JHT READ FOR CREDIT ARTICLE # 097

Clinical Decision Making and Therapists

Autonomy in the Context of Flexor
Tendon Rehabilitation
Gail N. Groth, MHS, OTR/L, CHT
University of Wisconsin-Madison, Department of
Kinesiology, Watertown, Wisconsin 53098
ABSTRACT: Sound clinical decision making (CDM) is one critical
factor in the delivery of quality health care. The purpose of this
cross-sectional study was to examine therapists autonomy in
CDM, to describe therapists clinical reasons influencing CDM,
and to describe the influence of autonomy on actual clinical prac-
tice. A survey was distributed to 754 hand therapists and descrip-
tive statistics was performed. Of the 754 surveys, 191 were
returned (response rate 25.3%). Autonomy in CDM was perceived
to be low by most therapists. Greatest autonomy was seen in setting
the frequency of rehabilitation sessions, and the least autonomy in
choosing the protocol and the timing of initiation of rehabilitation.
Shared decision making between therapist and surgeon occurred
frequently, however, CDM was rarely fully collaborative. Clinical
reasoning strategies were consistent with a novice-type approach.
The perceived lack of autonomy in CDMnegatively impacted ther-
apists compliance with surgeons preferences.
J HAND THER. 2008;21:25460.
Successful rehabilitation of flexor tendon (FT)
injuries is a complex process that requires numerous
clinical decisions by the occupational or physical
therapist over a 12e to 16-week period. Complexity
of the injury in combination with a fragile surgical
repair makes sound clinical decision making (CDM) a
critical factor in the delivery of quality rehabilitation.
Examples of difficult FT clinical decisions that hand
therapists may face include how to optimally posi-
tion the digits and wrist in what type of postoperative
splint, when and how to deviate from a standard
protocol in response to unusual patient characteris-
tics, and how to communicate clinical intervention
preferences to the referring surgeons, particularly
under the conditions of geographical distance.
Sound CDM regarding rehabilitative treatment
interventions is one critical component in the
delivery of quality health care. CDM is defined as
the point of clinical choice or judgment between alter-
natives
1
and occurs when one course of action is se-
lected and chosen over all other options, even if the
course of action includes doing nothing.
2
Clinical
reasoning is defined as the cognitive processes and
strategies used to arrive at clinical decisions.
3
Many team members contribute to the CDM pro-
cess within FTrehabilitation. Of particular interest in
this study are the interactions and relative contribu-
tions of the referring surgeons and treating hand
therapists to the clinical decisions in FTrehabilitation.
In many cases, surgeons and therapists work in
proximity with frequent communication; in other
cases, therapists work in separate clinics with signif-
icantly less communication. In either case, the same
clinical decisions regarding progression of rehabili-
tation must be made in a timely manner. Therapists
autonomy in CDM is therefore an important
consideration in the delivery of quality health care.
Autonomy in CDM is one of the key traits of a
profession and implies a defined scope of practice, a
distinct knowledge base, and expertise in a domain.
4
For the purposes of this paper, autonomy is defined
as a therapists freedom to use judgment and clinical
reasoning skills to make clinical decisions regarding
patients rehabilitation needs. Current practice in
the United States stipulates that hand rehabilitation
CLINICAL/ORIGINAL PAPER
This study was supported in part by the American Hand Therapy
Foundation Burkhalter Grant 2002. Aportion of the study data was
presented at the Annual Meeting of American Society of Hand
Therapists, Hollywood, California, 2003.
Correspondence and reprint requests to Gail N. Groth, MHS, OTR/
L, CHT, University of Wisconsin-Madison, Department of
Kinesiology, 1406 Beacon Drive, Watertown, WI 53098. e-mail:
<groth.gail@gmail.com>.
0894-1130/$ esee front matter 2008 Hanley & Belfus, an imprint
of Elsevier Inc. All rights reserved.
doi:10.1197/j.jht.2007.10.022
254 JOURNAL OF HAND THERAPY
is physician-prescribed and is, in this sense, not fully
autonomous. However, hand therapists do operate
under a defined scope of practice with a distinct
knowledge base
5
and expertise.
6
Furthermore, most
referrals to hand therapists include at least an ele-
ment of eval and tx, with the expectation that ther-
apists make autonomous clinical decisions regarding
optimal rehabilitation interventions.
Expectations for shared versus autonomous CDM
in FT rehabilitation may vary among and between
therapists and surgeons. If shared CDM is the expec-
tation, then communication between therapist and
surgeon must occur frequently, despite organiza-
tional or clinical barriers. If autonomous CDM is
the expectation (or the reality of geography), then the
therapist must possess and be able to critically apply
an expert knowledge base that permits sound CDM.
Negative consequences of low therapist autonomy in
CDM include delayed progression of treatment, lack
of attention to the individuals illness experience, and
inadequate tailoring of complex exercise regimens.
Each of these consequences is capable of prohibiting
the restoration of finger range of motion, reengage-
ment in activities of daily living, and therefore
participation in life roles.
The purpose of this cross-sectional study within the
context of FTrehabilitation was to examine therapists
autonomy in CDM, to describe therapists clinical
reasons influencing CDM, and finally, to describe the
influence of autonomy on actual clinical practice.
METHODS
A 52-item questionnaire was developed by the
author to describe current clinical practices for reha-
bilitation of FT injuries. Specifics of questionnaire
development, content, and distribution were previ-
ously reported.
7
The questionnaire was disseminated
to a convenience sample of 754 occupational and
physical therapists attending one of three continuing
education courses in the Midwest region of the
United States in 2002. Six items queried therapists
autonomy in CDM regarding progression of specific
FT rehabilitation interventions with three response
options (MD Only, assigned value of zero; MD/thera-
pist, assigned value of one; and Therapist only, assigned
value of two):
This (these) professional(s) choose the post-operative protocol my
patient(s) follow:
This (these) professional(s)
decide when therapy should be initiated:
on the frequency of scheduled therapy visits:
when to initiate active ROM exercises for my patients:
when to discontinue protective splinting for my patients:
when to initiate resistive exercises for my patients:
Three items queried therapists clinical reasons influencing their CDM
and included:
The reason(s) active ROM is initiated in the typical
patient:
The reason(s) protective splinting is discharged in the
typical patient:
The reason(s) resistive exercise is initiated in the typical
patient:
Response options (circle as many responses as necessary): number of days
post-op, MD order, ROM measurements, suture technique, established
protocol, compliance issues, other [explain].
Data Analysis
An Autonomy Scale was createdwith values ranging
from zero to 12 (higher values indicate higher thera-
pist autonomy) based on the values assigned to
the three response categories (zero, one, or two).
Responses indicatingnoautonomy(MDonly) received
zero points, a mediumlevel (both) received one point,
and a high level of therapist autonomy (therapist
only) received two points. An Autonomy Ratio was de-
rived by dividing the Autonomy Scale score by 12, the
maximum score possible. Values range from zero to
one with higher values indicating higher therapist au-
tonomy. A Collaboration Scale was also created. This
was a dichotomous (Yes/No) variable with Yes in-
dicating therapists responded MD/Therapist to all six
items and No indicating that some other responses
were provided. In all cases, therapists who did not
provide responses to all six items were excluded
from the analyses. Descriptive statistics were per-
formedontherapists demographics. Anindependent
research-consulting agency performed all data entry
(coding and cleaning) and data analyses using SPSS
11.5 (SPSS Inc., Chicago, IL) for Windows.
RESULTS
One hundred and ninety-one questionnaires were
completed (response rate of 25.3%). Therapists cre-
dentials, experience, and practice settings were de-
scribed in a previous study
7
and a brief summary
follows (Table 1). Nearly half (41%) of the respondents
were CertifiedHandTherapists (CHTs) withanevenly
TABLE 1. Characteristics of surveyed therapists (n 191)
Disciplines of surveyed therapists (n 191)
CHT (OT) 62 (32.5%)
CHT (PT) and/or PT 33 (17.3%)
OT 62 (32.5%)
Number of years experience in hand specialty (n 178)
,5 71 (39.9%)
5e9 50 (28.1%)
10e14 37 (20.8%)
$15 20 (11.2%)
Primary practice setting (n 191)
Hospital-based 69 (36.9%)
Corporate-owned 55 (29.4%)
Therapist-owned 34 (18.2%)
Physician-owned 22 (11.8%)
Other 7 (3.7%)
JulyeSeptember 2008 255
distributed range of years of specialized hand experi-
ence. Sixty percent of therapists reported having five
or more years of hand therapy experience, and there-
fore were considered expert hand therapists.
6
Practice settings of the therapists included hospital-
based, corporate-owned, therapist-owned, physician-
owned practices, and other practice settings. Most
therapists (61.7%) rehabilitated between one and
nine FT patients during the past year (range 0e15).
Therapists Autonomy in CDM
Therapists autonomy for specific clinical decisions
varied throughout the progression of FTrehabilitation
(Table 2). Therapists reported experiencing the high-
est degree of autonomy in the determination of the
frequency of therapy sessions (therapist only 24.8%)
and the lowest autonomy for the choice of protocol
(therapist only 1.8%) and initiation of therapy
(therapist only 1.2%). Overall, referring surgeons
generally have more autonomy regarding the key
elements of rehabilitation than do therapists.
The mean Autonomy Scale score was 5.16 (n 165,
r 1e12) indicating that CDM most frequently clus-
tered at the midpoint of the scale and was shared
between therapist and surgeon. The Autonomy
Ratio was 0.43 (n 165), indicating that therapists
perceived a reliance on the surgeon in coordinating
rehabilitation. Collaboration (shared decision making
between therapist and surgeon in all six items)
occurred in 13.8% of the cases.
Clinical Reasoning
Following an established protocol, counting the
number of days post-op, and following the MD order
were the three clinical reasons most frequently
reported (range 55e70%) by therapists for initiat-
ing all three items (active ROM, discharging protec-
tive splint, and initiating resistive exercise) (Table
3). The clinical reasons least used during CDM were
ROM measurements, compliance issues, and suture
techniques (range 19e38%).
Influence of Therapists Autonomy on Actual
Clinical Practice
Actual clinical practice varied from therapists
preferences in two key elements: initiation of therapy
and initiation of active ROM exercises. Therapists
reported preferences for earlier initiation of therapy
and earlier initiation of active ROM exercises than
what occurred in actual practice (therapy, p 0.00,
active ROM, p 0.00). It is presumed that if thera-
pists initiated rehabilitation and active ROM exer-
cises later than they prefer, it is in concordance with
the surgeons preferences. This finding is consistent
with the lowlevel of autonomy reported for initiating
therapy (1.2%) and initiating active ROM (8.5%),
however, is somewhat surprising considering most
therapists (77%) reported shared decision making in
the initiation of active ROM. No significant differ-
ences were noted between actual and preferred
practice regarding initiating resistive exercise, dis-
continuing protective splint, or frequency of visits.
Twenty-five percent of all therapists reported
agreed or strongly agreed to occasionally prescribing
therapy the referring surgeon might disagree with.
This percentage varied when cross-tabulated with
years of experience (Fig. 1). Forty percent of thera-
pists with 10e14 years of specialty experience per-
ceive that their prescriptions may vary from the
surgeons preferences. It is unknown if the smaller
percentage (27.8%) for therapists with 15 or more
years of experience is indicative of greater compli-
ance with surgeons preferences, or simply fewer
therapists in that category within this study. Sixty-
three percent of therapists with less than five years
experience disagreed or strongly disagreed with the
statement. It is to be noted that this question referred
globally to FT rehabilitation and not any specific
intervention or component of rehabilitation.
DISCUSSION
This study examined therapists autonomy in six
specific clinical decisions and found that autono-
mous CDM occurs infrequently for both therapists
and surgeons in the context of FT rehabilitation. The
types of clinical decisions examined included an
intervention decision (choosing of protocol), several
TABLE 2. Autonomous Clinical Decision Making
in Specific Components of Flexor Tendon
Rehabilitation (n 191)
Key Element MD (%) Both (%) Therapist (%)
Protocol 17.6 80.6 1.8
Initiation 66.1 30.3 1.2
Frequency 6.7 70.3 24.8
AROM 15.2 77.0 8.5
D/C protective splint 17.0 73.3 9.1
Resistance 13.9 70.9 13.9
TABLE 3. Comparative Reasoning between the Initiation
of Three Key Elements (n 191)
Initiation
of Active
ROM
Discharge
Protective
Splint
Initiation
of
Resistance
Novice clinical reasoning
Established protocol 1: 63.6% 1: 61.9% 1: 70.3%
Number of days post-op 2: 62.4% 2: 58.5% 2: 58.8%
MD order 3: 57.0% 3: 55.2% 3: 55.2%
Advanced clinical reasoning
Suture technique 4: 38.2% 6: 22.4% 5: 24.8%
Compliance issues 5: 27.3% 4: 33.9% 6: 24.2%
ROM measurements 6: 19.4% 5: 30.3% 4: 38.2%
Other 7: 5.5% 7: 4.8% 7: 8.5%
Therapists were instructed to circle all applicable choices, there-
fore the totals are not 100%.
256 JOURNAL OF HAND THERAPY
timing decisions (initiation of rehabilitation, active
ROM exercises, discharge of protective splint, and
initiation of resistive exercises), and a service deliv-
ery management decision (frequency of therapy
visits). The low response rate from this convenience
sample requires that caution be exercised in the
interpretation of the data.
Therapists Lack of Autonomy in CDM
Shared decision making between therapists and
surgeons occurred far more frequently than autono-
mous CDM in all but one of the six clinical decisions
(initiation of rehabilitation). However, full collabora-
tion defined within this study as shared decision
making for all six decisions did not occur often (13.8%
of the time). This low percentage demonstrates that
while shared decision making occurs frequently,
many decisions in the context of FT rehabilitation
are not fully collaborative. Instead, clinical rehabili-
tation decisions tend to be made by the surgeon.
The issue of establishing an optimal level of ther-
apists autonomy in CDM to achieve the best patient
outcome clearly needs to be addressed. Perhaps,
neither high levels of autonomy by the surgeon nor
by the therapist are optimal but full collaboration
would be the most desirable goal. Within this study,
however, we did see therapists who sought full
autonomy in CDM whereas others abdicated and
sought only to follow surgeon orders. It appears,
therefore, that optimal autonomy is dependent on
both the individuals providing therapy and the site of
care delivery.
Autonomous decision making should be examined
under the paradigmof evidence-basedpractice (EBP).
In this paradigm, few clinical decisions made by
health professionals are autonomous. This is because
EBP is defined as the integration of best research
evidence with clinical expertise and patient pre-
ferences.
8
The implication is that clinical decisions
do not solely belong with the therapist, but rest in
a shared state between patient and therapist.
Similarly, a therapist integrates evidence received
from the surgeon along with patient preferences to
arrive at the optimal clinical decision. In neither case
does the therapist make autonomous clinical decisions.
Clinical Reasoning Strategies
Another interesting issue arising from this study is
the frequent utilization of clinical reasoning strate-
gies that are characteristic of novice reasoning (Table
3).
9,10
The most commonly reported clinical reason-
ing strategy of using established protocols to make clin-
ical decisions (such as the Modified Kleinert
11
or
Duran
12
protocols) has been suggested by other stud-
ies outside the context of FTrehabilitation to suppress
clinical reasoning when the protocols are used non-
discriminately.
9
Nondiscriminate use of clinical pro-
tocols occurs when individualized care is not
provided. The second most commonly reported rea-
soning strategy of the number of days post-op is an ex-
tension of the first as most FT protocols are described
chronologically and again, little clinical reasoning is
exhibited. Finally, the third most commonly reported
strategy of following MD orders does not require or en-
hance clinical reasoning. An alternative explanation
for the predominance of these clinical reasoning strat-
egies is that the therapists were asked to respond
according to a typical or routine patient. Perhaps an
atypical scenario would stimulate deeper or more
advanced clinical reasoning.
Conversely, advanced clinical reasoning strategies
were infrequently reported. These included knowl-
edge of suture technique, compliance issues, and ROM
measurements. The first two of these strategies are con-
sidered advanced because they require knowledge of
the surgical procedure and of the psychosocial attri-
butes of individuals, and the implications of the ap-
plication of this knowledge on rehabilitation. Using
ROM measurements to assist in CDM demonstrates
advanced clinical reasoning because this strategy
demonstrates an understanding of the implication
of tendon adhesions on finger ROM. For example,
the pyramid program is a method of exercise pre-
scription in FT rehabilitation that is based on ROM
measurements.
13
CDM Frameworks
Developing an understanding of autonomy in
CDM is enhanced by examining theoretical frame-
works of CDM.
14
Many CDM frameworks originated
in medicine and have found extensive support in
nursing literature.
15
There is a growing body of reha-
bilitationliterature that examines these frameworks.
16
The literature on CDM may be summarized by two
different and seemingly opposing frameworks: ana-
lytic and intuitive.
15
A third framework (Cognitive
21.2
17.4
40
27.8
0
5
10
15
20
25
30
35
40
45
<5 5to 9 10 to 14 15 or more
Years of Hand Specialty Experience
P
e
r
c
e
n
t
FIGURE 1. I occasionally prescribe therapy that the re-
ferring surgeon might disagree with: Cross-Tabulation
of Years of Hand Specialty and Agree (n 38).
JulyeSeptember 2008 257
Continuum Model) proposes that therapists may use
a combination of these two frameworks that depends
on the nature of the particular clinical decision.
17,18
The analytic framework
15
describes a systematic
and conscious process where therapists use a variety
of cues (i.e., zone of injury, suture technique, range of
motion, and previous experience) to weigh opposing
options for a clinical decision.
3,19e24
The intuitive
framework describes CDM as occurring at a more
subconscious level
25
and the therapist, rather than
the cues, serves as the primary decisional force.
26
Therapist expertise plays a significant role in the
use of intuition
27
with experts using a more intuitive
framework
28
and novices using a more analytic
framework. The most frequently used clinical reason-
ing strategies in our study support an analytic frame-
work (Table 3).
Other Factors that Influence CDM
Our study describes a single factorautonomyin
several specific clinical decisions in the context of FT
rehabilitation, however, many other factors are
thought to influence CDM in rehabilitation and are
worthy of future study. These include, but are not
limited to, different types of decisions,
29,30
level of
expertise,
22,28
complexity of the clinical decision,
31
types of reasoning used, the effect of time constraints
in CDM, economic factors from the health organiza-
tion or the insurance companies, shared decision
making between patients and therapists, and avail-
ability of research evidence for CDM. For one specific
example, level of expertise (either years of experience
or familiarity with FTrehab) is likely to influence the
clinical reasoning process underlying the decisions,
however, this factor was not analyzed in this study.
In a second example, further characterization of the
relationships between surgeons trust and therapists
autonomy on the dependent variable of CDM is also
likely to impact the results.
Several limitations impact the findings of this study.
Self-reports and retrospective recall have been
shown to differ from observations of actual CDM.
32
Qualitative methods such as nonparticipant observa-
tion, in-depth interviews, or think-aloud protocols
would provide deeper insight into therapists clinical
reasoningthanthe quantitative methodused. Because
of the quantitative methodology used in conjunction
witha lowresponse rate, it is unknownif the available
data are representative of the population of hand
therapists. Responses may be different if the same
survey was distributed to a random sample or if a
larger response rate was achieved. Furthermore, the
data were collected in 2002 and it is unknown if ther-
apists autonomy and physicianetherapy relations
have systematically changed in that time. The low
response rate indicates the need for additional study
to reexamine these same issues addressing the
methodological shortcomings. However, this paper
represents the first empirical study examining CDM
in a population of hand therapists, and the methodol-
ogy serves to generate hypotheses for future studies.
CONCLUSION
Therapists autonomy within the context of six
specific FT rehabilitation decisions was perceived to
be low by most respondents. The greatest autonomy
was reported in setting the frequency of rehabilita-
tion sessions and the least autonomy in choosing the
protocol and the timing of initiation of rehabilitation.
Clinical reasoning strategies used in CDM were
indicative of novice reasoning, however, this may
be a result of the methods used in this study. Shared
decision making between therapists and surgeons
occurred frequently, however, full collaboration was
unusual. The perceived lack of autonomy in CDM
negatively impacted therapists compliance with
surgeons preferences.
Acknowledgments
The author thanks all the therapists who were generous
with their time and expertise in filling out the survey. She
also thanks the course coordinators who facilitated the
distribution of the surveys (Nancy Cannon, Barb Haines,
and Rebecca von der Heyde) and the American Hand
Therapy Foundation for funding assistance.
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JHT Read for Credit
Quiz: Article # 097
Record your answers on the Return Answer Form
found on the tear-out coupon at the back of this is-
sue. There is only one best answer for each
question.
#1. Shared CDM between therapist & surgeon was
found to be
a. most often fully collaborative
b. rarely fully collaborative
c. almost never collaborative
d. unimportant to therapists answering the
survey
#2. The highest rate of autonomy in CDMby the ther-
apists was found in deciding
a. when to initiate active motion
b. when to initiate resistive exercise
c. when to initiate PIP flexion contracture
splinting
d. the frequency of clinical visits
#3 Of the respondents to the survey approximately
what percentage were CHTs
a. 80
b. 60
c. 40
d. 20
#4. The rate of response to the survey requires the
reader of this study to
a. accept the Null Hypothesis
b. reject the Null Hypothesis
c. be cautious when interpreting the data
d. be sophisticated in the understanding of
statistics
#5. While this study was limited to considerations
about CDM with flexor tendon management,
the data can clearly be applied to most other
hand therapy situations
a. false
b. true
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups
of 3 or more to get full credit.
260 JOURNAL OF HAND THERAPY