CLINICAL REASONING: PART 2

In the first part of our discussion about clinical reasoning, we explored types, stages and influences upon clinical reasoning. We also looked at what the therapist must consider and utilize in  order to be effective and make sound, clinical decisions. Now we will explore what can go wrong if the therapist is not diligent in being objective in examining data, fails to "hear" what the client is saying, and neglects to remain focused upon the needs of the client. 

CAUSES OF COMMON CLINICAL REASONING ERRORS

Pre-Assessment Hypothesis Generation

An accurate pre-assessment image (made prior to seeing the client) allows the experienced therapist to filter virtually every observation and interaction through a screen making each item on the evaluation useful in determining the client’s level of function.

Without a pre-assessment image, the inexperienced therapist is essentially without a filter. He may be aware of problem areas in the realm of perception and cognition, but have difficulty predicting how impairment will affect function and deciding upon the most effective treatment approach. If a pre-assessment image is inaccurate, and the therapist recognizes it promptly and revises plans accordingly, negative impact may be avoided or minimized.

It is important to realize that every diagnosis has a range in the severity and frequency of symptoms experienced.  The individual may have other medical issues which may impact the condition listed and their ability to cope with the situation.

Initial Assessment Hypothesis Generation

When the therapist arrives at an explanation of the nature of the disability before all the data are collected, a bias could affect how further data obtained is perceived and utilized.

As a result, contradictory cues suggesting a different hypothesis may be overlooked and important information may not come to light or may be discounted in the interpretation of the findings.

This may be attributed to the tendency to “chunk” or compartmentalize information in memory in order to remember it better. In recognizing a few items from a particular information “chunk”, a therapist may go on to assume that other elements associated with the “chunk” are present as well, leading to a clinical reasoning error.  The therapist must be vigilant in maintaining focus upon the client in front of them versus grouping that individual with others having a similar condition or situation.

The use of standardized assessment tools when possible can help ensure information is gathered uniformly and not limited to anticipated findings. Avoid relying solely on the medical record for all pertinent and accurate information as clients often look and function very differently from the way their medical diagnoses suggest they might. The hypotheses formed prior to first meeting the client must be held as just that – a hypothesis to be proven or not.

Use of a Standard Evaluation

Therapists often follow a standard client evaluation which can be useful in reducing certain types of clinical reasoning errors. However, these evaluations can’t possibly cue the therapist to symptoms or the functional consequence of a condition, particularly if the condition is a rare one.  Without a working knowledge of conditions, therapists run the risk of making clinical decisions based on information from these evaluations which is too detailed, not detailed enough, or irrelevant.

It is important to understand why the client is being referred to OT, as this will guide the direction of the evaluation vs. the evaluation form guiding the process. Become familiar with or develop functionally based assessment tools vs. those driven by diagnosis. The DC plan may be used to guide data collection for the evaluation process.

Failing to Meet Client Needs

This often occurs when activities are pulled out of a file drawer or closet and given to almost any client without much preparation, without a focus upon goals, or without direct observation of the client when completing these activities.  

This is frequently seen when clients are placed into groups to address organizational productivity needs vs. the needs of the client. When therapists rely on treatment options like these, the focus is often placed on one particular area (i.e. UE strength or ROM).The therapist fails to consider the full scope of the client’s issues, areas being addressed by other disciplines  (i.e. PT, speech). This leads to the client being asked to engage in tasks which fail to meet their needs in a meaningful way.

An experienced therapist might too easily assume that a case is “routine” and this practice is best practice or will work when planning time is short. An inexperienced therapist might be too consumed with procedural details to notice unique or intricate details of the case, or have an insufficient number of cases to compare in order to detect a difference.

The therapist must remain alert to the client’s experience of the disability to avoid this type of clinical reasoning error. It is critical for the therapist to cultivate listening skills, empathy, and appreciate most clients have a limited experience with therapy and place blind trust they are receiving what they need.

The therapist must be receptive to nonverbal cues such as the client’s level of participation in treatment and facial expressions during a particular activity. When responses are less enthusiastic than anticipated, it is important to understand why that is in terms of the client’s own values and beliefs.

Goal Conflicts

Clinical reasoning is most problematic for practitioners of all skill levels of skill when the client’s goals or wishes conflict with the practitioners’ values or with realistic societal allowances. For example, a client who sustained a TBI and now experiences seizures, wishes to return to work as a truck driver.

Clients must be active participants in goal setting to help ensure engagement in the process.  The client must “own” treatment goals in order for participation and progress to occur. Clients must be allowed to make informed choices and may require additional information for the process to be realistic. They may need additional information from the MD, RN, specialists, etc. in order to view the situation more clearly.

Abbreviated hospital stays affect the amount of time clients are given to progress to their desired level of independence and are sometimes discharged at functional levels less than hoped. Therapists’ ideas of appropriate goals to prepare for discharge within that time frame may differ from the client. Concerns exist when therapists and caregivers have many serious concerns about the client’s level of function but the client does not.

It is often necessary to identify a compromise between the therapist, client and family. Communication and respect are key components in facilitating this process. Establishing a good rapport with the client will help increase willingness to engage in the process. When negotiating common ground, the therapists must make it clear the intention is to serve the client’s best interests. The therapist should clearly state the anticipated results of therapy should the client identify unrealistic goals.

Ex. “I can’t promise the function in your arm will recover 100%. We will work towards that goal and I will help you to learn to do many of the tasks you did before in a new way.”

Mismatching Stories

This refers to the tendency of health care providers to form conclusions to the client’s story reflective of their personal beliefs vs. those of the client. Therapists use a variety of means to elicit client stories while subconsciously constructing their own descriptions regarding the client’s premorbid lifestyle, values, and occupational performance.

Understanding the client story is a dynamic process requiring the therapist to make adjustments as more information is provided by the client. When a therapist’s approach to the client does not reflect what the client is telling the therapist, trust will evaporate quickly.

When clients subscribe to unconventional beliefs and values about wellness, and how best to achieve it, it is almost inevitable stories will not match despite being compassionate and respectful. The therapist must respect the client’s experience even when cognitive deficits exist. Personal experience is no less potent to the individual with cognitive impairments than it is to anyone else.

Engaging in a brief but meaningful discussion related to how the client is feeling about their situation will help all parties remain focused on the true picture. Clarification of information and tailoring communication style to the client’s needs will go a long way to help avoid errors.

SHARE YOUR EXPERIENCE

Describe a situation where you may have misjudged a client, failed to utilize some information they gave you, or lost focus upon the client's goals. 

• What information did you have but may have discarded and why?
• What occurred that made you recognize the process had gotten off course?
• What steps did you take to get the situation back on track?