An Exploration of the Impact of Practice Setting on Clinical Reasoning and Implications for Teaching

INTRODUCTION: Recent perspectives emphasize that clinical reasoning (CR) is not purely internal but emerges from the dynamic interaction between clinician, patient, and environment. Ecological psychology, a theory within the broader classification of situativity theory, posits that thinking and learning result from the learner's intentional interactions within a context-rich environment. The purpose of this study is to explore how expert physical therapists' CR is informed by the affordances of their practice settings. REVIEW OF LITERATURE: Ecological psychology views CR as arising from intentional interactions among the clinician, patient, and environment, revealing opportunities for action. The goals and intentions of the clinician drive perception and actions within the environment, whereas the environment simultaneously shapes the clinician in a bidirectional relationship. Ecological psychology has been applied in academic medicine in CR teaching, assessment, and mentoring but has not yet been applied in physical therapy. SUBJECTS: Eleven board-certified physical therapists in orthopedics, pediatrics, cardiopulmonary, and neurology. METHODS: The study uses an exploratory and descriptive, multiple case study design, using a think-aloud protocol. The multiple case study design allows for across-case analysis, identifying differences and similarities across practice settings. RESULTS: Across-case analysis revealed similarities and differences in CR. All therapists asked questions regarding history, patient's goals, and examined movement. Essential differences arose because of the interaction between the therapist and practice setting. The impact of the setting was evident in examination choices, prioritization of items, rationale for selection, and what appeared to be the underlying intention of the therapist's reasoning. DISCUSSION AND CONCLUSION: The significant result of this work is the beginning of an understanding of the impact of the environment, specifically practice setting, on the CR of physical therapists. These findings may influence how CR is taught in PT education.