Elsevier

Manual Therapy

Volume 15, Issue 1, February 2010, Pages 93-99
Manual Therapy

Original Article
Defining the construct of masters level clinical practice in manipulative physiotherapy

https://doi.org/10.1016/j.math.2009.08.003Get rights and content

Abstract

The study is the first to have explored the behaviours indicative of the construct of masters level manipulative physiotherapy clinical practice. An exploratory case study was employed, using multiple methods of interviews and participant observation, informed by initial documentary analysis. One ‘case’ of a university postgraduate course in manipulative physiotherapy in the UK was selected. Purposive sampling identified the participants (clinical tutors and students). Data analysis was an iterative process developing inductive categories from the data through a constant comparative process. The identified analytic categories were subsequently linked to form theoretical propositions. Saturation of the data was achieved. Data collection was concurrent with a previously reported Delphi study and the findings of each showed convergence. A high level of clinical reasoning was identified as the most important behaviour associated with the construct for manipulative physiotherapy. This was then subdivided into core components of practice; prioritisation for example. This study provides a sound basis for future research by affording insight into the construct of masters level manipulative physiotherapy clinical practice. Convergence of data with the Delphi study supported validation of the construct. The trustworthiness of the findings appeared good, and therefore provides justification for use of the construct in informing curriculum development at masters level.

Introduction

Recent development in healthcare knowledge and technology demands greater clinical expertise by healthcare professionals in managing more complex problems, a need that is addressed partly by masters level education. The emphasis on developing clinical expertise is evident in the recent proliferation of masters level courses, commonly taken following an initial Honours degree (Judge et al., 2005). The definition of expertise has been recognised as a difficult exercise, and has been explored across professions (Delitto et al., 1989, Coulon et al., 1996) being commonly articulated as the capacity to perform using cognitive and practical skills not employed by novices.

Differentiation of academic level has been identified as important for clinical courses in nursing and physiotherapy (Donaghy and Gosling, 1999, Gerrish et al., 2000, Whyte et al., 2000) as well as in the wider educational literature (Winter, 1994, Atkins and Redley, 1998). Some clarity regarding level has been afforded by the defined frameworks for Higher Education qualifications in the UK (QAA [Quality Assurance Agency], 2001), and the Dublin descriptors (JQI [Joint Quality Initiative], 2004) enabled through the Bologna Declaration in 1999. The emphasis within the existing frameworks is on knowledge at masters level. Findings from limited research in healthcare do however identify different areas of importance for clinical courses, for example, the application of skills to the clinical context (Davis and Burnard, 1992), improved confidence and clinical reasoning, and advanced clinical skills (Green et al., 2008). A previous study that explored the characteristics of existing masters courses in various healthcare professions (Rushton and Lindsay, 2007) supported these differences and identified a central issue as the articulation of the ‘masters levelness’ of clinical practice.

Rushton and Lindsay (2008) afforded insight into the construct of masters level clinical practice through a three round Delphi study, with participants comprising the course tutors of all masters courses aiming to develop clinical expertise for healthcare professionals in the UK in the 2002/2003 academic year. 21 behaviours indicative of the construct were prioritised. Participants demonstrated consensus for the content of the behaviours, but differences in the prioritisation of the behaviours across professions and specialities. For example, consensus across all participants identified a high level of clinical reasoning as having the greatest importance to the construct, but this ranking was different between the professions and participants reported that they would rank differently according to speciality within a profession. High expectations of students on masters courses were reflected in the high number of behaviours agreed. The characteristics of the QAA and Dublin descriptors were reflected in the agreed behaviours and this was anticipated owing to the current use of the descriptors to inform course design.

Manipulative physiotherapy is a specialist area of physiotherapy that has not been explored to date. Postgraduate development informed by international and subsequently nationally applied standards of educational practice (International Federation of Orthopaedic Manipulative Physical Therapists [IFOMPT], 2008). The identification of behaviours indicative of masters level (postgraduate) practice in manipulative physiotherapy is therefore important to inform ongoing development of educational standards.

Section snippets

Design

An exploratory case study (Robson, 1993) enabled exploration of the construct of masters level manipulative physiotherapy clinical practice in its real life context, employing multiple methods of qualitative data collection. The case study was naturalistic, holistic, and idiographic (Lincoln and Guba, 1985) with overlapping processes of design, data collection, and analysis.

Data collection for the case study was concurrent with the Delphi study previously reported (Rushton and Lindsay, 2008).

Theoretical propositions and analytic categories

The data from the interviews and observations were triangulated (Table 2) in the primary researcher's perceived order of importance (determined from the balance of time and emphasis applied to the components by the participants), illustrating good agreement for most components of the construct and order of importance. The students and clinical tutors equally emphasised the importance of knowledge and clinical reasoning (cognitive and metacognitive problem solving processes), with participant

Expertise

It is possible to delineate the theory of expertise within healthcare into two ‘generations’ of thinking that illustrate a process of evolution (Jensen et al., 2000). The emphasis on clinical reasoning in this study reflects the first generation of thinking regarding expertise (Jensen et al., 2000), that centred on the expert as an individual; highlighting the individual's reasoning strategies employed to solve problems. The emphasis on the hypothetico-deductive model using cues to develop,

Conclusions

Validation of the construct through ‘convergence’ and ‘discrimination’ (Kerlinger and Lee, 2000) is good. The converged findings from the Delphi and case study were congruent with the issues literature regarding expertise, the QAA and JQI descriptors, and the empirical work in healthcare, supporting validation, but also reliability and validity/truthfulness. This enabled articulation of the derived model as the theory behind the construct was congruent across both methods. Similarly the data

References (49)

  • J.W. Creswell

    Research design: qualitative, quantitative, and mixed method approaches

    (2003)
  • B.D. Davis et al.

    Academic levels in nursing

    Journal of Advanced Nursing

    (1992)
  • A. Delitto et al.

    On developing expert-based decision-support systems in physiotherapy: the NIOSH low back atlas

    Physical Therapy

    (1989)
  • Department of Health

    The NHS plan

    (2000)
  • M.E. Donaghy et al.

    Specialization in physiotherapy: musings on current concepts and possibilities for harmonization across the European Union

    Physical Therapy Reviews

    (1999)
  • I. Edwards et al.

    Clinical reasoning strategies in physical therapy

    Physical Therapy

    (2004)
  • A.S. Elstein et al.

    Medical problem solving: an analysis of clinical reasoning

    (1978)
  • M. Eraut

    Developing professional knowledge and competence

    (1994)
  • P.J. Feltovich et al.

    Issues of generality in medical problem solving

  • K. Gerrish et al.

    Some dilemmas of master's level nurse education

    Journal of Advanced Nursing

    (2000)
  • R.A. Hatala et al.

    The effect of clinical history on physicians' ECG interpretation skills

    Academic Medicine

    (1996)
  • J. Higgs et al.

    Clinical reasoning in the health professions

    (2008)
  • International Federation of Orthopaedic and Manipulative Physical Therapy [IFOMPT]

    Educational standards document, part A

    (2008)
  • G.M. Jensen et al.

    Expert practice in physical therapy

    Physical Therapy

    (2000)
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