Elements of Clinical Reasoning

Clinical reasoning may be characterized into three elements: scientific, ethical, and artistic.¹² The scientific element addresses the question, “What are the possible things that can be done for this client?” The answer to this question is found in the evaluation and assessment procedures used to determine strengths and weaknesses of the client, the writing of a plan to guide and direct the change process, and the selection of therapeutic modalities that result in successful occupational performance outcomes. The scientific element demands careful and accurate assessment, analysis, and recording.

By determining the child’s strengths and weaknesses in light of the medical condition, Marie used scientific reasoning to plan the child’s intervention. Frequently, clinicians start the clinical reasoning process using scientific reasoning because this type of reasoning follows the medical model. Scientific reasoning helps practitioners understand the client’s process and story. Thus, it makes a good starting point.

The ethical element addresses questions such as, “What should be done for this client?” and “What is the right and fair path to take?” The answer takes into account the client’s perspective and his or her goals for intervention. Each individual has different views on health, what is important in life, and how things are accomplished. When the OT practitioner understands and respects the client’s perspective, an intervention plan that preserves the client’s values can be developed.¹² The OT practitioner consults with the client so that he or she can participate in making decisions regarding intervention goals and methods. The OT practitioner considers all of the scientific and ethical information in relation to the individual’s needs, goals, culture, environment, and lifestyle.¹²

This example illustrates one of many ethical dilemmas OT practitioners may face. The practitioner must consider the right of the client and decide based upon the ethical principles of practice (see Chapter 8). The practitioner uses clinical reasoning to examine all of the alternatives, predict future success, and investigate the client’s needs. In this case, the clinician uses clinical reasoning to investigate all areas that might interfere with Mark’s living alone. This information can help the team develop alternative ethical solutions. Ethically, she is contributing to the desires of the client without letting the team down.

The artistic element of clinical reasoning is evident in the skill used by the OT practitioner to guide the treatment process and select the “right action” in the face of uncertainties inherent in the clinical process.¹² The therapeutic process involves integrating and blending many areas, such as deficiencies to be addressed, the client’s interests and wishes, the medium or activity to be used, and the interpersonal climate that is to support the therapy process. The therapeutic relationship and the way in which the OT practitioner interacts with the client play a major role in the artistic element. The artistic element involves using creativity to skillfully design intervention specific to a client. This requires the practitioner to modify activities, use humor or coaching, and read the cues of the client when interacting.

Missy has developed a rapport with Brian, and the art of this interaction is evident as Missy reads Brian’s words as joking. Missy knows she has connected with Brian and can afford to joke with him. This same scenario may be interpreted as refusal of therapy and handled differently for another client. The art of therapy involves reading the client’s cues within the context of the setting and the client–therapist relationship. Artistic reasoning requires skill in the therapeutic relationship, creativity, reflection, and self-awareness (see Chapter 16).

Thought Process During Clinical Reasoning

Clinical reasoning is a cognitive thought process in which many diverse bits of information are gathered together (evaluation), many outside factors are considered (e.g., life space, prognosis, and desires), the demands of activities are analyzed (activity analysis), time investment choices are made (plan), and identifiable goals are organized (intervention). Clinical reasoning used throughout the therapy process requires analysis of data, use of specific knowledge bases, and synthesis of the process and information. The OT practi-tioner must actively think and process information from multiple sources.

Rogers and Holm¹³ describe the steps in the thought process of clinical reasoning that is used during the occupational therapy evaluation and intervention process. During each step, the OT practitioner gathers, organizes, analyzes, and synthesizes information.¹³ See Box 17-1.

In the first step, the OT practitioner forms a preassessment image of the client, an initial outline that will be used for further assessment of the client. The practitioner considers the client’s diagnosis, age, and contexts (e.g., time in life). The OT practitioner seeks to find out information related to the diagnosis, client’s life roles, and functional status prior to the injury or trauma. At this stage, the practitioner is forming a general picture of the person.

The OT practitioner uses the preassessment image to begin the cue acquisition step. This step involves gathering the data regarding the client’s current functional status, occupational roles, and past experiences. The purpose of this stage is to gather data, or cues, to inform the intervention planning.

The practitioner generates a hypothesis using the cues regarding the client’s needs. The practitioner organizes the data that have been gathered and makes tentative assumptions, which serve as the basis for therapeutic action. The hypotheses generated are based on all available data, knowledge of models or practice and frames of reference, and the practitioner’s experience.

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