Narrative analysis to track the development of clinical reasoning during residency

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Keshrie Naidoo
Jane Baldwin
Jessie Lesar
Laura Plummer


Purpose: Reflective narratives are valuable pedagogical tools that document and develop clinical reasoning. The purpose of this study was to investigate (through thematic analysis of reflective narratives) whether residents who were exposed to a specific clinical reasoning strategy showed development in the type and number of reasoning strategies used over the course of residency training.

Methods: This retrospective analysis used narrative research and thematic analysis of reflective narratives written by five residents over the course of a 12-month orthopaedic residency program. Narrative research involves the analysis of stories that are in text form. Residents were introduced into the clinical reasoning strategies (CRS) model, which describes eight types of reasoning strategies used by expert physical therapists: diagnostic, narrative, intervention procedures, interactive, collaborative, reasoning about teaching, predictive, and ethical reasoning. Researchers coded resident narratives for the types of CRS used by residents, and then analyzed the code frequency to describe the development of resident clinical reasoning.

Results: Researchers identified seven of the eight CRS strategies in resident narratives: diagnostic, narrative, reasoning about intervention procedures, interactive, collaborative, reasoning about teaching, and predictive reasoning. Residents used an average of 4.8 CRS at the beginning of residency and 5.8 at the end of the residency training. Reasoning about diagnostic and intervention procedures were used most frequently. Collaborative reasoning showed the most development, with 100% of the residents leveraging collaborative reasoning by the end of the residency.

Conclusion: Narratives serve as valuable pedagogical tools to help residents engage in reflective processes and understand the context of caring for their patients. This study illustrates using qualitative data analysis to evaluate the development of clinical reasoning skills throughout residency training. Clinical narratives can both foster and provide valuable insights into the development of clinical reasoning skills.


  1. American Physical Therapy Association. Core competencies of a physical therapist resident January 2020. Available from:​d87e401563e/core-competencies-pt-resident.pdf [cited 20 June 2021].

  2. Cunningham S, McFelea J. The influence of an orthopedic manual therapy residency program on improved knowledge, psychomotor skills and clinical reasoning in Nairobi, Kenya. Front Public Health (2017) 5: 1–5. doi: 10.3389/fpubh.2017.00055

  3. Cunningham S, Litwin B, Fernandez-Fernandez A, et al. Influence of residency training on the clinical reasoning development of Kenyan physiotherapists. J Man Manip Ther (2019) 27(4): 237–44. doi: 10.1080/10669817.2019.1597434

  4. Furze JA, Greenfield BH, Barr JB, et al. Clinical narratives in residency education: exploration of the learning process. Physiother Theory Pract (2019) 35: 1202–17. doi: 10.1080/09593985.2018.1472686

  5. Gilliland S, Wainwright SF. Patterns of clinical reasoning in physical therapist students. Phys Ther (2017) 97(5): 499–511. doi: 10.1093/ptj/pzx028

  6. Wainwright SF, Gwyer J. (How) can we understand the development of clinical reasoning? J Phys Ther Educ (2017) 31(1): 4–6. doi: 10.1097/00001416-201731010-00003

  7. Greenfield BH, Jensen GM, Delany CM, et al. Power and promise of narrative for advancing physical therapist education and practice. Phys Ther (2015) 95(6): 924–33. doi: 10.2522/ptj.20140085

  8. American Board of Physical Therapy Residency and Fellowship Education. Part III: quality Standards for Clinical Physical Therapist Residency and Fellowship Program June 2017. Available from: [cited 20 June 2021].

  9. Wainwright SF, Shepard KF, Harman LB, et al. Factors that influence the clinical decision making of novice and experienced physical therapists. Phys Ther (2011) 91(1): 91–101. doi: 10.2522/ptj.20100161

  10. Kolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984.

  11. Nesbit PL. The role of self-reflection, emotional management of feedback, and self-regulation processes in self-directed leadership development. Hum Resour Dev Rev (2012) 11: 203–25.doi: 10.1177/1534484312439196

  12. Pearson A, McTigue M, Tarpley J. Narrative medicine in surgical education. J Surg Educ (2008) 65(2): 99–100. doi: 10.1016/j.jsurg.2007.11.008

  13. Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Phys Ther (2004) 84: 312–30. doi: 10.1093/ptj/84.4.312

  14. Ertmer PA, Newby TJ. Behaviorism, cognitivism, constructivism: comparing critical features from an instructional design perspective. Perform Improv Q (2013) 6: 50–72. doi: 10.1002/piq.21143

  15. Lochmiller CR, Lester JN. An introduction to educational research: connecting methods to practice. Thousand Oaks, CA: Sage; 2017.

  16. Riessman CK. Narrative analysis. Vol 30. Newbury Park, CA: Sage; 1993.

  17. Miles MB, Huberman AM, Saldaña J. Chapter 12: writing about qualitative research. In: Miles MB, Huberman AM, Saldaña J, eds. Qualitative data analysis: a methods sourcebook. Thousand Oaks, CA: Sage; 2014, pp. 323–337.

  18. QSR International Pty Ltd. (2020) NVivo (released in March 2020), Available from

  19. Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract (2000) 39: 124–30. doi: 10.1207/s15430421tip3903_2

  20. Purtilo R, Doherty RA. Ethical dimensions in the health professions. 5th ed., St Louis, MO: Elsevier Saunders; 2013.

  21. Karpicke JD, Roediger III HL. Expanding retrieval practice promotes short-term retention, but equally spaced retrieval enhances long-term retention. J Exper Psychol Learn Mem Cog (2007) 33(4): 704–19. doi: 10.1037/0278-7393.33.4.704

  22. Roediger III HL, Pyc MA. Inexpensive techniques to improve education: applying cognitive psychology to enhance educational practice. JARMAC (2012) 1(4): 242–8. doi: 10.1016/j.jarmac.2012.09.002

  23. Brown JS, Collins A, Duguid P. Situated cognition and the culture of learning. Educ Res (1989) 18: 32–42. doi: 10.3102/0013189X018001032

  24. Lyons K, McLaughlin JE, Khanova J, et al. Cognitive apprenticeship in health sciences education: a qualitative review. Adv Health Sci Educ. (2017) 22(3): 723–39. doi: 10.1007/s10459-016-9707-4

  25. Woolley NN, Jarvis Y. Situated cognition and cognitive apprenticeship: a model for teaching and learning clinical skills in a technologically rich and authentic learning environment. Nurse Educ Today (2007) 27(1): 73–9. doi: 10.1016/j.nedt.2006.02.010

Article Details

clinical reasoning, reflective narratives, residency, constructivism, narrative research
Original Research Articles
How to Cite
Naidoo, K., Baldwin, J., Lesar , J. ., & Plummer, L. (2022). Narrative analysis to track the development of clinical reasoning during residency. The Journal of Clinical Education in Physical Therapy, 4.