PHYS THER
Vol. 87, No. 6, June 2007, pp. 788-791
DOI: 10.2522/ptj.20060152.ic
Invited Commentary
Gail M Jensen
GM Jensen, PT, PhD, FAPTA, is Dean, Graduate School, Associate Vice President in Academic Affairs, and Professor of Physical Therapy, Creighton University, Omaha, NE 68178 (USA)
Address all correspondence to Dr Jensen at: gjensen{at}creighton.edu
It is a privilege to be providing commentary on the article by Wohlin Wottrich and colleagues. The authors have begun to "shine the light" on an area of physical therapy that we know so little about, that is, systematic investigation of the tacit knowledge held by practitioners. Although I will address specific issues within the article with my comments, I will also tie that discussion to these broader issues in need of further investigation in the global community of physical therapy: tacit knowledge and clinical reasoning in the context of practice, the work of interdisciplinary teams, and the role of qualitative methods in physical therapy research.
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Linking Purpose and Method
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I applaud the authors for providing us with an excellent example of a well-developed argument that clearly links the purpose of the research to the use of qualitative methods. They argue that the contextual factors in the International Classification of Functioning, Disability and Health (ICF) model are poorly understood aspects of patient care. These factors include both personal factors (eg, background, upbringing, habits, coping style, social background, sex, age, and other health conditions) and environmental factors (eg, physical, social, and attitudinal environment). They assert that health care professionals need to develop a better understanding of how contextual factors influence function so that they can incorporate such understanding into their strategies for rehabilitation. They focus their investigation on stroke rehabilitation in the home, as it is a complex process that requires teamwork and interaction across a multidisciplinary team. Furthermore, within the teamwork and interactions, there is likely to be tacit understanding and knowledge that contribute to clinicians' clinical reasoning processes. The qualitative research method used in this study, a phenomenological approach, is well suited for the in-depth exploration and interpretation of the experiences of the multiprofessional team.
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Clinical Reasoning and Tacit Knowledge
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The authors state in their introduction, "Clinical reasoning is based on knowledge gained from tacit understanding and through experiences. It involves more than the application of theory, because complex clinical tasks, like rehabilitation in the home environment, require an approach governed by the particular patient's needs and context." I see the focus on clinical reasoning and tacit knowledge as the most critical assumption underlying the design and interpretation of findings in this research.
Uncovering the knowledge that is part of the clinician's clinical reasoning process focused on interpreting or making sense of the patient's personal and environmental factors (context) is critical to care. The challenge for physical therapy is that this tacit knowledge is not easily observed, described, or measured. It is part of our practice that we seem to take for granted. For example, how often do we talk about the importance of "reading the patient?" This reading of the patient implies that we fully understand the values, beliefs, and meanings that the patient holds and can successfully integrate our interactions and interventions with the patient's beliefs and expectations. Physical therapists use a great deal of skilled communication grounded in observation, active listening, and thoughtful questions. It is likely that these skills contribute to a "successful read" of the patient, but we have little evidence to support this assertion.1 Often this knowledge is tacit knowledge, that is, knowledge that is acquired through everyday experience but has an implicit, unarticulated quality.2,3 In the literature, we see different labels given to tacit knowledge, as seen in Titchen and Ersser's description of professional craft knowledge:
Professional craft knowledge is often tacit and unarticulated and sometimes intuitive. This knowledge is brought to bear spontaneously in the care of patients, and guides day-to-day actions in the clinical area. It underpins the practitioner's rapid and fluent response to a situation .... Since professional craft knowledge is tacit and embedded in practice, it is important for us to understand its nature if we are to access it, study it, develop it further, and make it available for others to acquire expertise and improve practice.4
One strategy to gain access to this tacit knowledge is to elicit the knowledge through some form of reflective or metacognitive process.1,2,4 Wohlin Wottrich and colleagues used the Empirical Phenomenological Psychological (EPP) method to gather the therapeutic story of the rehabilitation of particular patients. The therapeutic story served as a powerful tool in reconstructing a reflective or metacognitive process for clinicians being interviewed. I believe that this therapeutic story also represents a narrative approach that serves as a window into further understanding the patient in this rehabilitation process. Using a narrative tool such as having therapists tell a "therapeutic story" has important significance in the clinical reasoning process. Well-known nursing researcher Patricia Benner has long argued, "I believe that clinical knowledge that enables the clinician to practice in particular situations is understood and captured best by narrative understanding ...clinical learning is experienced as a story."5
The study's findings also lend support to Edwards and colleagues' research in physical therapy and proposed dialectical model of clinical reasoning.6,7 Edwards and colleagues asserted that the clinical reasoning process for therapists is patient centered and includes 2 core dimensions or poles that therapists need to integrate in clinical practice: (1) the biomedical pole that centers on disciplinary knowledge about the disease, pathology, and physical impairments and (2) the lived experience pole where the therapist must work to understand the patient's illness experience, beliefs, and culture. The knowledge conception for the biomedical pole draws from an empirical-analytical paradigm as the clinician interprets physical signs, symptoms and conditions in an objective manner. The knowledge conception for the lived experience pole draws from the clinician's understanding of the patient's meaning perspectives or "therapeutic story." Here the knowledge is socially constructed and drawn through an interpretive paradigm as the clinician constructs meaning through understanding the patient's illness experience, beliefs, and culture through a narrative reasoning process. I believe the authors are using these therapeutic stories to further uncover the lived experience pole of the clinical reasoning process. In the case of this research, it is the collective stories and construction of meaning of the rehabilitation process that are revealed.
The authors provide us with a good example of how much in-depth investigative work is needed to more fully uncover the knowledge embedded in practice. In further analysis or investigative work, the authors may want to more fully explore and discuss the theoretical connections between their findings and tacit knowledge.
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Multiprofessional Team
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The stated purpose of this study was to identify meaning of rehabilitation in the home environment after stroke from the perspective of members of the multiprofessional team. Given that stated purpose, one might expect more description and focus on the interactive work of the multiprofessional team. Although we know these disciplines included physical therapy, occupational therapy, speech and language therapy, and social work, we know little about the functioning of the team, whether the team worked collaboratively and functioned as an interprofessional team or worked more as disciplines in a parallel fashion.8 There is some evidence of communication across the team with a reference to team member agreeing to practice the same activity with a patient because the patient needed extensive practice.
It also would be helpful to know more about the contextual factors surrounding the health care delivery system in Sweden. For example, in the United States, it would be unusual in urban areas for patients to be followed to their home environment by the same health care professionals who had seen them in the hospital or rehabilitation center. With continued research in this area, it would be important to determine whether the core theme in the findings—supporting continuity—is dependent on the continuity of the same health care professionals.
Given the common understandings and strong focus on patient-centered care visible in therapeutic stories across team members, we can hypothesize that engaged teamwork and effective communication were probably in place. There is evidence to show that collaborative delivery models can be more effective and efficient than traditional models.8 Some people would argue that good patient care depends on egalitarian interprofessional collaboration and that this kind of mutual respect is a moral imperative.9 As we continue to see a growing role for interprofessional teamwork, further investigation of the work of health care teams will be important. Although there were no comparisons of any differing views of the therapeutic stories across disciplines, it is a question that the authors raise in their discussion. I believe that looking at the data set across disciplines may be of some value as well as an important question for future investigations.
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The Central Role of Skilled Teaching and Patient Learning
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The findings draw from one main theme—supporting continuity—with 4 subthemes: making a journey, enabling the experience of functioning, refraining from interventions (encouraging patient problem-solving skills), and looking for a new phase (uncertain endings). While one can explain findings from various theoretical perspectives, including the phenomenological approach used here, or the creation of grounded theory emerging from the data itself, I see strong evidence of the critical importance of skilled teaching and patient learning that could be explained from an integration of social cognitive theory10 (self-efficacy) with motor learning theory.11 Let me explain. Under the main theme of supporting continuity, the authors state,
Taking part in the patients' home life gave them unique opportunities to find associations or links to former (prestroke) activities. The team members enabled the patients to reestablish these previous activities and to find substitutions in meaningful alternatives with which they could connect.
The strategy clinicians often used was to ask patients to tell them their life stories so that they could uncover activities that patients valued. Clinicians were facilitating a self-reflective process for patients that could be interpreted as a tool for enhancing patients' self-efficacy. Self-efficacy is a type of self-reflective thought process that can affect a person's behavior.10 For example, patients are much more likely to engage in activities or exercises if they are meaningful activities that they value.
Team members also focused on enabling experiences of patient's function from previous patterns of behavior, refrained from interventions, and encouraged patient problem-solving skills, as seen here: "It was possible for the team member to wait with interventions or to refrain from conducting a planned intervention in order to encourage the patients to find appropriate solutions on their own or take own actions." In motor learning, there is some evidence that use of practice conditions that allow errors and encourage individuals to problem solve actually enhance learning.11,12 Therefore, there may well be several important factors that explain why patients should be active participants in production of their movements. These are just brief examples, but what I see in the contextual data is real evidence of an integrated teaching and learning process that draws from the theories underlying the teaching of psychomotor skills as well as the theories of social cognitive learning. This is summed up well in the authors' statement, "The findings revealed that working with body function (ie, performing purposeful and meaningful activities) was central to home rehabilitation after stroke."
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Qualitative Methods
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This research used a phenomenological approach to gain further insight into and understanding of the meanings that are embedded in rehabilitation done at home. In physical therapy, we lag behind our colleagues in nursing, occupational therapy, social work, and perhaps even medicine in depth and breath of qualitative research. In our profession, we need to continue to explore and uncover the meanings that are embedded in our practices so that we can more fully describe and codify evidence in support of what we do. Physical therapy is as much a human science as a physical science, and as such we are in need of diversity of methods that can help us observe, document, analyze, and interpret the characteristics and meanings that are part of everyday practice.
Phillips and Benner eloquently described aspects of the human science found in clinical practice:
We understand the human sciences as informed by the lives, meanings, ideas, experiences and knowledge of people they seek to know. More specifically, any social scientific knowledge of practice must submit itself to the lived knowledge of practitioners and enter into dialogue with those practitioners .... The sort of knowledge that caring practices (and other practices) make possible is context-dependent, historically developed, and concerned with action as well as deliberation .... Practical wisdom is a knowledge embodied in persons and communities.13
Again, I believe that Wohlin Wottrich and colleagues have begun to shine the light on how we can uncover the "tacit knowledge" in practice. It is critically important for the physical therapy profession to acknowledge that legitimate evidence in support of clinical practice can come from knowledge that is socially constructed. Furthermore, we desperately need investigations using a broad array of research methods to help us uncover and codify this tacit knowledge and integrate those understandings with the abundance of evidence coming from the more traditional research paradigms.
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References
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- Jensen GM, Gwyer J, Hack LM, Shepard KF, eds. Expertise in Physical Therapy Practice. 2nd ed. St Louis, Mo: Saunders-Elsevier; 2007.
- Sternberg R, Forsythe G, Hedlund J, et al. Practical Intelligence in Everyday Life. Cambridge, United Kingdom: Cambridge University Press; 2000:104–117.
- Polanyi M. Personal Knowledge: Toward a Post-Critical Philosophy. Chicago, Ill: University of Chicago Press; 1962.
- Titchen A, Ersser S. The nature of professional craft knowledge. In: Higgs J, Titchen A, eds. Practice Knowledge and Expertise in the Health Professions. Woburn, Mass: Butterworth-Heinemann; 2001:35.
- Benner P, Hoper-Kyriakidis P, Stannard D. Clinical Wisdom and Interventions in Critical Care. Philadelphia, Pa: WB Saunders Co; 1999:18.
- Edwards I, Jones MA. Clinical reasoning and expert practice. In: Jensen GM, Gwyer J, Hack LM, Shepard KF, eds. Expertise in Physical Therapy Practice. 2nd ed. St Louis, Mo: Saunders-Elsevier; 2007:192–214.
- Edwards I, Jones MA, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther. 2004;84:312–335.[Abstract/Free Full Text]
- Barr H, Koppel I, Reeves S, et al. Effective Interprofessional Education: Argument, Assumption and Evidence. Oxford, United Kingdom: Blackwell Publishers; 2005.
- Grace P, Willis D, Jurchak M. Good patient care: egalitarian interprofessional collaboration as a moral imperative. American Society for Bioethics and Humanities Exchange. 2007;10(1):8–9.
- Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
- Krakauer JW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Curr Opin Neurol. 2006;19:84–90.[ISI][Medline]
- Nicholson DE. Teaching psychomotor skills. In: Shepard KF, Jensen GM, eds. Handbook of Teaching for Physical Therapists. Woburn, Mass: Butterworth-Heinemann; 2002:387–422.
- Phillips S, Benner P, eds. The Crisis of Care. Washington, DC: Georgetown University Press; 1994:11.
Copyright © 2007 by the American Physical Therapy Association.
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