Clinical reasoning and decision-making of pre-professional speech–language therapists during clinical swallowing examination

Background: Sound clinical reasoning is crucial for synthesizing assessment and contextual information into evidence-based and patient-centred management decisions. Whilst clinical reasoning processes and development have been explored in broader health contexts, to date there has been limited evaluation of how clinical reasoning skills are employed by pre-professional speech–language therapists (SLTs) who conduct clinical swallowing examinations (CSEs). Aims: To evaluate how pre-professional SLTs (senior undergraduate students) apply reasoning and decision-making processes during simulated CSEs. Methods & Procedures: A qualitative approach, using an audio-assisted think-aloud protocol, was employed to evaluate participants’ clinical reasoning and decision-making processes before and after completing two simulated learning activities. The Supported CSE (Activity 1) consisted of a simulated CSE with guidance and assistance, whereas the Independent CSE (Activity 2) consisted of a CSE without any guidance or assistance. Four Bachelor of Speech Pathology students in their penultimate year of study participated in the Supported CSE (Activity 1), and three of those participants returned 12 months later for the Independent CSE (Activity 2) after having completed an adult dysphagia placement. From transcribed interviews, three types of concepts maps were generated to reflect the clinical reasoning processes used: a descriptive map, a reasoning map and a hypothesis map. The concept maps were qualitatively examined with regard to the CSE structure used, the clinical facts gathered, the types of reasoning used, and the hypotheses generated. Outcomes & Results: Pre-professional SLTs structured their CSEs in the same way that has been reported previously in expert SLTs, with some variation in individual assessment components and a step-by-step assessment structure. Participants generated a range of facts, with an emphasis on the biomechanical aspects of swallowing. They engaged in more inductive hypothesis generation than deductive hypothesis testing and, similar to expert clinicians, demonstrated cycles of inductive and deductive reasoning. Participants also generated a range of hypotheses, largely related to the biomechanical aspects of swallowing. Conclusions & Implications: Pre-professional SLTs engaged in processes that favoured a step-by-step assessment structure, a hallmark of reasoning undertaken by novices. Emerging cycles of inductive hypothesis testing and deductive hypothesis testing suggest early progression towards more refined reasoning skills as observed in expert clinicians during CSE. Taken together, the findings highlight the importance of providing speech pathology graduates with authentic learning experiences that facilitate the development of clinical reasoning and pattern recognition skills, which, in turn, will enable efficient and high quality CSE. WHAT THIS PAPER ADDS: What is already known on this subject Expert SLTs engage in cycles of inductive hypothesis generation and deductive hypothesis testing during CSE, which enables efficient and accurate clinical decision-making. What this paper adds to the existing knowledge Pre-professional SLTs engage in a similar approach to CSE as expert SLTs, but using a more item-based, step-by-step assessment approach with a focus on biomechanical aspects of swallowing and a stronger focus on inductive hypothesis generation. What are the potential or actual clinical implications of this work? The findings of this research illustrate the approaches to clinical reasoning in CSE taken by pre-professional SLTs. These findings broaden our understanding of clinical reasoning development from novice to expert and can be used to inform early career mentoring and clinical skill development as well as how pre-professional university curricula can prepare students for work-integrated learning activities and facilitate entry level competency development.