CLINICAL REASONING: PART 1

Clinical reasoning is a higher-level cognitive process required by therapists to solve complex problems and make sound decisions meet the needs of the client. The therapist must access relevant knowledge and explore past clinical experience in order to apply it effectively to the situation. 
The therapist is then able to identify the best path or direction in which to proceed with the client.

The thought process involved in clinical reasoning is unique to each therapist and situation. However, most therapists relay on data available to them, best practice knowledge, and impressions to help them. 

TYPES OF CLINICAL REASONING

Procedural Reasoning

Used when addressing the client’s disability and various means of reducing it. Also used in learning and performing actual therapy techniques. 

Examples include:

       What do I know about this diagnosis?                                            

       How does the diagnosis affect client function?

       How will team members be addressing with the client?                 

       What is the recovery process and time frame?

       What techniques work best to improve function?

Interactive Reasoning

Used to understand the client as a whole as well as to understand his illness experience. Helps to establish a sense of trust with the client.

Examples include:

       What is the client’s point of view regarding the disability?              

       What are the client’s goals?

       What is the client’s environment?                                                    

       Is the treatment going well?

Conditional Reasoning

Represents a higher level of thinking about the client within the social contexts of family, community, etc., both prior to and with the disability. It is described as “future oriented” as it enables the therapist to envision a client’s likely course following dc. 

Examples include:

       What is the client’s social environment?                                        

       Who are the “key players”?

       How does this social network support or hinder client progress?  

       What did the client do prior to the illness/injury?

       What are the client’s roles within the family, community, etc.?      

       What does the client hope to continue to do?

Narrative Reasoning

Refers to the way in which therapists talk and think about their clients. It seeks to discover the human motivations for action and relationships between events. Therapists will create and tell stories about clients as a way of developing an understanding and envisioning a future for them.

Pragmatic Reasoning

This enables the therapist to identify how other influences may affect client progress and care.  

Examples include:

       Reimbursement and time with client                                               

       Ability to provide individual vs. group treatment

       Organizational expectations for productivity and accountability    

       Staff support, family support

LEVELS OF COMPETENCE

The development of clinical reasoning skills can take many years and there exist different 
levels of competence:

Novice   

Learning the skills of assessment, diagnostics and treatment planning

Advanced Beginner  

May not see whole picture but is refining skills and picks up on additional cues

Competent  

Able to identify more clearly, determine significance of cues which contributes to a broader understanding and improved ability to individualize treatment

Proficient  

Sees the “whole”; easily able to modify plans during treatment

Expert 

Knows the rules, uses intuition and is able to rely on past clinical situations to process imagined outcomes for clients 

THOUGHT PROCESS OF CLINICAL REASONING

The following information addresses pieces of the process therapists rely upon to get to the point where they feel ready to make the best decision with examples of each to illustrate each area.

Pre-Assessment Image           

This perception is based upon the client’s age, diagnosis, gender, previous functional level. This will influence the therapist’s expectations of the client, an idea of what to expect regarding the client’s abilities and disabilities. How the therapist interprets this information will be affected by experience with clients of similar medical and demographic backgrounds.

The OTA is working with Jenny, a 32-year-old mother of 2, diagnosed with a L CVA involving the middle cerebral artery. Though the OTA never worked with such a young stroke patient, he expects this patient will gain function more quickly than an 80-year-old individual with the same diagnosis. The OTA also expects the patient will be motivated to work hard in therapy to be able to care for her children.  

Cue Acquisition             

This occurs when the therapist is engaged in the process of gathering data related to the client’s current functional status and occupational roles. It requires the therapist to use honed skills of observation, as some cues may be subtle and require further exploration.

The clinical image created based on this information guides the therapist in deciding which cues to attend to and which to disregard.

The OTA notices Jenny has a history of Type II DM, s/p a R radial fx 15 years ago, and underwent an appendectomy 7 years ago. The therapist mentally disregarded the surgical and fracture events as insignificant. The information about DM is significant however, and the OTA makes a special note of that as it will likely impact feeding and meal prep activities, as well as health management I-ADL tasks.

Hypothesis Generation       

Occurs when data are organized and assumptions made. The therapist begins to organize data into explanations for the pattern of deficits observed. Often more than one explanation is generated.

When the OTA first meets Jenny, he notices Jenny’s arm hanging off to the side of the wheelchair, she does not attempt to use it to shake his hand when he extends his hand to her, and she does not say hello but nods instead. The OTA thinks Jenny is unable to shake his hand due to abnormal tone vs a visual perceptual issue. When she does not say hello he thinks it is likely due to expressive aphasia. He does wonder if she may be depressed due to her loss of function and independence and will monitor that as he works with her.  

Cue Interpretation and Hypothesis Evaluation                       

The therapist continues to gather cues and categorize each according to the hypothesis it supports or refutes. It contributes to the identification of an action plan using best evidence as a basis for treatment and guides the next steps in the plan.

When observing Jenny wash her face, the OTA notices she only washes the left side of her face using her left hand. The OTA wonders if Jenny is doing this due to visual perceptual issues or due to hypotonicity affecting coordination…or both. He decides to incorporate some weight bearing preparatory activities before continuing with the grooming task to help normalize tone. Following this, he notices Jenny initiates using her right hand more automatically when brushing her teeth. 

Next time, we will address factors which can contribute to errors in clinical reasoning which could impact treatment outcomes.

SHARE YOUR EXPERIENCE

Describe a situation where you needed to "tease out" what was going on with a client.

Discuss the two primary options you needed to choose between in order to move forward with the patient? 

What information did you use or need to obtain to make your final decision about the best course of action?

Describe the end result and any changes you would make next time you find yourself in a similar situation.