424
N. M. Otterman et al.
tion in professional development activities (i.e. know-
ledge about evidence-based guidelines, completion of
the post-Bachelor’s Dutch Neurorehabilitation course,
and participation in professional activities, such as
teaching, participation in networks, case discussion
meetings) did explain a substantial part of the variance
of outcome. In other words, each of these 3 factors
contributed significantly to higher SCT scores. This
finding suggests that education and active participation
in knowledge transfer are important aspects that drive
specialization experts in stroke rehabilitation.
A strength of this study was the thorough and careful
development of the case vignettes for the SCT test. All
steps were discussed with professionals in the field of
stroke rehabilitation and experts in educational sci-
ences. In addition, the web-based design makes it easy
to access and use. Another strength of this study is the
measurement of clinical reasoning; the development
of a valid assessment tool contributes to the body of
knowledge on clinical reasoning and to the improve-
ment of clinical reasoning, which is a vital component
of clinical competence.
Limitations
The current study had some limitations. First, the sam-
ple size was relatively small, mainly restricted by the
limited number of participants in the group specializing
in neurology. Secondly, some PTs reported that items
were multi-interpretable. The literature shows that
clinical reasoning strategies among healthcare profes-
sionals differ, depending on the content and the context
of the clinical problem. We assume that the empirical-
analytical approach of hypothetico-deductive reaso-
ning does not always match the reasoning strategies
of participants. Thirdly, the SCT we have developed
is relevant only for a limited period, since evidence
and healthcare evolve. Therefore, an SCT should be
a “living test”, which is adjusted to fit new evidence
that becomes available and new developments in
healthcare, such as precision medicine. The SCT of-
fers the opportunity to take variability into account; for
instance, by presenting the same reasoning dilemmas
in different individual contexts of clinical uncertainty.
However, it should be investigated whether the indi-
vidual variability that precision medicine accounts
for is also assessed validly with the SCT. Fourthly,
the SCT could have resulted in greater contrast if the
variability among the answers of the reference panel
could be reduced, since it seems that there was little
consensus between panel members on some items. A
follow-up consensus round in the reference panel to
construct the scoring algorithm might reveal if outliers
can be reduced and the validity increased further. We
www.medicaljournals.se/jrm
recommend this as an extra step in constructing an
SCT. Furthermore, an SCT is not useful for all guide-
lines. The variability in the answers relates to the level
of evidence, therefore guidelines that lack a high level
of evidence are prone to variability in the scoring by
experts and thus in the scoring algorithm. This will
translate into low contrasts in SCT scores between
PTs, making the SCT less valid for discrimination of
experts from non-experts in the field.
Other validation studies of SCTs in the medical do-
main have examined the differences between students,
residents and specialists (18–21). The total number of
questions, and thus the time needed for completion,
varied from 40 questions in 30 min to 153 questions
in 3 h. These mean scores (50–80) from these studies
found similar validity and is comparable to the current
study. The authors of these studies concluded that the
SCT is an innovative test that can distinguish between
different levels of clinical reasoning, and that an SCT
is a potential tool for professional development. The
current study confirms that SCT is also applicable in
the field of physical therapy.
These findings suggest that completion of the Dutch
Neurorehabilitation course is associated with higher
SCT scores and thus stimulates consistent integration
of the CPG Stroke in clinical reasoning. Explicit lear-
ning methods, such as peer assessment, facilitate the
integration of knowledge in clinical reasoning. This
is crucial to learning how to integrate knowledge in
clinical reasoning, since this is the way to cope with
new rapidly growing evidence.
In contrast to physical therapy specializations, such
as manual therapy and paediatric physical therapy,
the Royal Dutch Society of Physical Therapy does
not keep a country-wide registry of PTs working in
the field of neurorehabilitation in the Netherlands.
To support continued development, we suggest deve-
loping a postgraduate specialization programme for
PTs specializing in neurology in the Netherlands. The
programme could include active learning methods
and systematic continuous professional development
activities with built-in feedback and peer assessment in
order to provide a full continuous quality improvement
cycle. Highly motivated PTs can join the programme
and make their continuous education activities trans-
parent to different stakeholders. We believe that the
construction of such a programme should be initiated
by the physical therapy profession, with the aim of
creating a learning environment.
Future research should focus on improving the
psychometric properties of the SCT and its clinical
use. It would be of interest to study whether the test
is responsive to individual scores and subscores. This
could reveal the components of clinical reasoning and