step I "Cue Phase": Studies in clinical reasoning show that the expert assembles an initial concept of a patient's problems with lightning speed from critical cues inherent in the first encounter. Step II "Hypothesis Phase": Within moments after the first encounter, almost simultaneously with the initial concept, the expert in medicine generates 2-5 hypotheses or problem statements that literally "pop" into mind. Hypotheses or problem statements can be ideas, hunches, guesses, or impressions that can explain causes for the patient's problems.

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27 Step III "Maximization Phase": Experts process all of their hypotheses (problem statements) in parallel manner; then they stop and deduce which hypotheses (problem statements) are most likely responsible for the patient problem. They then rank order their hypotheses (problem statements) . Step IV "Case Building Phase": Experts search the data again, modifying their problem formulations, altering, rejecting, and revising any hypotheses (problem statements) that need it. Step V "Closure Phase": Experts stop when they have just enough data to formulate a final hypothesis or problem statement, (pp. 2230) Barrows and Bennett (1972) and Barrows and Tamblyn (1980) worked primarily with medical students, while Elstein et al. (1979) further clarified the hypotheses generating activities of the CRP as used by experts. Elstein et al. found that three phases of hypothesesgeneration were being used by experts. Phases in the hypotheses generation activity (Elstein et al., 1972) are as follows: 1. Generate a list of alternative hypotheses or actions a. Multiple competing hypotheses b. Probability (consider the most common diagnosis first) c. Utility (consider seriously those diagnoses for which effective therapies are available and in which failure to treat would be a serious omission) 2. Gather data a. Form a reasoned plan for listing hypotheses (problem statements) (1) Relate diagnostic decisions to treatment alternatives (2) Every datum gathered must have a reason b. Branch and screen: history taking and physical examination should be branching procedures; develop adequate screening

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28 tactics to help make overly detailed examinations unnecessary c. Cost-benefit calculation; estimate whether seeing other specialists and performing other medical tests are beneficial and cost effective d. Precision; strive for the degree of reliability needed for the decision at hand; more is not necessary Aggregating data, evaluating hypotheses, and selecting a course of action a. Actively seek out and evaluate evidence that tends to rule out any hypothesis (problem statement) or action alternative as well as evidence that tends to confirm it; be aware of the tendency to discount or disregard evidence likely to disconfirm your favorite hypothesis (problem statement) b. Multiple diagnosis; consider the possibility that a patient with multiple problems or complaints has more than one disorder (or more than one etiology for abnormal movement) c. Bayes' theorem; revise probabilities after collecting data 1. In assessing problems, give special weight to a particular dysfunction if it is a commonly found dysfunction 2. If clinical findings are relatively more likely in problem A than in B, revise opinion in favor of A 3. If hard data are presented, weight each finding as at least confirming, disconf irming, or not changing one's prior belief 4. If problems are rank ordered on the basis of predominance of findings in their support, this ranking will correspond roughly to a probability scale d. Probability and utility should guide action 1. Consider clustering problems that would be treated identically; this nesting effectively reduces the number of alternatives to be evaluated 2. Among the benefits and penalties of medical action, consider quality of life. (p. 297)

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29 Watts (1985) described clinical reasoning as it related to physical therapy. She combined all of the steps used by Barrows and Tamblyn (1980) and Elstein et al. (1979) into two steps. The first, a global step, was oriented toward identification of the patient's primary problem with movement. It should be noted that in physical therapy literature the words "patient problem" were sometimes substituted for the word hypotheses. The primary movement problem in physical therapy would be the same as primary diagnosis in medicine (Olsen, 1983; Echternach & Rothstein, 1986; Watts, 1985). In addition to the problem identification step. Watts designated a second step that she termed the "decision tree" (p. 15) . This second part of Watts' model was mentioned here for the purpose of completeness, however, the focus of the current study was Watts' global step one. A description of the Watts model follows: Step I Narrow and delineate the problem focus by 1. specifying type of patients to which this problem focus can be applied; 2. listing characteristics of the patient's disorder that are of greatest interest; and 3. noting the specific action decision to be addressed. Step II Structure the decision process over time and diagram it. (p. 15) Others in physical therapy have described clinical reasoning analyses and designated them as models of

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30 clinical decision making (May & Newman, 1980; Olsen, 1983; Rothstein & Echternach, 1986) . May and Newman (1980) created a behavioral model for facilitating clinical problem-solving strategies. The model was adapted to and used in a physical therapy program. May and Newman found it necessary to define the students' progress by documenting the students' completion of problem-solving skills in the cognitive, affective, and psychomotor domains. May and Newman, like Barrows and Bennett (1972), Elstein et al. (1972), and Watts (1985), saw the need to avoid an excess of facts and data that may be related to a problem but would not be essential in solving that problem. May (1977) reported that the traditional approach to training physical therapists led her to observe that the development of problem-solving skills occurred inconsistently when instructors followed the stepwise or textbook approach to data collection. She explained in a later article (May & Newman, 1980) that not telling the students all the facts may be difficult for the traditional instructor to accept, but that effective clinical problem solving skills were "best learned in an environment in which the student is free to test thinking skills, explore alternatives, and discover solutions" (p. 1140). May's Behavioral Model is depicted in Table 1. Olsen (1983) and Echternach and Rothstein (1986) refined and delimited two problem-solving models for use

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31 in patient diagnosis and treatment planning. Both schematic representations closely follow the clinical diagnostic steps set forth in the clinical reasoning process devised by Elstein et al. (1972) and Barrows and Bennett (1972) except that Olsen did not use branching. (See Figures 1 and 2.) Watts (1985) and Echternach and Rothstein (1986) stated that the further sophistication of the overall problem-solving model or paradigm in clinical practice must include a part two, or "branching program." Both physical therapy models, therefore, included problem identification and treatment management phases, whereas Barrows and Tamblyn's medical model differed in that it emphasized primary problem identification or diagnosis (see Figures 1 and 2) . Terminology employed by researchers in medicine and in physical therapy differed. Watts (1985, p. 15) used the words "decision analysis" and "clinical decision making," while Barrows and Tamblyn (1980) retained the wording more popularly used in medicine in the 1970s and early 1980s, i.e., clinical reasoning. Gordon (1973) and Elstein et al. (1972, 1979) coined the phrase hypothetico-deductive reasoning. Suchman (1980) , an educator, termed a teaching model with similar characteristics "inquiry training" (Joyce & Weil, 1980, p. 61) ; while Delitto, Shulman, and Rose (1989) , in the

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PART ONE 1. . Collect initial data (eg. interview, history, cnan review, subjective information) 2. Generate a problem statement Refen-al to other — practitioner (if no hypotheses can be generated) \ I / Establish goals (measurable and functional with a temporal element) 3. Examination (collection of data) 1 4. Generate working hypxJtheses about why goals are or cannot be met at the present time (establish testing criteria for each hypothesis) \ Ask whether goals are viable • if no. modify • if yes, proceed 5. Plan reevaluation methodology (schedule dates for reevaluations) Consultation, if needed I 6. Plan treatment strategy based on hypotheses (overall treatment approach) I 7. Plan tactics to implement strategy (specifics of treatment plan) I 8. Implement tactics (treatment) Ficfure 2. Hypothesis-oriented algorithm for clinicians Part One: Guidelines for evaluation and treatment planning (Echternach & Rothstein, 1986, p. 1389) .

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36 PART TWO 9. Reassessment Have goais been met? No Discharge patient Are tactics being implemented correctly? (Is treatment being implemented as planned?) Are tactics appropriate? • Yes Is strategy correct? Yes V Are hypotheses viable? (ie. if testing criteria have been met and goals are not met. new hypotheses are needed) 1 No Generate new hypotheses — Go to 4 No Improve implementation — Go to 8 No Change tactics — Go to 7 No Change strategy — Go to 6 Figure 2 — continued . Part Two: Branching prograim. All numbers less than 9 refer to the steps in part one of figure (Echternach & Rothstein, 1986, p. 1390) .

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37 physical therapy literature, termed the process or set of strategies "the method of experts" (p. 554) . The processes described were consistent across authors, despite the differences in the names given to the process. In this study the term clinical reasoning process (CRP) was chosen. The set of strategies used in this study was the steps in the CRP as described by Barrows and Tamblyn 1980) . Clinical Reasoning and the Physical Therapy Student May (1977) reported that "Students enter physical therapy with a developed approach to solving problems" (p. 807) . However, their problem-solving techniques as applied to patient-related problems may or may not be successful because May (1977) noted that there are as many ways to solve problems as there are categories of problems. May saw that patient problems may require a problem-solving methodology that was not within a student's initial repertoire, either because the student lacked understanding of the basic knowledge structure of the discipline, or because the student for some reason did not begin processing like experts (Boshuizen & Claessen, 1982). May, like Elstein et al. (1972, 1979) in medicine, found that many physical therapy entry-level professionals did not have medical problem-solving skills after they had graduated despite the fact they possessed the basic content knowledge of the discipline. Some of these entry-

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38 level therapists never seemed to become good diagnosticians, whereas others, whether taught or not, automatically began using clinical reasoning to solve patient problems. Burnett and Pierson (1988) explained that encouraging physical therapy students to practice problem solving was not without difficulties. Learning situations that demanded multiplicity in thinking and that required students to use limited experience and information met with varying degrees of student responsiveness. Burnett and Pierson (1988) developed a group of problem-solving activities for the classroom that included written patient case scenarios that were presented to first-year physical therapy students. The ultimate goal of the activities was to have students complete a problem-oriented patientstatus written note. Evaluation of the activities and problem-solving course work was carried out based on students' evaluations. Students believed the course helped in developing problem-solving skills, but only 31% reported that the course was important. The majority of students saw the course as boring but this may have been due to the fact that they were first year students and could not see the relevance of the activities so early in their training. Slaughter, Brown, Gardner, and Perritt (1989) studied 31 first-year physical therapy students. The researchers

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39 used prepared written case studies. The Slaughter et al. students discussed these prepared cases with their clinical instructors by asking a set sequence of questions termed "the analytical questioning sequence" (p. 28, 444) . Pretest and posttest evaluation of the learning experience was done by administering the Watson Glaser Critical Thinking Appraisal (CTA) (Slaughter et al., 1989). The authors found no significant results and attributed the lack of significance to inadequacies in the CTA. Beginning CTA scores for these first year students had a percentile rank of 97% to 99% so that with high initial scores it would have been very difficult to show improvement . In summary, the Burnett and Pier son (1988) and Slaughter et al. (1989) studies demonstrated that the development of problem-solving abilities in physical therapy students is a relevant topic in physical therapy education. Prior to this time, traditional physical therapy textbooks, case study techniques, and faculty instructional approaches demonstrated a step-by-step method of mastery of content by encouraging data-gathering habits. This data-gathering method has been relevant early in physical therapy instructional programs because beginning students have needed to acquire a basic knowledge structure. Without basic knowledge the students lacked the basis for generating hypotheses or problem

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40 statements. For this reason Burnett and Pierson and Slaughter et al. anticipated that the first-year students would have an inability to recognize the importance of learning problem-solving techniques. It appears from this study and others that, as the students mature, exposure to an approach used by experts may help physical therapy students in the transition from compulsive data gathering to focusing on relevant cues and to analyzing and synthesizing data with greater accuracy and efficiency (Barrows, 1983; Barrows & Tamblyn, 1980; Burnett & Pierson, 1988; Delitto, Shulman, & Rose, 1989; Glaser, 1984, 1985; Groen & Patel, 1985; Payton, 1985). One way that has been shown to be an effective way to provide exposure to the strategies of expert clinicians is the presentation of a patient case by video. Presentation by Using Videotape Patient Cases In order to present the instructional structure that revolved around a patient case evaluation a video format was used to package the program for easy, reliable use with students. Vander Sijde et al. (1987) described the development of audiovisuals for problem solving in physical therapy education. The authors developed the audiovisuals to assist students with patient diagnosis and management. Although the videos did not include the steps in the clinical reasoning process, a simple, easily

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41 reproduced format for patient evaluation was included. The authors explained their work as follows: In an attempt to close the gap between acquiring theoretical knowledge and learning through experience to solve patients ' problems which we consider the major objective of physical therapy education, we started to record patient case histories on videotape with the intention of giving students the opportunity of practicing problem-solving skills. . . . The following steps in the development of those case histories are described as 1. choosing a model for videotaped case histories ; 2. implementing the model; 3. structuring the videotape; 4. using the videotaped case histories, (p. 555) The objective of the Vander Sijde project was to develop a series of videotapes for training physical therapy students. These video tapes were based on proper theoretical constructs relating to what the students needed to know about their patients and what procedures students needed to use. The authors did not determine whether students could actually make decisions and solve problems better after exposure to the videos, nor did they ascertain which processes were used by students to make their decisions. These authors did present the first formal attempts at video formatting for case evaluations and they also added a problem-solving questioning protocol to the video (see Figure 3) . It remained to be determined whether students improved in their skills after watching

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42 MODEL OF VIDEO INSTRUCTION fiUESTION: What do you want to as)c in the .edieal historytaking process? Historytaking process QUESTION: Were the questions asked useful? Did you miss any questions? Wliat do you do next? Inspection of the patient QUESTION: What did you observe? What are your next steps in examining the patient? Examination of the patient QUESTION: Did differences exist between your examination proposal and the one you saw? What is your conclusion? Evaluation of the case by a physical therapist Figure 3 . Video structure and model (Vander Sijde et al-, 1987, p. 556) .

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videos and if so, if these students had identifying personality characteristics. Studies Relating Problem Solving to Myers-Brigqs Personality Diroensions There were many studies in the literature relating one particular personality indicator entitled the Myers Briggs Type Indicator to problem-solving abilities. It was decided for the purpose of clarity and expediency that the studies should be put into a table format (see Appendix A, Table A-3) . The Myers Briggs Types Indicator (MBTI) was chosen for this study due to the large data bank of studies relating it to problem solving. (A description of the MBTI is also included in Appendix A.) The MBTI was developed in 1962 to identify personality type differences. The indicator was based upon Carl Jung's theory of psychological type. The essence of Jung's theory was that seemingly random variations in behavior were actually quite orderly and that differences between people in their behavior were basically differences in the way that people used perception and judgment. Perceptions are the ways people become aware of environmental happenings, ideas, etc. while judgments are the ways that people come to conclusions about what they perceived (Myers & McCaulley, 1962, 1985, 1987). The MBTI was based on identifying these ideas of Jung about perception and

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44 judgment. The test author, Isabel Briggs Myers, characterized 16 psychological types based upon a person's perception and judgment preferences in four polar dimensions: extraversion (E) versus introversion (I) , sensing (S) versus intuition (N) thinking (T) versus feeling (F) and judging (J) versus perceiving (P) . The dimensions of sensing versus intuition and judging versus perceiving have been found by various researchers to be the most relevant to problem-solving ability (Myers & McCaulley, 1962, 1985, 1987). Consequently, these two dimensions were considered for inclusion in the analysis for this study (Myers & Myers, 1980) . In Table A-2 personality problem-solving dimensions as they were related to instructional models, media, and methods in past studies were presented. In addition. Table A-3 contains further information about the characteristics frequently associated with each type, definitions of the four dimensions, and an exploration of how student motivation effects personality type. Burnett and Pierson (1988) in the physical therapy literature alluded to the role personality characteristics play in developing a student's abilities to problem solve in clinical practice. Following the contents of Table A-2 a full description of the studies was included herein for the reader. Eggins (1979) , in a classical aptitude-treatmentinteraction (ATI) study reported in Myers and McCaulley

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(1987) , combined the idea of a structured learning model with personality characteristic information that facilitated problem solving at three different levels. She reported on the effects of three models of instruction on 350 sixth-grade students who were asked to do an animal classification task. The teaching models that Eggins used were three concept attainment models: (a) the inductive reasoning model based on the ideas of Bruner, Goodrow, and Austin (1967) (moderate structure, moderate conceptual level); (b) a didactive approach based on Ausubel's (1963) advanced organizer (high structure, low conceptual level) ; and (c) the concrete examples approach of Gagne (1965) (high structure, low conceptual level) . The Bruner et. al (1967) model imposed the least structure on learners by providing an opportunity for them to see common characteristics and relationships for themselves. The Bruner approach was helpful to intuitive types. Ausubel's (1963) model presented facts in a structured way like Gagne 's approach, but the advanced organizer was designed to help students relate facts to concepts. The Ausubel model bridged the gap for both sensing and intuitive types (Myers & McCaulley, 1987) . Gagne 's (1965) model presented a linear structure that was useful for sensing types. Eggins randomized her subjects to one of the three methods. The subjects were tested immediately and again after 10 days. Key findings were

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46 that (a) students classified as intuitive benefited most from Bruner's inductive, less-structured approach; (b) students classified as sensing types learned better with the highly structured Gagne method; (c) students classified as judging types with high intelligence did best with Ausubel's didactic approach or Bruner's inductive approach; (d) students classified as perceptive types with high intelligence did best with Gagne 's highly structured design; sensing judging (SJ) and intuitive judging (NJ) types succeeded with all three models; and sensing perceptive (SP) and intuitive perceptive (NP) types were significantly affected by the level of structure in their instruction. The SP types did best with a highly structured model, i.e., the Gagne method. Eggins (1979) also mentioned a difference in learning based only upon the judging perceptive (JP) dimension. High intelligence Js (those with moderate to high conceptual levels) preferred the instructional model of Bruner because it facilitated inductive (creative) reasoning. The high intelligence Ps, however, preferred the highly structured, step-by-step Gagne model. McCaulley's (1981) general summary of research on the MBTI identified a number of studies that are indirectly related to the learning aspects of sensing/intuitive differences. Sensing types did well in tasks related to practical skills and were motivated to learn if they saw

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47 the practical usefulness of the task. Intuitive types prevailed in mental tasks that required manipulation of symbols and verbal reasoning. Sensing students preferred televised instruction with orderly, sequenced steps aimed toward the accomplishment of preset goals. They did not like dealing with analogies, recognizing figurative and symbolic language, or establishing relationships and alternatives. They failed to get involved in classroom discussions and resisted instructional models that attempted to facilitate such interaction (Carskadon, 1978; Nisbet, Ruble, & Schurr, 1981) . Intuitive types liked instructional models that required self-instruction, reading, drawing analogies, group discussion, manipulation of symbols and verbal reasoning. They wanted to deal with alternatives and the relationships between them (Carskadon, 1978; Kilmann & Taylor, 1974; Nisbet et al., 1981) . Griesen (1972) studied beginning medical students who were given a choice between a traditional program or a new independent study program; judging types chose the former, whereas perceiving types wanted to try the new independent program of study. The two instructional programs were very different: the traditional approach had high structure, whereas the independent approach had low structure .

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48 John and Miller (1957) investigated the problemsolving behaviors of 59 students from various class levels of the University of Chicago as they completed electronically operated logic exercises on the Problem Solving and Information (PSI) apparatus. The PSI determined the proper logical sequence of pushing buttons on the apparatus to illuminate a central panel light. When John and Miller (1957) graphed the number of tests versus time, they found a regularity of processes involved in the solution and stated, "It appears that individuals display different but highly characteristic rates of making decisions based on the evaluation of a body of data" (p. 296) . They attempted to correlate a number of psychological measures with performance and concluded that "correlation of certain of the variables with other available measures show that personality factors such as anxiety, perceptual factors such as speed and flexibility of closure (Thurstone's Primary Mental Abilities), and cognitive factors, were all involved in problem-solving performance" (p. 229) . Ross et al. (1986) intercorrelated the four MBTI scales with 15 ability tests, 7 experimental interest tests, and 10 scales from the Personality Research Inventory. Five hundred and seventy-one high-school students were tested. Through a factor analysis it was determined that, for males, intuition was associated with

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structure in general problem solving, whereas slowness or carefulness in problem solving was associated with sensing. McCaulley and Natter (1974) , using a sample of 521 secondary school students, agreed that the choice of learning tools and strategies of sensing versus intuitive types differed drastically. Hoy and Vaught (1981) , in a study of the relationships between problem-solving personality characteristics and problem-solving skills among 39 entrepreneurs, found that of the four MBTI scales, only sensing/intuition correlated with problemsolving skills. The authors reported that high scores were correlated with intuitive types (N) . Lewis (1976) studied 85 psychology students. Intuitive types tended to be associated with efficiency on an intuitive problemsolving scale. Hunter and Levy (1982) studied the relationships between problem-solving behaviors and Jungian personality types. They presented two problem-solving exercises to 80 subjects from Howard University. They grouped students by SJ, SP, NP, and NJ, thus using only two of the four MBTI dimensions to form four possible dimension combinations. On one exercise, the Embedded Figures Test, intuitive perceptive types (NP) attempted more problems and solved them correctly more often then sensing judging (SJ) types. Sensing judging (SJ) types had a greater tendency to adhere to the concrete aspects of stimuli. Intuitive

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50 judging (NJ) types saw beyond the literal aspects of stimuli and tended to be orderly, systematic, and persistent in tedious tasks. The NJs were able to list significantly more possible solutions to the box problem. Westcott (1968) gave subjects verbal and numerical series problems and analogy problems. Information as to problem solution was given in small amounts in a fixed sequence. Westcott hypothesized that intuitive (N) people would need less information to solve the same problems. He identified four categories based on the amount of information and time needed for solution: intuitive thinkers (little information, high success) ; wild guessers (low information, low success) ; careful guessers (high information, high success) ; and careful failures (high information, low success) . Westcott also found that "subjects who relate to stimuli by perceptual responses rather than by judgmental responses, regardless of whether one perceives details or implications, are more successful on intuitive problem solving [p < .05]" (p. 22). Weber (1975) again investigated problem-solving skills, this time based on results from the Embedded Figures Test and the MBTI. His results supported two of his hypotheses. Intuitive types performed better than sensing types (p < 0.01 for timed tests, p < 0.05 for untimed tests) . Male perceiving types produced more correct responses than did judging males, perceiving

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51 females, or judging females. He also found that sensing types produced more incorrect responses than intuitive (p < 0.01). Lastly, intuitive perceiving (NP) types produced more correct responses overall on untimed tests (p < 0.01) . Summary This review of literature provided support for the use of the medical problem solving set of strategies known as the CRP that was used in this study. These strategies, although varying in descriptions, are similar in concept across numerous researchers. In the review of the literature it has been noted also that there are general patterns of problem-solving performance exhibited among persons who belong to the two MBTI dimensions of sensing versus intuition (S/N) and perceiving versus judging (J/P) . Persons with sensing type personalities preferred to solve problems in standard, practical ways, contrary to intuitive type persons, who preferred to apply imagination in finding new problem-solving methods. Judging type people strive for closure, acting quicker and with less information than perceptive type people, who generally spent more time and acquired more information before moving toward a solution. Researchers have noted that the consistencies in type of behavior exhibited by a certain person were combined with certain regularities in the process used to solve

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52 problems. Indications were that some variation in problem-solving behavior could be attributed to personality dimensions (see Appendix A) . Some studies found the sensing versus intuitive dimension (S/N) to be the most significant variable, whereas others chose from the four possible combinations: SP, NP, SP, NJ. (See Table A-3 in Appendix A.) All studies found significant relationships between these dimensions and the problemsolving model, the environment, and the task which the learner was given. A summary of the models of problem solving and MBTI related problem solving studies mentioned in this chapter are included in Appendix A-3. In the next chapter the methodology of the study will be discussed.

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CHAPTER III METHODOLOGY In this chapter the methodology of the study is presented. The purpose of the study was to determine the effects of using the clinical reasoning process (CRP) as a teaching tool for entry-level physical therapy professionals. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the clinical reasoning process. The investigation was conducted by means of an experimental study. Seventy-five entry-level physical therapy students from Florida institutions volunteered to participate. These students were randomly assigned to either the control or experimental groups. All students participated in the learning experience that involved the students' ability to use the clinical reasoning process (CRP) in identifying the problems of a patient in a case portrayed in a video. The methodology of the study has 53

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54 been included here in the order followed by the researcher in setting up the experimental study: statement of the hypotheses, instrumentation, pilot study, experimental study, and data collection and analysis. Statement of the Hypotheses The three hypotheses tested (stated in null form) were as follows: Hypothesis 1: There will be no significant difference at the .05 level between the mean scores of the experimental group and the control group on diagnostic efficiency (critical cues list) based on: efficiency score 1 — patient history, efficiency score 2 — physical examination, or efficiency score 3 — volitional movement. Hypothesis 2: There will be no affect at the .05 level of personality dimensions or structure in instruction on diagnostic efficiency scores in three areas: patient history, physical examination, or volitional movement. Hypothesis 3: There will be no significant difference at the .05 level between the mean scores of the experimental and the control group between key phrase agreement of students and experts on a primary problem statement. The primary problem statement was used to represent the diagnosis of the patient's primary movement dysfunction.

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55 Instrumentation The Videos The instructional video model was designed to encompass three basic instructional components: (a) pediatric physical examination items (explicit cues from Harris (1987) , (b) video patient evaluation design (Vander Sijde et al., 1987), and (c) rules and strategies of the CRP (Barrows & Tamblyn, 1980) . Two separate videos were produced. Both depicted the physical examination tests (Harris, 1987) and the patient evaluation design (Vender Sijde et al., 1987). One video was edited to include the structured instructional rules and contextualized implicit cues considered to represent the clinical reasoning process used by experts in medicine and physical therapy (Barrows, 1983, 1986; Barrows & Bennett, 1972; Barrows & Tamblyn, 1980) (see Appendix C) . A pediatric patient case vignette was chosen as the sample content for the video instruction because pediatric diagnosis is a complex diagnostic problem in physical therapy. The 2 year old patient had cerebral palsy; this neurological deficit represents a group of disabilities that freguently remain undiagnosed until well into the first or second year of life (Campbell et al., 1989; Illingworth, 1965) . The developmental milestones such as crawling and walking are the cues that most physicians use to evaluate normal development in infants; however, these

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56 cues are sometimes not present until the last quarter of the infant's first year. Physical therapists have learned to look at other cues and to look for these cues earlier than the second year of life. The importance of early physical therapy to minimize later motor handicaps has been emphasized by the proponents of early intervention (Bobath, 1967; Kong, 1966; Quintin, 1986). Data have been conflicting on the effectiveness of early therapy, but the variance may be partially due to failure on the part of physical therapists to make reliable movement diagnoses, to use precise and quantifiable measures and to implement effective treatment management strategies within the child's first two years. The test items termed "cues selected for the physical examination" part of the video presentation were taken from the work of Harris (1987), who conducted comprehensive longitudinal research concerning the early abnormal movement signs of cerebral palsy. (See Appendix B.) There are elements from four relevant movement variables shown in the video: muscle tone, primitive reflexes, automatic reactions, and volitional movement (Chandler, Andrews, & Swanson, 1980) . In addition, the video began with a patient/parent interview that included the patient history. Physicians indicated that the patient/parent interview was considered critical to early diagnosis in pediatric physical therapy and therefore the video included three related sections:

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57 patient history, physical examination, and volitional movement (Georgieff, Bernbaum, Hoffman-Williamson, & Daft, 1986; Gorga, Stern, & Ross, 1985; Ross, Lipper, & Auld, 1986; Stanley & English, 1986). To establish the validity of the critical cues lists and of the primary problem statement, 10 experts in pediatric physical therapy were asked to participate in identifying key behaviors and in writing problem statements. These results were necessary to obtain in order to compare students' abilities to identify cues and to write primary problem statements with the abilities of the experts in those areas. Development of the Scoring Key Experts were chosen on the basis of the definition offered by Delitto, Shulman, & Rose (1989) . An expert is one who is well informed, highly skilled, and recognized by colleagues in physical therapy as possessing efficient, accurate clinical judgment in a particular specialty area. The expert's judgment should be consistent with the judgment of other experts on similar patient cases. Ten expert licensed physical therapists agreed to assist in the development of the scoring keys for the critical cues list and for the primary problem statement. All were certified in the neurodevelopmental treatment approach to pediatrics. These same 10 therapists were recommended by knowledgeable University of Florida faculty

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58 members in physical therapy. They were also all working full-time as pediatrics practitioners, and two were assistant instructors in the neurodevelopmental treatment approach to enhance the practicing therapists' ability to diagnose and treat pediatric patients. These experts met on two separate occasions. First occasion . On the first occasion experts were shown the video presentation of the pediatric patient evaluation. The same patient and same evaluation procedures were portrayed in the two videos shown to subjects throughout the study. There were two steps taken on this first occasion. 1. The critical cues list. The panel of experts were given a blank form that was headed critical cues list. (See Appendix D.) They were told to write in every cue that they observed while watching the video. After the video was shown, they were asked to review their list of cues and score the cues by placing a (+) by cues that were somewhat important, a (++) by those that were important, and a (+++) by cues that were critically important for one to observe in diagnosing the patient's primary movement dysfunction. There was no opportunity for collaboration among the experts. Nine out of ten experts listed the same eight critical cues. This list of eight expert-generated critical cues was used

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59 ultimately in the critical cues rating lists for experimental study subjects. 2. The primary problem statement. On this same first occasion of the experts participation, the experts were presented with a problem statement form (see Appendix D) . They were asked to each write one statement that indicated the patient's primary problem with movement. Nine out of ten experts wrote contextually similar primary problem statements. Their key words and phrases were used as the basis of the scoring key for the problem statement form. A list of all key words/phrases was developed. The primary problem statement forms of the experts provided the basis for comparison with primary problem statements developed by students later in the course of the study when they watched the video. The researcher questioned the experts about that point in time during the video viewing when they had formulated their original idea about the patient's primary problem. The experts reported that they had formulated their idea almost immediately upon viewing the patient during the patient history segment of the video. This concurred with Barrows and Tamblyn (1980) who reported that experts in medicine stated that they had an immediate idea about the patient's primary problems. The experts formulated their diagnosis within the first seconds of the

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60 doctor-patient encounter. The experts were apparently relying on implicit cues that their knowledge and experience taught them to identify as critical in identifying patient problems. Because the implicit cues list was generated by experts on the critical cues rating list in the patient history section, and because these explicit cues helped the experts write their final problem statements, this list was presented later to the experimental group subjects. Second occasion . On the second occasion, when the experts met they were given another cues form. On this occasion the cues that the patient case video had been formatted to include were contained on a rating list. The cues were drawn from the work of Harris (1987) on physical examination for early identification of cerebral palsy and from the two sections (patient history and volitional movement) recommended by physicians in the literature review. The cues from Harris' work were labeled on the video to avoid confusion. The experts were asked to view the video and to rate the cues using a system developed by Fleisher (1972): (+) if the cue was somewhat important, (++) if the cue was important, and (+++) if the cue was critically important in determining this child's primary problem. The experts placed a +++ score or "critical" score by an average of nine cues on the rating list. Again, this result was in agreement with the finding of

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Barrows and Tamblyn (1980) who reported that experts in medicine usually rated between 9 and 13 cues as being critically important. Of the 10 experts, 90% agreed on eight of these nine cues. After the second occasion, each of the three subsections of the critical cues rating lists was compared across all 10 experts, and cue scores by each of three subsections were averaged by section to form a scoring key. This list was the scoring key against which subjects' ratings were compared. The experts after the two meetings had generated the scoring keys for the two dependent measures in this study. The dependent measures consisted of (a) Critical Cues Rating List with three dimensions, and consequently, three separate scores, and (b) a problem statement list (see Appendix C) . Before student subjects were asked to carry out tasks similar to those asked of experts, the students were given the Myers-Briggs Type Inventory. This measure was used to determine whether personality type influenced students' ability to advantageously use the clinical reasoning process or to recognize certain types of cues. The Mvers Briaas Type Indicator The MBTI, a 126 item, dual-response inventory, measures personal preferences along four dimensions. First published in 1962 by the Educational Testing Service, the MBTI consists of the scales which can be used

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to determine how an individual uses one, two, or more of the four dimensions in relating to his or her environment. The Indicator was designed "explicitly to make it possible to test C. J. Jung's theory of psychological types" (Myers & McCaulley, 1987, p. 11). There is a large data bank indicating that MBTI measures are consistent with Jung's theory. The theory was explained in the statement that "random variation in behavior is actually quite orderly and consistent. It is based upon differences in four dimensions" (Myers & McCaulley, 1987, p. 1). Since its publication, the Indicator has been used in various capacities to assist in explaining personality and behavioral characteristics. Over 250,000 completed protocols to the MBTI have been studied and evaluated by Myers and McCaulley (1985, 1987) . The MBTI has been shown to have reliability and validity. Reliability evidence includes internal consistency, test-retest, and continuous score correlations for each preference type. The validation evidence includes correlation with other instruments measuring similar psychological constructs, some of which are much longer than the MBTI. For the research project in clinical reasoning two mental processes, sensing and intuition, and two styles, judging and perceiving, were supported by the literature as having bearing on individuals' abilities to problem

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63 solve (Burnett & Pierson, 1988; Hunter & Levy, 1982; Lawrence, 1984a, 1984b; Lewis, 1976; McCaulley, 1981; Myers & McCaulley, 1985, 1987; Myers & Myers, 1980). These dimensions were chosen for data collection. The data consisted of responses from each subject for the pilot study, and for the experimental study. Each subject completed the entire Indicator. The MBTI protocol was scored by the Center for Application of Psychological Type. Each subject received a complimentary personality profile compiled by the Center. From each subject's total score the S/N and J/P dimension scores were used in data recording. The first subjects to complete this process were those who participated in the pilot study. The Pilot Study In the time period immediately after the expert panel met on the first occasion, the researcher was informed that the 1988 graduating class of physical therapy students at the University of Florida had agreed to participate in a pilot study. The researcher obtained permission to proceed from the Human Subjects Review Board, University of Florida. Subjects for the Pilot Study The pilot study group consisted of 27 graduating physical therapy students. In order to be considered for the study, students had to be able to complete the video learning experience after they had completed all didactic

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64 and clinical components of their training and before they graduated. The time, consequently, for administering the study was limited to less than one week for all subjects. To make the administration of the MBTI more complicated for the researcher in the pilot study, the availability of the subjects was realized less than three months before they graduated. Since students were away from the University on clinical rotations. Therefore, the MBTI was mailed to participants. All subjects completed and returned the MBTI prior to returning to their university for graduation and viewing of the video. Through the administration of this pilot study the researcher learned how to sequence these tasks of MBTI administration and video viewing cost effectively. Method of the Pilot Study Subjects were randomly assigned to the experimental or control group using a coin toss per name on a list. The experimental group watched the video structured to include the rules of CRP. The control group saw the unstructured pediatric case evaluation. The subjects were given critical cues forms and asked to write in the cues they observed in the video. After completing the writing assignment, they were given time to review the video and rate each cue as: somewhat important (+) , important (++) , or critically important (+++) . The subjects consistently listed the cues that were labeled on the video screen.

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65 They rarely listed the implicit or expert-generated cues, possibly because these were not labeled on either video, but also because they apparently were at a professional level where cues of this nature may have been truly implicit. Such implicit cues may be noticed only by experts . Analyzing the critical cues list from the pilot study group proved to be difficult due to the number of inconsistencies on student forms. It appeared that a scoring key would not relate to the forms. A rating sheet was generated from the list of explicit cues labeled in the video. When the panel of experts met on the second occasion, they established the scoring key by rating each cue (see Appendix D) . The subjects of the pilot study also completed a problem statement form. When key word/phrase agreement on the problem statement form was analyzed visually, comparison could be made easily with the forms filled out by experts. The problem statement form remained unchanged and was later used with subjects in the experimental study. (See Appendix D.) Results of the Pilot Study Subjects who viewed the structured video performed better on problem statement agreement with greater than 75% (N = 10 of 13) of the pilot subjects achieving agreement with the experts. Less than 10% (N = 2 of 14)

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..•» 66 of those viewing the unstructured video achieved this level of agreement. In summary, from analysis of the findings, it was determined that score form changes needed to be made on the critical cues list to increase clarity and ease of administration. It was also determined from the same analysis of findings that the problem statement format was functional for the purposes of the study and did not require changes. In addition, it was also determined that the two independent measures of the study, the instructional videos and the MBTI were acceptable without further change. The Study Implications from the pilot study were that the researcher could continue with the study after making changes in the critical cues history. Therefore, educational program chairman were contacted to make the final arrangements with graduating students in physical therapy in Florida. The student subjects were asked to volunteer to participate in the study and to do so within two to three days of their anticipated date of graduation. Subjects The subjects for the study were volunteers, graduating students from four university physical therapy education programs in Florida. The four programs in physical therapy were located at Florida A&M University

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67 (1) , Tallahasse; Florida International University (2), Miami; University of Florida (3), Gainesville; and the University of Miami (4), Miami. Only the University of Miami graduates were entry-level master's degree students. The other graduates were entry-level bachelor's degree students. University of Miami students graduated in December, 1988, while students from the other three schools graduated in August, 1989. There were 107 graduating students in the Florida physical therapy programs; 90 volunteered; however, 15 were unable to participate at the last minute. A total of 75 volunteers participated . Method A table of random numbers was used to assigned subjects to the experimental or to the control group. Each subject completed the MBTI. The personality dimension scores for all subjects were recorded on the data recording forms. To begin the learning experiment, all subjects in both experimental and control groups were pretested. Each of the four subject groups at the Florida educational programs in physical therapy had a designated date and time for viewing the video instructional models as a group. In the pretest subjects viewed the unstructured video and completed the critical cues rating list (without implicit cues) and problem statement form.

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68 The experimental group reviewed a short instructional sheet that explained the steps in the GRP. Subjects were told to note changes in their critical cues rating list and that the new list included implicit cues generated by experts. They were also told to note the implicit cues and to rate them along with rating the explicit cues. The implicit cues were not included in the data analysis. It was thought that asking subjects to rate these cues would focus student attention on the implicit cues. After they received the instructions, the experimental group subjects were shown the structured video. The control group again viewed the unstructured video. They completed the same answer sheets that were used in the pretests for both groups and waited in their classroom until experimental subjects completed the study. Along with randomization of subjects to control and experimental groups, the pretesting was carried out to eliminate the effects of differences in the prior knowledge and experience of subjects. Pretest scores were used as the covariable in analysis of efficiency measures. The problem statement measure with scores of 0 or +1 could have indicated a +1 when subjects were guessing about patient diagnosis so a pretest covariable was not used in the accuracy analysis. (See Appendix D.)

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69 Data and Recording Analysis Recording After completion of the pretest and posttest viewings, each subject's efficiency scores were recorded next to his or her group and personality dimension variables. Scores for efficiency were divided into three sections. A section score was given for patient history, physical examination, and volitional movement ratings. Each subsection rating was recorded then compared with the experts' ratings to obtain a disagreement point score for the pretest and the posttest. The pretest scores were used as the covariable in a multiple analysis of covariance (MANCOVA 2X2X2). The primary problem statements from the problem statement forms of each subject were analyzed visually for key word/phrase agreement with experts and a score of "0" indicating no agreement or a score of +1 indicating agreement was put into the data recording forms. Problem statement forms were the same for experimental and control groups. In addition to scores from the rating list and problem statement form a student's MBTI S/N and J/P dimension scores were recorded along with each subject's group (experimental or control) and School (i.e., FAMU, UF, FIU, UM) . (See Appendix E for data recording forms.)

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70 Analysis The video structure in CRP represented the categorical independent variable group: E/C, and the personality dimensions represented two additional categorical independent variables: SN and JP. There were three dependent variables represented by the three efficiency scores. These were the variables used in a 2 X 2X2 multiple analysis of covariance to determine the significance of the structured learning experience had on students' efficiency in diagnosing a pediatric patient's movement dysfunction. (See Figure 4.) The problem statement form dichotomous scores of 0 or +1 were analyzed on posttest scores only. A chi-square analysis for nonparametric data was conducted. Personality dimension scores could not be added to the chi-square analysis because a subject sample of 500 or more would have been needed to perform a three-way log linear analysis on nonparametric data. When the study was conceived subject sample considerations were made and it was determined that a subject sample of 500 entry-level physical therapy professionals (or greater than 25% of all physical therapy programs) would not be within the scope of this researcher's capabilities; however, if personality characteristics were normally distributed it was determined that log linear analysis would be valid.

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in 71 (a) Group Personality SN E / /_ C / / N / / / / / y I I !/ / I I !/' / / Personality JP Subjects (r^ to / Experimental \ Control (b) Group 0 1 Posttest Accuracy Figure 4 . Experimental design. (a) 2X2X2 MANCOVA with pretest scores as covariable and efficiency scores 1, 2, 3 as dependent variables; (b) Chi square table (personality dimensions not included due to insufficient N) .

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72 SummarY The purpose of this study was to determine the effects of using the CRP as a teaching tool for entrylevel physical therapy professionals. The relationship between two personality dimensions and successful use of this problem-solving paradigm was investigated in an effort to identify students who would benefit from being taught to use explicitly structured rules of the clinical reasoning process. To do so, two instructional videos were generated. One included an explicitly structured analysis of a patient evaluation according to the rules of the CRP, and the other showed the same evaluation without rules (unstructured) . In the unstructured video there were no cues given to the viewer to help in organizing problem solving strategies along a specific path. Seventy-five subjects from the four Florida programs in physical therapy volunteered to participate. They were given the MBTI, and two dimension scores were recorded for each subject on the data recording forms. Subjects were pooled across all four programs and then randomized to an experimental or a control group using a table of random numbers. All subjects participated in a pretest and a posttest experience and generated scores for: (a) a critical cues rating list and (b) a problem statements form. Scores from the list and the form were recorded in

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the data-recording forms along with the subjects' personality dimension scores (see Appendix E) . Data on efficiency scores were analyzed using a 2 X X 2 multiple analysis of covariance while analysis of accuracy scores was done using the chi-square technique for nonparametric data. Results obtained through the analysis are reported in the next chapter.

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CHAPTER IV RESULTS Objectives of the Study The results reported in this chapter were obtained from a research study carried out from October 1988 through August 1989 and based on a pilot study done in August 1988. There were three objectives of the study. The first objective was to investigate whether experimental and control groups differed in their ability to rate efficiently cues that experts verified as being observable in the video and important to patient diagnosis. If they did differ, an investigation was conducted to determine whether the differences were based on watching a video edited to facilitate use of the clinical reasoning process. The second objective was to investigate whether there was a relationship between two personality dimensions and successful use of this problemsolving paradigm known as GRP. The third objective was to investigate the subjects' ability to accurately diagnose a pediatric patient movement dysfunction, and to determine if experimental subjects differed as a result of viewing a 74

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75 video edited to facilitate use of the clinical reasoning process. The study was conducted out in five steps: (a) statement of the hypotheses, (b) instrumentation including development of the videos and the scoring keys, (c) administration and scoring of the MBTI, (d) conducting the learning experiment, and (e) data analysis. There were three research questions and consequently three hypotheses generated to satisfy the objectives of the study. Data analyses were performed to answer the research questions and to establish rejection or acceptance of each of the three hypotheses. Research Questions 1. Can instruction in the method known as the clinical reasoning process that experts use to diagnose patient movement dysfunction affect entry-level physical therapy students' ability to rate patient movement behaviors efficiently? 2. Will there be an affect of students' personality dimensions or characteristics and instruction in the use of the CRP on the way students efficiently rate patient cues? 3. Can instruction in the method of experts (CRP) assist entry-level (preservice) physical therapy students to accurately diagnose a patient's primary problem with

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76 movement, so that student's key words/phrases agree with those of experts? H ypotheses The three hypotheses tested (stated in null form) were as follows: Hypothesis 1: There will be no significant difference at the .05 level between the mean scores of the experimental group and the control group on diagnostic efficiency (Critical Cues Rating List) based on: efficiency score 1 — patient history, efficiency score 2 — physical examination, or efficiency score 3 — volitional movement . Hypothesis 2: There will be no affect at the .05 level of personality dimensions or structure in instruction on diagnostic efficiency scores in three areas: patient history, physical examination, or volitional movement. Hypothesis 3: There will be no significant difference at the .05 level between the mean scores of the experimental and the control group between key phrase agreement of students and experts on a primary problem statement. The primary problem statement was used to represent the diagnosis of the patient's primary movement dysfunction.

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Findings are discussed as they relate to the objectives, research questions, and hypotheses of this study . Objectives To fulfill objective one, an experimental and a control study group of volunteer graduating physical therapy professionals viewed the videos. Half of all subjects (control group) viewed the unstructured video and the other half (experimental group) viewed the structured video. The experimental study group responded to one of two critical cues lists and those responses were analyzed to establish an efficiency score for each subject. (See score forms in Appendices C and D.) To fulfill objective two, each subject completed the Myers Briggs Type Indicator prior to the video learning experiment. Their preferences on the S/N dimension and the J/P dimension were recorded (see Appendix A) . These scores were entered in to a multiple analysis of covariance with the efficiency scores in order to satisfy objective two. (See data recording forms in Appendix E.) To fulfill objective three, subjects from the pilot study and the experimental study groups completed the problem statement form. The primary problem statement on these completed forms was compared for key word/phrase agreement with experts.

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78 Research Questions and Hypotheses To answer research questions one and two a 2X2X2 MANCOVA was used and two personality dimension scores along with pretest scores (covariables) were entered into this analysis. Results of the analysis established that the answers to research questions 1 and 2 were "no" and that null hypotheses 1 and 2 continued to be accepted. To answer research question 3 and hypothesis 3 a chisquare analysis was performed on posttest only scores from the problem statement scores. Results of this analysis related to question 3 and established that null hypothesis 3 should be rejected. Expanded results from the work with the panel of experts and formal experimental study groups are presented here. Both pilot and major study findings appear in relation to each question. Development of the Scoring Key Occasion One: Experts On occasion one, experts listed all the cues that they observed in the video. An implicit list of cues was generated from the cues consistently listed. Eight cues were consistent across 90% of the 10 experts. These eight cues were considered implicit. (See Appendix D for the Critical Cues Rating List for the experimental group subjects. )

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79 Occasion Two: Experts There were three sections to both video patient evaluations. Experts rated each subsection as to the importance of each individual cue that they saw in the video. Cues were rated as (1) somewhat important, (2) important, (3) critically important, or (4) don't know (if it is important) . There were no (4) ratings among the experts but it was anticipated that some students may want to use this category if they could not see the relevance of a cue and its • importance in making a patient diagnosis. Therefore, the category was inserted in the Rating List prior to the experts* ratings. Experts rated the critical cues list by subsection and a subsection score was obtained by averaging the experts' scores to obtain a mean score per subsection (see Table 2) . Experts' Agreement Scores Based on Cues Generated from the Work of Harris (1987) Table 2 Efficiency Score Subsection Label Experts ' Mean Score 1 Patient History (8 cues) 16.2 2 Physical Examination (16 cues) 35.5 3 Volitional Movement (2 cues) 5.7

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80 Accuracy/Problem Statement Form Occasion one: Experts . After viewing the video experts were asked to fill in the problem statement form. The video screen contained instruction on filling in the form. Experts completed the problem statement form. Conceptual agreement about the primary movement dysfunction was obtained across 9 of the 10 experts (see Table 3) . Key words/phrases were taken from the statements of the nine experts who were in agreement. Occasion two: Experts . The problem statement form generated from occasion one were sufficient for development of the key for accuracy. There was no need to again elicit responses from the experts on occasion two. Pilot and Experimental Study Groups Efficiency scores: Pilot study group . Results from the original pilot study group were explained in Chapter III because these results were used to further develop the critical cues rating list (efficiency score form) and should be considered as part of the methodology of the study (see Chapter III) . Efficiency scores: Experimental study group . Scatter plots were generated from the efficiency scores on each of the three subsections: 1 — patient history, 2 — physical examination, and 3 — volitional movement.

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81 Table 3 Results ; Expert Panel ' s Problem Statements Expert • s Number Expert's Problem Statement 1* The child has a problem with movement coordination showincj fluctuations in tone. but more on spastic side. 2 This child's main nroblem is with trunk postural tone. 3 This child's main problem is with proximal strenath and control . 4 Underlying low tone. 5 This child's primary problem with movement is her increased tone in extremities, decreased tone in trunk. 6 Poor trunk control with associated pelvic instability. 7 Linden has low trunk tone. 8 The patient exhibits primarily low-tone characteristics . 9 Primary problem is lack of trunk and lower extremity control. 10 Linden has a low tone base. *Only one of the 10 experts did not agree that the primary movement problem is based upon one of these key phrases: (1) trunk postural tone, (2) proximal strength and control, (3) underlying low tone, (4) decreased tone in trunk, (5) poor trunk control, (6) lack of trunk control, (7) low trunk tone, (8) low tone characteristics, and (9) low tone base.

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82 Efficiency score — patient history . There were four outliers, that is, subjects who had statistically significant differences between their pretest and posttest scores because their change or difference scores were more than two standard errors away from the group mean. Of these subjects, three were from the experimental group and one was from the control group. Two experimental group subjects and one control group subject increased their disagreement with experts, while one experimental subject made a drastic improvement and improved the agreement with experts (decreasing from a disagreement point score of 6.8 to a score of 1.0). Interestingly, all four outliers on efficiency score — patient history were students from the same program in physical therapy at School (1) . See Figure 5. Efficiency score — physical examination . There were three outliers and all were experimental group subjects. One subject significantly improved in agreement with experts, while two significantly increased their disagreement scores. This means that the improved student had pretest scores of more than two standard errors away from the mean and decreased the error to within one standard error of the mean. Two outliers (one who improved and one who regressed) were students from School (2) , while the other subject who regressed attended School (1) . See Figure 6.

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83 6 o • o o o o • o o o o (0 >, mo 900 0 o o o • E UJ o • o 3 m 0) o « /—V * O (O) • O • • © © (•) • o o •t I I I t t I I iV t I I I I I I I I I I M I I I I I I I I b A OB '<» b b b b b to b b '-^ b Pretest Efficiency Score Figure 5 . Scatter plot for efficiency score — patient history; • indicates experimental group scores, o indicates control group scores, and a circle aroxind the dot indicates an outlier score.

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84 21.5 r18.5 © 15.5 (D I'" o I 9.5 it UJ 0 6.5 V) O Q. 3.5 0.5 • O O O O O O O OO O O • O • O O • o o o • • o • • o • o o o • o © ± ± ± © 0.0 2.5 5.0 7.5 12.0 15.0 17.5 Pretest Efficiency Score J 20.0 22.5 Figure 6 . Scatter plot for efficiency score — physical examination; • indicates experimental group scores, o indicates control group scores, and a circle around the dot indicates an outlier score.

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85 Efficiency score — volitional movement . There were two outliers who increased in their disagreement with experts between pretest and posttest situations. These students had functioned on the posttest with scores that were greater than two standard errors away from the mean. Both were control group subjects from School (1) . See Figure 7 . With the outlier scores included, the variances remained homogeneous. The slopes for all three efficiency scores were also homogeneous. See Table 4. Adjusted means and standard deviation scores were generated by group, by personality dimensions and by school. The posttest scores were adjusted relative to pretest scores on each efficiency measure. See Tables 5, 6, and 7. Frequency distribution bar graphs provided a better visual comparison of the data between pretest and posttest for the experimental and the control group subjects, because actual pretest versus posttest score averaging, that is adjusted means and standard deviations, masked some differences between groups. Efficiency score — patient history . Experimental group posttest scores were in greater disagreement with experts, while the control group improved in ability to observe cues, agreeing more with the experts. The normally distributed graph of pretest scores became

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86 2.3 2.1 1.9 1.7 0) L. o O 1.5 (0 o t= 1.3 o £ LU (0 0 1.1 0) o Q. 0.9 0.7 0.5 0.3 © 0.2 0.4 1 I 0.6 0.8 1.0 1.2 Pretest Efficiency Score 1.4 1.6 1.8 Figure 7. Scatter plot for efficiency score — volitional movement. There was more than one sxibject in the experimental group indicated by the •, however, this single dot represents the scores of this group. As can be seen control group (o) subjects varied widely and two subjects were outlier (circle around the dot) .

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87 Table 4 Homogeneity of Slopes Source DF F PR > F a. EFFICIENCY — Patient History Pretest Efficiency Score 1 * Group 1, 62 .89 .3485 Pretest Efficiency Score 2 * Group 1, 62 .04 .8441 Pretest Efficiency Score 3 * Group 1, 62 .31 .5785 b. EFFICIENCY — Physical Examination Pretest Efficiency Score 1 * Group 1, 62 0 .00 .9948 Pretest Efficiency Score 2 * Group 1, 62 1 .21 .2749 Pretest Efficiency Score 3 * Group 1, 62 .34 .5629 c. EFFICIENCY — Volitional Movement Pretest Efficiency Score 1 * Group 1, 62 1 .20 .2766 Pretest Efficiency Score 2 * Group 1, 62 .75 .3901 Pretest Efficiency Score 3 * Group 1, 62 .09 .7630

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88 Table 5 Efficiency Score 1 — Patient History Adjusted Means and Standard Deviation Disagreement Scores by Group. Personality Dimension, and School for Posttest Posttest Mean Standard Deviation Groups : Control 2.43 .299 Experimental 3.02 .311 Personality Dimensions: Intuitive 2.91 .279 Sensing 2.54 .335 Judging 3.02 .269 Perceiving 2.45 .357 Schools: (1) 3.13 .351 (2) 2.95 .455 (3) 2.15 .356 (4) 2.69 .603 Note. Lower scores indicate higher agreement with experts .

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89 Table 6 Efficiency Score 2 — Physical Examination Adjusted Means and Standard Deviation Disagreement Scores by Group. Personality Dimension, and School for Posttest Posttest Mean Standard Deviation Groups : Control 5.53 .596 Experimental 5.98 .621 Personality Dimensions: Intuitive 6.06 .559 Sensing 5.45 .669 Judging 6.19 .538 Perceiving 5.33 .714 Schools: (1) 5.07 .703 (2) 6.13 .910 (3) 4.54 .712 (4) 7.30 1.210 Note. Lower scores indicate higher agreement with experts.

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90 Table 7 Efficiency Score 3 — Volitional Movement Adjusted Means and Standard Deviation Disagreement Scores by Group ^ Personality Dimension, and School for Posttest Posttest Mean Standard Deviation Groups : Control .613 .119 Experimental .716 .124 Personality Dimensions: Intuitive .741 .112 Sensing .588 .134 Judging .633 .108 Perceiving .697 .143 Schools: (1) .916 .141 (2) .638 .182 (3) .549 .142 (4) .556 .241 Note. Lower scores indicate higher agreement with experts .

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91 positively skewed in the efficiency posttest — patient history for the control group. (See Figures 8 and 9) . Efficiency score — physical examination . Neither the experimental nor control groups changed between pretesting and posttesting. (See Figures 10 and 11.) Efficiency score — volitional movement . All patterns showed a bimodal distribution because there were only two scorable observations in this data set. (See Figures 12 and 13.) Experts' scoring for both observations averaged a point score of 5.7. The bimodal results of the subject groups showed that either both control and experimental groups were very close to agreeing with experts and thus had a low disagreement score (range ,3 to .7) or they were completely out of touch with expert opinion and had a high disagreement score range (1.6 to 2.25). Four control-group subjects did not know the importance of the volitional movement efficiency score observations at the time of the posttest, while six experimental subjects scored the same on the posttest. Over and above these indecisive subjects, in general, control and experimental subjects aligned with the experts and were relatively efficient at observing the importance of these volitional movement cues .

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1084co o CO N=a % 10.67 N=5 % 6.7 N=6 %a.oo N=7 % 9.33 N=2 %2.67 N=0 % O.OO Si E 1086N = 7 %9.33 4 2 Posttest N'9 »/o 12.00 N=7 %9.33 N=6 %8.00 N»4 %S.33 N>3 %4.00 N=2 %2.67 1.5 23 33 4.5 5.5 6.5 Disagreement Point Score Figure 8. Patient History — Experimental Group, Frequency distribution bar graph of pretest/posttest scores on efficiency score (1) .

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CO -4— ' o .© CO 12108 642N = I2 %I6.00 Pretesr N=7 % 9.3 3 N=8 % 10. S7 N=5 %6.S7 M = Z N = 2 %Z-67 %2.67 N=i % 1. 33 ^ 12-. O E 103 8642ON = I4 % 18.67 Posttest N=7 %9.33 N=5 %6.67 N=4 N=4 %5.33 %5.33 N = 3 % 4.00 N=0 % 0.00 0.5 1.5 2.5 3.5 4.5 5.5 6.5 Disagreement Point Score Figure 9 . Patient History—Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (1) .

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14 -| 1210864203 •— > o 0) CO o 5 14 ii2%I8.S7 94 N= 9 % 12.00 N>9 %9.33 N=€ o/eS.OO %l.33 N=0 H-0 "VoO.OO %0.00 %l.33 loH 8642N3l3 % r.7.33 Posttest N = I2 «/e 16.00 N-6 %8.00 N=4 %5.33 N>2 %2.67 N^O
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95 864co CO 0 H— o N = !2 N=' %iS.O; 0-.-or-£ N38 %I0.67 N*6 %8.00 N»0 N^O NsO p^o.oo %o.oo %o.oo E 3 108642O N3|4 Posttest %I8.67 N«l I %I4.67 N'lO N>l N^l N^O N^O %l.33 %J.33 %0.00 %0.00 1^ 4.5 7.5 10.5 13.5 16.5 19.5 Disagreement Point Score Figure 11. Physical Examination — Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (2) .

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%36 .CC 2520-^ 15-^ loco « ° o © 25-1 E 50 N=7 %9.33 N=0 N=0 •/oO.OO %0.00 %0.00 N=2 N-2 N=o %2.S7 %2.S7 0.4 0.6 0.a 1.0 1.2 1.4 1.6 N«22 ^29.33 Posttest N'9 %l2.0O N«6 %a.oo N*0 %0.00 N'l %l.33 N'O N>0 I 1 ^0.00 %o.oo a45 0.75 1.05 1.35 1.65 1.95 Disagreement Point Score 2.25 Figure 12. Volitional Movement — Experimental Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (3) .

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CO o (D n CO 12108642. Pretest %30.s: N=8 %I0.S7 N = 0 N=0 N=0 •/oO.OO %O.0O %0.00 H-A •/o5.3 3 N=2 "Vo2.67 0.4 0.6 0.8 1.0 1.2 1.4 1.6 0 iio-^ 8642O N = 23 %30.S7 Posttest N»9 12.00 N'4 N'O %l.33 N'O N>0 %0.00 I ) %0.00 ^O.OO 0.45 0.75 1.05 1.35 1.65 1.95 2.25 Disaareement Point Score Figure 13 . Volitional Movement— Control Group. Frequency distribution bar graph of pretest/posttest scores on efficiency score (3) .

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98 Although the bar graphs show some change for all three efficiency scores on pretest versus posttest, the subjects across experimental and control groups were in agreement with the experts. The range of scores was not wide (8-32 points on efficiency score — patient history (1) , 16-64 points on efficiency score — physical examination (2) , and 1-8 points on efficiency score — volitional movement (3)), experts scored near mid-range with mean scores of 16.2, 35.5, and 5.7, respectively, and subjects in general had low mean disagreement point scores. Because range limitations existed and many of the score distributions were positively skewed the power of the Mancova was anticipated to be decreased (see Figures 9 through 12) . Mvers-Briqqs Type Indicator The Myers-Briggs Type Indicator (MBTI) was used to determine the two personality dimensions involved in the study S/N and J/P. These two variables were entered into the analysis along with efficiency scores after the learning experiment was completed. The following section was devoted to explanation of personality dimension scores for the 1988-89 graduating entry-level physical therapy students in the state of Florida. All subjects were given the MBTI which was scored by the Center for Application of Psychological Type (CAPT, University of Florida, Gainesville) . Personality

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dimensions were obtained for all sections of the MBTI to render a type score for each subject and a problem-solving dimension score for each subject (see Table 8) . The type scores were reported for the interest of the reader. The problem-solving dimension scores of S versus N and J versus P were recorded for study purposes. Descriptive statistics of the combined dimensions, that is SJ, SP, NJ, NP, showed an unequal proportion: 37.3% SJs to 9.3% SPs. However, only separate dimensions were submitted for analysis and cell distributions for each single dimension proved to be statistically sufficient (see Tables 9 and 10) . Table 8 Student MBTI Profile Table No. School Type Sex Problem Solving Dimension 0013 (1) ISTP M SP 0027 ENFJ F NP 0004 ISFJ F SJ 0029 ISTP F SP* 0028 ISTJ M SJ 0016 ESTJ M SJ 0023 ISTJ M SJ* 0001 ENTJ M NJ 0025 ENFP M NP 0007 ISTP M SP 0005 ENTP F NP 0021 ENFJ F NJ 0017 ENTJ F NJ 0020 ISFJ F SJ 0008 ENFJ M NJ 0024 ENFP F NP 0015 ESTP F SP 0012 ENFP F NP

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100 Table 8 — Continued. No. School Type Sex Problem Solving Dimension \J\J £t £t \ / £ior u Q.T ou n m n U U X u £jO XU Q.T ou KJKJKJ O xor u P ou nm 1 VJ L/ J. X IjO xu P ou nm 4 Hi O 1/ i M C!P nm R TNPP Xil £^ XT P NP li i:^ nnnQ xxi r u P N.T llU nn? fi ^ \j TNTP xn X £^ M NP nm Q W \J X -7 TNTP xxi X P NP* VJ \J VJ D PMTP HjIi X p NP nnn"? U VJ VJ ^ XO XU p r C T Ou nm 1 ( '>\ P NP 0008 X O X u M Q.T ou 0017 ESTJ F SJ 0005 INFJ F NJ 0015 P ou 0009 ENFlT P X N.T liU 0004 ISFJ F X «;j* ou 0016 FNT.T P NT INU 0007 F
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101 Table 8 — Continued. No. School Type Sex Problem Solving Dimension 0003 (3) ESFJ F SJ 0009 ENFJ F NJ 0022 INFJ F NJ 0020 ESFJ F SJ 0021 ENTJ F NJ 0007 ESFP F SP 0001 INFP F NP* 0005 INFJ F NJ 0006 ENFP F NP 0019 ISTJ F SJ 0026 ENFP F NJ 0024 ISFJ F NP 0015 ENFJ F SJ 0025 ENTP F NJ 002 (4) ENTJ F NJ 003 ENTJ F NJ 008 ESFJ F SJ 009 INFP F NP 014 ENFJ F NJ 001 ENTP F NP 005 ISTJ F SJ 007 ISTJ F SJ 013 ESTP M SP Indicates a volunteer who did not show up for the study. Note. Combined %: N = 37.3% SJ 9.3% SP 26.7% NJ 26.7% NP Although the subjects were not randomized by personality dimension, frequency distributions were obtained to check for equal sample size by personality dimension. Sample size equality was achieved statistically for both dimensions (sensing versus

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102 intuitive type subjects and judging versus perceiving type subjects) . See Tables 9 and 10. In the control group there were 54.1% N and 45.9% S subjects. In the experimental group there were 52.6% Ns and 47.4% Ss. In the control group 56.8% were Js and 43% were Ps, and in the experimental group 71% scored as Js and 29% as Ps. Table 9 Group SN by Number of Subjects Per Cell and by Percent of Subjects in Cell Intuitive Sensing Total 1 Control N = 1 20 N = 1 17 N = 37 % = 26.7 % = 22.7 % = 49.33 Experimental N = 20 N = 18 1 N = 38 % = 26.7 % = 24 % = 50.67 Total N = 40 N = 35 1 N = 75 1 % = 53 . 3 1 % = 46.7 1 % = 100.0 Results; Accuracy Scores Frequency score distributions per cell in the 2X2 chi-square table can be seen on Table 11. In the control group 78.4% of the subjects had a posttest score of 0 and 21.6% had a posttest score of 1, while in the experimental group 32.4% of the subjects scored 0 and 67.6% scored 1.

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103 Table 10 Group JP by Number of Subjects Per Cell and by Percent of Subjects in Cell Judging Perceiving Total Control Experimental Total N = 21 1 N 1 16 N 37 % = 28 % 21.3 % 49.3 N = 27 1 N 11 1 N 38 % = 36 % 14.7 % 50.7 N = 48 N 27 1 N 75 % = 64 % 36 % 100.0 Table 11 Frequency Distribution for Control and Experimental Groups Posttest Scores 0 1 Control Group N = 29 N = 8 % = 78.4 % = 21.6 Experimental Group N = 12 % = 32.4 N = 25 % = 67.6

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104 Results; Research Questions 1 and 2 and Test of Hypotheses 1 and 2 A 2 X 2 X 2 MANCOVA was used to analyze the difference between groups on three factors: group E/C; S/N (sensing versus intuition) ; and J/P (judging versus perceiving) . Pretest scores on the efficiency measures were the covariables. The dependent variables were the efficiency posttest scores. The MANCOVA was performed to determine whether there were differences in the overall efficiency scores of the control and experimental groups based on the teaching tool (structure) , whether there would be an affect based on the MBTI personality dimensions or a combined affect of teaching tool (structure) and personality dimensions on subject efficiency in evaluating pediatric movement dysfunction. There was no significant difference between the two groups in change scores (Wilk's lambda = .9595, p > .45). The affect of personality dimensions and teaching tool were not significant (SN dimension Wilk's lambda = .9714, p > .60; JP dimension Wilks' lambda = .9598, p > .46). The pretest scores for efficiency patient history, and physical examination scores were related to posttest scores and consequently were reliable measures to use as covariables, while efficiency volitional movement scores were related to posttest scores. Only two scorable observations were included in this test rendering it

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105 inadequate in number of observable responses and inadequate as a reliable measure for the study. (See Table 12.) Table 12 2X2X2 MANCOVA Table Source Wilk's lambda PR > F Group .9595 .4532 SN .9714 .6052 JP .9598 .4571 Covariates: Pretest Efficiency 1 .7636 .0007* Pretest Efficiency 2 .8792 .0426* Pretest Efficiency 3 .9560 .4142 The MANCOVA was performed using Wilks' criterion to analyze the overall differences among the three grouping factors. This multivariate test showed no difference between factor groupings. Using a preestablished alpha level of .05 led to failure to reject Hypotheses 1 and 2 (at alpha < .05): (a) Hypothesis 1: There will be no significant difference at the .05 level between the mean scores of the experimental group and the control group on diagnostic efficiency (Critical Cues Rating List) based on patient history efficiency score 1, physical examination

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106 efficiency score 2, or in volitional movement efficiency score 3; (b) Hypothesis 2: There will be no combined affect at the .05 level of personality dimensions or structure in instruction on diagnostic efficiency scores in three areas: patient history, physical examination, or volitional movement. After the MANCOVA was performed the accuracy scores were analyzed using the chi square method. Results: Research Question 3 and Test of Hypothesis 3 A chi square analysis was used to analyze the posttest by group (E/C) scores for accuracy. A score of "1" indicated key phrase agreement with experts and a score of "0" indicated lack of agreement. One hypothesis was applicable to the chi square test in this study: Hypothesis 3: There will be no significant difference at the . 05 level between the mean scores of the experimental and the control group between key phrase agreement of students and experts on a primary problem statement. (The primary problem statement was used to represent the diagnosis of the patient's primary movement dysfunction.) To have included personality dimensions in this nonparametric analysis using Fienberg's (1980) saturated model for data would have rendered a three-way log linear table 2X2X2 with up to two-way interactions. A model of this complexity would be appropriate for data sets with a subject sample much greater than the size in this study (i.e., N > 500); however, with statistical equality in the

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107 two personality dimensions achieved it may have been possible to establish sufficient numbers in each log linear cross classification. This did not occur because of the 90 original volunteers there were 15 who dropped out of the study. Of those who dropped out or did not appear for the study there was a high proportion of Ss (N=6) and Ps (N=8) . Chi-square analysis was, therefore, performed to analyze posttest by group cross classifications for each cell (Table 11) . The test statistic chi square model was = 2 E F^, log (F^, /Fg) . Based on Fienberg, this model would be an appropriate analysis for testing hypothesis 3. The chi-square statistic was significant for a posttest difference between groups (X^ = 9.13; p < .0025). (See Table 13.) Null hypothesis 3 was subsequently rejected. It was determined that training in the use of the CRP did improve Florida entry-level physical therapy students' ability to accurately diagnose this pediatric patient's primary movement dysfunction. (See Tables 12 and 13.) Summary The results indicate that although entry-level physical therapy students did not appear to improve significantly in their ability to understand the importance of the cues that they observed during pediatric patient evaluation these students did improve

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108 Table 13 Chi Square Analysis Source Df Chi Square (x') Pr > Intercept 1 .25 .6200 Posttest Scores Accuracy 1 9.13 .0025* significantly in their ability to recognize and identify the patient's primary movement dysfunction. This second skill can be recognized by professionals in medicine and physical therapy as diagnostic accuracy. The ability to accurately diagnose is the initial step in patient management. Patient diagnosis is a critical skill for physical therapists due to increased autonomy of practitioners as a result of changes in the delivery of health care. Personality dimensions or characteristics did not appear to be a relevant variable as to the students' abilities to observe and understand the importance of clinical cues. Despite the repeated mentioning by researchers in the past of the phenomenon of personality characteristics and their relationship to problem solving, such a relationship was not established in this study.

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109 The personality characteristics of student physical therapists upon entering the profession may have undergone changes along with the changes in cognitive development that allow the entry-level therapist to accept problemsolving exercises with greater ease and improved open mindedness regardless of the therapist's preferred learning mode based on personality characteristics. The results of this study do have implications for the individual entry-level therapist, the profession and the academic and clinical portions of physical therapy educational programs. Implications also exist for further research into the area of clinical reasoning and further exposure of the student to the strategies of the GRP. The implications and directions for research are presented in the next chapter.

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CHAPTER V DISCUSSION In this chapter a discussion of the study, including the background, subjects, purpose, and findings is presented. This discussion provides a basis for determining the implications of the findings for educators planning instructional programs for physical therapists, for students, and for entry-level physical therapists, and for the profession at state and at national levels. Directions for future research are also offered. Discussion of the Study A physical therapy patient evaluation traditionally has been carried out by a physician's referral that determined which tests would be given, and then the physician used the results to plan the patient's treatment. This traditional practice has changed to allow physical therapists more autonomy in decision making about patient care, subsequent to the changes in state licensure laws. As a result of decision making autonomy, practitioners in physical therapy are finding that their profession now places increasing demands upon them. 110

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Ill Professional physical therapists are being called upon to take increasing responsibility in diagnosing patient problems. In 48% of the states physical therapists now have full responsibility for patient care. In most states physical therapists are establishing private practices independent of the hospital setting, thereby incurring more responsibility and liability. The role of the therapist has become one of decision making about the tests to use in evaluation, conducting the tests, determining the nature of the patient's primary problem and the cause of that problem. In the next phase of analysis the therapist plans treatment. Furthermore, physical therapists are faced with increasing complexity in their decision making. Medical practitioners in the computer age are being given greater amounts of information they must consider in analyzing patient problems. One response in the profession of physical therapy has been to create specialties to allow individuals to become proficient in one area of practice such as pediatrics. It is imperative that the physical therapist in this specialty who is working independently of direct physician supervision be able to diagnose the patient's primary dysfunction with movement and then integrate that diagnostic information into treatment planning and implementation.

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112 Previous studies have shown that while some practitioners efficiently and accurately diagnose immediately upon beginning their professional practice, others did not (Barrows & Tamblyn, 1980; May & Newman, 1980) . Some never appeared to have developed the strategies they needed to determine the diagnosis. Traditional instructional programs have not provided information about these strategies to students. The question for physical therapy faculty who plan instructional programs for student physical therapists was whether a specific set of cognitive strategies in clinical diagnosis could be taught and, if so, to whom should these strategies be taught? All entry level students in this study were treated as novice learners. Despite the fact that School (4) has an entry level master's degree program and all others were entry level bachelor's degree programs, no significant differences were found that would indicate School (4) students performed better. Researchers have shown that there are reasoning strategies underlying efficient, accurate patient diagnosis that some physicians and physical therapists employ. An entire issue of Physical Therapy (Vol. 69, number 7, 1989) was dedicated to the "proceedings of the APTA Conference on Clinical Decision Making in Physical Therapy Practice, Education, and Research." One set of strategies related to clinical decision making that this

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113 researcher found reported in the medical literature was the CRP (Barrows & Tamblyn, 1980) . The purpose of this study was to determine the effects of using the CRP as a teaching tool for entrylevel physical therapists. The relationship between two personality dimensions and successful use of this problemsolving paradigm was investigated in an effort to identify students who would benefit from being taught to use the explicitly structured rules of the CRP. The study was focused on skills relevant to the specialty of pediatrics. Summary of the Procedures The subjects were 75 graduating physical therapy students from the four training programs in Florida. All subjects completed the Myers-Briggs Type Indicator and two of their personality dimension scores were recorded on the data recording forms. Personality dimensions Sensing versus Intuitive and Judging versus Perceiving were equally distributed throughout the experimental and control groups despite the fact that the subjects were not randomized based on the personality dimension facts. All subjects were pretested by viewing a video that presented a pediatric case for diagnosis. They completed a rating list of cues that was important in diagnosis of the case. They next wrote a problem statement. The control group repeated these steps a second time. The experimental group viewed a video that had been structured

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114 to include the strategies of the GRP. They filled out the critical cues rating list and wrote a problem statement. The scores of all subjects on the critical cues rating list were determined by comparison with the scores of a panel of experts in the area of pediatric diagnosis. These scores were recorded as efficiency scores which were divided into three sections. A section score was given for patient history, physical examination, and volitional movement ratings. Each section rating was compared with the ratings of the panel of experts and a point disagreement score was obtained on both the pretest and the posttest. The pretest scores were used as the covariable in a multiple analysis of covariance (MANCOVA 2x2x2). (See Figure 5.) The efficiency score analysis was not significant for comparison between groups (Wilks* Lambda = .9595 p > .45) or for personality dimension S/N or J/P (Wilks' Lambda = .9714 p >.60; .9598 p > .46). Efficiency scores were positively skewed in general in both experimental and control groups. This occurrence decreased the power of the analysis by violating the homogeneity of variance assumption. The scores from the accuracy measure were determined by matching key words/phrases from the students' forms with those from the experts' scoring key. A score of zero represented lack of key word/phrase agreement and a score of 1 represented key word/phrase agreement with experts.

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115 Diagnostic accuracy was analyzed using a chi square analysis for nonparametric data. The accuracy score analysis was significant (X^ = 9.13; p < .0025). Summary of the Findings There was no significant difference in efficiency in patient diagnosis subsequent to instruction in use of the GRP. There were also no significant relationships between use of the CRP and personality dimensions or characteristics as seen from the multiple analysis of covariance results. The students did, however, significantly improve in the accuracy of their diagnosis of pediatric movement dysfunction. This finding that diagnostic accuracy did improve has implications for the individual entering the practice of physical therapy, for the professionals in practice, and for the educators planning instructional programs. Implications Diagnostic accuracy in a pediatric case improved for entry-level physical therapy students in the four educational programs in Florida when the subjects were provided with a set of processing strategies in an instructional video of a pediatric case evaluation. Their ability was measured against that of expert practitioners in the field. Pediatric diagnosis of movement dysfunction is a complex process that is not learned easily. Traditionally, entry-level physical therapists have not

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116 been expected to acquire these skills soon after they graduate. However, with many therapists now practicing away from direct physician supervision, there is a need for them to be able to accurately diagnose. For those subjects who do not automatically use the particular set of problem-solving strategies identified by research as contributing to the ability to accurately diagnose, training in use of the CRP before graduating can provide assistance to them in becoming accurate diagnosticians of pediatric patients. This information can be incorporated by educators into the educational programs in Florida because the subjects were representative of the four programs in Florida, each of which had differences in didactic and clinical training components. The students can develop the ability to accurately diagnose, preparing them for some decision-making practices in pediatric physical therapy. The entry-level practitioners who have received this training, including those working independently of supervision, will be more competent and more confident, knowing they have achieved a level of ability in identification of patient problems similar to the level exhibited by experts. More competent and confident professionals will improve their ability to know when they can or cannot achieve success with a patient.

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117 The increased competence and confidence of recent graduates within a specialty of the profession is especially important in a time when lobbying to achieve autonomy in practice has begun in many states. This autonomy may well be a reality in the 1990s in all states. Florida is a leading state in population growth. The actions of this state have national implications. If Florida physical therapy faculty members incorporate the CRP with its potential for improving instruction in pediatric diagnosis, and the ability of Florida graduates to accurately diagnose rises accordingly, these actions may attract national attention. Directions for Future Research There are a number of directions for future research. These include extending the study to physical therapists in other states, to specialties other than pediatrics, and to investigations of personality factors through using larger subject samples. The findings of this study involved only Florida physical therapy educational programs and problem solving in pediatrics. The investigation of personality factors was not based on a large enough sample to draw conclusions. In the future, researchers could investigate each of the areas of the MBTI. In this study after instruction in use of the CRP, problem-solving ability improved, allowing entry-level

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118 physical therapists to determine causes of complex patient problems accurately. Physical therapists in training programs in other states could be subjects in further testing employing the structured video and other instruments. If the results are replicated, then instructional programs could be modified to incorporate the findings. Physical therapists in other specialties may also benefit from training in the CRP. Researchers in other areas such as post surgery, orthopedics, geriatrics, etc. could investigate by testing in the manner employed in this study. Further research should include a replication of the study with a larger sample size in different components, i.e., varied clinical settings and with different types of patient cases. A sample size of 500 or more may be necessary to include personality dimensions into a nonparametric analysis. The large subject sample would be necessary because in three of the four schools admissions selectivity in regard to personality dimensions was similar; however, in the fourth school personality dimensions of the subjects were different. In addition, a future look at improving efficiency score — patient history could prove helpful if the cues list could be narrowed to include only the explicit and implicit cues that help most

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119 precisely in improving the thoroughness of subjects' observations. Research on Instructional Use of CRP Future research should be carried out also after instructional modifications are in place. Developing skill in use of the CRP will not be without difficulty for some students, but using problem-solving strategies like the CRP may assist weaker students in coming to closure and in accurately diagnosing patient problems. In instructional programs students should be encouraged to reflect on the questions and processes that must be used to achieve accuracy. Videos could be developed of various clinical cases with the strategies of the CRP superimposed. Clinical instructors could also explicitly employ these strategies in evaluations during the students' final clinical clerkships. These strategies of the CRP could provide two avenues for clinical instruction: (a) a practice experience by cuing students during their examinations of patients, then reminding students of the cues and asking students about their thoughts at the time of the cuing. This would be a good basis for discussion following the students' attempts at patient evaluation; (b) a basis for evaluation of the student to assist in determining the students' level of understanding in case evaluation (i.e., can the student accurately diagnose the patient ' s primary problem) . There

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120 are other classroom and clinical uses for the set of strategies termed CRP. Faculty and clinical instructors could combine these strategies with others like the analytical-questioning method of Slaughter et al. (1989) to improve student motivation and interest in clinical problem solving (See Appendix A-2) . Further research should be conducted into methods and evaluation after implementation of instruction using the CRP. Summary and Conclusions This study addressed the topic of clinical reasoning in diagnosis of movement dysfunction in physical therapy in particular, pediatric movement diagnosis. A teaching tool, a video, for entry-level physical therapy professionals was structured to include pertinent case information and the rules and implicit cues of the CRP as elucidated by Barrows and Tamblyn (1980) and Elstein et al. (1979) . These rules are based on the strategies used by experts in medicine and physical therapy. Entry-level physical therapy students were selected because these students had completed all phases of professional training and should have been prepared to perform the task. Benefits from certain problem-solving experiences could not be realized unless the students had attained a sufficient degree of cognitive development within the discipline and unless their personality characteristics had been influenced by some degree of professional

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121 development. Outcome of the video learning experience was measured by assessing the students' abilities to efficiently and accurately diagnose a pediatric patient's primary movement problem. Students did not become more efficient but they did significantly improve in accuracy. The students reacted positively to the task in this particular situation and with this particular type of problem. Their willingness to accept and complete this exercise involving a complex patient problem was seen as a positive indication that Florida entry-level therapists realize their responsibility to make prudent clinical decisions. Results of the study offer an empirical basis for introduction of strategies of CRP into instruction at the academic and clinical levels. Although results are not generalizable across populations and geographic regions, the fact that instruction in CRP helped these subjects to become accurate in diagnosis indicates that field testing should be carried out in other locations and with other populations. Further research could validate these and other model strategies for programs in physical therapy education so that the discipline can meet the demands to accurately problem solve in clinical physical therapy.

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APPENDIX A LITERATURE REVIEW TABLES OF STUDIES OF PROBLEM SOLVING AND MYERS-BRIGGS TYPE INDICATOR

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124 ecu m m o a « • w u M 0 & Ob * I i O « 0 ** O -* « a. « *< i w • u w « O « 4« I u « • • » •M B 4J 3 W B « O ^ • ^ Of ^ a s u M ^ m ^ o a A ' saw n ^ • AO « O « M U U O. A* > ^ m >> m • O • M • « h « f b O w w w X mo B M B b CL « • « w ^ a ^4 ^ o £ 9 a •* m m W > 3 « «^ 9 O ^ £ O »4 81 *M 5 > o a a • • u » o e > <«4 • ^ «M o m > -4 ^ «H ^ £ « -4 • • ** m u o I 9 • u • *M w o • e • ' « »s > »H o ^ • ft« • ^ fc* b M b a t« • • 9 « > ki f W « O w 6 6 O > O • ^ • > a. « tM > i5 S b m W 4 e a q a. 9 X X ^ X ^ b « M w o X 9 e o « u « a o a . w a • • BaaaauA''-' « X X B W a w u •o 9 a B a B a «M a 4« w a a ^ X a a a X a « w a wxaaoB'<^>H a9a<*4flaa>a u B w 9 a -H c ) w c a a ^ ^ o « a >«>H u • B a • w 9 a o 41 o a i^o a M wuu«*H 6 a a >« >«cnHxx Ob^x hx I «M ox w M X i u -4 B a o • a UK ^ K ax as a a ^ a B w > a : a 'H B *4 > X a A* w ^ a «w a a a u w ^ ^ wt 9 a u X M X ^ ck>^ a o B o a a X b a w > o 9 ^ Ba V Bk a u a o 5 * : a o I « X s a » _ > ^ • o u ^ IMX •HO ** m a, K I M 9 tx »* m u IK-** aeaovwaaa ix> u-^aa o»* k aiaaMM aikaa iTi •xa^aflM^i* o la •b'HO.a.^o sv-H w-^oB Ca a&BM iaa>axoi«8u *r4a 1^ au
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Table A-2 Analytical Questioning Sequence 126 Category-Item Number Question Assessment 1 What structure (s) may be involved? 2 Does the severity of the patient's condition limit your ability to perform a complete evaluation? 3 Is there any additional information you would need in making an assessment? If so, what? 4 Is there extraneous information? If so, what? 5 Are there any psychological or social factors that should be considered for this patient? If so, what are they? Problem Identification 6 Identify patient problems or complaints relevant to physical therapy. 7 What are the possible causes of these problems or complaints? 8 What do you perceive the primary problems to be? Why? 9 What data assist or support your analysis? Treatment Planning 10 What treatment (s) might you use to influence the problem (s) you identified in item 6? 11 How will the treatment (s) influence the problem (s)? 12 How will the treatment (s) influence the cause of the problem(s)?

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127 Table A-2 — Continued. CategoryNumber Item Question 13 What do you think is the most appropriate way of delivering the treatment (s) you identified in item 10? 14 What modalities or equipment do you need to implement your solutions? 15 What is (are) your anticipated frequency (ies) and duration (s) of treatment? 16 What factors may change your frequency (les) and duration (s)? 17 What is (are) your short-term goal(s)? 18 What is (are) your long-term goal(s)? 19 How can you assess the effectiveness of your treatment plan? 20 What might be an alternate plan? Adapted from: Slaughter, D.S., Brown, D. S., Gardner, D. L. , & Perritt, L. J. (1989). Improving physical therapy students' clinical problem-solving skills: An analytical questioning model. Phvsical Theraov . 69(6), 441-447.

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132 STUDENT HOnVATIOr: A..D PERSOIIALITY TYPES * schools across the ""Jted Sta^s urban -Jj"^^'^^ J.-VSsl'pe'S^^ that students' lack of Jnt f2??vaS?is! o?cSurse! very Smplex. tent and perplexing prob ens. "9j;y;J;°;„''';„; areksures having its roots in fannly ^."ll??;";!;' ''bS teJ^ers do have the ^r''^ SSS sISdeTttJiJaS^^-rsiL^^-ts; and o. key to that po«er ban be seen in the tyne concepts. Type theory suggests that «e br^ak down motivation into four parts, corresponding to the four dimensions of tyoe: nHrcuTfetier interests core deeolv. Attending ixre often to the inner KoSTSf pfrSSons and judgn«nts. Introverts take » reflective !nnrn*ph to life Hhile extraverts take an active, tnal-and-error Jp^SS. Of 2irS exiSverts often do look inward and introverts S turn outward. All four pairs of P^^^^^^f" ^" thil section refer to habitual, but not constant tendencies. 2. The sensing-intultion preference reveals basic ^f"^"? ^^'At!!''^"'^Sensing stidents attend ocst often to the litera ™"^"9 tney find iTconcrete exoariences. They learn best by roving sten-bv-step trough a new experience, with their senses ^s ^jganed as possible InSitive students' attention is drawn most often to things that stimilate iSnation. to possibilities not found in sensory exnenence. ISeir Snds woric by skins and jumps, looking for patterns wherever the insairation takes them. 3 The thinki no-feeling diiaension shows oattems of cotnmftnents and values • S asSt The thinking student con.nits to activities tnatr^^^^^ to logical analysis, where illogical human factors don t interfere. T^feelina student connrits to personal relationships, to a teacher or 52lrs Ind avoidTSitSSons where personal harmony can't be maintained. 4 T^ie judging-oerceiving dirension shows work habits. Students with a ildqinn attitude are drawn toward closure, wanting a clear work n an to fSllH? 5isl?king unsettled situations, they my sometimes lock into a Surse of action Without looking at enough of the relevant J^ta Stu^nts with a oerceivina attitude resist closure, wanting to keep all^annels open for new dati. Disliking fixed olans, they may sometimes postDor.2 dSsiotsTleaving much to be done in a rush as a deadline closes in on them. By taking these four natural motivators into account in planning instruction, by airting with them rather than against them, the teacher can better direct ^ t in 't' w f energies toward learning. •frnn People Tynes and Tioer Strines, Second Edition, Gordon Lawrence. Publisned bv Canter tor rtnolicarTons of Psychological Type, Inc. 414 Southwest 7th Terrace, Gainesville, FL 32501

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133 LU o s s UJ a an S i i i w ii 19 V — — K » ^ • « I 15= sis ^sziZ s5 * Sm» • * — • •«5 i =1 =i iSi s iiifi S . s5 51 a 8 r wt _ W « » s i I ili . e m Mi • a = H i s s 0 i Zm m m m s s m — w «« A. — Mt ^ S z * • 8 S . n m m « M i ac 8 " 1^ S i i s . = s s |Z ».s 1 M ^ £ S— t S S i i 1 ^ • s — " — K S = 2a ; £ si S S s s •» ^ w u UJ « • i 12 = 5 CO "3s " g — £ S 1" r • SCO -s 2 ILU "g r 1 ^ K 3 u • C f * " 2 = s 1-1 m m baa 5H its •I 8 Sirs

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APPENDIX B FORMAT AND PRESENTATION OF THE MODEL OF VIDEO INSTRUCTION FOLLOWING THE CLINICAL REASONING PROCESS Title of Model: Structured Video Model for Teaching Clinical Evaluation The essence of the model is to involve the students in a problem-solving design that can be used by clinicians not only to manage a pediatric patient problem but also to learn the methodology of accurate, efficient patient diagnosis as it relates to physical therapy. Further, the model is designed to introduce the student to theory testing of a teaching model that is alluded to in medical literature but that has not as yet been developed into an instructional model (Joyce & Weil, 1980) . Syntax Phase One (Cue Observation) An area of investigation is posed to the student, including key movement variables that must be used in the investigation. The student is oriented to relevant patient concerns through the patient history. The student is asked to immediately generate problem 134

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135 statemenrs relative to movement difficulties that include cause and extent. The srudent must generate two or three problem statements (Ben Bassat, 1986; McGuire, 1985) . Phase Two (Problem Generating) Results of testing and volitional movement skills are shown. The task of the student is to use physical examination and movement data and list or rate each critical cue if it is important to a problem statement. Phase Three (Problem Reorganization) Students are asked to experiment mentally by watching the patient volitionally move and by relating that to reflex and muscle tone testing sections of the video. Students then reject, revise, or create new problem statements about the movement disorder. They then structure their problem statements. Phase Four (Problem Prioritization) Students can speculate about whether their primary problem statements would help to solve the patient's movement problem, or they can look back on all their negative or disconf irmatory cues and prioritize problems that they should have allowed. Then again they can speculate on problem solution. Phase Five (Closure) An expert's way of solving the problem is recommended for students' consideration. The students are then asked for their primary problem statement.

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136 Social Syst:ein Students learn to state problems vigorously; they learn personal challenge and something about the development of problem statements. Research design and deductive reasoning skills are facilitated. Principles of Reaction The teacher's task through the video presentation is to facilitate data verification and experimentation skills. Students should be turned toward problem generation and prioritization skills. Support System A flexible instructor who is skilled in: (a) facilitating problem statement development through either video or live cueing, (b) demonstrating pertinent patient testing, and (c) motivating student compliance is necessary to this model. Instructional and Nurturant Effects This model is designed to teach the process of clinical reasoning in the diagnosis of movement disorders. It assists students to see and listen to cause/effect or effect therefore cause. It facilitates the balancing of alternatives, that is, several concurrent ideas or problems, and it encourages development of quick, accurate, and efficient evaluative skills.

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137 Application This model • s aim is to instruct physical therapystudents in video data collection and in the visual analysis and synthesis processes necessary to practice deductive thinking leading to problem solutions for stability and mobility disorders. The video is structured to introduce students to 1. the relevant cues in medical history and patient complaint and/or goal statements; 2. the three ways to use observation, that is, as it relates to treatment, as it relates to evaluation, and as it relates to long-term management; 3. cause and effect, showing the student that movement disorders relate to cause, not just to location of disorder; 4. multiple causation, showing the student that multiple, concurrently entertained causes can be presented due to a single movement disorder. If the child has increased muscle tone, then primitive reflexes, automatic reactions, and volitional movement all will demonstrate the disorder in a particular manner. Circular analysis skills such as the above help students realize the complexities involved in developing a theoretical approach to the treatment of neurological dysfunction.

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138 Summary Chart: Structured Video Model for Teaching Clinical Evaluation Syntax Phase One Area of investigation posed. Student generates 2-3 problem statements. Phase Two Student verifies data and relates it to key movement variables. Phase Three Student restructures problem statements. Phase Four Student reorders problem statements and starts to prioritize. Phase Five Student rethinks and prioritizes problem statements and the critical cues that go with the primary problem statement .

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139 Social System The model has moderate structure and a vigorous intellectual climate. Principles of Reaction Video encourages quick data identification and collection and stresses analysis and synthesis skills. Support System The model requires an expert skilled in various movement evaluation and treatment skills and a good problem area or areas of investigation.

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APPENDIX C THE VIDEO MODEL This video had its origin in an actual case history. The findings were modified to eliminate redundant or misleading cues. The case history cues offered represent the significant findings that can be seen in the pediatric literature as relevant to the child's diagnosis of cerebral palsy in the child. Because the child could not give problem and goal statements, the parents were requested to do so. These statements were included because they are noted to be important cues by the majority of authors describing the steps involved in patient evaluation. The prone/supine lying test items of the physical examination were selected in an attempt to demonstrate the movement and posture items found by Harris (1987) to be early significant predictors of cerebral palsy. These same cues were used as test items for the students, who may later test younger infants and toddlers suspected of having cerebral palsy. The prone/supine test items formed the database for the concept involved in evaluation of abnormal development: primitive reflexes (Chandler et al., 1980; Harris, 1987). 140

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141 The movement items were shovm because they allowed the student to evaluate four concepts of abnormal development recognized by experts: postural tone, primitive reflexes, automatic reactions, and volitional movement . The physical examination cues were elaborated upon by a therapist from each of two disciplines: occupational and physical therapy. This team was used to model a team approach to evaluation, and also to motivate the child to demonstrate her movement abilities as independently as possible. The quality of activities shown to motivate movement gave the viewer an appreciation of the cognitive skills of the patient and of how patient cognition and motivation can assist one in movement evaluation. These elaborations allowed the instructional video to answer all reasonable questions relevant to a complete movement examination. Experts were asked to review the entire database to detect conflicting information and conspicuous omissions in order to ascertain the adequacy of the case vignette. A final list of positive findings and important negative findings were compiled as a critical cues list. The experts were physical therapists, all having a minimum

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142 of five years' experience in pediatrics or neurodevelopmental training in pediatrics. Many had neurodevelopmental treatment coursework and were also adjunct instructors for a curriculum in physical therapy. The case was judged by the therapists to represent a nontrivial movement diagnostic and management problem in the specialty area of pediatric physical therapy. The experts expected the case to be challenging but within the range of ability of competent graduating physical therapists. Students were being asked only to diagnose the movement problems and plan preliminary elements of a treatment strategy. A description of the case is as follows: Case Vignette — Child with Cerebral Palsy Linden is a 2-year and 6-month-old spastic cerebral palsied child — quadriplegia . She has a highly significant birth history including prematurity of 2 1/2 months and asphyxia requiring ventilation. Her birth weight was 2000 grams, average for her gestational age. Her parents state that her major problem is inability to walk, and their goal statement relevantly portrays their level of reality and coping ability in regard to Linden's movement disorder. Linden has had private therapy, but inconsistently. During physical

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143 examination the following movement cues were elicited (in this order) : 1. Visual tracking and convergence 2. Tonic Labyrinthine Reflex Supine = TLRS 3. Hands to midline 4. Lower extremity extensibility 5. Plantar grasp 6. Tonic Labyrinthine Reflex Prone = TLRP 7. Prone suspended: Landau 8. Trunk incurvatum (Galant) 9. Prone equilibrium 10. Head righting lateral in vertical suspension 11. Sitting: protective reactions 12. Sitting: equilibrium reactions 13. Hearing 14. Oral motor control 15. Sensory testing: light touch and stereogrosis 16 . f ^ W^X. J. W W ^ JL V ^ IIUXUXIIM 17. Standing and moving 18. Foot appearance General cues seen in this video are: 1. Alignment: head, neck, trunk 2. Functional ability to respond to gravity: dynamic alignment and symmetry

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144 Movement Research Results in Pediatric Physical Therapy The significant predictors for cerebral palsy in infancy are the following (Harris, 1987) : Significant Predictors: Muscle Tone 1. Extensibility < .001 2. Posture supine < .001 3. Posture prone < .001 4. Posture prone suspended < .001 Significant Predictors: Primitive Reflexes 1. TLRS < .001 2. TLRP < .001 3. Plantar grasp < .005 4. Trunk incurvatum < .004 Significant Predictors: Automatic Reactions HR, Lateral < .001 HR, Extension < .001 Rotation in trunk < .001 Landau < .006 Equilibrium reactions < .004 Significant Predictors: Volitional Movement Visual following < .001 Head centering < .001 Open hands < .001 Hands to midline < .001 Active use of hips < .001 Head position — Anterior/ posterior < .002 *The above test items are those that form the physical examination section of the instructional video.

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145 Transcript of Video Presentation Introduction This is a video presentation of a pediatric therapy assessment. Some of you will be given explicit rules to assist in structuring your thinking. Others will not be given these explicit rules. Without explicit rules, you will have to base your assessment of this child on your own personal strategies that you have used in the past. You will be asked to determine this child's primary problem and to write a statement about it after the video. Video Instruction Please be sure you have two forms: one entitled a Critical Cues List and the other entitled Problem Statement List. Complete the Critical Cues List and Problem Statement List during the video and write your primary problem statement in the box at the bottom of the page after the video. Be sure your code numbers are placed in the upper right corner of both the lists. About the Video On the video you will see a window appear with a normal child moving. This normal child is the same age as the patient and the window was inserted so that you may compare and contrast certain aspects of normal versus abnormal movement.

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146 The video will consist of tiiree sections: Patient History, Physical Examination, and Volitional Movement. You will see the Physical Examination section two times because it moves along rapidly. Remember all of you will be asked to write a primary problem statement at the end of the video. A Problem Statement is a statement that explains the primary reason for this patient's inability to move normally. PHASE I CUE OBSERVATION PHASE PATIENT INTERVIEW AND HISTORY Begin checking the boxes in your Critical Cues List. The first eight cues that you should observe are related to the statements on the following page. Check the importance of these eight cues while you watch the patient history portion of the video that follows (Suchmann, 1962; Barrows & Tamblyn, 1980; Cutler, 1985; Echternach & Rothstein, 1980) : Note the significant history questions. Note child's appearance, age, sex, dress, manner, and movement. What does Sharon Menzel hope treatment can do for Linden? find out whether Mrs. Menzel sees this as a long or short term effort.

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PATIENT INTERVIEW AND HISTORY Miss Blanche said: "I am Miss Blanche and this is Miss Vicki. Can you introduce us to your parents? What's Mommy's name? Sharon. And how about Daddy? Daddy. We have Sharon and Daddy with us today. Can you tell us a little bit, Sharon, about Linden's birth history and that kind of thing?" Sharon said: "Sure. Linden was born prematurely at 30 weeks gestation. Her birth weight was 3 1/2 pounds; she was 17 inches long; her Apgar scores at birth at one minute were three, and at five minutes nine. She was a vaginal delivery with forceps used and she was on the respirator for about 12 hours after birth. She was born in Deland, Florida, and then about 5 1/2 hours after birth transferred to Shands Hospital. She remained at Shands for about three days and then transferred back to West Volusia for about 3 1/2 weeks, and then discharged. She weighted 4 1/2 pounds when she was discharged. She had some spells of apnea and brady cardia during that period of time in the hospital." Blanche said: How about you Linden? Could you answer a guest ion for me? Miss Vicki and I would like to know how old you are. You have us guessing. How old are you? How old?"

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143 Sharon said: "Are you one, or two? Tell me." Blanche said: "Two and a half. Linden, you are getting big." Blanche said: "Can you tell us a little bit more, Rob, about your family? Does Linden have siblings?" Rob said: "Linden is our middle child. We have another child, Tyler, who is five years old, and we also have another one, Collin, who is coming up on one year old, so she's right in the middle." Blanche said: "How much therapy has Linden had to date?" Sharon said: "She started therapy when she was three months old at the Easter Seals Center in Daytona Beach and she continued therapy about three times a week with them, at that time. We enrolled her in private therapy also during that time, maybe once or twice a week." Blanche said: "Maybe you can answer this together, but what do you see as her short-term goals for treatment? If we should start treatment?"

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149 Sharon said: "I think we would like to see her standing more independently, pulling up at tables, chairs, more easily?" Blanche said: "How about long term? What's your idea?" Rob said: "We have the same long-term goals for Linden as we do our other children. We'd like her to be healthy and happy and have a good perspective and a good outlook on life in general. That's the number one long term goal, but more specific to therapy, we would like to see Linden walking on her own, skipping, hopping, jumping, those sorts of things, in the next four or five years, being able to walk on a balance beam, doing those types of activities usually associated with children that age, and we see that again in the four or five year time frame . " PHASE II PROBLEM GENERATING PHASE AFTER PATIENT HISTORY STOP NOW and list two to three ideas, hunches, impressions or diagnoses about this child's movement problem. We will call these Problem Statements and you will list them on the top of your Problem Statement List.

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150 Some experts advocate using the patient's or parent's chief complaint as one of the Problem Statements, but in pediatrics the patient many times cannot explain his or her problem while the parents may lack depth and precision in their cognitive representations of the cause of the child's disability. The parents' goal statements may need to be modified or enriched by what you as the physical therapist can see through professional level observation. Make your problem statements relate to the child's movement diagnosis. Do not write problem statements like: "Linden has Developmental Delay." This is too general, and does not specifically relate to diagnosing Linden's true problem with movement. Remember there are many problems in pediatric physical therapy that are similar with many common characteristics. Each, however, has a singular primary problem that acts, per se, as the essence of the movement abnormality. As you view the remainder of the video, you will find many cues that you can rate as critical evidence for your problem statements. Later in the video you will be asked to refine your problem statements, because you will have more evidence from the cues that you see during the Physical Examination and Volitional Movement sections.

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151 In order to match your primary problem statement with what pediatric experts have agreed upon as the primary problem, you will have to pick up your two or three major ideas or hunches for your preliminary problem statements during the patient history (Benbassat, 1986; McGuire, 1985) . Now continue to check Cues as you watch the remainder of the video. Try not to worry about everything you see in the video. Rate only Cues that are listed and their level of importance in confirming your original ideas about the patient's primary problem with movement (primary problem statement) . An example of a problem statement might be: "Linden is unable to ambulate independently." This problem statement is, however, not a movement diagnosis. It is not the primary reason for the child's lack of normal movement. Your problem statement should reflect the primary reason for lack of normal movement.

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PHYSICAL EXAMINATION TESTS HORIZONTAL AND VERTICAL TRACKING CONVERGENCE HANDS TO MIDLINE TONIC LABYRINTHINE REACTION SUPINE TLRS LOWER EXTREMITY EXTENSIBILITY PLANTAR GRASP TONIC LABYRINTHINE REACTION PRONE TLRP LANDAU/ PRONE SUSPENSION GALANT/TRUNK INCURVATION PRONE EQUILIBRIUM PROTECTIVE REACTION-SITTING EQUILIBRIUM REACTION-SITTING HEAD RIGHTING-VERTICAL SUSPENSION ORAL MOTOR CONTROL Miss Vicki said: "Linden, would you like a cookie for a snack? What's your favorite kind of cookie? I can't hear you could you say that louder? I can't hear you; say it louder; say it so Mommy and Daddy can hear it." Linden said: "Chocolate chip." Miss Vicki said: "O.K., that wasn't very loud." HEARING Miss Vicki said: "What was that? A bell?

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STEREOGNOSIS Miss Vicki said: "We're going to do something with our toys, O.K. Here are Linden's toys. Miss Vicki 's got the same toys. Do you remember when we tried this?" Linden said" "Yeah." Miss Vicki said" "O.K. What we're going to do is, Miss Vicki is going to put one of those toys just like yours in your hand when you're not looking — you're not using your eyes. And you have to tell me which one it is. Tell me when you're ready. Ready? Can I have one hand please? Turn one hand up. Don't look — don't look. What was that? Good girl! That was really good. Let's do another one, O.K.? Let me have that hand again. What's that one? Can you tell which one that one is? Which one of those toys was that? What's that called? I can't hear you. O.K., now I want you to hold your arm up like this — hold it there. Can you keep it there? Keep it nice and straight. Hold it up there, Linden. Hold it, hold it, hold it. Oh, oh. Let's do it again. Hold it up there — hold it; keep it there, Linden; don't let it fall down; keep it there; keep it there — good girl. How about this arm? Keep it up there, just like that. Hold it nice and straight — hold it — hold it — hold it. I'm going to let go; don't let it go. Don't let it fall down.

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154 PHASE III PROBLEM REORGANIZATION PHASE BETWEEN SEGMENTS OF PHYSICAL EXAMINATION TESTS You will now review the Physical Examination Test. This will give you the opportunity to alter, delete, or add to the preliminary Problem Statements that you now have. You may also re-evaluate the cues that you think may relate to your problem statements. During this time rewrite your preliminary problem statements making them clearer and more concise. PHYSICAL EXAMINATION TESTS Repeated . PHASE IV PRIORITIZING PROBLEMS PHASE BEFORE VOLITIONAL MOVEMENT SECTION During and immediately after watching the Volitional Movement section of this video, review all of your Problem Statements and Cues. Again, rewrite your problem statements, making them more concise. VOLITIONAL MOVEMENT Blanche said: "Would you like some help?" Vicki said: "What would you like? The big bench moved?"

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Blanche said: "Where would you want Miss Vicki rc pur rhar big bench?" Vicki said: "Where should I put it?" Blanche said: "Should she move that? Where? You're going to have to tell her." Miss Vicki said: "Right there? Is that where you want it?" Linden said: "Yes." Miss Vicki said: "Very nice, little lady. Can we get two at a time? Over here . " Linden said: "Wrong side." Miss Vicki said: "Do you want to get another blue one over here? Can you get it over there? What a long reach that was. Linden, way over here. Almost — now you're going to have to get it back. Way over here. Can you believe that? Can you get it?" Linden said: "Yes."

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Miss Vicki said: "Oh, that was terrific. Down here — almost rouch the ground. Can you find it? Step back here. Hey, Linden, look here, what's down here? Snowf lakes, both of them. Put them on the pile now. Way to go! Another one? Do you want to get another snowflake down there? It must be on the other side. Where is she? There she is. Good girl. She's going to come back with you I think. Super. Oh, there she is? She made it. Good girl . " Linden said: "Where are you going?" Miss Vicki said: "I don't know. Maybe it's time to go home." Linden said: "Oh." Miss Vicki said: "Where would you like to go? The grocery store?" Linden said: "Yes, the grocery store with Baby Boo Boo . Good bye . " Miss Vicki said: "Oh, okay. Let's say good bye." Linden said: "Good bye." THANK YOU.

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157 PHASE V CLOSURE PHASE AT END OF VIDEO NOW, prioritize your problem statements. Experts generally prioritize based upon the patient's chief complaint, treatment needs, treatment urgency, and the functional results that they can offer to the patient. Refer to your Problem Statement Form and Critical Cues List and write your primary problem statement in the box at the bottom of the Problem Statements Form. Turn in the Critical Cues List and Problem Statements Form. Be sure your code number is in the upper right-hand corner on all the pages. END OF VIDEO.

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APPENDIX D RATING/STATEMENT FORMS FOR EXPERTS, PILOT STUDY GROUP, EXPERIMENTAL AND CONTROL GROUPS CRITICAL CUES LIST — ORIGINAL EXPERTS' SURVEY: PILOT STUDY GROUP List here important observations that you make during the course of each of the three sections of the video. The three sections are entitled: Patient History, Physical Examination, and Volitional Movement. Please write cues only in their respective sections. Important observations are critical cues that can help you formulate an idea about what the patient's problems with movement are: Patient Physical Volitional History Examination Movement 1. I I 2. I I 3. I I 4. I I 5. I I 6. I I 7. I I 8. I I 9. I I 10. I I 11. I j 12. I I 13. I I 158

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159 Compilation of Cues — Experts Average number of cues per expert deemed by experts to be critical was 13 cues over all three dimensions of the videos; patient history, physical examination, and volitional movement. PATIENT HISTORY 1, Began therapy early 2 . STG — parents 3 . LTG — parents Foor crunK conuroj. , appears ixoppy in urunK. 5. 2 1/1 year old *6. Sits with good head control *7. Difficulty initiating and grading movement *8. Lacks lower extremity dissociation *9. Posterior pelvis *10. Able to pull self erect with abdominals Arms held abducted, elbows flexed *12. Dependent on mother for postural support 13 . Family — cooperative parents *Eight implicit cues found in patient history by experts. All eight had a 90% agreement by pool of experts. None of the other patient history, physical examination, or volitional movement cues had a 90% agreement rate. Harris' research cues were used as explicit cues.

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160 PHYSICAL EXAMINATION 1. Transitions from kneestand to quadriped independently 2 . Movements slow and labored 3. Hands to midline 4 . Poor pelvic control 5. Wide B.O.S. in creeping and kneeling 6. Knees not under hips in creeping and kneeling/weightshifting insufficient 7. Incomplete transition in pull to sit on bench — no 1/2 kneel 8. Keeps shoulders abducted and internally rotated in supine with wrists flexed 9. Poor scapular stability in weightshifting/poor scapular cocontraction 10. Poor scapular depression and adduction in prone propping 11. STNR influence in prone 12. Prone equilibrium delayed 13. Equilibrium in sitting delayed 14. Turtle's head 15. Increased tone in lower extremities 16. Uses arms to pull to bench 17. Limited or no hip abduction in or out of equilibrium reactions 18. Protective extension bilaterally in sitting 19. Shoulder elevation excessive during lateral protective extension in sitting

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16 20. Delayed sitting equilibrium 21. Creep to kneel standing by assuming bunny hop position 22. Lack of normal lordotic curve in lumbar area 23. Delayed head and trunk righting in sitting and vertical suspension 24 . Increased extensor tone in landau in lower extremities 25. Increased plantar grasp 26. Wears inhibitive cast boots 27. Rib flaring — weak abdominals 28. Poor lip closure 29. Poor proximal stability 30. Abductor and gluteal weakness 31. Influence of TLRS 32. Poor trunk rotation 33. Proprioceptive holding only momentary 34. Poor lateral and rotary jaw movements/munching 35. Spasticity in hip adductors 36. Decreases respiratory volume (soft voice)

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162 VOLITIONAL MOVEMENT 1. Decreased quality of movement 2 . Weakness indicated by intermittent flexion of knees (lateral/anterior/posterior play of body in standing) 3 . Lack of movement from static standing 4. Poor weightshifting in standing 5. Narrow B.O.S. in standing, narrower without TRAFOs 6. Difficulty with lateral weightshifting in standing 7. Stands with hip flexion and increased lumbar lordosis 8. In standing, supports self with upper extremities 9. No active weightshifting observed in trunk in standing 10. Abnormal movement increases when child is over-chal lenged 11. Difficulty with stand to 1/2 kneel 12. Poor pelvic control of right knee in stand to 1/2 kneel; ess in left knee 13. Some graded control of right knee in stand to 1/2 kneel ess in left knee 14. Much increased shoulder elevation in standing activities 15. Poor dissociation glenohumeral , scapular, pelvis, and L.E.s 16. Poor control out of midline in standing 17. Poor abdominals 18. Difficulty in midranges

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163 19. Leans against table with trunk 20. Locks knees in standing for stability 21. Lack of single leg stance 22. Locked into flexion/ extension L.E. patterns, poor plantar-flexion (up onto toes) 23. Inadequate hip extension in standing 24. Assymmetry 25. Extreme pes cavus prominent navicular bilaterally, poor heel contact or toes clenched, feet pronated and inverted 26. Social, alert — appears to understand

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164 PRIMARY PROBLEM STATEMENT FORM FOR UNSTRUCTURED VIDEO — EXPERT GROUP Code Number: Primary Problem Statement:

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SCORE FORMS FOR EXPERIMENTAL AND CONTROL GROUPS In order to accurately diagnose a movement disorder the therapist must elicit or perceive a significant proportion of the diagnostic findings. As has been stated previously, many diagnostic cues bear redundant bits of information and thus it may not be necessary to elicit or identify all the cues. This study will seek to determine how the use of experimental versus idiosyncratic rules will affect the number of critical cues subjects can perceive. A list of critical findings will be obtained from the pediatric experts. The experts will be instructed to list each of the findings seen in the video as critically important in arriving at the movement diagnosis (Score: +++) ; important (Score: ++) ; somewhat important (Score +) . The experts' judgments were averaged over each cue. The subject's process score was a comparison of the difference between the cue scores as listed by each student and the experts average for each cue. A disagreement score between students and experts was established for each experimental and control group student.

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Eight implicit cues from the original experts critical cues survey were included in the final cues rating list. All other cues were labeled following the research of Harris (1987) . Students viewing the structured video were asked for one to three problem statements. They were asked to put these on the Problem Statements Form. At the end of the video they narrowed the list of three to one primary problem statement. Students viewing the unstructured video were asked to write only one problem statement after they viewed the video but were told that they could use the lines at the top of the form to jot down notes, etc. about the patient.

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COOB linMBEa:_ cm T i cai. CUBS Hansc list . s SDHVD/snnnarrs' QQPBRZMBHTAL SBOCF SmtVET — Ple-ae check the .ppropri-te box in the left coln-n ^hiform 70U will find > U»t of cue. or otaerrnitions that are included in this video. Aa yon obaerve the P^""" in the box to the right the lerel of ia^wrtance of the cue. SOMEWHAT This cue would not be an iapoftant IMPORTANT finding in ay aaaesaBent of the chlia s fiy priaary Boveaent probXaa. mPORTAMT This cue would be =°n»l-'*«E^,^"Sild^J — {^y^ ijaportant in my asaoaaaant of the child a priaary aovaaant problea. OOTICALLY Observation of this cue is of critical IMPORTANT iaportance in ay aasoasaant of the — TTi child's priaary aoveaent problea. Without this cue, I could not write a problea stateaent ahotit this child. Do not know if this cue is iaportant or not in ay aBsosBBBnt of the child's priaary aoveaent protalaa. PATIENT HISTORY EXPLICIT CUES 1. Preaacure birth 2. Apnea/Bradyciirdia 3. Began therapy early 4. Two siblings/'linden is middle child 5. Short Tera CoalParents 6. Long Tera GoalParents 7. 2 1/2 Years Old 8. Family-Cooperative Parents IMPIJCIT COES 1. Poor Trunk Control; Appears floppy in trunk 2. Sits with good head control 3. Difficulty initiating and grading aoveaent 4. Lacks lower extremity dissociation £. Posterior Pelvis 5. Abie -= psill self erect witn abdominals 7. Arms held abductedelbows flexed E. Dependent on mother fsr suDDort CPE IMPORTANCE SOMEWHAT CRITICALLY IMPORTANT IMPORTANT IMPORTANT 727 1W DON'T KNOW (4J

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CTE IMPOHTANCS PATIENT HISTORY ^St SeORTMT Sli?^' — (T) (2) (3) PHYSICAL EXAMINATION I, Visual Tracking and convergence 2Tonic Labyrinthine Reflex Supine— TLRS 3. Hands to Midline 4. Lower extremity Extensibility 5. Plantar Grasp 6. Tonic Labyrinthine Reflex Prone=TLRP 7. Prone Suspended Landau 8. Trunk IncurvatuB (Galant) 9. Prone Equilibrium 10. Head Righting Lateral in Vertical Suspension II. Sitting: Protective Reactions 12. Sitting: Equilibrium Reactions 13 . Hearing 14. Oral Motor Control 15. Sensory Testing: Light Touch & S t ereogros is 16. Proprioceptive Holding VOLITIONAL MOVEMENT 1. Standing and Moving Z . FasADoearancs

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169 rzmm. CTES HATIHG LIST Please check the atsnroDriare box in the left column of this form. You will find a lisr of cues or observarions that are included in this video. As you observe the cue, please nors J the box to the right the level of importance of the cue. SOMEWHAT IMPORTAJIT (1) IMPORTANT (2) CRITICVLLY IMPORTANT (2) DON'T KNOW (4) This cue would not be an inpor^ant^ jinding in my assessaent of the child's primary aovement problea. This cue would be considered incidentally iaportant in ay assessaent of the child's primary movement problem. Obser-zation of this cue is of critical importance in my assessment of the child's triaary* movement problem. Without this cue, I could not write a problem statement about this child. Do not know if tliis cue is important or not in my assessment of the child s primary movement problea. SOMEWHAT PATIENT HISTORY IMPORTANT (1) EXPLICIT CUES 1. Premature birth | | 2. Apnea/Bradycardia | | 3. Began therapy early [ | 4. Two sihlings/Linden | | is middle child 5. Short Term Goal| | Parents 6. Long Term Goal| | Parents 7. 2 1/2 Years Old | | a. Family-Cooperative | | Parents CUE IMPORTANCE CRITICALLY DON ' T IMPORTANT IMPORTANT KNOW (2) (3) (4)

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170 PATIENT HISTORY CJE IMPORTAilCZ ScPORTANT IMPORTANT IMPORTANT SOHEnHAT DON": KNOW PHYSICAL EXAMINATION 1. Visual TracJcing and Convergence 2. Tonic Labyrintiiine Reflex Supine — TLRS 3. Hands to Midline 4. Lower extremity Exransibility 5. Plantar Grasp 6. Tonic Labyrinthine Reflex Prone=TLRP 7. Prone Suspended Landau 8. Trunk Xncurvatum (Galant) 9. Prone Equilibrium 10. Head Righting Lateral in Vertical Suspension 11. Sitting: Protective Reactions 12. Sitting: EquilibriuB Reactions 13. Hearing 14. Oral Motor Control 15. Sensory Testing: Light Touch & Stereogrosis 16 . Proprioceptive Holding VOLITIOWAL MOVEMENT 1. Standing and Moving 2. Foot Appearance

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Code Number: PROBLEM STATEMENTS FORM CONTROL/EXPERIMENTAL STUDY GROUP 1. 2. 3. Primary Problem Statement:

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172 Student Instructions Structured Video STEPS IN THE CLINICAL REASONING PROCESS (Barrows & Tamblyn, 1980) STEP I "Cue Phase": Studies on Problem Solving (PS) show that the expert assembles an initial concept of a patient's problems with lightening speed from clues inherent in the first encounter. STEP II "Hypothesis Phase/Problem Generating": Within moments after the first encounter, almost simultaneously with the initial concept, the physician generates 2-5 problem statements that literally "pop" into his mind. Problems can be ideas, hunches, guesses, impressions that can explain causes for a patient's problems. STEP III "Maximization Phase/Problem Reorganization Phase" : Experts process all of their patient's problems in parallel manner; then they stop and deduce which problems are most likely responsible for the patient's primary difficulties. STEP IV "Case Building Phase/Problem Prioritizing Phase": Experts search the data again, modifying their problem formulations, altering, rejecting, revising any that need it. They then rank order their problem statements. STEP V "Closure Phase": Experts stop when they have just enough data to formulate a final problem statement. They select the priority problem that is associated with certain criticla cues.

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APPENDIX E DATA RECORDING FORMS

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175

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REFERENCES Arand, J. U. , & Harding, C. G. (1987, Feb.)An investigation into problem solving in education: A problem solving curricular framework. Journal of Allied Health , 8-16. Ausubel, D. (1963). The psychology of meaningful verbal learning . New York: Grune & Stratton. Barrows, H. (1983). Problem based self-directed learning. Journal of the American Medical Association , 250(22), 3077-3080. Barrows, H. (1986) . A taxonomy of problem-based learning methods. Medical Education , 20, 481-486. Barrows, H. S., & Bennett, K. (1972). Experimental studies on the diagnostic (problem solving) skill of the neurologist: Their implications for neurological training. Archives of Neurology , 26(3), 273-277. Barrows, H. S., & Feltovich, P. J. (1987). The clinical reasoning process. Medical Education , 21 , 86-91. Barrows, H. S., & Tamblyn, R. M. (1980). Problem-based learning: An approach to medical education . New York: Springer. Ben Bassat, J. (1986). Teaching differential diagnosis to beginning clinical students (a letter to the editor) . The American Journal of Medicine , 81, 562-563. " Berner, E. S. (1984). Paradigms and problem solving: A literature review. Medical Education , 65, 625-632. Bobath, B. (1967). The very early treatment of cerebral palsy. Developmental Medicine and Child Neur ology, 9, 373-390^ ' Boshuizen, H. P. A. , & Claessen, H. F. A. (1982). Problems of research into medical problem solving: Some remarks on theory and method. Medical Education , 16, 81-87. 176

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177 Bruner, J. S., Goodnow, J. J., & Austin, G. A. (1956). A study of thinking . New York: Wiley. Bruner, J. S., Goodnow, J. J., & Austin, G. A. (1967). A study of thinking . New York: Science Editions. Burnett, C. N. , Mahoney, P. J., Chidley, M. J., & Pierson, F. M. (1986) . Problem solving approach to clinical education. Physical Therapy , 66(11) , 1730-1733. Burnett, C, & Pierson, F. M. (1988). Developing problem solving skills in the classroom. Physical Therapy . 68(9), 1381-1385. Campbell, D. T., & Stanley, J. C. (1983). Experimental and guasi-experimental designs for research . Boston: Houghton Mifflm. Campbell, S., Anderson, J., & Gardner, H. G. (1989). Use of survey research methods to study clinical decision making: Referral to physical therapy of children with cerbral palsy. Physical Therapy , 69(7), 610-615. Carskadon, T. G. (1978) . Uses of Myers-Briggs Type Indicator in psychology courses and discussion groups. Teaching of Psychology , 5(3), 140-142. Center for Applications of Psychological Type. (1988) . Gainesville, FL: Author. Chandler, L. S., Andrews, M. S., & Swanson, M. W. (1980) . Movement assessment of infants . Rolling Bay, WA: Rolling Bay Press. Cutler, P. (1985) . Problem solving in clinical medicine: From data to diagnosis (2nd ed. ) . Baltimore, MD: Williams and Wilkms. Delitto, A., Shulman, A. D. , & Rose, S. J. (1989). On developing expert-based decision-support systems in physical therapy: The NIOSH low back atlas. Physical Therapy , 69(7), 554-558. Echternach, J. L. , & Rothstein, J. M. (1986). Hypothesis-oriented algorithms (HOAC) . Physical Therapy , 66(9), 1388-1391. Echternach, J. L. , & Rothstein, J. M. (1989). Hypothesis-oriented algorithms. Physical Therapy , 69(7), 559-564.

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178 Eggins, J. A. (1979). The interaction between structure in learning materials and the personality type of learners (Doctoral dissertation, Indiana University, Bloomington, 1979) . Dissertation Abstracts International, 40A , 3886. (University Microfilms No. DDJ80-00731) Einhorn, H. J. (1986) . Expert judgment: Some necessary conditions and an example. In H. R. Arkes & K. R. Hammonds (Eds.), Judgement and decision making; An interdisciplinary reader (pp. 480-491) . Cambridge, England: Cambridge University Press. Elstein, A. S., Kagan, N., Schulman, L. S., Jason, H. , & Loupe, M. J. (1972) . Methods and theory in the study of medical inquiry. Journal of Medical Education , 47(2), 85-92. Elstein, A. S., Schulman, L. S., & Sprafka, S. A. (1979) . Medical problem solving: An analysis of clinical reasoning (2nd ed.). Cambridge, MA: Harvard University Press. Feely, T. (1976) . Critical thinking: Toward a definition, paradigm and research agenda. Theory and Research in Social Education , 4(1), 1-19. Fienberg, S. E. (1980). The analysis of cross-classified categorical data . Cambridge, MA: MIT Press. Fleisher, D. (1972) . Case study problem: A new form of evaluation. Journal of Medical Education , 47 , 820. Fleisher, D. S., & Schmenker, J. (1987). Isomorphic patient management problems: A method of creating equivalent problem solving tests? Medical Education, 21, 207-212. Gagne, R. N. (1965). Condition of learning . New York: Holt, Rinehart & Winston. Georgieff, M. K. , Bernbaum, J. C. , Hoffman-Williamson, M. , & Daft, A. (1986). Abnormal truncal muscle tone as a useful early marker for developmental delay in low birthweight infants. Pediatrics , 77(5), 659-663. Glaser, R. (1984). Education and thinking: The role of knowledge. American Psychologist , 39(2), 93-104. Glaser, R. (1985). All's well that begins and ends with both knowledge and process: A reply to Sternberg. American Psychologist , 40(5), 573-574.

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9 179 Gordon, M. J. (1973). Hueristic training for diagnostic problem-solving among advanced medical students (Doctoral dissertation, Michigan State University, 1973) . Dissertation Abstracts International , 34A , 5713. (University Microfilms No. DDJ74-06050) Gorga, D. , Stern, F. M. , & Ross, G. (1985). Trends in neuromotor behavior of preterm and fullterm infants in the first year of life: A preliminary report. Developmental Medicine and Child Neurology , 27 , 756-766. Greeno, J. G. (1978) . Nature of problem-solving abilities. In W. K. Estes (Ed.), Handbook of learning and cognitive processes. Vol. 5: Human information processing . Hillsdale, NJ: Lawrence Erlbaum. Griesen, J. V. (1972) . Independent study versus group administration in medical education (Doctoral dissertation, Ohio State University, 1971) . Dissertation Abstracts International , 32A, 6100. (University Microfilms No. DDJ72-15214) Groen, G. J., & Patel, V. L. (1985). Medical problem-solving: Some questionable assumptions. Medical Education , 19, 95-100. Harris, S. (1987). Early neuromotor predictors of cerebral palsy in low birth weight infants. Developmental Medicine and Child Neurology , 29(4) , 508-517. Heifer, R. E., & Slater, C. H. (1971). Measuring the process of solving clinical diagnostic problems. British Journal of Medical Education , 5, 48-52. Hoy, P., & Vaught, B. C. (1981). The relationship between problem-solving styles and problem-solving skills among entrepreneurs. Research in Psychological Type , 4, 38-45. Hunter, F., & Levy, N. (1982). Relationship of problem-solving behaviors and Jungian personality types. Psychological Reports , 51(2), 379-384. Illingworth, R. S. (1965). The diagnosis of cerebral palsy in the first year of life. Developmental Medicine and Child Neurology , 8, 178-194. John, E. R. , & Miller, J. G. (1957). The acquisition and application of information in the problem solving process: An electronically operated logic test. Behavioral Science . 2, 291-301.

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180 Joyce, B., & Weil, M. (1980). Models of teaching (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Kern, L., & Doherty, M. E. (1982). Pseudodiagnosticity in an idealized medical problem-solving environment. Journal of Medical Education , 57, 100-102. ~ Kilmann, R. H., & Taylor, V. (1974). A contingency approach to laboratory learning: Psychological types versus experimental norms. Human Relations , 27(9), 891-909. Knight, S. L. (1987). Teaching critical thinking skills effectively. Phi Delta Kappa Newsletter , April. Kong, E. (1966) . Very early treatment of cerebral palsy. Developmental Medicine and Child Neurology , 8, 198-202. Lawrence, G. (1984a) . People types and tiger stripes; A practical guide to learning styles (2nd ed.). Gainesville, FL: Center for Psychological Type. Lawrence, G. (1984b) . A synthesis of learning style research involving the MBTI. Journal of Psychological Type , 8, 2-15. Leaper, D. J., Gill, P. W. , Staniland, J. R. , Harrocks, J. C, & de Dormbal, F. T. (1973). Clinical diagnostic process: An analysis. British Medical Journal, 3(9), 569-574. Lewis, A. T. (1976). The relationship between intuition and affective sensitivity (Doctoral dissertation. University of Notre Dame, 1976) . Dissertation Abstracts International , 37/ 1491B-1492B. (University Microfilms No. 76-19, 470) Margolis, C. Z., Barnoon, S., & Barok, N. (1982). A required course in decision-making for preclinical medical students. Medical Education , 57, 184-190. Marshall, J. R. (1983). How we measure problem solving ability. Medical Education , 17, 319-324. May, B. J. (1977). An integrated problem-solving curriculum design for physical therapy education. Physical Therapy , 57, 807-813. May, B. J., & Newman, J. (1980). Developing competence in problem solving: A behavioral model. Physical Therapy , 60(9), 1140-1145.

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181 McCaulley, M. H. (1981). Jung's theory of psychological types and the Myers-Briggs Type Indicator. In P. McReynolds (Ed.), Advances in psychological assessment (Vol. V, pp. 294-352). San Francisco: Jossey-Bass. McCaulley, N. H. , & Natter, F. L. (1974). Psychological (Myers-Briggs) type differences in education. In F. L. Natter & S. A. Rollin (Eds.), The Governor's Task Force on Disruptive Youth: Phase II report . Tallahassee, FL: Office of the Governor. (Available from Center for Applications of Psychological Type, Gainesville, FL) McGuire, C. H. (1985) . Problem solving: A critique of the literature. Journal of Medical Education , 60, 587-595. Miller, G. A. (1956) . The magical number seven, plus or minus two: Some limits on our capacity for processing information. Psychological Review , 63, 81-97. Morgan, M. W. (1987) . Relationships of problem-solving performance and psychological type (Doctoral dissertation. University of Florida, Gainesville, FL) . Dissertation Abstracts Internation al, 49(8), 2158A. ~ — Myers, I. B. (1980). Manual: The Myers-Briggs Type Indicator . Princeton, NJ: Educational Testing Service. (Available from Consulting Psychologists Press, Palo Alto, CA) Myers, I. B. , & McCaulley, N. H. (1962). Manual : A guide to the development and use of the Myers-Briggs Type Indicator (1st ed.). Palo Alto, CA: Consulting Psychologists Press. Myers, I. B. , & McCaulley, N. H. (1985). Manual : A guide to the development and use of the Myers-Briggs Type Indicator (2nd ed.). Palo Alto, CA: Consulting Psychologists Press. Myers, I. B. , & McCaulley, N. H. (1987). Manual : A guide to the development and use of the Myers-Briggs Type Indicator (3rd ed.). Palo Alto, CA: Consulting Psychologists Press. Myers, I. B. , & Myers, P. B. (1980). Gifts differing . Palo Alto, CA: Consulting Psychologists Press. Nisbet, J. A., Ruble, V. E., & Schurr, K. T. (1981, March) . Myers-Briggs Type Indicator: A key to diagnosing learning behaviors in high risk college students . Paper presented at the 5th Annual National Conference on Remedial Development Studies in Post-Secondary Institutions, Dayton, OH.

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182 Norman, D. A. (1976) . Memory and attention: An introduction to human information processing (2nd ed.)' New York: John Wiley & Sons. Olsen, S. L. (1983). Teaching treatment planning. Physical Therapy , 63(4), 526-529. Payton, 0. D. (1985) . Clinical reasoning process in physical therapy. Physical Therapy , 65(6), 924-928. Physical Therapy , Journal of the American Physical Therapy Association. Proceedings from the APTA Conference on Clinical Decision Making in Physical Therapy Practice Education and Research, 69(7), July 1989. Pickard, N. (1989, October 18). American Physical Therapy Association progress report , 18(9), 9. Quinton, M. (1986, October) . Personal communication, Advanced Movement Analysis Seminar, Seattle, WA. Rezler, A. G., & French, R. M. (1975). Personality types and learning preferences of students in six allied health professions. Journal of Allied Health , 4(1) , 20-26. Ross, G., Lipper, E. , & Auld, P. A. M. (1986). Early predictors of neurodevelopmental outcome of very low birthweight infants at three years. Developmental Medicine and Child Neurology , 28(2), 171-179. Rovezzi-Carroll, S. (1981). Predicting major fields of study in allied health education with selected personality variables (Doctoral dissertation, University of Connecticut, 1981) . Dissertation Abstracts International , 42A, 1500. (University Microfilms No. DDJ81-22360) Shannon, C. E. , & Weaver, W. (1949). The mathematical theory of communication . Urbana: University of Illinois Press. Slaughter, D. S., Brown, D. S., Gardner, D. L. , & Perritt, L. J. (1989), Improving physical therapy students' clinical problem solving skills: Analytical questioning model. Physica l Therapy, 69(6), 441-447. Stanley, F. J., & English, D. R. (1986). Prevalence of risk factors for cerebral palsy in a total population cohort of low birthweight (less than 2000g) . Developmental Medicine and Child Neurology . 28(5), 559-568.

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183 Suchman, J. R. (1980) . Inquiry theory. In B. Joyce & M. Weill (Ed.)/ From facts to theories (pp 61-74). Englewood Cliffs, NJ : Prentice Hall. Vander Sijde, P. C. , Sellink, W. J. L. , & Wurms, R. J. (1987) . Developing audiovisuals for problem solving in phsical therapy education. Physical Therapy , 67(4), 554-557. Watts, N. (1985). Practical diagnosis. In S. L. Wolfe (Ed.), Clinical decision making in physical therapy (p. 15) . Philadelphia: F. A. Davis. Weber, W. J. (1975). The Jungian typology as a predictor of individual differences in performance of an experimental task . Master's thesis. University of Florida, Gainesville. Westcott, M. R. (1968) . Antecedents and consequences of intuitive thinking . Final report. Poughkeepsie, NY: Vassar College. (ERIC Document Reproduction Service No. ED 021292)

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BIOGRAPHICAL SKETCH Blanche Ann Burt DuPont was born in Miami, Florida. Following a primary and secondary parochial education in Dade County, she came to Gainesville and the University of Florida, where she received a Bachelor of Science degree in physical therapy in 1969. She was married in September 1970 to Ed DuPont, and became the mother of Brandi Anne DuPont in 1975 and Ed DuPont, Jr. (Rory) in 1977. In 1978 she began graduate work at the University of North Florida where she received a master's degree in allied health in 1981. In 1984, Mrs. DuPont began work on her Ph.D. in educational leadership at the University of Florida. Mrs. DuPont began work in 1969 as a physical therapist in pediatric and adult rehabilitation in Miami for one year. After marriage she worked in various roles as a physical therapist, a chief physical therapist at Hope Haven Children's Hospital, a senior physical therapist and county consultant in public school physical therapy in three school districts and a director of rehabilitation in adult rehabilitation. In 1983 Mrs. DuPont opened a private practice in pediatric physical therapy in Jacksonville, Florida. 184

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185 For three years Mrs. DuPont pursued special training in treatment techniques for the pediatric patient. She is certified in the pediatric neurodevelopmental treatment approach and in neurodevelopmental treatment of the baby. Mrs. DuPont developed the Developmental Dance Approach to pediatrics in 1981 and currently teaches workshops on dance activities for the pediatric patient throughout the state and periodically on a national level. She also is the clinical instructor in pediatrics to senior physical therapy students from seven programs in physical therapy including four programs in Florida, two in California, and one in New York. Mrs. DuPont 's publications include articles in Clinical Management in Physical Therapy . The Journal of Physical Therapy Education , and various journals in the field of exceptional child education. She has also introduced national-level, special-interest topics and presented research and poster presentations for the American Physical Therapy Association, Florida Physical Therapy Association, American Academy of Cerebral Palsy and Developmental Medicine, the National Council for Exceptional Children, and the National Down Syndrome Congress. She has functioned as board member for the Spina Bifida Association of Florida and special committee member on a statewide project for creation of pediatric

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186 evaluation instruments for public school physical therapists. She is currently involved in the Very Special Arts of Florida Program where her Developmental Dancers (all neurologically impaired children) perform regularly on the local and state level. She is a member of the American and Florida Physical Therapy Associations, Neurodevelopmental Treatment Association, the American Academy of Cerebral Palsy and Developmental Medicine, Pi Lambda Theta (education honor) , and Eta Rho Pi (health professions honor) .

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. ames W. Hensel, Chairperson Professor of Educational Leadership I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Mary K. pVkes / Professor of Special Education I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Martha A. Clendenin Professor of Physical Therapy I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Education. Forrest W. Parkay (7 Professor of Educational Leadership

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Education. This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. May, 1990 Martha C. Wroe Professor of Physical Therapy Dean, College of Education Dean, Graduate School