Introduction

Clinical reasoning is a concept widely studied among healthcare-related professions.¹ In general terms, it refers to the integration of critical thinking and decision-making in clinical situations; besides, its definition may vary depending on the healthcare-related profession in which it is used.²

In the case of physical therapy specialty, clinical reasoning is an iterative and adaptive process that is based on the interaction of the physical therapist with the patient, with the environment in which the patient is treated and with the healthcare team. In this context, physical therapy interventions and goals are defined according to the information reported by the patient, the clinical context, and the clinical assessment of the patient; therefore, clinical reasoning allows making well-grounded decisions that take into account evidence-based recommendations, clinical practice guidelines, the experience of the physical therapist and the patient's expectations.^3-7

Furthermore, in the field of physical therapy, clinical reasoning can be also defined as an integrative and cognitive process that considers both movement analysis and the interaction of the patient with their environment, that is, it is an adaptive, iterative, and collaborative process that brings physical therapists closer to using a biopsychosocial model in clinical practice,^4,6 which implies being able to design an optimal communication strategy with the patient. With this in mind, clinical reasoning, in this context, is the ability of the physical therapist to argue their clinical hypotheses.⁷ In addition, it requires a full ethical commitment to science during clinical practice to optimize the achievement of positive health-related outcomes.^4,5,7-9

In the field of physical therapy, knowing how to solve problems faced during clinical practice by making responsible and timely clinical decisions is of great importance, which is why clinical reasoning is a fundamental skill for the proper professional performance of physical therapists.^9-11 However, physical therapy programs have a hard time to include in their study plans methodologies that promote the development of clinical reasoning since early stages of training,¹² given the differences between students and experienced physical therapists in terms of clinical reasoning, that is, the level of their skills to reflect when making clinical decisions.^2,3,9,12,13

In this sense, the physical therapy program offered at Universidad Andres Bello is based on the achievement of learning outcomes (LO) by means of instructional methods focused on what physical therapy students need to learn for having an adequate performance during their professional life.^14-16 It should be noted that LOs are defined as the knowledge and understanding of a given topic, action or process that a student shows at the end of a training period, that is, the evidence of the student's level of compliance with the training process.^17-23

Objective structured clinical examination (OSCE) allows assessing standardized clinical skills and is used for the training and evaluation of health sciences students who perform tasks in healthcare teams in clinical practice scenarios.^24,25 Its objective is directly related to developing and integrating critical thinking and planning, as well as to using the acquired knowledge in specific situations that involve carrying out professional healthcare-related tasks that require clinical reasoning.^9,22-25 This type of examination strengthens the sense of security, practical ability, operability, and critical judgment of students and prepares them for their professional practice.^25,26

The OSCE methodology focuses on evaluating clinical skills that promote the development of clinical reasoning by placing the student in a clinical setting in which they must use the acquired knowledge and their own abilities to solve a clinical situation,^1,27 this is why, situations proposed in OSCE stations are designed to measure clinical reasoning-related skills, and not only memory-related or mechanical (repetition of procedures) skills.²⁸

Furthermore, clinical reasoning includes both formal and informal thoughts in the decision-making process; thus, taking into account the students' perception of the OSCE is also important.²³ For this reason, evaluating the student's level of satisfaction with the OSCE methodology is recommended, since this will provide feedback regarding the design and execution of the stations used in the OSCE and will allow them to improve their clinical skills during their training, since, through this methodology, they can reflect and introspect on the development of their clinical reasoning during their training as physical therapists.^26,29

Therefore, the objective of this study was to describe the implementation of an OSCE to evaluate the clinical skills associated with the development of clinical reasoning in physical therapy students and to determine their level of satisfaction with this methodology.

Material and methods

Results

The median global score was 142 points (IQR: 132-150) and 61.1% of students obtained a passing score.

Upon analyzing the behavior of the scores obtained in each station, only S1 and S8 showed a distribution similar to the normal curve, while the remaining stations had an asymmetric distribution, where a higher frequency of high scores was observed.

Considering that the maximum scores per station varied between 8 and 24 points, median scores ranged from 8 to 21 points (Figure 1 and Table 3).

Source: Own elaboration.

Figure 1 Score distribution by stations. 

Perfect score and passing score frequencies by station ranged from 0% to 50.94% and from 2.52% to 96.86%, respectively (Table 3).

According to these results, S5, S7 and S3 were the stations where most students obtained a passing score (96.86%, 85.53% and 78.62%, respectively); on the contrary, the lowest passing score frequencies were observed in S8 (2.52%), S9 (44.03%), S10 (41.14%) and S11 (57.23%).

Regarding the OSCE satisfaction survey, when asked if the OSCE had been useful for their training as physical therapists, 48.43% and 38.35% of the students chose "agree" and "strongly agree", respectively. In addition, 45.91% agreed and 38.36% strongly agreed that taking similar tests improves their training, and 36.48% and 59.12% agreed and strongly agreed that taking tests that evaluate their clinical skills is important (Table 4).

Discussion

The objective of the present study was to describe the implementation of an OSCE as an adequate tool to evaluate clinical skills associated with the development of clinical reasoning in physical therapy students and to determine their level of satisfaction with this assessment methodology. However, it should be noted that the OSCE was implemented in second year students, who, given the study plan of the Physical therapy program at Universidad Andres Bello, had just started their clinical practice activities, where they began obtaining a certain degree of real-life professional experience. In this regard, the implementation of the OSCE allows measuring, in an adaptive manner, the clinical skills associated with the development of clinical reasoning according to the achievement of LOs by the student in early training stages.^2,3,9,13,23

The OSCE allows for the integration of problem solving and clinical practice, which is crucial to provide physical therapy students with a knowledge basis that enables them to develop clinical reasoning and then to consolidate it throughout their professional training,^1,12,42,43 thus the use of this methodology contributes to the strengthening of the training processes of future physical therapists.^23,44

In the present study, it was observed that the scores obtained in standardized patient stations were higher than those obtained in other types of stations (S3= median score: 18, maximum score reached: 21; S5= median score: 21, maximum score reached: 23, and S7= median score: 14, maximum score reached: 17), which differs from the findings by Beom Park et al., ²⁸ who, in a study conducted in 65 fourth-year medical students from a South Korean university, reported higher mean and maximum scores in the history taking station (71.6 and 88.7, respectively) compared to the physical examination station (46.6 and 72.1). This could be explained by the fact that asking and memorizing contents, without necessarily involving clinical reasoning, could imply a lower degree of difficulty.²⁸ This reinforces the need to design each station properly, so that the student is able to use clinical reasoning and its components adequately during the implementation of the OSCE according to the LOs addressed in all of its stations.^45-47

Several studies in which the OSCE has been used to assess clinical skills and specific skill associated with clinical reasoning have reported that students have better results in theoretical dimensions; for example, Bustamante et al., ⁴⁸ in a study conducted in 13 Chilean medical interns, reported that the best results were found in stations where cognitive skills were predominant, as it was observed in the cardiac arrest station, in which the performance of students in the execution of the skills needed to deal with cardiac arrest was much lower than their performance when answering theoretical questions about cardiac arrest (66% vs. 98%), which differs from our findings, where the best results were observed in station S7 (Standardized patient - cardio respiratory assessment # 2), in which 85.53% students obtained a passing score; this difference could be explained by the fact that in our study, the design of both the standardized patient and the scenario stations integrated cognitive, psychomotor and affective skill associated with clinical reasoning in physical therapy, which implied higher levels of difficulty for the students, as they were faced with problem solving in clinical practice simulated scenarios.^23,49,50

On the other hand, the worst performance was observed in mailbox stations (S8, S9, S10 and S11), which required cognitive or psychomotor skills, where less than 60% of students obtained a passing score (2.52%, 44.03%, 42.14%, and 57.23%, respectively); this situation may be associated with the fact that the reflection and writing process takes longer and is affected by the stress resulting from the evaluation.^13,49

Likewise, another factor that could explain the students' poor performance in the mailbox stations is that the activities in these stations required to be performed according to a rehabilitation problem-solving form, the International Classification of Functioning, Disability and Health, and a biopsychosocial model, which implies a greater cognitive challenge.^13,51 In addition, the time allocated for the completion of all stations (5 minutes for each station) could have affected the performance of the students in this type of stations, since it is likely they did not have enough time to fully carry out the activities in these stations, given the increased cognitive challenge they implied; however, it should be noted that the time given for the completion of each of the 11 stations of the OSCE in the present study is in line with the recommendations for the development of OCSEs.^47,48,52-54

Regarding the students' level of satisfaction with the implementation of the OSCE methodology, 44.03% and 7.55% (i.e. more than 50%) reported they agreed and strongly agreed with the general organization of the tool. This is consistent with the findings of a study carried out in 2019 in Jamaica by Majumder et al. ⁵³ in Bachelor of Medicine-Bachelor of Surgery students, where 66.7% and 14.8% (over 80%) of them agreed and strongly agreed with the use of the OSCE; however, it should be noted that only 54 students participated in the above mentioned study,⁵³ which could have been a factor influencing these results, as the proportion of students who were satisfied with the OSCE in our study was somehow smaller, but our sample size was larger (n=159).

Furthermore, in the present study, 52.83% and 21.38% of students agreed and strongly agreed that the OSCE stations were adequate for their level of knowledge, which is also similar to what Majumder et al. ⁵³ describe (66.7% and 18.5%). These findings would allow inferring that the OSCE is an evaluation tool that successfully addresses the contents learned during the Reasoning in Physical Therapy course of the Physical Therapy program at Universidad Andres Bello.

Regarding its relevance, 95.6% of the students considered that the OSCE was useful for the acquisition of clinical skills associated with the development of clinical reasoning, that is, less than 5% of the sample did not believe the OSCE was a useful tool for this purpose, which differs from the findings reported in the study by Majumder et al. ,⁵³ where 29.7% of the students stated there was no relationship between the OSCE and the development of clinical skills (very little relationship: 20.4%, and no relationship at all: 9.3%), this difference could be explained by the fact that familiarization with the OSCE methodology, as it was the case of our study, favors its positive evaluation by students as an assessment instrument that promotes the acquisition of clinical skills and the development of reflective thought.^40,53-56

Conclusions

The OSCE was successfully designed and implemented to evaluate the clinical skills associated with the development of clinical reasoning in physical therapy students, which confirms this is an excellent methodology to train and evaluate these students.

Moreover, a high level of student satisfaction with the use of the OSCE methodology was observed, since most students value its objectivity and the fact that the instrument may bring them closer to the development of clinical skills in situations similar to real-life clinical practice.

Finally, future studies should carry out this type of examination not only in physical therapy students, but also in students enrolled in other undergraduate health sciences programs offered at Universidad Andres Bello, for it will facilitate their professional development. Also, future studies must analyze if there is a correlation between the student's self-perception of their performance in the OSCE and their performance in this type of examination.