Processes of Reflection to Enhance Clinical Reasoning Skills in Athletic Trainers

by Scott Heinerichs

RETURN
edited 8/21/11

Proposal and Justification

The National Athletic Trainers Association Board of Certification (NATABOC) has issued a new standard for its continuing education requirements. The NATABOC has mandated that of the 80 contact hours required every 3 years, at least five hours can be obtained from attending a clinical reasoning workshop held annually and five hours from the demonstration of clinical reasoning skills within ones practice. By issuing this mandate the NATABOC has recognized the significance the development of clinical reasoning skills are in athletic trainers. However, the NATABOC has not given specific guidelines as to how an individual can demonstrate the use of clinical reasoning skills in one's practice. Clinical reasoning is similar to critical thinking but refers not only to the what and why of patient care but also the how to provide the care. Clinical reasoning relies on both declarative knowledge and procedural knowledge; the process is an interactive merge between theory and practical skills (1).

I propose that reflection be used to enhance the clinical reasoning skills of athletic trainers to allow for competent health care delivery. Athletic trainers have an ethical obligation to deliver competent health care to the physically active population. By not using reflection to enhance their clinical reasoning skills they are under serving their patient population.

Health professionals across the disciplines require competence in clinical reasoning to aid in their decision-making process. Such abilities are an important part of clinical practice and enable the clinician to deal effectively with clinical practice within the context of the constant changes occurring in the medical science, in health care systems and in society. An integral part of this process is the ability to generate and use knowledge effectively (2). If athletic trainers are not competent in all areas of knowledge and skills of practice that are expected of them, health care is compromised. This is why it is necessary for athletic trainers to be able to clinically reason in order to deliver competent health care. However, this is not an easy task, but one way athletic trainers can develop the ability to clinically reason is through the use of reflection.

Although there is little research on the use of reflection within athletic training similar allied health professions (nursing, physical therapy, etc) have found that the use of reflection during clinical experiences has assisted in the development of learning and clinical reasoning skills. The advantages of utilizing reflection in one's practice are infinite. Reflection allows the athletic trainer the ability to become an effective practitioner because one is always questioning the decision-making process to ensure that it is accurate and is appropriate for the given situation (3). Furthermore, this technique has been shown to reduce error rates (4) and individuals who reflect have been found to be more active in their learning process, more self aware, self-regulated and more complex in their thinking (5,6,7). A famous quote by anonymous states: "what is heard is forgotten; what is seen is remembered; but what is written is understood." By having athletic trainers reflect upon their experiences it will allow them to understand and value the how portion that is necessary to enhance their ability to clinically reason which will allow for competent health care delivery. Without reflection, there is no merge between theory and practice. Athletic trainers who do not utilize reflection are merely technicians rather than practitioners.

Technicians "stick with a recipe" and make little adjustments for individualized patient needs and do not deliver competent health care (8). No two patients are alike, and not everyone responds the same way to an injury or the treatment of an injury. If an athletic trainer is to practice as a technician eventually the cookbook approach will be inaccurate at the patient's expense. Reflection will allow an athletic trainer to analyze how a specific case differs from the textbook or from previous similar cases and presents itself in the current clinical setting, thus bridging the gap between theory and practice. By using reflection it enhances the clinical reasoning ability of the practitioner because they are now giving meaning to an incident and providing the care necessary based on the specific needs of the patient and not the general approach of one size fits all, which in turn allows for competent health care delivery.

Charts and Graphs

Toulmin's Structure of Proposal

Claim: I propose that reflection be used to enhance the clinical reasoning skills of athletic trainers to allow for competent health care delivery.

Evidence:

Health professionals across the disciplines require competence in clinical reasoning to aid in their decision-making process. Such abilities are an important part of clinical practice and enable the clinician to deal effectively with clinical practice within the context of the constant changes occurring in the medical science, in health care systems and in society. An integral part of this process is the ability to generate and use knowledge effectively (2).

Reflection allows the athletic trainer the ability to become an effective practitioner because one is always questioning the decision-making process to ensure that it is accurate and is appropriate for the given situation (3)

Without reflection, there is no merge between theory and practice. Athletic trainers who do not utilize reflection are merely technicians rather than practitioners.

Warrant: Athletic trainers have an ethical obligation to deliver competent health care to the physically active population. By not using reflection to enhance their clinical reasoning skills they are merely technicians who do not merge theory and practice together. If reflection has been shown to enhance clinical reasoning skills which are necessary for athletic trainers practice then they should do it to assist in the delivery of health care that is expected of their profession.

Backing: The NATABOC has issued a mandate that continuing education units can be obtained from attending workshops on clinical reasoning. Because the governing body of our organization sees this as an important skill, athletic trainers should take advantage of it to enhance their practice. By not doing it, it is unethical and a disservice to the patients they treat.

Cue, Concern, Control-

1. Significance of Indicator Variance: The NATABOC has issued a mandate allowing for continuing education units in the area of clinical reasoning skill development to assist athletic trainers in providing competent health care. Reflection has been proven in other allied health professions as being beneficial to enhancing ones ability to clinically reason.

2. Indicator Relevance: By having athletic trainers utilize the technique of reflection it will enhance their ability to clinically reason by merging theory and practice together.

3. Non-Subversion: There is no evidence for nor reason to believe the indicator has been deliberately manipulated to deceive anyone.

4. Interest: This issue is of concern because if athletic trainers do not utilize reflection to enhance clinical reasoning skills they are merely technicians rather than practitioners. Technicians utilize a "cookbook" approach to patient care which allows for incompetent health care delivery.

5. Non-naturalness: Reflection will not make things worse but will allow for the development of clinical reasoning skills which are necessary in athletic training.

6. Practicality: The benefits of this proposal are the ability of athletic trainers to develop clinical reasoning skills and be doing so they will deliver competent health care. The cost of this intervention is the time it takes to reflect. However, the quality of an experience should never outweigh the quantity of the experience.

7. Liabiity: The physically active population that athletic trainers practice with each day will suffer because if athletic trainers are not utilizing reflection to connect theory into practice and allowing individualized treatment of patients because incompetence develops. Also the profession as a whole may not be looked upon favorably if athletic trainers cannot deliver the competent care that is expected of them.

8. Innocence: Not applicable

9. Obligation: We are obligated to act on the principle that everyone deserves competent health care. Furthermore, the health care system credence is "Do No Harm", and athletic trainers must be willing to understand how to individualize evaluation and treatment parameters to carry this out. Reflection allows an athletic trainer the ability to do this.

10. Optimality: This course of action is the best alternative because it will allow for competent health care delivery while allowing athletic trainers to develop into effective practitioners by gaining meaning from their experiences.

Cost/Benefit Analysis

References

Higgs, J. (1993). A Programme For Developing Clinical Reasoning Skills In Graduate Physiotherapists. Medical Teacher, 15(2), 1-11.

Kaiser, D. (2004). Using Reflective Journals in Athletic Training Clinical Education. Athletic Therapy Today, 9(6), 39-41.

Kuiper, R. & Pesut, D. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing, 45(4), 381-391.

Gargallo, B. (1993). Basic variable in reflection-impusivity: A training programme to increase reflectivity. European Journal of Psychology of Education, 8(2), 151-167.

Powell, J.H. (1989). The Reflective Practitioner in Nursing. Journal of Advanced Nursing, 14, 824-832.

Richardson, G. & Maltby, H.(1995). Reflection-on-practive: Enhancing student Learning. Journal of Advanced Nursing, 22, 235-242.

Knight, K & Draper, D. (2004). Critical Thinking and Therapuetic Modalities. Athletic Therapy Today, 9(6), 28-30.

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