Search

This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice," which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.

Background and Purpose: Clinical reasoning remains a relatively under-researched subject in physical therapy. The purpose of this qualitative study was to examine the clinical reasoning of expert physical therapists in 3 different fields of physical therapy: orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (home health) physical therapy., Subjects: The subjects were 6 peer-designated expert physical therapists (2 from each field) nominated by leaders within the Australian Physiotherapy Association and 6 other interviewed experts representing each of the same 3 fields., Methods: Guided by a grounded theory method, a multiple case study approach was used to study the clinical practice of the 6 physical therapists in the 3 fields., Results: A model of clinical reasoning in physical therapy characterized by the notion of "clinical reasoning strategies" is proposed by the authors. Within these clinical reasoning strategies, the application of different paradigms of knowledge and their interplay within reasoning is termed "dialectical reasoning.", Discussion and Conclusion: The findings of this study provide a potential clinical reasoning framework for the adoption of emerging models of impairment and disability in physical therapy.

Background Many patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study. Methods The qualitative methodology applied was a constructivist grounded theory approach. Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled. Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes. Results Our analysis highlighted 'predicted discharge destination' as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient's pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress. Conclusions Our qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients. [ABSTRACT FROM AUTHOR]

Background There has been a widespread call for an ethics in the management of patients with chronic pain which is patient centered and takes into account the lived experience of the patient. It has been argued in literature that current 'duty' or principlist-based models of ethics (so-called 3rd person ethics) have not adequately addressed the needs of either patients or practitioners in this area. Method Two strands of literature within phenomenology were reviewed: the literature of interpretative phenomenological analysis and the study of the lived experience of the person with chronic pain; and the contribution of phenomenology in neo- Aristotelian virtue ethics (1st person ethics). Findings Patients experience chronic pain in existential and moral terms in addition to their biomedical issues, facing dilemmas in understanding their own self-identity and in attempting to recover a sense of moral worth and agency. Discussion We outline a patient-centered ethics to underpin contemporary collaborative, multimodal approaches in the management of chronic pain. We firstly describe an agency-oriented, neo- Aristotelian 1st person ethics and then outline a hermeneutic relationship with extant 'duty-based,' 3rd person bioethics. The utility of the ethics model we propose (the ethical reasoning bridge) lies in its capacity for developing a sense of moral agency for both practitioner and patient, resonating with the current emphasis of seeking active engagement of patients in management. [ABSTRACT FROM AUTHOR]

Background and purpose: It is well recognized that physical therapy practitioners need to go beyond adherence to professional codes of conduct and have skills of ethical reasoning in order to address the ethical issues which arise in clinical practice. There is little consensus in physical therapy regarding approaches to teaching ethical reasoning. The purpose of this research was to study changes in the moral reasoning schema and organization of ethical reasoning knowledge of final year physical therapy students following a 6 week intensive ethics course with a teaching focus on two particular ethical reasoning models: the Four Component Model and the Ethical Reasoning Bridge. Methods: A pre-test post-test design was used to evaluate changes in moral reasoning schema (using the Defining Issues Test version two (DIT2)) and changes in the organization of students' ethical reasoning knowledge using concept maps. Results: Thirty-seven students completed all four portions of the research, a response rate of 68·5%. There was a significant increase in post-conventional reasoning (so called N2) scores (35·2 to 39·7, P = 0·006). Concept maps post-test displayed a shift from a pre-test quantitatively oriented and organised set of ethical knowledge concepts to a more integrated and qualitatively oriented new knowledge framework. Conclusion: This study has demonstrated that a 6 week course using curricular strategies involving the interpretation of experience and perspective transformation can facilitate in a cohort of final year physical therapy students both the development of ethical reasoning ability (moral judgment) and a richer organization of the types of knowledge required for ethical decision making. [ABSTRACT FROM AUTHOR]

Chronic conditions now provide the major disease and disability burden facing humanity. This development has necessitated a reorientation in the practice skills of health care professions away from hospital-based inpatient and outpatient care toward community-based management of patients with chronic conditions. Part of this reorientation toward community-based management of chronic conditions involves practitioners' understanding and adoption of a concept of population health management based on appropriate theoretical models of health care. Drawing on recent studies of expertise in physiotherapy, this article proposes a clinical reasoning and decision-making framework to meet these challenges. The challenge of population and community-based management of chronic conditions also provides an opportunity for physiotherapists to further clarify a professional epistemology of practice that embraces the kinds of knowledge and clinical reasoning processes used in physiotherapy practice. Three case studies related to the management of chronic musculoskeletal pain in different populations are used to exemplify the range of epistemological perspectives that underpin community-based practice. They illustrate the link between conceptualizations of practice problems and knowledge sources that are used as a basis for clinical reasoning and decision making as practitioners are increasingly required to move between the clinic and the community. [ABSTRACT FROM AUTHOR]

Popular debate about the appropriate place of victims in criminal justice decision-making tends to be couched in terms of 'balance. This rhetorical device precludes a comprehensive analysis of the issues raised by victim involvement. This article argues that an analysis of the concept of participation is more fruitful. I delineate four different participatory roles for victims, each envisaging a particular relationship between victim and criminal justice decision-maker. I then discuss a recent reform in England and Wales--the Victim Personal Statement Scheme--to illustrate the ambiguity that can arise in a victim's participatory role when governments pay insufficient attention to the issues underlying rationales for victim involvement. [ABSTRACT FROM AUTHOR]

The article presents a cast study of an elite football player who wishes to return early to training against the wishes and advice of the physical therapist. It offers guidelines in resolving the tensions between a therapist and patient conundrum. The author reflects on the need to examine carefully therapist-patient conflicts where there exist absolutist right and wrong solutions and courses of actions.