clinical reasoning

Question 1

By any other name…..

Answer 1

Clinical reasoning (landmark studies in 1980’s and 1990’s)

Professional reasoning

Therapeutic reasoning

Professional and therapeutic reasoning used to de-emphasize medical model and settings, and encompass educational settings and wellness models. Although all are acceptable, clinical reasoning is still the widely accepted term.

Question 2

Metacognition

Answer 2

Metacognition: thinking about thinking, aware of the cognitive process of reasoning rather than just acting without reflection. Requires conscious thought and reflection

Clinical reasoning is NOT an intervention technique or a theory; it is the process of thinking that is informed by theory, observation, experience to direct and frame intervention

Question 3

clinical reasoning

Answer 3

PROCESS of providing and directing services

HOW and WHY we do what we do

Cognitive processes of therapist / metacognition

Reflection on client care

a form of artistry, difficult for the novice to master, and relies on clinician experience, conscious reflection, critical analysis and self-criticism to develop this complex set of skills (Rogers, 1983)
“largely tacit, highly imagistic, and deeply phenomenological mode of thinking” (Mattingly, 1991, p. 979)

Question 4

Clinical Reasoning Contributors

Answer 4

Observation, evaluation of occupational performance
Assessments, including client factors
Gathering complete data
Understanding impact of context
Therapeutic use of self, interviewing
Tacit information and knowledge
Experience

Question 5

how to inform reasoning

Answer 5

Therapist uses their own sensory information to inform reasoning (what does client feel like, ie tone, how much physical assistance do we provide, etc.)

Therapeutic use of self needed to get best information

Question 6

Assessments

Answer 6

Assessments: standardized, non-standardized, choose what is relevant. Just make sure to get enough data to make informed decisions.

Question 7

context

Answer 7

Context: may need to find out what home is like for client, what environments and supports will influence occupational performance.

Question 8

tacit

Answer 8

Tacit – implied, unspoken. What do you “feel” or how does your intuition influence the case?

Question 9

Clinical Reasoning involves…

Answer 9

Gathering, understanding and integrating information based on:

1. Prior experience
2. Knowledge of condition
3. OT theory
4. OT process
5. Paradigms / procedures

Question 10

experience

Answer 10

Experience: What have been key issues for people with these conditions in the past? What are the things that might contribute to understanding of prognosis? From similar patients, what are the current expectations? How do the therapists frame or “chunk” information from the past to understand the current client?

Question 11

knowledge

Answer 11

Knowledge: What are typical deficits of this condition? What should be included in assessment and intervention?

Question 12

ot theory

Answer 12

OT Theory: provide a structure for framing and understanding the deficits and developing interventions that fit those problems and their causes. Theory used more in unfamiliar settings or with new conditions, when experience is limited.

Question 13

ot process

Answer 13

OT Process: development of interventions based on assessment / evaluation data

Question 14

Paradigm / Protocols / Procedures:

Answer 14

Paradigm / Protocols / Procedures: how are things done at that setting? What personal theories or perspectives influence how you work with individuals?

Question 15

Cognitive Processes

Answer 15

Organization of information into frames / chunks and that promote scripts.

• Cue acquisition
• Pattern recognition
• Problem and asset formulation
• Prioritization
• Problem solution

Question 16

Framing / chunking information

Answer 16

Framing / chunking information

• Decide what the issues might be for this patient, based on all the pieces of clinical reasoning (from last slide)
• Relies on therapist’s memory and making connections between past clients, knowledge, and current observations / assessments
• Frames support effective information processing

Question 17

Cue acquisition:

Answer 17

Cue acquisition: Find the most relevant and useful information, based on cues from the client (what they say or do, may be formal or informal cues). Search for targeted information

Question 18

Pattern recognition:

Answer 18

Pattern recognition: what are similarities / differences when compared to past clients?

Question 19

Problem / asset formulation (only problems in text):

Answer 19

Problem / asset formulation (only problems in text): understanding what is going on with current client; what the main problems are that may be addressed in therapy, and what strengths / supports the client has that may support.

Question 20

Prioritization:

Answer 20

Prioritization: given constraints of setting / time, what is important to address first? Should there be a focus on the overall functional skills (top down approach) or the client factors and performance skills that make up function (bottom up approach)

Question 21

Problem solution:

Answer 21

Identify course of action / intervention

Question 22

Therapist as Multi-tasker

Answer 22

Concurrent and conditional processes of:

• Scientific reasoning
• Procedural reasoning
• Narrative reasoning
• Interactive reasoning
• Pragmatic reasoning
• Ethical reasoning

Question 23

scientific reasoning

Answer 23

Scientific: based on knowledge of diagnosis, review of evidence (usually assumes Diagnostic reasoning as well – this is explicit in Willard and Spackman).

Question 24

procedural reasoning

Answer 24

Procedural: included as type of scientific in Willard and Spackman, separate in most other sources. What are the protocols or routines for specific conditions? What procedures must be followed for safety?

Question 25

narrative reasoning

Answer 25

Narrative: What does the condition mean to the person? What stories do they tell? What do they view to be their future?

Question 26

interactive reasoning

Answer 26

Interactive: Starts with narrative, but incorporates collaborative process of therapist. How does therapist relate to client and facilitate progress toward his/her goals?

Question 27

pragmatic reasoning

Answer 27

Pragmatic: practical issues, what are the documentation requirements for reimbursement? How is work scheduled and done at that setting? How can the therapist mediate the workplace demands with client needs?

Question 28

ethical reasoning

Answer 28

Ethical: What is the right thing to do? What are the benefits of therapy, and how does that impact decisions? Are there barriers that need to be addressed?

Question 29

conditional reasoning

Answer 29

Conditional: Sometimes considered another type of reasoning, sometimes considered a “blend” of the others (W&S uses “blend” approach). View of potential outcomes for the client and deal with day-to-day considerations.

Question 30

Development of Reasoning

Answer 30

Novice
Advanced Beginner
Competent
Proficient
Expert

Question 31

reflection

Answer 31

REFLECTION is necessary part of the reasoning process and of professional and personal development

Question 32

development of reasoning includes…..

Answer 32

Includes thinking “on our feet” in the midst of providing care. Also important to reflect on what goes well after therapy sessions and what we need to improve. What do we see in our clients, peers, supervisors, colleagues that might make us better? Think about how our performance is evaluated, and what we learn from others.