It is not easy to put forth a simple definition of clinical reasoning, since this is quite a complex construct. To start, we must acknowledge that clinical reasoning is also described in the occupational therapy literature as ‘therapeutic reasoning’ (Kielhofner & Forsyth 2002), ‘professional reasoning’ (Schell & Schell 2008) and ‘occupational reasoning’ (Rogers 2010). All of these are also excellent terms. The terms ‘professional reasoning’ and ‘therapeutic reasoning’ acknowledge that occupational therapy practice is not confined to the clinic. Using the term ‘occupational reasoning’ ensures that our thinking is targeted to the ‘systematic method of thinking about the occupational engagement of humans that supports the occupational therapy process’ (Rogers 2010, p.57). But renaming the clinical reasoning rose does not make it smell any sweeter. Therefore, while this chapter adopts the traditional term that is so easily recognized, the reader is asked to consider that other terms can also be used.

The second issue to raise, before a definition is offered, concerns the intertwined nature of clinical reasoning and clinical decision-making. In discussing reasoning and decision-making in occupational therapy practice, Harries and Duncan (2009) observed that, in the occupational therapy literature, clinical reasoning tends to be used to cover all the thinking processes that involve reasoning, problem-solving judgement and decision-making. These authors go on to present material on two theories of judgement and decision-making from cognitive psychology, cognitive continuum theory (Hammond & Brehmer 1973) and dual-processing theory (Stanovich & West 2000), and show how these theories can further our understanding of occupational therapy practice. Harries and Duncan describe how, within dual-processing theory, two thinking systems are outlined that have been shown to be neurologically different (Goel et al 2000). The S1 system, as it is called, is a fast automatic form of processing. Through the S1 system, judgements are largely tacit. On the other hand, the slower and more deliberate S2 system is more analytical, focuses on one task at a time, and considers the outcome of different decisions from a more objective basis. The S1 system is more focused on the art of clinical reasoning, and the S2 on the science of objective decision-making. Ideally, we need both these elements in a successful clinical practice, and we need to explore both literatures to gain an understanding of what these approaches offer us. However, it is beyond the size and introductory nature of this chapter to explore both these concepts. This chapter focuses on the more context-dependent, phenomenologically grounded clinical reasoning. Texts that delve deeper into clinical reasoning in the allied health literature include those by Schell and Schell (2008) and Higgs et al (2008). The chapter will refer to, but not describe, decision-making in any detail. To gain an appreciation of the full complexity of the science of judgement and decision-making, the reader is referred to Klein et al., 1993 and Dowie and Elstein, 1988 or Hardman (2009).

It is hard to be succinct when defining clinical reasoning. The Oxford Dictionary defines reasoning as ‘the intellectual faculty by which conclusions are drawn from premises … [and] to reach conclusions by connected thought’ (Thompson 1995, p.1144). But this definition does not convey the scope or complexity of clinical reasoning in occupational therapy. Higgs and Jones (2000, p.11) define clinical reasoning as ‘a process in which the clinician, interacting with significant others (client, caregivers, healthcare team members), structures meaning, goals and health management strategies based on clinical data, client choices, and professional judgment and knowledge’. In occupational therapy, clinical reasoning can be defined as the reflexive thinking associated with engaging in a client-centred professional practice. This includes the thinking when planning to be with the client (and their caregivers and other health professionals), when the therapist is with the client and afterwards when reflecting on time with the client. Clinical reasoning draws on empathy, intuition, judgement and common sense. Clinical reasoning is constantly changing in response to a multitude of hidden and overt influences and contextual factors, which may be inhibitory or enabling. Clinical reasoning plays out in the occupational therapist’s mind in narratives and images (adapted from Unsworth 1999). Within the clinical reasoning construct, many modes or types of reasoning have been identified. These are described in the next section of the chapter.

Mattingly documented how occupational therapy was a profession that sat comfortably between two practice cultures, and therefore described occupational therapy as a ‘two body practice’ (1994, p.37). On the one hand, occupational therapists work within a biomedical framework. Even when therapists do not work in a medical setting, our profession is primarily concerned about the relationship between health, occupation and well-being. Therefore, our concern with health connects us to medicine and a biomechanical understanding. Occupational therapists also have their own professional practice culture, which operates in the social, cultural and psychological sphere that is concerned with the client’s experience of the illness and the meaning of the illness (Mattingly 1994). Usually, a biomechanical or scientific approach (the body as a machine) does not sit well alongside the more phenomenological sphere (the lived body). However, in occupational therapy, these two seem to make perfect sense. As Mattingly (1994) notes, occupational therapists seemed to have the ability to shift rapidly and easily between thinking about the client and the disease process and resulting occupational performance issues (for example), and developing an understanding of the person and the client’s experience of the illness.

When therapists are thinking and working in a biomechanical sphere, they use chart talk to present information on the client and discuss evaluation and intervention issues. Hence, chart talk is generally used when the occupational therapist is talking about the client’s medical problem, or writing case notes using brief and factual language. This kind of communication fits well in the biomedical world. However, when working in the more phenomenological practice sphere, occupational therapists use narrative reasoning to tell the story of therapy (Mattingly, 1994 and Unsworth, 2004a). Storytelling is never static. Stories can be told of the past and of the present and created for the future. Stories can be rewritten and changed mid-stream. Hence, thinking in narratives fits perfectly with the ever-changing therapy environment.

While narrative reasoning may be described as a core form of reasoning, Fleming (1994) went on to develop the idea of ‘the therapist with the three-track mind’ (p.119). The therapist with the three-track mind describes three dominant modes of reasoning found in the clinical reasoning study and confirmed in more recent research (Alnervik and Sviden, 1996 and Unsworth, 2004a). Fleming argued that therapists use these different kinds of reasoning when working in the different practice spheres. Therefore, procedural reasoning, which is similar to the problem-solving or hypothetico-deductive approach used in medical enquiry, fits well in the biomechanical sphere. The other forms of reasoning described by Fleming, interactive reasoning and conditional reasoning, fit more readily in the phenomenological or meaning making practice sphere (Fleming 1994). These forms of reasoning are all defined and described in Table 16.1. However, it is important to note how intertwined these are throughout the therapy process. Mattingly and Fleming (1994) described how the perspective gained from reasoning in one track might inform reasoning in another. This idea, that the different forms of reasoning interact and overlap, has been supported in subsequent clinical reasoning research (Unsworth 2004a).

Early clinical reasoning researchers, such as Rogers and Masagatani, 1982 and Barris, 1987, as well as researchers following in the footsteps of Mattingly and Fleming, have also contributed terms to describe modes of clinical reasoning, or to describe constructs that fit with clinical reasoning. Some of these terms, such as ethical, scientific, pragmatic, generalization and diagnostic reasoning, and related constructs such as intuition, embodiment, worldview and reflection, are defined and illustrated in Table 16.1. It is important to note that some of these terms, such as procedural, interactive, conditional and pragmatic reasoning, fit better within an S1 or reasoning approach to understanding thinking processes. Other terms, such as scientific and diagnostic reasoning, fit better with an S2 approach.

Research in occupational therapy on novice–expert differences has often portrayed this construct as a dichotomy. However, as described by Dreyfus and Dreyfus (1980) in their work on chess players and airline pilots, and then adapted for use in the health sciences by nursing researcher Benner (1984), expertise occurs on a continuum. It is now widely accepted that there are five phases one passes through on the journey from novice to expert, and these are novice, advanced beginner, competent, proficient and expert. It is also widely documented that increasing years of experience do not always equate with increasing expertise; some therapists never reach expert status but remain stuck at the level of competent or proficient practice (Benner et al., 1996, Gibson et al., 2000 and Unsworth, 2001). There have been several occupational therapy studies on the differences between novice and expert therapists (Hallin and Sviden, 1995, Strong and Gilbert, 1995, Robertson, 1996, Gibson et al., 2000, Unsworth, 2001 and Mitchell and Unsworth, 2005). One of the consistent findings from these studies and from studies of other health professionals is that experts think and reason differently from novices; experts know how (non-propositional or tacit knowledge) rather than know what (propositional or factual book-learned knowledge), their knowledge is embedded in action and experience, and much of their knowledge is automatic and intuitive (Dreyfus and Dreyfus, 1980 and Dreyfus and Dreyfus, 1986). Occupational therapy research in this area has revealed that, while novice and expert differences may be readily apparent, the differences between the other levels of expertise are not so apparent. Further research is required to help us identify the hallmarks and key reasoning patterns at each of the three mid-phases (advanced beginner, competent, proficient) so we can aid therapists who are ‘stuck’ at a particular level to move forward on their journey to expertise.

One of the goals of an occupational therapy educational programme is to ensure that students exit with the skills, tools, behaviours, attitudes and reasoning abilities needed to be excellent occupational therapists. Therefore, educators use novice–expert research findings to help students and novices to gain insights into expert thinking so they may hasten their journey on this continuum. However, expertise is not a point of arrival but rather a lifelong quest. This is because expertise is heavily context-dependent and a clinician who excels in one field of practice, such as psychiatry, may have novice skills only in working with clients who are recovering from stroke. In addition, clinicians who have attained expert status in a particular context must continue to expand and hone skills on their quest for professional excellence. Hence, novices and experts alike can benefit from undertaking an activity that has been shown as a key to enhancing clinical reasoning, and that is reflection.

Reflection, as described in Table 16.1, is concerned with reviewing one’s performance and examining it in detail by relating it to past knowledge and experiences and relating it to future action, to enhance understanding. Reflection is often referred to as the bridge that links theory and practice (Schön, 1983, Alsop and Ryan, 1996 and McKay, 2009). It is essential that all therapists, novices as well as experts, have the time and opportunity to reflect on practice both alone and with a supervisor or mentor. Reflective activities designed to enhance clinical reasoning include storytelling, pre-briefing and debriefing, reflective questions after working with a client, reflective journal writing, reviewing critical incidents with a mentor, participation in discussion groups, and videotaping and viewing sessions with clients. Additionally, activities with a reflective partner can also be helpful; together therapists can note significant similarities and differences between clients with similar disease processes or occupational performance issues and consider how these differences can influence treatment (Alsop and Ryan, 1996 and McKay, 2009). Therapists who take the time to reflect nurture their clinical reasoning skills, thus promoting excellent practice.