The Role of Movement in Physical Therapist Clinical Reasoning.

OBJECTIVE: The purpose of this study was to explore how physical therapists use movement as a component of their clinical reasoning. Additionally, this research explored whether movement as a component of clinical reasoning aligns with the proposed signature pedagogy for physical therapist education, human body as teacher. METHODS: The study utilized qualitative, descriptive methods in a multiple case studies design (each practice setting represented a different case for analysis purposes) with cross-case comparisons. Researchers conducted 8 focus groups across practice settings including acute care, inpatient neurological, outpatient orthopedics, and pediatrics. Each focus group had 4 to 6 participants. Through an iterative, interactive process of coding and discussion among all researchers, a final coding scheme was developed. RESULTS: Through exploration of the research aims, 3 themes emerged from the data. These primary themes are: (1) movement drives clinical reasoning to optimize function; (2) reasoning about movement is multisensory and embodied; and (3) reasoning about movement relies on communication. CONCLUSIONS: This research supports a description of movement as the lens used by physical therapists in clinical reasoning and the integral role of movement in clinical reasoning and in learning from and through movement of the human body while learning from clinical reasoning experiences in practice. IMPACT: As the understanding of the ways physical therapists use and learn from movement in clinical reasoning and practice continues to emerge, it is important to continue exploring ways to best make this expanded, embodied conception of clinical reasoning explicit in the education of future generations of physical therapists.

Improving Health through Action on Economic Stability: Results of the Finances First Randomized Controlled Trial of Financial Education and Coaching in Single Mothers of Low-Income.

OBJECTIVES: Evaluate the health impact of a novel financial education and coaching program in single mothers of low-income in Omaha, Nebraska. METHODS: Employed, single mothers earning no more than 200% of the 2017 Federal Poverty Level (n = 345) enrolled in the study between April 2017 and August 2020 and were randomized to receive a novel financial education and coaching program, the Financial Success Program (FSP) or no intervention control. Demographics, biometrics, financial strain, health behaviors and healthcare utilization were assessed at baseline and the 12-month study visits. RESULTS: Participants who completed the FSP demonstrated significantly reduced financial strain, an increased rate of smoking cessation, and a reduction in avoidance of medical care due to cost compared to participants in the control group. CONCLUSIONS: The FSP represents an effective model in promoting economic stability in vulnerable individuals through a reduction in financial strain. Health behavior changes including an increased rate of smoking cessation were demonstrated within the first 12 months of intervention.

Physical Therapist Residency Competency-Based Education: Development of an Assessment Instrument.

OBJECTIVE: The objective of this study was to develop generic domains of competence (DoC) with associated competencies and milestones for physical therapist residency education. This work was intended to culminate in establishing validity evidence to support a competency-based assessment instrument that could be used by residency programs to evaluate resident achievement of the competencies, regardless of specialty area. METHODS: Employing the modified Delphi method, a residency education work group developed an evaluation instrument that included 7 DoC and 31 associated competencies with 6 milestones as rating scales for each competency. The instrument was distributed to mentors and residents in accredited physical therapist residency programs to establish validity evidence. Evaluations (measured by milestones) and demographics were collected at 3 time points (program entry, midterm, and final). Scores across these time points were compared using Kruskal-Wallis tests. Reliability was assessed with kappa statistics (interrater reliability) and alpha reliability coefficients (internal consistency). Construct validity was examined using confirmatory factor analysis via structural equation modeling. RESULTS: Overall, 237 mentors and 228 residents completed 824 evaluations (460 by mentors and 364 resident self-evaluations) across the time points. Scores significantly increased from entry through final time points. The interrater reliability of the associated behaviors ranged from moderate to substantial agreement (κ = 0.417-0.774). The internal consistency was high for all DoC at every time point (α reliability coefficients = .881-.955 for entry, .857-.925 for midterm, and .824-.902 for final). After confirmatory factor analysis with structural equation modeling was performed, a model that included 7 DoC and 20 associated competencies was proposed. CONCLUSIONS: The residency assessment instrument developed demonstrates interrater reliability and validity evidence and therefore supports competency-based assessment of resident clinical performance across specialty areas. Additionally, the instrument aligns the physical therapy profession with other professions, such as medicine, dentistry, and pharmacy, that have transitioned to competency-based education. IMPACT: This study outlines the benefits of moving to competency-based education for physical therapist residents, using a sound evaluation tool that evaluates residents across specialty areas. The instrument will allow for transition to competency-based education in physical therapist residency education programs.

The Fate of Foodborne Pathogens in Manure Treated Soil.

The aim of this review was to provide an update on the complex relationship between manure application, altered pathogen levels and antibiotic resistance. This is necessary to protect health and improve the sustainability of this major farming practice in agricultural systems based on high levels of manure production. It is important to consider soil health in relation to environment and land management practices in the context of the soil microflora and the introduction of pathogens on the health of the soil microbiome. Viable pathogens in manure spread on agricultural land may be distributed by leaching, surface run-off, water source contamination and contaminated crop removal. Thus it is important to understand how multiple pathogens can persist in manures and on soil at farm-scale and how crops produced under these conditions could be a potential transfer route for zoonotic pathogens. The management of pathogen load within livestock manure is a potential mechanism for the reduction and prevention of outbreaks infection with Escherichia coli, Listeria Salmonella, and Campylobacter. The ability of Campylobacter, E. coli, Listeria and Salmonella to combat environmental stress coupled with their survival on food crops and vegetables post-harvest emphasizes the need for further study of these pathogens along with the emerging pathogen Providencia given its link to disease in the immunocompromised and its' high levels of antibiotic resistance. The management of pathogen load within livestock manure has been widely recognized as a potential mechanism for the reduction and prevention of outbreaks infection but any studies undertaken should be considered as region specific due to the variable nature of the factors influencing pathogen content and survival in manures and soil. Mediocre soils that require nutrients could be one template for research on manure inputs and their influence on soil health and on pathogen survival on grassland and in food crops.

Motivations to Pursue Physical Therapy Residency Training: A Q-Methodology Study of Stakeholder Perspectives.

BACKGROUND: Residency training is recognized as a valuable form of professional development and pathway to specialization. Currently residency is voluntary for physical therapists, with less than 12% of DPT students choosing to apply upon graduation. Motivations that drive the decision to pursue residency are currently unknown as is the extent of similarity and difference in perspective among various stakeholders. OBJECTIVE: The purpose of this study was to identify the dominant perspectives on motivations to pursue residency held by various stakeholders. DESIGN: This study was conducted using Q Methodology, which incorporates aspects of quantitative and qualitative techniques into the examination of human subjectivity. METHODS: Program directors, faculty, and current residents from all accredited physical therapy residency programs were invited to complete a forced-choice sorting activity where potential motivations for residency were sorted by perceived level of importance. Principal component analysis was used to identify dominant perspectives, which were interpreted based on emergent themes in the cluster of motivations identified as most important. RESULTS: Four dominant perspectives were identified: (1) desire to provide better patient care, (2) preparation for specialty practice, (3) fast track to expert practice, and (4) career advancement. These perspectives provided context and utility to 2 broad meta-motivations: improved clinical reasoning and receiving mentoring. Both within- and between-group differences among stakeholders were identified. However, subsets from each role-group population were found to share similar perspectives. LIMITATIONS: Results from this study may not apply to potential residents in all specialty areas, and the implications of having a particular perspective are unknown. CONCLUSIONS: Identification of the dominant perspective on motivations for pursuing residency may aid in promoting participation, program development, matching residents to programs and mentors, and future research.

Clinical Reasoning in Physical Therapy: A Concept Analysis.

BACKGROUND: Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research. OBJECTIVE: The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research. DESIGN/METHODS: The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified. RESULTS: Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management. LIMITATIONS: Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded. CONCLUSIONS: A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.

The acute effect of Bowen therapy on pressure pain thresholds and postural sway in healthy subjects.

OBJECTIVE: The purpose of the study is to determine the immediate effect of Bowen Therapy in pressure pain threshold and postural sway of healthy individuals. DESIGN: Crossover, randomized, and double blinded study. SETTING: University. PARTICIPANTS: Participants aged 18 years old or over, naïve to Bowen therapy were recruited among university students. An a priori sample size calculation determined that 34 participants were needed. METHODS: Each participant attended two sessions and received Bowen Therapy and a sham procedure. The order in which Bowen or the sham procedure were administered was randomized. All participants had their postural control and pressure pain thresholds assessed in sessions 1 and 2 both at baseline and at the end of the session. MAIN OUTCOME MEASUREMENTS: Postural control was assessed using a force plate and centre of pressure antero-posterior and medio-lateral displacement, velocity and total sway area were calculated. Pressure pain threshold was measured at 10 different body sites on the paraspinal muscles from C1 to S1 using an electronic algometer. RESULT: The results showed a significant increase in the anteroposterior displacement (p = 0.04) and a significantly lower decrease in the mean velocity (p = 0.01) of the centre of pressure and a significant increase in the pressure pain thresholds of two (out of ten; p ≤ 0.04) body sites in the group receiving Bowen Therapy compared to the group receiving the sham. No other significant differences were found. CONCLUSIONS: The findings suggest that Bowen Therapy has inconsistent immediate effects on postural control and pain threshold in healthy subjects. Further studies are needed using symptomatic participants.

DNA testing in homicide investigations.

Objectives With the widespread use of DNA testing, police, death investigators, and attorneys need to be aware of the capabilities of this technology. This review provides an overview of scenarios where DNA evidence has played a major role in homicide investigations in order to highlight important educational issues for police, death investigators, forensic pathologists, and attorneys. Methods This was a nonrandom, observational, retrospective study. Data were obtained from the collective files of the authors from casework during a 15-year period, from 2000 through 2014. Results A series of nine scenarios, encompassing 11 deaths, is presented from the standpoint of the police and death investigation, the forensic pathology autopsy performance, the subsequent DNA testing of evidence, and, ultimately, the final adjudication of cases. Details of each case are presented, along with a discussion that focuses on important aspects of sample collection for potential DNA testing, especially at the crime scene and the autopsy. The presentation highlights the diversity of case and evidence types in which DNA testing played a valuable role in the successful prosecution of the case. Conclusions By highlighting homicides where DNA testing contributed to the successful adjudication of cases, police, death investigators, forensic pathologists, and attorneys will be better informed regarding the types of evidence and situations where such testing is of potential value.

Clinical Reasoning: Survey of Teaching Methods, Integration, and Assessment in Entry-Level Physical Therapist Academic Education.

Background: Although clinical reasoning abilities are important learning outcomes of physical therapist entry-level education, best practice standards have not been established to guide clinical reasoning curricular design and learning assessment. Objective: This research explored how clinical reasoning is currently defined, taught, and assessed in physical therapist entry-level education programs. Design: A descriptive, cross-sectional survey was administered to physical therapist program representatives. Methods: An electronic 24-question survey was distributed to the directors of 207 programs accredited by the Commission on Accreditation in Physical Therapy Education. Descriptive statistical analysis and qualitative content analysis were performed. Post hoc demographic and wave analyses revealed no evidence of nonresponse bias. Results: A response rate of 46.4% (n=96) was achieved. All respondents reported that their programs incorporated clinical reasoning into their curricula. Only 25% of respondents reported a common definition of clinical reasoning in their programs. Most respondents (90.6%) reported that clinical reasoning was explicit in their curricula, and 94.8% indicated that multiple methods of curricular integration were used. Instructor-designed materials were most commonly used to teach clinical reasoning (83.3%). Assessment of clinical reasoning included practical examinations (99%), clinical coursework (94.8%), written examinations (87.5%), and written assignments (83.3%). Curricular integration of clinical reasoning-related self-reflection skills was reported by 91%. Limitations: A large number of incomplete surveys affected the response rate, and the program directors to whom the survey was sent may not have consulted the faculty members who were most knowledgeable about clinical reasoning in their curricula. The survey construction limited some responses and application of the results. Conclusions: Although clinical reasoning was explicitly integrated into program curricula, it was not consistently defined, taught, or assessed within or between the programs surveyed-resulting in significant variability in clinical reasoning education. These findings support the need for the development of best educational practices for clinical reasoning curricula and learning assessment.

The efficacy of self-directed modules for clinical learning: advanced competencies in entry-level physical therapy education.

BACKGROUND: Prior to graduation, students often express an interest to advance clinical and professional skills in teaching, research, administration, and various niche practice areas. The acquisition of advanced education in selected areas of practice is believed to improve employment opportunities, accelerate career advancement including eligibility for professional certifications, and contribute to personal satisfaction in the profession. PURPOSE: The purpose of this paper is to (1) describe an innovative model of education, the Directed Practice Experience (DPE) elective, that incorporates a student-initiated learning process designed to achieve student-identified professional goals, and (2) report the outcomes for graduates who have completed the DPE in an entry-level program in physical therapy education. METHODS: Students who met select criteria were eligible to complete a DPE. Applicants designed a 4- to 6-week clinical education experience consisting of stated rationale for personal and professional growth, examples of leadership and service, and self-directed objectives that are beyond entry-level expectations as measured by the revised Physical Therapist Clinical Performance Instrument, version 2006. RESULTS: Twenty-six students have completed DPEs since 2005. Fifty percent resulted in new academic partnerships. At least 25% of graduates now serve as clinical instructors for the entry-level program. Those who participated in DPEs have also completed post-graduate residencies, attained ABPTS Board certifications, authored peer-reviewed publications, and taught in both PT and residency programs. CONCLUSION: The DPE model allows qualified students to acquire advanced personal skills and knowledge prior to graduation in areas of professional practice that exceed entry-level expectations. The model is applicable to all CAPTE accredited physical therapy education programs and is especially beneficial for academic programs desiring to form new community partnerships for student clinical education.

The role of the clinical preceptor: an integrative literature review.

The clinical learning environment has been identified as being central to nursing education. The clinical learning environment provides undergraduate nursing students with the opportunity to combine cognitive knowledge with the development of psychomotor and affective nursing skills. The preceptor role in undergraduate nursing education is complex and multifaceted. Undergraduate nursing students identify preceptors as key to their learning in the clinical setting; however, staff nurse preceptors often feel unprepared to serve in this role. This integrative literature review explores the role of the staff nurse preceptor through the perspective of undergraduate nursing students, nursing faculty, and staff nurses who are assigned to precept students as a function of their nursing role. Recommendations are made to facilitate the preparation of clinical preceptors to fulfill this essential role in preparing nursing students for clinical practice.

Ditch the pinch: bilateral exposure injuries during subcutaneous injection.

BACKGROUND: Subcutaneous injection into an elevated skin fold poses a risk of "bilateral exposure" injury whereby the needle pierces the opposite side of a skin fold and subsequently enters the tissue of the health care worker (HCW). METHODS: Retrospective review was conducted examining the Exposure Prevention Information Network (EPINet) needlestick surveillance data. Data from 2,402 injuries occurring during subcutaneous injection were included for analysis. Descriptive data, statistical comparisons, and a logistic regression model reporting relative risk are provided. RESULTS: Eighty-five bilateral exposure injuries were identified between 2000 and 2009, representing 3.5% (n/N=85/2,402) of all injection-related percutaneous injuries. 65.4% Of the variance in bilateral exposure injury occurrence is explained through examination of the following: (1) manual elevation ("pinching") subcutaneous tissue prior to injection; (2) thin/emaciated patient; (3) injection of insulin; (4) injection of heparin; (5) injection of enoxaparin (Lovenox); (6) if a safety device was used; and (7) whether the health care worker was wearing gloves at the time of the injury (χ(2)7 = 424.2; P<.01). CONCLUSION: Manual tissue elevation should be avoided to minimize the risk of bilateral exposure injuries.

The first two years of practice: a longitudinal perspective on the learning and professional development of promising novice physical therapists.

BACKGROUND: Physical therapists work in complex health care systems requiring professional competence in clinical reasoning and confidence in decision-making skills. For novice physical therapists, the initial practice years are a time for developing professional identity and practical knowledge. OBJECTIVES: The study purpose was to extend previous research describing the experiences, learning, and professional development of 11 promising novice therapists during their first year of practice. The present study examined the continued development of the same therapists during their second year of clinical practice. DESIGN: Seven researchers from 4 physical therapist educational programs in the eastern and midwestern United States used a longitudinal, qualitative, multiple case study approach. METHODS: Eleven physical therapist graduates identified as "promising novices" were recruited using purposive sampling. Participants ranged in age from 24 to 29 years and entered varied practice settings. Data were collected for 2 years using semistructured interviews, reflective journals, and participant observation. RESULTS: A conceptual model describing the participants' ongoing development during the second year of practice emerged. The 3 themes were formal and informal learning, increasing confidence and expansion of skills, and engagement in an environment characterized by collaborative exchange and opportunities for teaching. The second year represented consolidation and elaboration of practice-based learning and skills. The expansion of confidence, skills, and responsibilities and the externalization of learning the participants experienced promoted professional role formation. Learning previously directed inward and self-focused turned outward, fueled by growing self-confidence. CONCLUSIONS: Research illuminating the professional role formation experienced during early clinical practice is not widely available. The current study and further research into the learning and development of novice practitioners may assist educators in the design of pedagogical strategies and learning environments that enhance the professional development of physical therapists.

Chinks in the armor: percutaneous injuries from hollow bore safety-engineered sharps devices.

BACKGROUND: Despite their overwhelming efficacy, safety-engineered sharp devices (SESDs) cause a residual fraction of injuries. Although the fraction of injuries from SESDs is less than that reported for nonsafety devices, it remains a "preventable fraction" and is a sizable target for further advances. METHODS: A retrospective review of 3,297 percutaneous injuries from hollow bore safety-engineered devices occurring between 2001 and 2009 was conducted examining the Exposure Prevention Information Network (EPINet) needlestick surveillance data. RESULTS: Nurses sustain 64.6% of all SESD injuries. 42.9% Of SESD injuries occur after device use and are likely preventable through consistent and effective use of safety-engineered technology. Excluding injuries that occurred during device use or between procedural steps, 71.8% (n/N = 28/39) of physician injuries, 58.2% (n/N = 645/1,109) of injuries to nurses, and 45.8% (n/N = 88/192) of injuries to phlebotomists occurred when an available SESD was not fully activated. CONCLUSION: Passive devices that do not require action on the part of the end user to engage a safety feature currently represent a small portion of the SESD market. Wider dissemination of a broader array of passive SESDs coupled with continual education of end users is essential to an effective sharps injury prevention program.

Chinks in the armor: activation patterns of hollow-bore safety-engineered sharp devices.

A retrospective review of secondary injury data was used to evaluate the characteristics of percutaneous injuries from safety-engineered sharp devices. Injury rates and safety device activation rates differed by healthcare provider type. Approximately 22.8%-32% of injuries could have been prevented had an available safety feature been activated after use.

Construct validity of the Health Science Reasoning Test.

UNLABELLED: The aim of this study was to evaluate the construct validity of the Health Science Reasoning Test (HSRT) by determining if the test could discriminate between expert and novice physical therapists' critical-thinking skills. METHODS: Experts identified from a random list of certified clinical specialists and students in the first year of their physical therapy education from two physical therapy programs completed the HSRT. RESULTS: Experts (n = 73) had a higher total HSRT score (mean 24.06, SD 3.92) than the novices (n = 79) (mean 22.49, SD 3.2), with the difference being statistically significant t (148) = 2.67, p = 0.008. CONCLUSION: The HSRT total score discriminated between expert and novice critical-thinking skills, therefore establishing construct validity. To our knowledge, this is the first study to compare expert and novice performance on a standardized test. The opportunity to have a tool that provides evidence of students' critical thinking skills could be helpful for educators and students. The test results could aid in identifying areas of students' strengths and weaknesses, thereby enabling targeted remediation to improve critical thinking skills, which are key factors in clinical reasoning, a necessary skill for effective physical therapy practice.

California Hispanic nurses: analysis of 1997, 2004, 2006, 2008 survey data.

Using data from the California Board of Registered Nursing Surveys of 1997, 2004, 2006 and 2008, this study explores demographic, human capital, and work environment changes in the Hispanic RN population and compared these changes to those occurring among non-Hispanic Whites. Results find several significant differences between the two groups. The most important finding is that Hispanic RNs enter and leave the profession at younger ages than their non-Hispanic White counterparts. There is an abrupt decrease in the proportion of Hispanic RNs after age 50, while the proportion non-Hispanic White continues to increase until age 65. Decided action is needed to increase recruitment and retention of Hispanic RNs in order to increase nurse-patient concordance and abate the looming nurse shortage.

Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities.

BACKGROUND: In 2007 and 2008, 115 patients were found to be either certainly or presumptively infected with the hepatitis C virus through the reuse of contaminated medication vials at two southern Nevada endoscopy clinics. A subsequent joint investigation by federal and state agencies found multiple breaches of infection control protocols. There was also strong anecdotal evidence that among clinic staff, unsafe patient care conditions often went unreported because of a general fear of retaliation. At the request of the Nevada legislature's Legislative Committee on Health Care, a study was conducted to examine Nevada RNs' experiences with workplace attitudes toward patient advocacy activities. This article presents the study findings and reviews how one public health tragedy led to the creation of effective health care policy. METHODS: A study questionnaire was developed and tested for reliability and validity. Questionnaires were then sent to an initial sample of 1,725 Nevada RNs, representing 10% of all RNs in the Nevada State Board of Nursing database with active licenses and current Nevada addresses. RESULTS: The response rate was modest at 33% (564 respondents). Of those who responded, 34% indicated that they'd been aware of a patient care condition that could have caused harm to a patient, yet hadn't reported it. The most common reasons given for nonreporting included fears of workplace retaliation (44%) and a belief that nothing would come of reports that were made (38%). CONCLUSIONS: The study findings underscore the need for a shift in organizational culture toward one that encourages clear and open communication when patient safety may be in jeopardy. These findings were ultimately used to support the passage of whistleblower protection legislation in Nevada. KEYWORDS: Las Vegas hepatitis C outbreak, patient advocacy, whistleblower.