FINAL PROJECT NARRATIVE

Most, if not all, literature on blended learning in Physical Therapy (PT) education discusses it in the context of acquiring psychomotor skills. The blending usually involves online delivery of content, providing theories and demonstrating techniques, while F2F meetings are reserved for demonstration of proficiency and testing of those techniques / psychomotor skills. This project is unique in that it focuses on teaching a process, and having students engage in the process and practice it repeatedly in preparation for the clinical education phase of the curriculum.

Clinical Decision-Making (CDM) requires 2 types of knowledge – content knowledge and structural knowledge. Content knowledge includes knowing the diagnosis, the etiology of a disease and the treatment for a specific disease or condition. Structural knowledge, on the other hand, is a form of a mental model that is created from knowing how the different domains of content knowledge interact with each other in a clinical problem. This course allows for a systematic acquisition of structural knowledge by novice students.

Experts (instructors) and novices (students) use different methods for CDM, with the former group exposed to more content and structural knowledge. Deductive reasoning is a top-down process where individuals predict consequences based on their ability to logically reason, arriving at a treatment plan. Inductive reasoning, on the other hand, is a process used in decision making which is described as a bottom-up process where individuals form hypotheses and theories based on the individual’s ability to recognize meaningful patterns and connections and uses these to arrive at a treatment plan. Novice practitioners use deductive reasoning, and expert practitioners use inductive reasoning. (Shin, 2019). This course, in a way, allows for students to undergo deductive reasoning individually, but then progresses on to experience inductive reasoning in the small group F2F session.

Inductive reasoning is the basis for the Hypothesis-Oriented Algorithm for Clinicians.

Background on Reform-Based Science Education:

The design of the course is consistent with the principles of reform-based science education which advocates for constructivist, inquiry-based methods. This course design combines and maximizes the benefits of both the traditional teacher-centered lecture-driven class (during individual, asynchronous engagement with content) and that of student-centered activity-based learning environment that includes opportunities for collaboration among students (during the small group F2F session). Repeated over time, the latter shifts from being a novel activity to a habit on clinical decision making for effective clinical practice. The design of this course does not ascribe to superiority of reform-based versus traditional science instruction, or vice-versa, but rather, it maximizes the use of both to develop effective and reflective practitioners.

NARRATIVE on the Blended Learning Course in Clinical Decision-Making:

The design of the blended course facilitates the creation of a community of inquiry. Cognitive presence is established with the online content. The online content is not meant to "spoon-feed" students facts. It is meant to harness their prior knowledge, identify gaps in this knowledge, and have the opportunity to fill-in these gaps. All these are designed to "prime" the student in preparation for the F2F session. Teaching presence is established when the instructor embeds online videos with formative questions, when facilitating the discussion, and during wrap-up on the lesson. Social presence is firmly established during the small group F2F CDM session and during the oral reports. Throughout the lesson, the onus on learning is on the student. This should be reflected in the individual student reflections. A robust community of inquiry is created during the small group F2F CDM session as students discuss and make decisions as colleagues and as equals. They support each other in understanding during learning activities.

I am also currently taking SCE 5140 Science Curriculum Development and, after engaging with the required process of curriculum development, the blended course I developed for EME 6059 is consistent with inquiry-based instruction and consistent with a reform-based science curriculum development. Garrison (2007) stated that “the ideal educational transaction is a collaborative constructivist process that has inquiry at its core. Social interaction and collaboration shapes and tests meaning, thus enriching understanding and knowledge sharing.” This blended course in clinical decision-making (CDM) engages students in this type of learning activities. He) added that “it is important to note that collaborative constructivist learning experiences are not conducive to “covering” a large amount of subject matter. Instead, the emphasis is on inquiry processes that ensure core concepts are constructed and assimilated in a deep and meaningful manner.” Inquiry is at the heart of the small group F2F session and the (group) oral reports.

This blended course in CDM is also consistent with his discussion on the conceptual foundation of blended learning. He described online and F2F instruction as being “blended into a unique learning experience congruent with the context and intended educational purpose….It represents a restructuring of class contact hours with the goal to enhance engagement and to extend access to Internet-based learning opportunities.” It is a “fundamental redesign that transforms the structure of, and approach to, teaching and learning.” The online and F2F learning activities of this CDM course are individually valuable, can stand-alone, but they also enhance and add value to each other.

The blending used in this course is somewhat different from the usual blending used in the physical therapy classroom (i.e. didactic content delivered online, psychomotor skill assessment performed face-to-face). This course uses the online platform to deliver content to “prime’ students for the F2F session, harnessing students’ prior knowledge while allowing them to self-assess gaps in their knowledge with the opportunity to mitigate these gaps. “Priming” through the online content provides the means for everyone to fully engage and effectively participate during the F2F session.The small group F2F session and the (group) oral reports allow students to ask questions, explore multiple answers, interact and collaborate to arrive at an answer on the subject of their inquiry. The F2F session focuses on students acquiring inductive reasoning for clinical decision-making. This goes beyond verification of correct hand-placement, correct positioning of self in relation to the patient, and practices required for safe patient encounters, which are practiced and verified during the F2F session of current blended learning designs. With reference to Bloom’s Taxonomy, engaging in inductive reasoning during clinical decision-making during the F2F session requires engagement in the highest level of the hierarchy.

The process described above puts the student in the path of practicing introspection and self-assessment, two important habits for life-long learning. This is important for success in being a clinician – the ultimate goal of each and every physical therapist education program. This introspection and self-assessment are also reflected in the assessed individual reflection of the small group F2F CDM session. This creates consistency between the online delivered content and the F2F experience in sowing the seeds for life-long learning – besides providing a continuum for inductive reasoning; both activities engage the student in introspection and self-assessment.

The online instructional materials, used to “prime” the student for the F2F session, provide flexibility to the instructor in designing the course. The online materials can be developed based on specific course goals, while still engaging the student in inductive reasoning.

There is some recognition in the profession that the excessive variability among programs is problematic. Simply put, when an individual goes to 2 physical therapists, those 2 PT’s will develop 2 different plans of care, often extensively different from each other. Maybe, the problem is not due to variability in content (i.e. interventions) being taught in programs. Maybe, the profession should explore uniformity in how clinical decision-making is being taught. If PT’s engage in the process using the same framework, maybe this will result in an acceptable level of heterogeneity, or homogeneity for that matter, in the interventions selected by PT’s as part of the plan of care.

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In the initial posting of my Blended Learning Curriculum Plan, one of the comments / questions was why have the oral reports on week 2, for the small group F2F CDM session held on week 1. In reality, the course can be designed such that the small group F2F CDM session is held in the first hour, and oral reports are done on the second hour for the same topic. If this sequence of activities is followed in the same F2F session (i.e. small group F2F CDM session followed by oral reports on the discussion during the small group), then the individual reflections will reflect both activities. Isolating the individual reflections to the small group session provides a more accurate picture of the effectiveness of the activity, the progression of the group with acquiring the skill of CDM, and the progression of each individual in CDM.

I feel that there are a few good reasons why the F2F session starts with oral reports from the previous week's small group F2F CDM session.

1. It gives time for students to reflect on their clinical decisions. As a clinician, this is how I do it in clinical practice. I look back and reflect on my decisions and the actions I took. When students are engaged in this introspection and self-assessment, this facilitates acquisition of an important habit - one that will also facilitate life-long learning.

2. Corollary to this, students have the ability to modify their decisions, and reflect this change in their oral reports . This conveys to students that it is acceptable to modify their original plan of care if it benefits their patients.

3. Finally, based on my experience, classroom management can become a challenge when the class starts out in small groups, then bringing them all together for the oral reports as one big group. Based on my experience as a student engaged in this process, the small groups might continue to discuss their group's Initial Examination / oral report even when the oral reporting has commenced. This negates the learning afforded by the oral reports, when groups are not focused on the activity.

Feedback / Questions from the Class:

How/when will students receive feedback during the face to face learning portion (i.e. will you be rotating and providing feedback to the groups or is it completely student led?)

During the small-group F2F CDM session, the instructor will be rotating. In a course such as this, there usually would be 2 clinicians assisting the instructor. So, 3 "facilitators" will be rotating around. During the oral reports in front of the class, the instructors will "facilitate" the discussion.

My only suggestion is to create a method of evaluation for the students’ synchronous face to face sessions.

After the small-group F2F CDM, the group will be submitting a completed Initial Examination form based on the vignette of the case provided to the group. The small group will be assessed using their submitted form. Each member of the group will submit a reflection on the process and their work-product. This is how members of the small group will be assessed individually.

SOURCES:

Garrison, D.R. & Vaughan, N.D. (2008). Blended Learning in Higher Education: Framework, Principles, and Guidelines. San Francisco: Jossey- Bass.

Bozkurt, A., & Sharma, R. C. (2022). In Pursuit of the Right Mix: Blended Learning for Augmenting, Enhancing, and Enriching Flexibility. Asian Journal of Distance Education, 16(2). (Links to an external site.)