The use of clinical case studies to develop clinical reasoning in sports therapy students:

The students’ perspective

Research article

Ross Armstrong, Sports Therapy Lecturer, Faculty of Arts and Sciences, Department of Sport

and Physical Activity, Edge Hill University, St Helens Road, Ormskirk, Lancashire, L39

4QP. Email: armsross@edgehill.ac.uk Phone: 01695 584246

Aims/Background: The aim of this study was to examine a cohort of undergraduate 2nd year

undergraduate sports therapy students’ perceptions regarding the effectiveness of clinical case

studies (CCS) in the development of clinical reasoning skills and how CCS may influence

performance in a Sports Injury Clinic.

Method: The study involved 55 students (n = 23 male, 32 female) and used a mixed methods

approach involving a questionnaire with open ended questions, Likert scale questionnaire and

interviews which aimed to determine students’ perceptions of their performance. Five main

areas were investigated via open ended questions: defining clinical reasoning; advantages of

CCS; disadvantages of CCS; the effectiveness of CCS in comparison to real patients; and

whether CCS helped students working in a Sports Injury Clinic. Students completed a 5 point

Likert scale which asked three statements regarding the clinical environment. Following the

questionnaire a sample of 15 students were randomly selected for individual interview.

Findings: The results suggested that the students’ responses were generally in favour of the

use of CCS to aid the development of confidence, communication and clinical reasoning.

Conclusions: Clinical learning is unpredictable due to patient interaction and therefore CCS

might be a learning tool that can be used to assist the journey to clinical competence.

Key words: Sports therapy, clinical reasoning, clinical case studies, clinical autonomy,

problem based learning

Clinical reasoning is the decision making process that enables the formulation of a diagnosis

to allow effective patient management (Terry and Higgs, 1993) and underpins the

management of musculoskeletal injury. The diagnosis and treatment of injuries provides a

unique learning opportunity to foster attitudes of enquiry in students and aid development of

clinical reasoning skills. Models of clinical reasoning include hypothetico-deductive (Terry

and Higgs, 1993), narrative reasoning (Edwards et al 2005) and pattern recognition (Jones,

1992). The essential elements of clinical reasoning which are developed through experience

and facilitation are: (1) Cognition (reflective inquiry). (2) Sound knowledge base of the

1

discipline. (3) Metacognition (involving creative integration of cognition and knowledge). (4)

Decision making. (Higgs and Jones, 1995).

Sports therapy is an area of healthcare that aims to reduce injury risk and provide a variety of

rehabilitation strategies to optimise occupational and sporting performance. The Society of

Sports Therapists are responsible for validation of the BSc (Hons) Sports Therapy and one of

their prerequisites is that undergraduate students must complete clinical hours to develop the

clinical autonomy required to practice as a sports therapist. Many undergraduate Sports

Therapy programmes use Sports Injury Clinics to develop the students’ experience of

musculoskeletal injuries. Sports Injury Clinics provide patients who are from university

sports teams or the general public with an appointment with an undergraduate sports therapy

student under the supervision of a clinical educator who facilitates the learning process. CCS

may develop the student experience of musculoskeletal injuries and utilise a real patient

presentation or a fictional scenario to stimulate clinical reasoning. One study (Munro-Wilson,

2012) has specifically investigated the use of CCS within sports therapy. This study

examined undergraduate sports therapy students’ experiences of CCS in the development of

clinical reasoning skills. Students completed a questionnaire with the majority of students

suggesting the use of CCS were beneficial, however students indicated that their injury

knowledge must be accurate to benefit from the CCS as a lack of understanding could lead to

a misdiagnosis and hinder development. Obtaining the correct answer in CCS was deemed

essential and it was suggested this may highlight a need for greater knowledge transfer.

The student experience of clinical reasoning is influenced by the number of patients and

different musculoskeletal injuries students encounter. If students do not experience a wide

range of musculoskeletal injuries it is possible that CCS may be used to develop injury

knowledge. The aim of this paper is to determine perceptions of a cohort of undergraduate

2nd year sports therapy students regarding the effectiveness of CCS in the development of

clinical reasoning skills and how CCS may influence performance in a Sports Injury Clinic

using a mixed methods approach. It was hoped the use of interview would provide a greater

depth of analysis regarding clinical reasoning development.

2

LITERATURE REVIEW

The clinic environment: Developing clinical competence through problem based

learning (PBL)

Traditionally education models were teacher centred resulting in the teacher dictating the

subject and style of teaching however such models may inhibit problem solving, initiative

and decision making (Sadlo et al, 1994). A shift towards a more student centred focus

approach resulted in the development of other models including PBL and self-directed

learning (SDL) which are utilised on undergraduate sports therapy programmes. The

McMaster Medical School developed PBL in the mid-1960s (Neufield et al, 1989) and it is

used in many healthcare educational programs including medicine, dentistry, physiotherapy,

occupational therapy, speech pathology, and nursing (Chung et al, 2011; Neufeld et al, 1989;

Hawthorn et al, 2004; Wood, 2003). PBL uses the patient as a framework for students to

acquire new knowledge and develop problem-solving skills (McParland et al, 2008) and

involves reflection and critical evaluation which places the student at the centre of the

learning experience with the process of learning rather than the content the focal point

(Whitcombe, 2001). PBL is a five step process which includes problem analysis, defining

learning objectives, information collection, summarising and reflection (Lin et al 2010). In

nursing students, PBL may improve critical thinking and is superior to traditional lectures

(Kong et al, 2014). SDL encourages students to take responsibility for their own learning and

involves the identification of a subject area which provides a framework for knowledge

development (Knowles, 1975). CCS can be used for PBL and SDL and are associated with

experiential learning which involves active engagement and exploration of the experience via

reflection resulting in a meaningful learning experience (Alsop, 1993). The development of

student centred educational strategies is supported by a variety of reviews (Merriam, 2001)

and CCS may aid the transfer of knowledge from classroom to clinic (Geisler and Lazenby,

2009).

Clinical education research involving undergraduate sports therapy students is extremely

limited. A substantial evidence base exists involving the clinical education of physiotherapy

students (Babyar et al, 2003; Gunn et al, 2012; Dissanayaka et al, 2012) and to a lesser

3

extent athletic trainer students (Weidner and Henning, 2003; Weidner and Henning, 2005) in

the USA. Both programmes have similarities to sports therapy as they use Sports Injury

Clinics to develop professional competence and therefore discussion of their findings is

relevant. Gunn et al (2012) investigated how PBL skills are used on clinical placements by

student physiotherapists and concluded that PBL learning is associated with positive

behaviour traits including high level of motivation and directed learning. These students

demonstrated great individual variability in skill transference which may be reflective of the

variety of conditions that present in actual patients. Dissanayaka et al (2012) assessed

physiotherapy students’ perception of PBL musculoskeletal physiotherapy including written

scenarios of hypothetical patients. Students felt that PBL was fun and 79% believed it

improved their critical thinking and fulfilled learning objectives. This suggestion of PBL

being fun, may be essential in helping students to achieve learning objectives.

Collaborative education

During peer work, students learn via collaboration through discussion of their experiences.

Collaborative models encourage peer support and discussion, team working, reflective

practice and clinical competence (Rindflesch et al, 2009) and enable students to teach their

peers regarding patients and medical conditions (Rindflesch et al, 2009). The advantages of

collaborative clinical education include increased self- confidence and learning opportunities

(Parker and Kersner, 1998), facilitation of reflective learning, critical thinking, problem

solving (Lincoln and McAllister, 1993) and improved student supervision (Currens and

Bithell, 2003). Clinical educators view the clinical setting as an interaction rather than a

lecture (Greenfield et al, 2014) which allows theory to become practice and involves

coaching students to develop clinical autonomy.

Balancing the students’ and patients’ needs

CCS have been used across a variety of healthcare disciplines including medicine (Bowe et

al, 2009) and nursing (Ghude et al, 2010) to develop clinical reasoning in an environment

distant from actual patient interaction which may prove less stressful. The clinical

supervision of athletic training students can have a positive or negative effect on professional

development (Curtis et al, 1998) dependent on the level of supervision which diminishes as

4

the students’ academic standing increases (Weidner and Pipkin, 2003). Clinical experiences

are a critical component of student learning (Weidner and Henning 2003,) however clinical

educators are under increasing pressure to meet both the needs of the patient and the student

(Weidner and Henning, 2005). It is of paramount importance that patients’ needs are

prioritised over the student learning experience for health and safety reasons and for student

development. A negative experience in the infancy of a students’ career may have serious

consequences for their long term development. It is important to determine whether the use of

CCS in a ‘safe’ environment aids the development of clinical reasoning. Comparisons with

CCS based literature in other medical professions may be limited by the type of the scenario.

In a medicine stimulation based model for resuscitation scenarios with resident physicians it

was suggested that preserving an equilibrium between patient care and learning was difficult

for both the physicians and the supervisors (Piquette et al, 2014). It is possible that

emergency care management scenarios may require a different approach to musculoskeletal

injury CCS.

METHODS

Design

The study was conducted during the academic year 2014-2015 and involved a mixed methods

approach using a questionnaire with open ended questions to determine the perceptions of

students regarding the effectiveness of CCS on clinical reasoning. Five main areas were

investigated which were: defining clinical reasoning; advantages of CCS; disadvantages of

CCS; the effectiveness of CCS in comparison to real patients; and whether CCS help when

working in a SIC. Students also completed a 5 point Likert scale which asked three

statements regarding the clinical environment. Following the questionnaire a sample of 15

students were randomly selected for interview by the researcher via drawing of student

numbers from an envelope. All 15 students agreed to be interviewed. The questions and

statements were constructed by the researcher following a review of similar approaches via a

pilot study involving undergraduate 3rd year sports therapy students who were not

participating in the study to determine that the questions were appropriate and to ensure face

validity. The CCS were reviewed by lecturers on the programme to ensure face validity and

that they were at an appropriate level for undergraduate 2nd year sports therapy students.

5

Participants

Participants were invited from a cohort of undergraduate 2nd year sports therapy students at

Edge Hill University (n = 23 male, 32 female, age range 19 - 24 years). Second year students

were selected as they had one semester of Sports Injury Clinic experience and were thought

to have a suitable level of clinical knowledge.

Procedure

Students worked in pairs with one student provided with the CCS to enable them to play the

role of the patient. The order was randomly selected via the drawing of names from an

envelope and those students who had played the role of patient did not get the same CCS

when they were in the role of the clinician. No time limit was placed on the scenarios

however most students took approximately 30 minutes. Prior to the CCS, the student playing

the role of clinician were provided with an information sheet which instructed them to

perform a subjective and objective assessment, develop a problem list, short term and long

term goals and formulate a treatment plan. Following completion of the CCS, students then

reversed roles to allow all students the opportunity to play the role of the patient. All students

participated in the CCS over a 6 week period. A total of 15 CCS were available for use.

The questionnaire consisted of 5 open ended questions to allow students to express their

thoughts in detail regarding CCS. The following questions were asked:

(1) How would you define clinical reasoning?

(2) What are the advantages of using CCS?

(3) What are the disadvantages of using CCS?

(4) In comparison to assessing a real patient how effective to do you think the use of CCS is?

(5) Do you think the CCS helped you when working in the Sports Injury Clinic?

The five point Likert scale (1 strongly disagree, 2 disagree, 3 neutral, 4 agree, 5 strongly

agree) asked three statements regarding three vital components of the clinical environment

namely communication, confidence and clinical reasoning. These were adapted from a

clinical acquisition skills survey devised by Meechan et al (2011). The following statements

were asked:

(1) The CCS improved my patient communication skills.

6

(2) The CCS improved my confidence levels when working in the Sports Injury Clinic.

(3) The CCS improved my clinical reasoning.

The questionnaires and Likert scale were distributed to students in an organised session

following the completion of the CCS. A subsample of 15 students (7 male, 8 female) were

selected for interview. Individual interviews were held between the researcher and the

students a week after the questionnaire and Likert scale had been completed and provided an

opportunity to clarify the points made in the questionnaire and ask for feedback regarding

how the CCS could be developed for future cohorts. Interviews were recorded by dictaphone

and students were provided with the opportunity to opt out of been recorded.

Ethical considerations

The Edge Hill University Ethics Committee provided ethical approval prior to the study

commencing and students completed informed consent forms. All students had the

opportunity to withdraw from the study at any time and were asked to read the following

information: http://www.edgehill.ac.uk/research/files/2012/05/Ethics-Output-Guidance-

EHU-Students-RESO-GOV-12.pdf). All research was performed in compliance with the

Helsinki Declaration of 1975. Those students who chose not to take part in the study did not

have to worry that refusal would have any affect on their grades as CCS were not assessed.

The data collected was securely stored on a computer using a password protection scheme

and only the researcher had access to the data. All students were given the opportunity to

withdraw their data up to 4 weeks after their last participation and only the researcher had

access to the questionnaire and interview recordings. Anonymity and confidentiality were

assured throughout.

Data analysis

Questionnaire responses were assessed via inductive category building based upon the

method of Batram and Bailey (2010). This process involved the identification of common

themes across the responses which were then grouped according to similarity and then

discussed and explored further via interviews. Themes had to be present in at least 10

separate questionnaire responses to be considered and theme analysis was reviewed by one

other lecturer on the sports therapy programme to confirm that identified themes were

7

appropriate. Data collected from the Likert scale was used to provide descriptive statistics.

Analysis was divided into males and females and the total cohort.

RESULTS

Likert scale

Students’ perceptions of whether CCS improve their patient communication skills are shown

in Figure 1 and demonstrates that the majority of students (n = 51) either strongly agreed or

agreed with this statement and only one student disagreed. Figure 1 here

Students’ perceptions of whether CCS improve confidence levels when working in the Sports

Injury Clinic are shown in Figure 2 and demonstrates that the majority of students (n = 51)

either strongly agreed or agreed with the statement and only one student disagreed.Figure 2 here

Students’ perceptions of whether CCS improved clinical reasoning are shown in Figure 3 and

demonstrates that the majority of students (n =53) either strongly agreed or agreed and the

remaining students neither agreed nor disagreed (n = 2).Figure 3 here

Questionnaire and interview

Defining clinical reasoning

Questionnaire analysis revealed 18 students used the words “justify” or “justification of

assessment” while other words that featured frequently were “prove” and “disprove

findings”, “discover, direct the assessment, detect, gather and evaluate.” One student

suggested clinical reasoning was:

“Deciding what treatment path to go down and not doing irrelevant things.”

Another student suggested:

“How to decide what to do in clinic in relation to injuries and treatment.”

While another suggested:

“Gathering the most important information to see if the problem is what you think it is.”

8

During interviews, 12 students alluded to clinical reasoning as combining their findings to

solve a problem.

Advantages of CCS

Fifteen students indicated via questionnaire that CCS would allow them to prepare for “real”

patients and 6 students used the term ‘it allows you to think outside the box”.

One student suggested:

“The CCS link all modules together and create thinking therapists.”

Ten students reported that the CCS “improved confidence” and reference was made to the

environment been more relaxed.

During interviews the theme of being better prepared and creating a mental list was

highlighted. Students felt they developed the routine of performing an assessment and

developed the correct medical terminology.

Disadvantages of CCS

Questionnaire analysis suggested that the student playing the role of the therapist may find it

difficult to act and that an incorrect presentation by the ‘patient’ may be misleading. It was

suggested that students require a good knowledge base to perform the role play and may not

have sufficient knowledge. In contrast it was suggested that students playing the role of the

patient may provide more help to the therapist due to their increased knowledge and may act

differently to a real patient. This was highlighted in the terminology used.

One student suggested:

“Patients will not necessarily say how the injury is presenting e.g. an intermittent ache, while

students may use this terminology.”

It was suggested some symptoms are difficult to recreate. One student suggested:

9

“You cannot always recreate situations in a realistic manner (e.g. ‘false’ reflexes,

inflammation).”

It was observed that:

“Scenarios are set however not all patients will present the same.”

Interview analysis suggested there was a tendency for students to work with their friends and

therefore they may help each other too much. It was suggested making students work with

individuals they did not normally work with to make the experience more formal. Some

students believed they would communicate differently with real patients however other

students disagreed with this suggestion.

Effectiveness of CCS in comparison to real patients

Questionnaire analysis suggested that confidence and self-confidence improved however 5

students suggested CCS might not be as effective for objective symptoms.

One student suggested:

“CCS are very effective for the subjective but not as good for the objective due to difficulty

in recreating symptoms.”

It was also suggested that:

“CCS allow you to make mistakes as you will not injure anyone.”

CCS were described as “less formal” than working with actual patients and “reduced

pressure.” One student suggested CCS “do not help with handling skills and if an area was

tender or inflamed your handling would be different.”

The interview responses suggested that CCS could provide a base of knowledge to allow

students to work with patients. When asked, 11 students indicated that it might be beneficial

to create more CCS for other body regions however it was unclear whether the students

10

would practice CCS in their own time with 7 students suggesting this was unlikely while 8

students wanted the opportunity.

Effect on working in the Sports Injury Clinic

Questionnaire analysis revealed that 15 students believed that CCS would improve

knowledge and that they felt more prepared (n = 8).

One student suggested:

“It improved knowledge and links modules and clinical reasoning.”

However some caution must be noted in that another student suggested:

“It helps with the routine of questioning but every patient is different.”

The main suggestion was that it improved communication and preparation.

During interviews 12 students suggested they would be more confident when treating actual

patients and CCS would allow them to identify areas for improvement. Five students

perceived detailed feedback from the student acting as the patient to be useful and some

suggested that it might be useful if they were observed by a clinical supervisor who could

provide the student with feedback.

DISCUSSION

The findings provided a number of interesting discussion points regarding the development of

clinical reasoning using CCS in undergraduate sports therapy students. The general student

perception was that the CCS were a useful adjunct to develop student clinical reasoning

skills. The aim of this paper was not to determine gender differences in perceptions of the

CCS however these findings are outlined to provide stimulus for future research and to allow

a comprehensive overview of the data. It must be noted that there was a greater number of

female students (n = 9) in this study when interpreting results. This greater number of

females is reflective of all three year groups of the current undergraduate programme.

11

Communication skills and confidence levels

The majority of students perceived that CCS improved their patient communication skills. No

male students reported any negative perceptions in comparison to 3 female students. This

difference may reflect the larger female sample size. The majority of students perceived that

CCS improved their confidence levels. There was no gender differences regarding negative

responses to perceptions of confidence levels. The similarity between the results for the

students’ perceptions of communication skills and confidence level developments may reflect

the interaction between good communication skills and developing confidence when working

with patients. Students require good communication to successfully complete treatment and

as they develop the framework of subjective questioning and objective assessment it is likely

that their confidence levels will improve. The findings of increased confidence levels are

supported by Parker and Kersner (1998) who advocated the use of collaborative education in

increasing self-confidence and learning opportunities. This collaborative model enhances

student supervision (Currens and Bithell, 2003). It is significant that students perceive they

can develop communication and confidence via CCS which suggests they may act as a

learning tool to make effective decisions. All of the scenarios used were based on real

scenarios, an approach which had been advocated by Ernstzen et al (2009).

Developing clinical reasoning

The majority of students perceived that CCS developed their clinical reasoning skills and

there were no negative responses regarding the effect of CCS. Students associated clinical

reasoning with their clinical performance and the collection of information before

determining their treatment. This process suggests the identification and ‘figuring out’ of

problems (Munro-Wilson, 2012) and identifies weak practice areas (Stradely et al, 2002). By

gaining access to the thought process behind clinical reasoning it may be possible to develop

the clinical reasoning process in students. This could potentially be achieved by working with

the students to identify key words that stimulate learning and then implementing these into

future scenarios which could be introduced by the patient. These might be condition specific

such as the use of special questions regarding meniscal injuries of the knee joint which may

involve questioning regarding locking and giving way of the knee. No gender differences

existed in the perception of the development of clinical reasoning skills however previous

research by Groves et al (2003) reported significantly higher clinical reasoning scores in the

12

measurement of clinical reasoning problems in female medical students. Goss et al (2011)

found that female medical students had significantly greater in the memory component using

the Diagnostic Thinking Inventory (Bordage et al, 1990) to assess clinical reasoning. Student

questionnaire responses suggested that clinical reasoning allows unnecessary parts of the

assessment to be excluded however it is vital that students do not neglect an important part of

the assessment. The asking of excessive questions and recording of irrelevant factors is a trait

often observed in the interaction between students and patients. Novice clinicians may use

hypothesis driven strategies by which the initial diagnosis the student makes then drives their

assessment. The collection of information to support this diagnosis may support the

hypothetic-deductive model (Terry and Higgs, 1993) that follows this process. Experience

allows the development of pattern recognition (Jones et al, 1992) and as students recognise

the problem they should use frameworks to develop their treatment. Those students who

struggle with framework development may benefit from additional support to develop

narrative reasoning (Edwards et al, 2005) which involves interpreting the patients ‘story’ and

experience of their injury to aid the clinical reasoning process. These students may need a

more detailed patient ‘story’ or direction towards verbal cues that aid clinical reasoning.

During interviews, 12 students described clinical reasoning as combining their findings to

solve a problem. Interestingly the students all believed that clinical reasoning process had an

end point while more experienced clinicians may suggest it is vital that an open mind is kept

in relation to the diagnosis. It is vital that students perceive the patient interaction as a fluid

ongoing process. It may help reduce student anxiety and improve student confidence to

communicate that even experienced clinicians are often unable to provide a full diagnosis and

that treatment should be viewed as ongoing process with potential to vary treatment and

assessment depending on patient response. Novice students have a narrow view of the patient

and a reduced ability to analyse situations effectively and make decisions by using conceptual

frameworks developed through their practice. The use of one theory to explain the process of

PBL might be too simplistic however the theories that may explain the process are contextual

learning which provides the student with the basic concepts to apply when they encounter a

problem in the future (Albanese, 2000) and information processing theory (Schmidt 1983)

which involves the activation of core knowledge elements. It is possible that all these

concepts are involved in the clinical reasoning process.

13

Advantages of CCS

The creation of ‘thinking therapists’ as suggested by student questionnaire responses is

encouraging. Students develop critical thinking by incorporating existing knowledge into new

situations and allowing development of a hierarchy of knowledge. This has been referred to

as scaffolding strategies (Hausfather, 1996) and case studies promote clinical scaffolding

(Peer and McClendon, 2002). Eva (2004) suggested experienced therapists may ask certain

questions that will hopefully lead to the solving of the problem via identification of clues.

The students’ suggestions of deeper thinking are encouraging and CCS may help bridge the

gap to treating actual patients. Facione et al (1995) proposed that individuals who critically

think use the following dispositions: inquisitiveness, open mindedness, systematicity,

analyticity, truth seeking, self-confidence and maturity and these are attributes required in

‘thinking therapists’.

In athletic training the number of hours completed in an injury clinic had little influence on

examination performance (Turocy et al, 2000). Leaver-Dunn et al (2002) investigated critical

thinking amongst undergraduate athletic training students and reported that there was no

correlation between critical thinking disposition and clinical experience hours suggesting that

quality of the clinic experience rather than quantity is important. This requires investigation

with sports therapy students and may suggest the need for clinical mapping of injuries to

ensure that students are exposed to a wide variety of injuries. CCS could potentially be used

to ensure that students are presented with musculoskeletal conditions not experienced during

Sports Injury Clinics.

The identification via questionnaire of the requirement to use the correct terminology

highlights that students were attempting to make the journey from novice to expert clinician.

The use of medical language is important in injury diagnosis and experts and novices may

use different terms to describe the same description (acute onset versus last night, recurrent

episodes versus the same knee) with students tending to write word for word what patients

describe (Bowen, 2006). Clinicians use numerous strategies to formulate a diagnosis and

students should use medical language to demonstrate understanding and aid the questioning

14

process. This development of medical language is required to aid the effective

communication with other healthcare professionals and ensure the patients welfare.

Disadvantages of CCS

The suggestion that some students may find it difficult to act was also supported by previous

findings (Munro-Wilson, 2012). Generally positive findings between role play and clinical

reasoning exist (Walker and Weidner, 2010; Guhde, 2010) however comparison must

consider differences in the types of students and methods employed. Difficulty in acting

might be overcome by the use of actors (Walker and Weidner, 2010) and it is possible that

future research could use performing arts students which may also aid their development. It

was suggested that the scenarios are inflexible in comparison to actual patients. Ambiguity

and multiple interpretations of the same problems can be useful in the development of

scaffolding frameworks as patient presentations are not always clear and may actually aid

development. Therefore there may exist a requirement to make some of the CCS more

ambiguous. The suggestion that students tend to work with their friends in CCS could be

overcome by using students from other year groups which may also aid their development.

Students were randomly allocated into pairs during the scenario to prevent over familiarity

however it is impossible not have a degree of familiarity. Difficulty in recreating some

objective signs and symptoms such as swollen joints and altered reflex patterns is true but

these clinical signs may be overcome by a video library of images which could be linked to

specific CCS. Computer based simulated patients have been used previously (Bergin and

Fors, 2003) and this is a concept that could perhaps be adapted to provide objective signs and

symptoms.

Effectiveness of CCS in comparison to real patients

The suggestion that CCS allow students to make mistakes without injuring the patient

indicates a degree of anxiety and therefore further investigation of when students are ready to

treat may be required. The level of anxiety could potentially be measured by a State Trait

Anxiety questionnaire such as that devised by Spielberger et al (1983). Excessive supervision

may inhibit the students learning opportunities while insufficient supervision may place the

patients and students at risk. CCS were described as “less formal” than working with actual

15

patients and resulted in “reduced pressure.” This could be viewed as having positive and

negative effect as the development of a professional manner and good time management are

skills required to be a good clinician yet the perceived reduction in pressure may allow

students to develop clinical reasoning. One student suggested that students should use a

template to record their notes as they may not complete the recording of their subjective and

objective assessment to the required standard. This template could be easily implemented in

future CCS. One student suggested CCS do not help with handling skills as areas of

inflammation would be handled differently in an actual patient. Although the presentation of

a swollen joint will alter handling it remains essential that students learn to handle joints in an

appropriate manner and initially this needs to be developed with normal joints. This is

supported by Radtke (2008) who identified that PBL requires a mixture of clinical skills and

PBL. These clinical skills may be best developed with a normal joint. The interview

responses suggested that CCS provide a base of knowledge to allow students to work with

patients and 11 students indicated that it might be beneficial to create more CCS for other

body regions. When questioned it was unclear whether the students would practice CCS in

their own time with some suggesting this was unlikely while others wanted the opportunity.

Prior life experience, academic and clinical instructors and case study presentations of actual

patients have been identified as developing clinical reasoning in physiotherapy students

(Babayar et al, 2003). These students suggested the following methods to teach clinical

reasoning via role play: discussion of cases before and after interaction with the patient

(60.8%), provide an opportunity for independent problem solving (16.9%), observation of

clinical instructor initially followed by patient discussion and gradually allow more student

involvement (12.2%). The discussion of CCS with students or observation of the clinical

instructor by students who are struggling to develop a framework for assessment may

therefore be beneficial and are teaching tools that could be developed in future CCS.

Effect of CCS on working in the Sports Injury Clinic

The suggestion that CCS improve knowledge and preparation is encouraging. The discussion

that all patients are different highlights that students were aware that CCS should be used as a

framework to develop skills and that they identified subtle differences in injury presentation.

Expert clinicians use pattern recognition in the analysis of clinical findings which is then

developed to test the provisional hypotheses (Norman, 1988). Some students may benefit

16

from clinical reasoning out loud during the developmental stage and this may allow the

‘clinician’ and the ‘patient’ to identify why certain decisions were made as students may fail

to focus on how problems are interlinked. In the future, subtle alterations could be made to

the CCS to alter student injury interpretation and study resources could be recommended for

each CCS post completion. The suggestion that CCS allow the identification of areas for

improvement may allow to students to develop their critical reason skills by providing a

template for various injuries. It may also be beneficial to provide students with CCS to

practice in their own time. Athletic trainers are thought to learn best from experience and

self-involvement which involves active hands on participation (Draper, 1989) and the

students believed that the hands on aspect of their CCS help prepare them for the Sports

Injury Clinic.

Implications for practice and limitations

Likert scale analysis revealed that the most positive effect was seen in clinical reasoning and

confidence levels. This may relate to the suggestion made by some students that the CCS do

not have an effect on actual patient communication. With relation to clinical practice this

might suggest that the predominant focus of CCS should be to develop clinical reasoning and

confidence and they may allow the development of an appropriate knowledge base. High

quality patient care and promoting diagnostic skills are the art of clinical teaching (Bowen,

2006) and the primary objective for students is to be able to perform a competent subjective

and objective assessment and devise a treatment plan with associated goals. Once this has

been achieved the student can concentrate on effective treatment. Clinical teaching should

ensure that the students feels confident to put into practice the skills they have acquired,

however the safety of patients should be of paramount importance. Students perceived that

clinical reasoning was associated with clinical performance and therefore it is vital that

students are given the opportunity to develop their clinical reasoning skills. The perception

that clinical reasoning has an end point might be suggestive of a goal orientated approach by

students but experienced clinicians would suggest it is vital that injury is regarded as an ever

evolving situation and students must consider this concept as failure to consider other

alternatives can lead to misdiagnosis. Professions such as medicine may look to make a

precise diagnosis while sports therapists may be more interested in solving a particular

movement problem and this may strengthen the need for a problem solving approach that was

17

highlighted during the interviews. Collaborative learning via CCS may develop the

foundations for interprofessional team working which may assist students post-graduation

when they may have to work with a number of health care professionals. Study limitations

include that objective symptoms such as inflammation cannot be recreated and that patient

communication is likely to be different to that used in role play. Working with patients

requires a greater level of professionalism and its vital students develop a humanistic

approach with patients which is difficult to assess and probably is best explained to the

students as developing a treatment approach that they would be happy to receive. CCS should

foster an understanding of the psychosocial issues that affect patient care to encourage a

holistic approach and this may need further development in CCS. These psychosocial issues

may include family issues and the effects of the injury on the capability to work.

The effect of PBL learning on performance has been investigated across medical disciplines.

Jones et al (2002) investigated the perceptions of medical students who had participated in

traditional teaching models or PBL 3 months after graduation and found students preferred

the PBL model and 5 competencies were significantly higher with PBL. In nursing students,

PBL and simulation demonstrated favourable perceived competence from small group

learning and simulations irrespective of final grade (Young et al, 2014). Specific student

feedback from this study that could be developed include asking the student who is acting as

patient to provide feedback and having the clinical supervisor observe the students during the

CCS so feedback could be provided. The use of group discussion to determine how students

formulated their diagnosis may aid development (Smith-Goodwin and Wimer, 2010) and this

could be implemented. It is possible that the level of feedback may need adjusting depending

on the students’ performance to enable optimal development. Within sports therapy the

potential relationship between CCS and academic achievement requires investigation in a

long term prospective study of clinical reasoning development. Future CCS research within

sports therapy could investigate the potential gender differences in the effectiveness of CCS

and how CCS may affect academic performance and post-graduation clinical performance.

The discussion of performance is based on the students’ perceptions of how the CCS may

influence them when working in a Sports Injury Clinic. The current study did not measure

performance directly and this might be an area for future investigation.

18

CONCLUSIONS

Student clinical education aims to develop clinical competence in an environment that is

unpredictable due to patient interaction and CCS may assist in achieving this goal. Student

responses were generally in favour of the use of CCS to aid the development of confidence,

communication and clinical reasoning. There is scope to develop the CCS to include more

CCS and investigate further whether feedback from the ‘patient’ may aid development.

KEY POINTS

A paucity of research exists in the use of CCS in sports therapy.

CCS provide students with the opportunity to develop key clinical skills in a safe

environment.

Clinical reasoning development is a key factor in becoming a competent therapist.

Patient communication, clinical reasoning and confidence levels benefited from the use of

CCS.

ACKNOWLEDGEMENTS

I wish to acknowledge Lynsey Munro-Wilson, Senior Lecturer in Sports Therapy, Edge Hill

University for her advice regarding CCS and Claire Farquharson, Senior Lecturer in Sports

Therapy, Edge Hill University for her assistance in the delivery of CCS to the students.

19

CONFLICTS OF INTEREST

There were no reported conflicts of interest.

REFERENCES

Albanese M (2000) Problem based learning: why curricula are likely to show little effect on

knowledge and clinical skills. Med Educ 34: 729-38.

Alsop A (1993) The development model of skill acquisition in fieldwork. Br J Occup Ther 56

(1): 7-12.

Babyar SR, Rosen E, Sliwinski M, Krasilovsky, G, Holland T, Lipovac M (2003) Physical

therapy students’ self-reports of development of clinical reasoning. J Allied Health 32 (4):

227-39.

Batram B, Bailey C (2010) Assessment preferences: a comparison of UK/international

students at an English University. Research in Post-compulsory Education 15 (2): 177-87.

Bergin R, Fors U (2003) Interactive simulated patient-an advanced tool for student-activated

learning in medicine and healthcare. Comput Educ 40 (4): 361-76.

Bordage G, Grant J, Marsden P (1990) Quantitative assessment of diagnostic ability. Med

Educ 24: 413-25.

Bowe CM, Voss J, Thomas Aretz H (2009) Case method teaching: An effective approach to

integrate the basic and clinical sciences in the preclinical medical curriculum. Med Teach 31

(9): 834-41.

Bowen JL (2006) Educational Strategies to Promote Clinical Diagnostic Reasoning. N Engl J

Med 355: 2217-25.

Chung EK, Hitchcock MA, A-Oh SA, Han ER, Woo YJ (2011) The relationship between

student perception of tutor performance and tutors background in problem based learning in

South Korea. Int J Med Educ 2: 7-11.

Currens JB, Bithell CP (2003) The 2:1 clinical placement model: Perceptions of clinical

educators and students. Physiotherapy 89 (4): 204-18.

Curtis N, Helion JG, Domsohn, M (1998) Student athletic trainer perceptions of clinical

supervisor behaviours: a critical incident study. J Athl Train 33: 249-53.

20

Dissanayaka TD, Marambe KN, Liyanage E (2012) Physiotherapy students’ perception on

problem based learning. Sri Lanka Journal of Bio-Medical Informatics 3 (3): 75-81.

Draper DO (1989) Students’ learning styles compared with their performance on the NATA

certification exam. Athletic Train J Natl Athl Train Assoc 24: 234-35, 275.

Edge Hill University (2014) http://www.edgehill.ac.uk/research/files/2012/05/Ethics-Output-

Guidance-EHU-Students-RESO-GOV-12.pdf) (accessed 9th June 2015).

Edwards I, Braunack-Mayer, A, Jones, M (2005) Ethical reasoning as a clinical reasoning

strategy in physiotherapy. Physiotherapy 91 (4): 229-36.

Ernstzen, DV, Bitzer, E, Grimmer-Somers, K (2009) Physiotherapy students’ and clinical

teachers’ perceptions of clinical learning opportunities: a case study. Med Teach 31 (3): e102-

15

Eva KW (2004) What every teacher needs to know about clinical reasoning. Med Educ 39

(1): 98-106.

Facione PA, Sanchez CA, Facione NC, Gainen J (1995) The disposition toward critical

thinking. J Gen Educ 44: 1-25.

Geisler PR, Lazenby TW (2009) Clinical reasoning in athletic training education: model

expert thinking. Athletic Training Educational Journal 4 (2): 52-65.

Goss B, Reid K, Dodds A, McColl G (2011) Comparison of medical students’ diagnostic

reasoning skills in a traditional and a problem based learning curriculum Int J Med Educ

2:87-93

Greenfield BH, Bridges PH, Phillips TA et al (2014) Exploring the experiences of novice

clinical instructors in physical therapy education: a phenomenological study. Physiotherapy

100 (4): 349- 55.

Groves M, O'Rourke P, Alexander H (2003) The association between student characteristics

and the development of clinical reasoning in a graduate-entry, PBL medical programme. Med

Teach. 25: 626-31.

Guhde J (2010) Using online exercises and patient simulation to improve students’ clinical

decision making. Nurs Educ Perspect 31 (6): 387-90.

Gunn H, Hunter H, Haas B (2012) Problem-based learning in physiotherapy education: a

practice perspective. Physiotherapy 98: 330-35.

21

Hausfather SJ (1996) Vygotsky and schooling: creating a social context for learning. Action

Teach Educ 18: 1-10.

Hawthorne L, Minas H, Singh B (2004) A case study in the globalization of medical

education: Assisting overseas-born students at the University of Melbourne. Med Teac 26 (2):

150-59.

Higgs J, Jones M (1995) Clinical reasoning in the health professions. Butterworth-

Heinemann, Oxford.

Jones A, McArdle PJ, O’Neil PA (2002) Perceptions of how well graduates are prepared for

the role of preregistration house officer: A comparison of outcomes from a traditional and

integrated PBL curriculum. Med Educ 36: 16-25.

Jones MA (1992) Clinical reasoning in manual therapy. Phys Ther 72: 875–84.

Knowles MS (1975) Self-Directed Learning: A Guide for Learners and Teachers.

Association Press, New York.

Kong L, Qun B, Zhou Y, Mou S, Gao H (2014) The effectiveness of problem based learning

on development of nursing students’ critical thinking: a systematic review and meta-analysis.

Int J Nurs Stud 51: 458-69.

Leaver-Dunn D, Harrelson GL, Martin M, Wyatt T (2002) Critical-thinking predisposition

among undergraduate athletic training students. J Athl Train 37 (4 supplement): S-147-S51.

Lincoln MA, McAllister LL (1993) Peer learning in clinical education. Med Teach 15 (1): 17-

25.

Lin C, Lu M, Chung C, Yang C (2010) A comparison of problem based learning and

conventional teaching in nursing ethics education. Nurs Ethics 17 (3): 373-82.

Meechan R, Jones H, Valler-Jones T (2011) Students’ perspectives on their skills acquisition

and confidence. Br J Nurs 20 (7): 445–50.

Merriam, SB (2001) Andragogy and Self-Directed Learning: Pillars of Adult Learning

Theory. New Dir Adult Contin Educ 89: 3–14.

McParland M, Noble LM, Livingston G (2008) The effectiveness of problem based learning

compared to traditional teaching in undergraduate psychiatry. Med Educ 38: 859-67.

Munro-Wilson, L (2012) Problem based learning and clinical reasoning in sports therapy

practice. Int J Ther Rehabil 9 (12): 682-88.

22

Neufeld VR, Woodward CA, Macleod SM (1989) The McMaster MD Program: a case study

of renewal in medical education. Acad Med 64: 423-32.

Norman GR (1988) Problem–solving skills, solving problems, and problem-based learning.

Med Educ 22: 279-86.

Parker A, Kersner M (1998) New approaches to learning on clinical placement…

communicating the evidence: the case for speech and language therapy. Proceedings of the

College’s 1998 Conference, Liverpool, 15th-17th October 1998. Int J Lang Commun Disord

33 suppl: 225-60.

Peer KS, McClendon RC (2002) Sociocultural learning theory in practice: Implications for

Athletic Training Educators. J Athl Train 37 (4 supplement): S-136-S40.

Piquette D, Mylopoulous M, Le Blanc VR (2014) Clinical supervision and learning

opportunities during simulated acute care scenarios. Med Educ 48: 820-30.

Radtke, S (2008) A conceptual framework for clinical education in athletic training. Athletic

Training Education Journal 2 (Apr-Jun): 36-42.

Rindflesch A, Dunfee H, Cieslak K et al (2009) Collaborative Model of Clinical Education

in Physical and Occupational Therapy at the Mayo Clinic. J Allied Health 38: 132-142.

Sadlo G, Warren D, Agnew P (1994) Problem based learning in the development of an

occupational therapy curriculum. Part 1. Br J of Occup Ther 57 (2): 49-53.

Schmidt HG (1983) Problem based learning: rationale and description. Med Educ 17: 11-16.

Stradley S, Buckley B, Kaminski T, Horodyski M, Fleming D, Janelle C (2002) A nationwide

learning style assessment of undergraduate athletic training students in CAAHEP-accredited

athletic training programs. J Athl Train 37 (4): S141-46.

Smith-Goodwin G, Wimer, JW (2010) Using problem-based learning to link classroom and

clinical education Athletic Training Today 15 (1): 23-27

Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA (1983) Manual for the State-

Trait Anxiety Inventory. Consulting Psychologists Press, Inc, Palo Alto, CA.

The Society of Sports Therapists (2008) Standards of Proficiency http://www.society-of-

sports-therapists.org/flipbooks/Standards_of_proficiency/index.html (accessed 9th June

2015).

23

Terry W, Higgs J (1993) Educational programs to develop clinical reasoning skills. Aust J

Physther 39: 47–51.

Turocy PS, Comfort RE, Perrin DH, Gieck JH (2000) Clinical experiences are not predictive

of outcomes on the NATABOC examination. J Athl Train 35: 70-75.

Walker SE, Weidner TG (2010) Standarized patients provide realistic and worthwhile

experiences for athletic training students. Athletic Training Education Journal 5 (2): 77-86.

Weidner TG, Henning JM (2003) Historical perspectives of athletic training clinical

education. J Athl Train 37 (Suppl 4): S222-S28.

Weidner TG, Henning JM (2005) Importance and applicability of Approved Clinical

Instructor Standards and criteria to certified athletic trainers in different clinical education

settings. J Athl Train 40: 326-32.

Weidner TG, Pipkin J (2003) Clinical supervision of athletic training students at colleges and

universities needs improvement. J Athl Train 37 (Suppl 4): S241-S47.

Whitcombe SW (2001) Using learning contracts in fieldwork education: the views of

occupational therapy students and those responsible for their supervision. Br J Occup Ther

11 (64): 552-57.

Wood DF (2003) Problem based learning. BMJ 326: 328-30.

Young S, Sang S, Sung H (2014) Effects of an integrated problem-based learning and

simulation course for nursing students. Nurs Health Sci 16: 91-96.

24

Strongly agree Agree Neither agree or disagree

Disagree Srongly disagree0

5

10

15

20

25

30

35

40

8

15

0 0 0

8

20

31 0

16

35

31 0

Male Female Male and Female

Num

ber o

f stu

dent

s

Figure 1 Student perceptions of the effect of CCS on their patient communication skills

25

Strongly agree Agree Neither agree or disagree

Disagree Strongly disagree0

5

10

15

20

25

30

35

9

13

0 1 0

12

17

3

0 0

21

30

31 0

Male Female Male and Female

Num

ber o

f stu

dent

s

Figure 2 Student perceptions of the effect of CCS on their confidence levels in the Sports Injury Clinic

Strongly agree Agree Neither agree nor disagree

Disagree Strongly disagree0

5

10

15

20

25

30

35

14

8

1 0 0

15 16

1 0 0

29

24

20 0

Male Female Male and Female

Num

ber o

f stu

dent

s

Figure 3 Students perceptions of the effect of CCS on clinical reasoning

26