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Investigating clinical reasoning through a series of web-based case studies Leznoff, Sandra Arlenene

Abstract

Clinical reasoning is used by health care practitioners to discover the nature of, and solutions to clients' problems. Students need opportunities to clearly explain and justify their decision making in order to develop their clinical reasoning skills. In academic settings it is difficult to provide students with exposure to authentic clinical cases with which they can practice and demonstrate their clinical reasoning before having to do so with actual clients. Case studies are often endorsed as the optimal way to do this. The limitations of traditional (paper) case studies are reviewed. A more authentic representation of clinical practice is presented through a series of web-based cases. The purposes of this study were to analyze whether or not a series of web-based case studies (WB): 1) allows students to demonstrate different forms of clinical reasoning; 2) encourages students to use the web to search for resources that support learning and clinical reasoning; and 3) is perceived by students to be advantageous or preferable to paper-based cases. The cases were designed based on constructivist learning theories and occupational therapy theories of practice and of clinical reasoning. The study uses a particularistic case study research methodology. All third and fourth year students (36 per class) from of the Occupational Therapy program in the School of Rehabilitation Sciences at the University of British Columbia in October 1999 were invited to participate in the study. Six students (all in third year) agreed to participate. One student withdrew from the study. All students were given the same three web-based case studies to complete by multiple choice and text entry responses. No time limit was imposed. The text entry data was matched using key words to forms of clinical reasoning used in occupational therapy. Students' use of the on-line resources (e.g. tutorials, web searches, and comparisons of their responses to the experts) were tracked. Students' preferences for WB or paper-based case studies were identified through semi-structured on-line interviews. The students were able to demonstrate different forms of clinical reasoning using the WB. The forms of clinical reasoning most frequently evident were procedural, interactive and pragmatic reasoning and schematic processing. Conditional reasoning was used by two students and only in the final case study. The other forms of clinical reasoning were used periodically. All of the students used links built into the case studies for feedback and comparisons with expert models. Two students used the built-in tutorials to guide their decision-making. Only one student used a hot link to a site on the web. No students initiated their own search on the web. A lack of time was the primary factor reported for this. The students voiced no strong preference for either web-based or paper-based case studies. They offered positive and negative issues with both formats. For example, access to the WB and technical difficulties were at times problematic however they were also said to be thought-provoking and interesting to those same students. It is concluded that these WB are useful for students to demonstrate different forms of clinical reasoning.

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