Critical features of physical therapists specializing in stroke rehabilitation
are of the opinion that adherence of PTs to changing
clinical practice guidelines in stroke rehabilitation (6,
7), including guideline-consistent clinical reasoning,
requires special skills that need to be trained in postgra-
duate specialization in stroke rehabilitation in order to
improve care for stroke patients. Supported by a grant
from the Dutch National Institute of Health, a 1-year
course, called the Dutch Post-Stroke Neurorehabilita-
tion Course, was started in the Netherlands (3).
Clinical reasoning is a vital component of clinical
competence (8), and its importance is recognized in
major policy documents about professional develop-
ment. Higgs and co-workers (9), as well as Edwards
and colleagues (10), defined clinical reasoning as a pro-
cess in which the therapist, interacting with the patient
and others, such as family members or other healthcare
providers, helps to structure meaning, goals, and health
management strategies based on clinical data, patient
wishes and choices, and professional judgement and
knowledge (9, 10). Systematic application of scientific
evidence in the clinical reasoning process is thought
to improve the effectiveness and quality of physical
therapy practice. We are therefore of the opinion that
assessment of the consistent use of clinical practice
guidelines (CPGs) in clinical reasoning can provide
feedback on the use of guidelines and can identify
areas of improvement (11). However, valid measures
of guideline-consistent clinical reasoning are scarce in
postgraduate physical therapy practice (Box 1).
The script concordance test (SCT) is a written test,
based on brief clinical scenarios, to assess clinical
reasoning in a context of uncertainty. This test mea-
sures the extent to which the clinical reasoning of an
individual professional matches that of a group of ex-
perts (8, 12, 13). Several studies on the assessment of
clinical reasoning in the medical domain have shown
that the SCT is a valid assessment tool across a variety
of continuing professional development activities (12,
Box 1. Glossary
Specialist physical therapist: a physical therapist who has formally
demonstrated an ability to apply advanced clinical competence in a
defined clinical area, within the scope of practice recognized as physical
therapy. A specialist physical therapist will work primarily in a specific
area of clinical and/or teaching practice, but would be expected to also
be involved in research and evaluation and practice/service development
relevant to their practice setting. (10).
Clinical competence: the ability to perform a specific task in a manner
that yields desirable outcomes in healthcare. This implies the ability to
apply knowledge, skills and abilities successfully to new situations, as well
as to familiar tasks for which prescribed standards exist. In addition to
skills, clinical reasoning is a vital component of clinical competence.
Guideline – consistent clinical reasoning: the consistent use of
recommendations from (inter)national guidelines on thinking and
decision-making in professional practice to guide practice activities, such
as establishing a diagnosis, and the choice of measurement instruments
and interventions. (9).
Test blueprint: a clear framework with specification of the test. It contains
the topics to be included in the test, as well as cognitive dimensions and
type of questions. The purpose of a test blueprint is to achieve content
validity.
419
14). However, no research evidence is available on the
validity of the SCT as a tool to assess the clinical reaso-
ning of PTs. We are of the opinion that this tool might
help us examine the use of guidelines in the clinical
reasoning process of PTs in stroke rehabilitation.
This paper first describes the development of an SCT
for physical therapy, focusing on the diagnosis, clinical
assessment, neurological and functional prognosis for
outcome, and treatment in accordance with the Dutch
CPG on Stroke in physical therapy (further referred to
as CPG Stroke) (2, 15). The study then evaluates the
validity of the SCT, defined as the degree to which the
scores (17) of the SCT are consistent with our hypo-
thesis that there are differences between the following
4 groups: (i) PTs specializing in neurology; (ii) PTs
focusing on neurology or geriatrics; (iii) other or non-
specialized PTs; (iv) undergraduate physical therapy
students. It was hypothesized that PTs specializing
in neurology could be distinguished by their higher
SCT score. Furthermore, it was identified whether
knowledge, expertise and professional development
of PTs were related to guideline-consistent clinical
reasoning, in order to identify the critical features of
PTs who specialize in stroke rehabilitation.
METHODS
Development of the script concordance test
Development of the content. The SCT was developed according
to the guidelines published by the Association for Medical
Education in Europe (AMEE) for SCT construction (8, 12, 13)
(Fig. 1). First, the project group carefully determined the scope
of the SCT, including operationalization of its purpose and the
focus of the assessment (Table I). Secondly, a test blueprint was
created to bolster the content validity of the SCT. The creation
of the test blueprint was a dynamic process, running in parallel
with the construction of the test, based on scientific reviews of
stroke rehabilitation (1, 2, 15, 16). Thirdly, clinical scenarios
were constructed, also known as item vignettes or case vignettes,
followed by a set of 2–3 questions, which could be scored on a
5-point Likert scale. The aim was to construct 20–25 vignettes
with a total of 60–75 questions in order to achieve sufficient score
reliability (12). Two authors (MM and NMO) were responsible
for developing draft vignettes. The authenticity of the clinical
Table I. General principles that defined the scope of the script
concordance test and on which the assessment is based
Construct to be
assessed
Guideline-consistent clinical reasoning as an
aspect of specialization
Assessment method Script concordance test
Purpose of test
Reflecting on guideline-consistent clinical reasoning
that can enhance learning. Discriminating between
professionals whose reasoning matches that of experts
and those whose reasoning does not.
Target group
Practicing physical therapists (postgraduate)
Knowledge domain Stroke rehabilitation
Focus of the test
Diagnostics and functional prognosis supported by
measurement instruments. Treatment planning; goal-
setting and choice of intervention
J Rehabil Med 51, 2019