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J Phys Ther Sci
J Phys Ther Sci
JPTS
Journal of Physical Therapy Science
0915-5287
2187-5626
The Society of Physical Therapy Science

2024-055
10.1589/jpts.36.588
Technical Note
The effectiveness of clinical thinking using a problem-solving model
Kato Kentaro RPT, MS 1 *
Sasagawa Kengo RPT, PhD 1
1) Educational Corporation Tsukamoto Gakuin: 2-14-19 Yada, Higashisumiyoshi-ku, Osaka-shi, Osaka 546-0023, Japan
* Corresponding author. Kentaro Kato (E-mail: katoken@0saka-geidai.ac.jp)
5 9 2024
9 2024
36 9 588591
09 5 2024
12 6 2024
2024©by the Society of Physical Therapy Science. Published by IPEC Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)
[Purpose] No established method for appropriately developing clinical thinking in physical therapy currently exists. This study examined whether clinical thinking can be appropriately developed using a problem-solving model. [Participants and Methods] Physical therapy students were asked to develop clinical thinking in the same two cases: one class using the problem-solving model and the other class using International Classification of Functioning, Disability and Health concepts. Each clinical thought was scored and compared based on consistency. [Results] In both cases, students who used the problem-solving model scored higher. [Conclusion] The hierarchical structure of the problem-solving model clarified the relationship between each element and this was easy to maintain, suggesting that it facilitated appropriate clinical thinking.

Problem-solving model
Hierarchical structure
Clinical thinking
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pmcINTRODUCTION

The three domains of Bloom’s taxonomy are widely known as representative elements that all healthcare professionals should acquire. When applied to physical therapy, the knowledge of physical therapy and problem-solving skills are assigned to the cognitive domain, therapeutic tools such as exercise therapy are assigned to the psychomotor domain, and consideration for the client is assigned to the affective domain. It is expected that many people in leadership positions, within and outside academia, struggle with teaching the cognitive domain because it concerns information processing that occurs within the brain and cannot be externally observed. It is easy to review simple knowledge by answering one question at a time. However, it is difficult to grasp the state of another person during application, comprehension, analysis, integration, and evaluation of information, which are high levels of cognitive complexity. These cognitive levels correspond to the clinical thinking part of the physical therapy process, which involves integrated interpretation, problem identification, goal setting, and plan formulation. Clinical thinking is an important aspect of clinical practice that students find problematic and it also represents an area of concern for training instructors about how they can best guide their students.

Externalization is a typical method of supporting thinking. Externalization entails expressing the object to be understood in a manner that others can observe and understand it, rather than merely thinking about it in one’s mind1). Externalization allows one to observe one’s cognitive processes and is stated to be effective in promoting introspection and internalization2). Some externalization methods that have been tested include mind mapping, drawing, and conceptual mapping. Among these techniques, Novak’s3) concept mapping method is known as a representative method for organizing thoughts through externalization. The concept map method links concept A to concept B and expresses the relationships between the two concepts in a straightforward manner using link labels. Concepts are often expressed at the word level that is more visible than the use of sentences. It has been reported as an advantage of human information processing that images and other forms of information are more easily recognized than text and other verbal information4). The conceptual map method contains textual information at word level and link labels are not sentences. Rather, they use simple expressions such as conjunctions. Therefore, the conceptual map is an effective means of apprehending content in a short period. Additionally, the person providing the information does not compose a structure; hence, the concept maps become a meaningful method for both parties.

No uniform method for clinical thinking exists in physical therapy. Here we define clinical thinking as a structural understanding of solutions to problems. The International Classification of Functioning, Disability, and Health (ICF) is a tool that is widely used to describe client in healthcare-related fields. It is an excellent tool for comprehensively describing a range of information about client. However, this tool is not apt for guiding healthcare professionals during clinical thinking to intervene between relationships among elements and root causes to provide physical therapy. Kato and Arima5) proposed using a method called the problem-solving model for teaching clinical thinking in physical therapy. This model applies the conceptual mapping method to understand and teach clinical thinking. Herein, we decided to examine whether students who developed clinical thinking using the problem-solving model could appropriately advance their clinical thinking capabilities.

PARTICIPANTS AND METHODS

The problem-solving model

The problem-solving model is based on ICF concepts and utilizes the conceptual cartography method of representation. Problem-solving model can be expressed simply in terms of the following five elements: (1) the initial state in which the problem is unresolved, (2) the target position in which the problem would be resolved, (3) the causes preventing problem-solving, (4) the solutions to such causes, and (5) the constraints confronted in implementing the solutions. If we translate these elements to the physiotherapy process, the target state denotes the goal, the cause represents the problem, the solution determines the treatment plan, and the constraints designate the risks. These five elements are viewed as smallest units of a single problem solution. Individual and environmental factors can be added as needed.

Clinical thinking using the problem-solving model begins with participation-related constraints. The current state of restricted participation is deemed the initial state, and the goal state is designated as the aim toward which the participation restrictions are to be alleviated. Problems that cause participation restrictions are examined in terms of activity limitations, and treatment plans and risks are considered in relation to the activity restrictions. Next, the activity limitations that are contemplated as the problem of the participation constraints are set as the initial state, and a goal is established to improve activity limitation. The problems causing the activity limitations are considered in terms of psychosomatic dysfunctions. Subsequently, treatment plans and risks pertaining to the psychosomatic structural disorder are considered. The thinking proceeds from psychosomatic dysfunction to a health status. In this way, the model hierarchically incorporates the causes, moving from participation constraints to activity limitations, psychosomatic structural dysfunctions, and health status (Fig. 1Fig. 1. Problem-solving model (osteoarthritis of the hip joint as an example).

ROM: range of motion.

).

Participants

The study participants comprised 38 second generation and 41 third generation physical therapy students from a three year technical college. The purpose of the study was verbally explained to both classes stating that it would not affect their grades, that personal information would be analyzed in a manner that individuals could not be identified, and that they could withdraw their consent at any time. Written consent was then obtained from the participants before conducting the study.

Methods

Clinical thinking was scored for both classes using a case of stroke recovery and a case of cerebral hemorrhage complicated by diabetes mellitus. The same two cases were used for both classes. The second generation students had previously developed their clinical thinking on ICF charts (Fig. 2Fig. 2. The International Classification of Functioning, Disability, and Health (ICF) chart (Osteoarthritis of the hip joint as an example).

) using ICF concepts. The ICF chart is a unique tool that utilizes the six components of the ICF and the concepts that make up each of them, and is a tool that was utilized to organize thinking. The elements in the ICF are interconnected. The ICF chart uses arrows to indicate which constructs in each component influences which other constructs. Thus, the ICF chart can be used to express which constructs are affected by which other constructs. Therefore, bidirectional arrows do not connect every component as in the ICF but to elements within the influencing component or to constituents of other components. Expressions may be linked using bidirectional arrows depending on a patient’s condition.

Third generation students used the problem-solving model to develop clinical thinking. Both classes were presented with relevant case information second generation students developed clinical thinking using the ICF chart, whereas third generation students developed clinical thinking using the problem-solving model. The process from problem identification to plan development was indexed on a 50-point Likert scale to determine whether the process was consistent (Table 1Table 1. Evaluation chart used

Propriate problem identification	0 • 5 • 10 • 15 • 20	
Goal setting corresponding to the problem	0 • 5 • 10	
Treatment plans to solve problems	0 • 5 • 10 • 15	
Risk management	0 • 1 • 2	
Overall consistency	0 • 1 • 2 • 3	

). In providing physical therapy, problem identification is important, so more points were given. Treatment plans are given more points next because they are directly related to problem solving. Finally, consistency throughout the entire evaluation was evaluated. Higher the score, better the consistency. A two-sample t-test was used with a 5% probability of significance, and SPSS (Ver. 16) was used as the statistical software.

RESULTS

A significant difference was noted in the clinical thinking scores of third generation students as opposed to second generation students in both the presented cases (p<0.005) (Table 2Table 2. Student performance

	Second generation	Third generation		
	
Ave	SD	Ave	SD	
Cerebral infarction recovery period	30.1	7.3	34.8	6.5	**	
Diabetic complications of cerebral hemorrhage	26.8	6.3	36.7	4.8	**	
Unit: points. **p<0.005. Ave: average; SD: standard deviation.

).

DISCUSSION

Third generation obtained high scores and small standard deviations in both cases using the problem-solving model. In particular, the scores were higher and the standard deviations were smaller for the case of cerebral hemorrhage complicated by diabetes mellitus. The higher the score, the higher the consistency, suggesting that the problem-solving model may be able to develop consistent clinical thinking from problems to proposed solutions.

The ICF chart considers the relationship between the constituent concepts but it does not offer a hierarchical structure and is considered a parallel way of understanding. Therefore, it enables one to consider the existence of relationships but the contemplation of causal relationships and pursuit of causes could become problematic. ICF has ICF codes and qualifiers, but there is concern that expressing that much in the ICF chart would complicate the arrows and impair visibility. In addition, the treatment plan, risk and goal setting must be described separately, and the problem-solving structure cannot be expressed in a single diagram. The structure of the problem-solving model begins with the participation constraint and causes are then reduced to activity limitations and psychosomatic dysfunctions. Therefore, we believe that clinical thinking can proceed in a top-down manner and consistency can be easily ensured. We believe that clinical thinking in physical therapy corresponds to the faulty structure problem6) of cognitive psychology. The problems, goals, solutions, and risks of service users must be defined by a physical therapist. Insight7) and analogy8) are considered effective for the resolution of ill-structured problems. The method of expression of the problem-solving model indicates a hierarchical structure and is thus visible. Hierarchical chain of causes in turn from participation restrictions to activity limitations. Therefore, it could become easier to construct insights and analogies during or after the creation process. According to the dual coding theory9), figures and linguistic information positioned in proximity are more effective. The linguistic information is noted at word level and is represented by simple arrows. Further, the arrows are clarified as causes because of the hierarchical chaining structure.

These findings suggest that the hierarchical scaffolding of the problem-solving model and its pronounced visibility facilitates clinical thinking. The limitation of this study is that both the cases used were cerebrovascular disorders, and clinical thinking was not evaluated for other diseases.

This study used some data previously presented at the 29th Kanto Koshinetsu Block Physical Therapy Conference.

Conflict of interest

The authors declare that there is no conflict of interest.
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