Common Reasoning Errors and the Role of the Tutor

appropriately to perform clinical reasoning is not an easy task. It requires both, teachers and clinical educators developing an understanding of these complex abilities and planning educational programmes, which help students to acquire them (Higgs, 1992; Alsop & Ryan, 1996; Neary, 2000). Traditionally, expert reasoning has been regarded as an intuitive art, non-specifiable and unteachable, and totally reliant for its development on prolonged trial-and-error experience in real clinical settings (Benner, 1984; Hammond, 1996). However, using authentic case studies coupled with “think out loud” formats led by competent tutors, the reasoning process can be deconstructed to reveal the teachable heuristics embedded within it. This approach enables students more quickly to acquire the critical thinking skills and attitudes necessary for making more accurate clinical decisions. Despite several models/approaches being available for teaching clinical reasoning skills, errors in reasoning occur for three principal reasons:

1. faulty perception or elicitation of cues,

2. incomplete factual knowledge(about a disease process or clinical condition) or 3. misapplication of known facts to a specific problem.

The first deficiency is one of basic clinical skills while the second is one of content knowledge. Each is readily identified and acknowledged by both tutor and student in the setting of case studies and corrected by clinical skills teaching and problem-based learning. The third involves incorrect use of heuristics and, while familiar to an experienced clinician, its causes and remedies are not so easy to elucidate.

Chapter seven CR: Implications for Curriculum Framework

As explained above, a number of common errors have been characterised which need to be recognised and explicitly discussed with students in reasoning exercises (Dawson & Arkes, 1987; Kassirer & Kopelman, 1991; Riegelman, 1991). The critical role of the tutor in facilitating development of students’ reasoning skills is important and cannot be over-emphasised. This role can be made more effective if tutors:

• insist on using a “thinking out loud” format to problem solving which makes the use of reasoning process (of both student and tutor) explicit and transparent;

• emphasise problem-specific reasoning rather than the recall of unconnected facts or performance of irrelevant routines;

• keep the reasoning process focused on the problem at hand while exploiting

opportunities to redress identified gaps in factual knowledge or deficiencies in use of heuristics;

• deliberately challenge strongly supported hypotheses (playing the devil’s

advocate) to highlight the need always to consider alternative explanations;

• adopt a didactic teaching role only when expert knowledge is critical to the

resolution of a problem and the opportunity cost to the student of obtaining it from other sources is inordinately high; and

• provide accurate, specific and constructive feedback to students about their use of reasoning heuristics at opportune times.

7.8 Summary

The key to facilitating reasoning rests with educators, both academic and fieldwork. Apart from being up-to-date with knowledge of the files they need to try creative and innovative ways of organising learning experiences and obtaining feedback from students so that modules can be fine-tuned. According to Dickson (1998) it is essential to have clarity of purpose regarding each particular fieldwork experience, so that both the means and ends are quite clear and the rhetoric and assignments reflect these goals.

In recent years, a considerable amount of research has been undertaken comparing the comprehension and problem solving of experts, intermediates and novices in domains of knowledge (Chi, Feltvich & Glaser, 1981; Robertson, 1996;

Chapter seven CR: Implications for Curriculum Framework

Unsworth, 2001). Researchers agree that novice and experienced clinicians maintain noticeably different clinical problem skills (Dutton, 1995; Robertson, 1996; Unsworth, 2001; Mitchell & Unsworth, 2005). To teach students and novice clinicians to think like experienced or more expert occupational therapists, researchers and educators have begun to explore ways to teach and improve clinical reasoning skills (Schwartz, 1991; Royeen, 1995; VanLeit, 1995; Neistadt, 1996). Roger’s model (1983) for teaching clinical reasoning appears to be an effective way to connect classroom theory to clinical practice and well worth the extra educator effort it involves. Further research is needed to examine the actual clinical carryover of this teaching approach in comparison with other models.

The use of clinical problems as the framework of a curriculum allows students to apply their existing knowledge and clinical experience to the management of clinical problems. Their simulated experience in solving the clinical problem replicates the process, which occurs during clinical practice. The reality of the clinical setting has many advantages for the exploration of clinical reasoning in action, even though it incorporates constraints such as time pressures and potential dangers to the patients. During clinical education, students can gain skills in many broad areas such as inter- personal communication, assisting patients with movements, teamwork and writing skills, as well as the technical skills of their discipline. Finally, the role of patients in teaching and providing feedback is a further advantage of clinical settings. It is necessary, therefore, that health science curricula actively utilise both classroom and clinical settings for this purpose.

It is not reasonable to expect occupational therapy students to graduate as competent, proficient, or expert therapists. Those levels of clinical reasoning require years of clinical experience and continuing education. However, it is possible for students to enter practice as novices or advanced beginners who are capable of

Chapter seven CR: Implications for Curriculum Framework

progressing to higher levels of clinical reasoning if their academic preparation for higher level fieldwork has given them as awareness of the types of reasoning they will be using in practice. This awareness of clinical reasoning concepts can help students to learn about their thinking and doing clinical practice simultaneously, intensifying the learning derived from clinical experience.

As noted, educators, academics and clinicians in many parts of the world are only recently becoming aware of the importance of developing clinical problem solving skills, so its importance has not yet been fully realised. The researcher of this study opines that there is an enormous potential for discovery and learning about this exciting aspect of clinical reasoning study. The lack of understanding of the learning of clinical reasoning process among occupational therapists led to growing interest among researchers in exploring representations of knowledge and processes separately.

As a member of a health care profession, occupational therapists are required to take responsibility for their actions. To do this they need to be capable of performing competently in autonomous, professional capacity, which includes effective reasoning and decision-making abilities, to be able to maintain competence and generate knowledge throughout their careers. They also need to be able to respond to the changing needs of the community (Higgs & Jones, 1995; Ranka & Chapparo, 2000). The successful enactment of this behaviour requires the ability to learn using a deep learning approach. Research in the area of student learning (See for examples, Marton & Säljö, 1976; Entwistle & Ramsden, 1983; Biggs, 1987a; Entwistle, 2000; McCune & Entwistle, 2000) has identified that contexts/curricula, which foster deep learning, are characterised by freedom in learning, less formality, and good teaching input, a good social climate and clear goals. Surface or rote learning approaches are more likely to occur where there are heavy workloads. Based on this, the next chapter considers

Chapter seven CR: Implications for Curriculum Framework

various students’ approaches to learning and examines ways of fostering the development of knowledge and reasoning competence in occupational therapists.

Chapter eight Students’ Approaches to Learning

Chapter 8

STUDENTS’ APPROACHES TO LEARNING

8.1 Introduction

Deep learning and attributes of autonomy, responsibility and critical analysis are championed in Western countries. They are also valued in traditional Confucian belief, which places great value on education both in terms of learning and as a process itself. Unfortunately, Confucian traditional belief appears to be contradicted by reports of Asian students as “rote learners” who are passive and complaint (Samelowicz, 1987; Kember & Gow, 1991; Watkins & Biggs, 1996; Kember, 2000). The research on student learning has shown the importance of shifting the focus from learning approaches to learning conceptions in developing and improving the outcomes of student learning. The purpose of this chapter is to consider various students’ approaches to learning, the influence of contextual and personal factors on approaches to learning, the relationships between approaches and learning outcomes and the links between the approaches and understanding. This section starts with a brief retrospective of earlier research affecting current definitions of the approaches to learning, particularly, a deep and surface approach dichotomy with a debate about how differing learning processes lead to qualitatively different outcomes.