16. The evolving theory of clinical reasoning
Carolyn A. Unsworth
This chapter explores clinical reasoning in occupational therapy. It provides an overview of the development of clinical reasoning in occupational therapy, definitions of the different types of clinical reasoning, and explains how acquisition of expertise is promoted through clinical reasoning. A major review of clinical reasoning research is then presented. While it has long been established that clinical reasoning enables therapists to integrate theory into practice, the final section of the chapter examines the process of theory development and maps this against developments and research growth in the area of clinical reasoning in occupational therapy. Hence, this chapter builds an argument that clinical reasoning is developing into a theory.
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• Clinical reasoning has been studied by occupational therapy researchers since 1982. Clinical reasoning is distinct from clinical decision-making.
• Many types or modes of clinical reasoning have been identified and described, including narrative, procedural, interactive, conditional, ethical and pragmatic reasoning.
• One of the hallmarks of expertise is the therapist’s ability to reason rapidly and intuitively. The clinical reasoning of an expert is deeply internalized, and the therapist can draw appropriately on relevant ideas, solutions or information from an extensive knowledge bank and range of experiences.
• There have been over 30 empirical studies conducted to investigate the clinical reasoning of occupational therapists. Qualitative and quantitative findings from this research are slowly building a picture of occupational therapy reasoning.
• Clinical reasoning is evolving into a theory in its own right. Research evidence to support the evolving theory of clinical reasoning is slowly assembling. Further studies that build on existing work, organize this phenomenon into a conceptual framework and empirically test this framework are urgently required.
In 1983, Schön (p.42) penned the following analogy:
In the varied topography of professional practice, there is a high hard ground in which practitioners can make effective use of the research-based theory and technique. Moreover, there is the swampy lowland in which situations are confusing ‘messes’ incapable of technical solution. The difficulty is that the problems of the high hard ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, whereas in the swamp, the problems of greatest human concern are found.
This chapter welcomes you to the swamp!
The way we think and reason, in essence, makes us who we are as individuals. Furthermore, groups of people who come together for specific purposes often share patterns, modes and constellations of thinking and reasoning. As a professional group, occupational therapists share a mode of thinking and reasoning that is quite particular and quite different from that of other health professionals. Of course, many elements and aspects of this thinking are shared with other clinicians, but it is the way the thinking is constructed and how this reasoning enables our theories of human occupation to be practised that is unique. Writing about clinical reasoning in occupational therapy today is commonplace, and all of the introductory texts and compendia in the profession include material on clinical reasoning. Furthermore, I would guess that all occupational therapy education programmes internationally include some training or exposure to the idea of clinical reasoning. However, clinical reasoning has only been described in our profession over the past 25 years or so. Although the idea was first brought to the attention of therapists by Rogers and Masagatani, 1982 and Rogers, 1982 and Rogers’ Eleanor Clarke Slagle lectureship the following year (1983), it was not till the American Journal of Occupational Therapy released its special edition on clinical reasoning in November 1991, and Mattingly and Fleming published their text, Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice, in 1994 that the idea of clinical reasoning entered mainstream practice and became the buzz word of the early 1990s. News of this concept spread rapidly around the occupational therapy world, and there was an ‘ah-ha’ moment as the profession collectively recognized clinical reasoning as a way of naming and explaining all the hidden elements of practice that were so essential in the art (as opposed to the science) of occupational therapy practice. Early scholarly activities investigating clinical reasoning revealed that our thinking was indeed special and unique, and construction of a language to describe the tacit as well as overt elements of practice commenced. But what exactly is clinical reasoning? How does a therapist do it? What can make a therapist better at it? Some ideas to answer these questions are provided in this chapter, commencing with the first section, which provides an overview of what clinical reasoning is.
What is clinical reasoning?
Issues in arriving at a definition
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).
Definition of clinical reasoning
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.
A language to describe the modes of clinical reasoning
Cheryl Mattingly (a medical anthropologist) and Maureen Fleming (an occupational therapist) worked with a large team of experts, including Gilette, Schön and Cohen, to conduct the first large-scale enquiry into the clinical reasoning of occupational therapists. The American Occupational Therapy Foundation funded a study between and 1986 and 1988 involving 14 therapists at a 900-bed acute care facility in a large city in the USA. The two major findings of the study were an understanding of the practice cultures that occupational therapists work within and the beginnings of a language to describe the modes of reasoning used by occupational therapists (Mattingly & Fleming 1994). Many refinements and additions have been made to this framework, but the fundamental ideas laid out in Mattingly and Fleming’s text provide the foundation for understanding clinical reasoning in occupational therapy. The language that has now developed in occupational therapy in the field of clinical reasoning has been drawn from medicine, philosophy, anthropology and sociology.
An overview of these different modes of clinical reasoning and related terminology used in the field are provided below, and Table 16.1 provides a detailed examination of the language of clinical reasoning in occupational therapy. The third column in the table provides an example of how this language might be used in clinical practice in the narrative (first-person) form. The use of narrative examples to illustrate how therapists reason is now quite popular in occupational therapy texts. Mattingly and Fleming’s text came to life through the use of these narratives, and several occupational therapy writers have since adopted this approach to illustrate texts with both what and how a therapist thinks (see, for example, Unsworth, 1999, Kielhofner, 2008 and Crepeau et al., 2009). This approach helps students and novice therapists to learn both what a particular therapy technique is, and, very importantly, what a therapist thinks as they engage in practice.
|Mode of thinking||Description (and examples of researchers who coined/use this term)||Clinical example|
|Narrative reasoning||The use of storytelling and creation to explore therapy. Used when therapists work in a more phenomenological practice sphere where the emphasis is on the meaning of the client’s illness and illness experience (Mattingly & Fleming 1994)||Robyn enters the hospital’s allied health staff lunch room and flops into a chair. Her colleagues, Dana, Matty and Pip, are already there. Pip observes that Robyn looks exhausted. Robyn replies:|
‘I’ve just been working with the new lad. He’s only four, but he spent the whole session wailing for his mum. The puppets caught his attention for a few minutes and I made a start but that was about it. His leg muscles are so tight, but I’m sure the [tendon release] surgery will make a huge difference in the long run … I just need to find what will turn on the light and get him interested and motivated. I’m going to try and call his mum later and get some more information from her …’
|Scientific reasoning||The process of hypothesis generation and testing that generally is referred to as hypothetico-deductive reasoning. Used to make a diagnosis of the client’s medical condition. Although more concerned with identifying the client’s occupational problems rather than the medical diagnosis, therapists do draw on the ideas of scientific reasoning when reasoning procedurally (Schell & Cervero 1993)||Saran reports on her initial assessment of 73-year-old Peter at the team meeting.|
‘I assessed the new client, Peter, yesterday in terms of ability to complete personal ADLs. I found him to be independent with verbal supervision for all tasks such as toileting, showering, dressing and grooming. He plans to return to his home without any support and use public transport to get to the shops, visit his doctor and do his banking. Given what I observed yesterday, I doubt he will be independent in all these activities by next week. I will commence an IADL assessment today, and intervention will aim at facilitating his independence and also putting local community supports in place.’
|Diagnostic reasoning||Used to identify underlying impairments or occupational performance issues, define desired outcomes, set goals, develop intervention/solutions (Rogers & Holm 1991)||Brian has been working in acute care for only a few months and has used a hypothesis testing approach (Unsworth 1999) to determine the underlying cognitive impairments that are limiting his client’s ability to make a cup of tea.|
‘He presents as really confused, and so I was very cautious in putting everything out on the bench and I didn’t have the water in the kettle any hotter than tap water. He started by breaking open the teabag and tipping the tea into the cup. Then he tipped in half the sugar from the sugar pot, played around with this for a while and then filled the cup with milk. Before the session, I was wondering what was going on and whether he had some complex perceptual problems. But over the session it became clear that he has ideational apraxia. This hypothesis fits with the fact that he has left brain damage as a result of the stroke and has quite severe receptive aphasia as well.’
|Procedural reasoning||The thinking associated with the procedural aspects of therapy, such as the evaluations and interventions to be used with the client, and how the client is performing. Procedural reasoning represents the more scientific components of practice, which include systematic data collection, hypothesis formation and testing (Mattingly & Fleming 1994)||Alex works on a stroke ward. His new client has cognitive and perceptual problems.|
‘So I did a dressing assessment with Mr P this morning and the hypotheses were just flying around my head. He has so many cognitive and perceptual problems but hardly any physical ones … so I just watched him and tried a few things as we went. He looks as if he has a unilateral neglect and some short-term memory problems, as well as complex perceptual problems … but I’ve got to check for homonymous hemianopia too. So I’m just trying to work out which standardized assessments to do … maybe the RPAB [Rivermead Perceptual Assessment Battery] or LOTCA [Lowenstein Occupational Therapy Cognitive Assessment] and the BIT [Behavioural Inattention Test] … but I probably don’t have enough time for all three, so maybe just the LOTCA and some confrontation testing to check for neglect versus homonymous hemianopia versus both.’
|Interactive reasoning||Concerned with how the therapist interacts with the client. Referred to as the underground practice by Mattingly and Fleming, since the therapists they studied were able to describe what they had done with the client but generally not their interactions. Therapists use interactive reasoning to engage the client in therapy, and consider the best approach to communicate with the client, to understand the client as a person, understand the client’s problems from the client’s point of view, individualize therapy, convey a sense of acceptance/trust/hope to the client, break tension through the use of humour, build a shared language of actions and meanings, and monitor how the treatment session is going (Mattingly & Fleming 1994)||Dana describes to her fieldwork student some of her interactive reasoning as she gets to know her clients during an initial interview. As Dana will get to know these clients over several months, she reasons that she has this time to use the initial interview to ‘go deep’.|
‘So what I do is just start off with the initial interview structure but explore any directions the client’s responses take me in. I don’t want to limit this opportunity to get to know the client by sticking to the form, as the sooner I can get my head around understanding who this person is and what makes them tick, the better the therapy plans we make will be. I try to keep it light and friendly so the client feels at ease and that it’s an open and sharing environment. If there is an opportunity to share a joke I will … or if the client becomes upset or distressed, then I take time to support them through this and slowly we move on. I guess what I’m aiming for is to get the clients to see me as someone who is going to be useful in their recovery and someone they can trust.’
|Conditional reasoning||Takes into account the whole of the client’s condition, as the therapist considers the client’s temporal contexts (past, present and future) and their personal, cultural and social contexts. Hence, this type of reasoning is used when trying to understand what is meaningful to the client in their world by imagining what their life was like before the illness or disability, what it is like now and what it could be like in the future (Mattingly & Fleming 1994)||Maryella is reflecting on a session with Joseph, a 5-year-old boy with developmental delay. She started by interviewing Joseph and then undertook Ayres Clinical Observation to examine his motor skills. She completed this assessment about 12 months ago as well.|
‘So I did this assessment last year and I haven’t seen Joseph for over 6 months since his family moved away for his Dad’s work. Now they’re back so I’m just checking on where Joseph is up to with school and socially, and how he feels about coming home and so on. So we’ve had a chat and I can really tell he’s made a lot of good gains. He’s a bit anxious about starting back at his old school, so I’ve been reassuring him about that and now I’m just using Ayres Clinical Obs assessment to run through his current performance. He’s made some nice gains over the time he’s been away; he has more core trunk stability and I can really see changes compared with the last time I saw him in terms of balance, righting reactions and even fine motor coordination. I think we can work on some more advanced goals now with him, such as …’
|Ethical reasoning||The thinking that accompanies analysis of a moral dilemma where one moral conviction or action conflicts with another, and then generating possible solutions and selecting action to be taken (Rogers, 1983 and Barnitt and Partridge, 1997)||Alan had a head injury and attends a day therapy programme as an outpatient. His therapist, Kate, reflects on the fact that Alan takes illegal drugs (Unsworth 2004b):|
‘So Alan still lives in his parents’ house, but he can’t stay there much longer, and they want him out. Alan takes drugs and I find it a real dilemma. I have to help him find other housing, but he shares his drugs around, and I’m really worried that if I help him find a group home, then he could be putting other people at risk. I also feel really disappointed because he’s made such amazing gains in therapy and he could do so much, but when he takes drugs he just loses all his cognition, basically. He just sits there and misses out on therapy, and it’s a real shame. Sometimes I think the therapy I provide is going to waste … should I spend less time with him and more with my other clients who seem to make more gains? I try not to dwell on it but it’s a bit disappointing, as if he didn’t do drugs, then he could easily be living in a good home and making fantastic progress towards independent living and getting some part-time voluntary work. Anyway, it’s his life and I try not to judge him. But I have to think some more about what kind of place he can live in so he doesn’t put others at risk as well.’
|Generalization reasoning||Within the forms of procedural, interactive, conditional and pragmatic reasoning, therapists use generalization reasoning to draw on past experience or knowledge to assist them in making sense of a current situation or client circumstance. The kind of reasoning in force when a therapist thinks about a particular issue or scenario with a client, then reflects on their general experiences or knowledge (i.e. making generalizations) related to the situation, and then refocuses the reasoning back on the client (Unsworth 2005)||Max works in a short-stay residential facility, helping adolescents with intellectual disability to become more independent.|
‘So Kate is making some good gains with her goal of grooming, which includes managing her long hair and doing some basic make-up. So often these kids have a kind of learned helplessness since their parents have often done everything for them. So with Kate, she asks for help all the time but really she can do it. So I think it’s more about reassurance and just reinforcing what a great job she’s doing. So that’s what I’m focusing on with Kate in this session, supporting and reassuring her that she can do her hair and so on and that she’s doing a great job.’
|Pragmatic reasoning/ management reasoning||Concerned with the therapist’s practice and personal contexts. The practice context includes organizational, political environments and economic influences, such as resources and reimbursement. Personal context includes the reasoning surrounding the therapist’s own motivation, negotiation skills, repertoire of therapy skills, ability to read the practice culture, and what Törnebohm (1991) described as life knowledge and assumptions (Schell and Cervero, 1993, Barris, 1987, Neuhaus, 1988 and Fondiller et al., 1990).|
Lyons and Crepeau (2001) labelled pragmatic (practice context) reasoning as management reasoning
|Xui Sing works in community health with elderly clients living at home.|
‘I really want to be able to provide my client, Mrs Beller, with an adjustable over-toilet frame, as I know her husband is having hip replacement surgery in 6 weeks and he’s a lot bigger than her. So if I get an adjustable one, they can both use it. But our centre has just had a major policy change in equipment allocation, and I think I can only provide a seat that is a fixed height and suitable for her. Maybe they can afford to buy an adjustable one now, or maybe we’ll have to worry about Mr Beller later when he has his surgery? I’ll have to work out the best solution based on their needs now, their budget and what my centre can provide.’
|Embodiment||Our bodies, as well as our minds, gather a great deal of information as we work with clients. For example, we can smell if the client has not washed or if a wound is not healing well, and we use our sensation to feel the client’s muscles and how their body moves. This is referred to as embodied knowledge and it is not always possible to put this knowledge into words. Although therapists have long recognized the importance of information from our bodies about our clients, the embodied nature of clinical reasoning is a relatively new area for research in occupational therapy (Schell & Harris 2008)||Helen describes how she knows when an autistic child begins to relax and settle into an activity.|
‘Well, if I describe a typical client, then I could tell you about Paul. So let’s say I’ve started with a warm-up activity outside climbing the rope ladder and swinging on the bars, so it’s a gross motor activity using major muscle groups. And that’s really helpful, so that when he comes inside I might then start with a large weighted floor puzzle. This kind of “heavy work”, with lots of joint compression seems to help kids like Paul to relax. And as he’s moving the puzzle, I can see his whole body kind of slows and I can place my hands over his back or at his hips, and feel the tension releasing and his muscles relaxing.’
|Worldview||Defined in philosophy as ‘a global outlook on life and the world’ (Wolters, 1989 and Hooper, 1997). Worldview is the influence of the therapist’s personal context on clinical reasoning. While some writers describe pragmatic reasoning as incorporating this personal context (e.g. Schell & Cervero 1993), others view this as a separate factor which has an impact on reasoning rather than being a separate form of reasoning (e.g. Unsworth 2004a)||Asher describes his worldview.|
‘Well, I suppose my worldview makes me who I am, and I guess it colours everything I think and do. It’s about my faith and what values I hold and my sense of right and wrong. Sometimes I’m aware of it but mostly I’m not. I guess I have to think about what my worldview is, when I’m confronted with it being different from the client’s. It’s times like these I really have to work at not making judgements about the client but try to see it from their point of view or try to accept that it’s OK to have that particular worldview. When I have OT fieldwork students, they find this hard at times. Often you can’t solve the dilemma for them, but at least you make them aware of what the problem is — in other words, you can at least look at it objectively for what the problem is, and also see that it’s normal to have to work at understanding these issues and resolving or making peace with these differences.’
|Intuition||Defined as the ‘knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process’ (Rew 1986, p.23). Within Cognitive Continuum Theory, Hammond (1996) posits that cognition can be ordered on a continuum from intuition to analysis||Fiona reflects on the development of her intuition and its value in her practice.|
‘When I first started in mental health, working with depressed clients, I would have done A, B and C as I was taught and expected to do by others in the team. But now I’m 8 years on, and I do so many things differently based on that experience. And I’m really comfortable with what the A, B, C is, and I can see where it will work and where it will need to be changed. And I just trust my intuition. When I was new at this job, I didn’t have the same “feel” or gut instinct for clients that I have now. But now I can just sense when something isn’t quite right or when the client is going downhill … even if that isn’t what they’re telling me. And I trust this intuition.’
|Reflection||Involves reviewing performance and examining it in detail by relating it to past knowledge and experiences and relating it to future action, to enhance understanding. There are several types of reflection, including reflection about past experiences (reflection on action), reflecting in the present (reflection in action) and looking forward or anticipatory reflection (reflection for action). Reflection is a bridge to link theory and practice (Schön, 1983, Alsop and Ryan, 1996 and McKay, 2009)||Akhmed describes the value in setting aside time for reflection in his practice.|
‘Each week I try to put some time aside on Friday to go back over the week and identify the highlights and low points, and I reflect on what worked well and the problems … both working with clients and with other staff. I don’t keep a journal but some of my colleagues do. But I try to make some notes about events and feelings, and use this time to think about doing things differently or better. Then I also have professional supervision once a month, and I identify something from these “Friday reflections” to really go into more detail … and I find these sessions really useful. My mentor really pushes me to think about the issue from so many different angles and I use her approach when I’m thinking back over the week on my own.’
Narrative reasoning and chart talk
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.
The therapist with the three-track mind
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).
Other modes of clinical reasoning and related terms
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.
Clinical reasoning and expertise
Differences between the clinical reasoning of novice and expert therapists
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.
Enhancing clinical reasoning skills through 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.
A review of empirical research on clinical reasoning in occupational therapy, 1982–2009
There have been over 100 journal articles, book chapters and books on clinical reasoning in occupational therapy written over the past 25 years. The sheer quantity of musings and research in this area reflects the value that our profession places on clinical reasoning and the commitment made to exploring and understanding it. While the reflective discussions and information presented in a lot of the writing on clinical reasoning provide a raft of ideas for research, this section of the chapter details the evidence or the empirical research published on clinical reasoning in occupational therapy. Occupational therapy practice requires a sound evidence base (Holm 2000). Evidence-based practice may be defined as the judicious use of evidence to make sound decisions about practice. Therefore, decision-making, thinking and reasoning are at the heart of putting evidence into practice. Occupational therapy urgently needs more empirical studies on clinical reasoning, so we are confident that we are judicious in putting the best evidence into practice. Hence, research into clinical reasoning where data were collected with occupational therapists and analysed in some way, either qualitatively or quantitatively, is summarized below. As a result of this process, we can more easily identify where work has been done, and clearly see how this can be built upon as we continue the mammoth task of exploring and understanding clinical reasoning in occupational therapy.
The literature between 1983 and 2009 was searched using the following databases: Medline, CINAHL, AMED and OTDBASE. The key terms used were ‘clinical reasoning’ or ‘reasoning’ or ‘thinking’ combined with ‘occupational therapy’. Reference lists of articles retrieved and many of the recent books or book chapters on clinical reasoning in the health professions were then searched by hand. Articles were included in the review if they met the following criteria:
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