clinical reasoning occupational therapy case study

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Clinical Reasoning

Clinical reasoning is the thinking process used by occupational therapists as they interact with clients throughout the occupational therapy process. Seven different types of clinical reasoning are defined and discussed below.

Scientific Reasoning

This type of reasoning focuses on the facts such as impairments, disabilities, and performance contexts.  It can be used to identify problems and to develop solutions.

Diagnostic Reasoning

This type of reasoning specifically relates to the client’s diagnosis and how that diagnosis affects the clinical picture.  It is sometimes considered a component of scientific reasoning.

Procedural Reasoning

This type of reasoning focuses on the process of what, when, and how interventions and other solutions will be carried out.  It focuses primarily upon the process of therapy.

Narrative and Interactive Reasoning

This type of reasoning relies on story telling in order to identify problem areas and solutions.  It requires interaction between client and therapist in order to gain an understanding of the situation.

Pragmatic Reasoning

This type of reasoning focuses on logistics such as cost, time, therapist’s skills, client wishes, and physical location.  It looks at the problems and the contexts and focuses on developing practical and realistic solutions.

Ethical Reasoning

This type of reasoning brings in the aspect of right and wrong as it looks at issues and aims to develop the best and most moral solution to a problem.

Conditional Reasoning

This type of reasoning is the most complex, and it encompases both an empathetic understanding of the situation, as well as a vision for its resolution.  It incorporates the other types of reasoning into an integrated picture of the client and a framework for selecting the most appropriate course of action in order to achieve the ideal end goal.

References and Further Reading:

Krajnik, S. (2015).  Clinical reasoning in occupational therapy  [Handout].

Pendleton, H., & Schultz-Krohn, W. (2011).  Pedretti’s occupational therapy for physical dysfunction (7th ed.).  St. Louis: Mosby Elseiver.

Clinical Reasoning in Occupational Therapy: An Integrative Review

1993, American Journal of Occupational Therapy

Related Papers

Iranian Rehabilitation Journal (IRJ)

Objectives: Clinical reasoning is at the heart of clinical work; it is affected by different field factors. A clear understanding of the reasoning process could solve practitioners' problems on how to make their underlying theories, assumptions and values more explicit. The aim of this research is to understand how clinical reasoning process is formed in the context of occupational therapists working in different clinical settings in Iran. Methods: A purposeful and theoretical sampling of 15 occupational therapists working in clinical settings was performed through semi-structured interviews. All the data were recorded, transcribed, and analyzed using Strauss and Corbin's (2008) grounded theory approach and constant comparative analyses. Results: Conceptual model was developed to explain the relationships among the main categories extracted through the grounded theory. Achieve an observable change emerged as the core category. Other important categories linked to the core category were, performing the continuum of clinical reasoning, context of clinical reasoning, and effective factors in clinical reasoning. Discussion: Findings showed that achieving an observable change in the client was the main consequence of the action/interaction strategies. Some facilitating factors related to the therapist, helped to process reasoning with a holistic and client-centered view, while also helping to develop the self-belief and professional identity. The dominance of medical views and a lack of health insurance were two intervening factors that constrained the dynamics of clinical reasoning within the context of practice.

Iranian Rehabilitation Journal

narges shafaroodi

The American Journal of Occupational Therapy

Elizabeth Crepeau

This qualitative case study focused on the clinical reasoning of a certified occupational therapy assistant who had 16 years of practice experience. Observation and interview methods were used to collect data. Transcripts and field notes were coded using a priori codes of the forms of clinical reasoning of occupational therapists identified in published research. The study participant demonstrated the use of pragmatic, procedural, interactive, conditional, and narrative reasoning. We encourage further research to support these findings and to increase the understanding of the forms of clinical reasoning used by occupational therapy assistants.

slayer blood

Medical journal of the Islamic Republic of Iran

Afsoon Hassani Mehraban

Clinical reasoning is generally defined as the numerous modes of thinking that guide clinical practice but little is known about the factors affecting how occupational therapists manage the decision-making process. The aim of this qualitative study was to explore the factors influencing the clinical reasoning of occupational therapists. Twelve occupational therapy practitioners working in mental and physical dysfunction fields participated in this study. The sampling method was purposeful and interviews were continued until data saturation. All the interviews were recorded and transcribed. The data were analyzed through a qualitative content analysis method. There were three main themes. The first theme: socio-cultural conditions included three subthemes: 1- client beliefs; 2- therapist values and beliefs; 3- social attitude to disability. The second theme: individual attributions included two subthemes 1- client attributions; 2- therapist attributions. The final theme was the workp...

Kathy Kuipers

Cecilia Villares

Australian Occupational Therapy Journal

Denis Bedard

Background: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community‐dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions.Aim: To synthesise current knowledge about community occupational therapists’ clinical reasoning.Method: A scoping study of the literature on community occupational therapists’ clinical reasoning was undertaken.Results: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists’ clinical reasoning, were reviewed. Community occup...

Background/aim: The aim of this paper is to describe the use of a structured interview methodology, the repertory grid technique, for investigating the clinical reasoning of an experienced occupational therapist in the domain of upper limb hypertonia as a result of brain injury. Method: Repertory grid interviews were completed before and after exposure to a protocol designed to guide clinical reasoning and decision-making in relation to upper limb neurological rehabilitation. Data were subjected to both qualitative and quantitative analyses. Results: Qualitative analysis focussed on clinical reasoning content. Common themes across the pre-and post-exposure interviews were the use of theoretical frameworks and practice models, the significance of clinical expertise, and discrimination of 'broad' and 'specific' aspects, as well as differentiation between 'therapist and client-related' aspects of the clinical situation. Quantitative analysis indicated that for both pre-and post-exposure repertory grids, clinical reasoning was structured in terms of two main concepts. In the pre-exposure grid, these were related to the therapist's role, and to the 'scope' of practice tasks (either broad or specific). In the post-exposure grid the two main concepts were upper limb performance, and client-centred aspects of the therapy process. Conclusions: The repertory grid technique is proposed as an effective tool for exploring occupational therapy clinical reasoning, based on its capacity for accessing personal frames of reference, and elucidating both the meaning and the structure supporting clinical reasoning.

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Factors affecting clinical reasoning of occupational therapists: a qualitative study

Narges shafaroodi.

1. Lecturer and Occupational Therapy PhD student, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. moc.oohay@7segran

Mohammad Kamali

2. Associate Professor, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. moc.ilamakm@ilamak

Soroor Parvizy

3. Associate Professor, Iran Nursing and Midwifery School, Centre for Educational Research in Medical sciences, Iran University of Medical Sciences, Tehran, Iran. ri.ca.smut@yzivrap_s

Afsoon Hassani Mehraban

4. Assistant Professor, School of Rehabilitation Sciences, Department of Occupational Therapy, Iran University of Medical Sciences, Tehran, Iran. ri.ca.smut@nabarhem-a

Giyn O’Toole

5. Lecturer Occupational Therapy, University of Newcastle, Newcastle, Australia. [email protected]

Background: Clinical reasoning is generally defined as the numerous modes of thinking that guide clinical practice but little is known about the factors affecting how occupational therapists manage the decision-making process. The aim of this qualitative study was to explore the factors influencing the clinical reasoning of occupational therapists.

Methods: Twelve occupational therapy practitioners working in mental and physical dysfunction fields participated in this study. The sampling method was purposeful and interviews were continued until data saturation. All the interviews were recorded and transcribed. The data were analyzed through a qualitative content analysis method.

Results: There were three main themes. The first theme: socio-cultural conditions included three subthemes: 1- client beliefs; 2- therapist values and beliefs; 3- social attitude to disability. The second theme: individual attributions included two subthemes 1- client attributions; 2- therapist attributions. The final theme was the workplace environment with the three subthemes: 1- knowledge of the managers of rehabilitation services, 2- working in an inter-professional team; 3- limited clinical facilities and resources.

Conclusion: In this study, the influence of the attitudes and beliefs of client, therapist and society about illness, abilities and disabilities upon reasoning was different to previous studies. Understanding these factors, especially the socio-cultural beliefs basis can play a significant role in the quality of occupational therapy services. Accurate understanding of these influential factors requires more extensive qualitative and quantitative studies.

Introduction

Clinical reasoning is an essential feature of health care practice focusing on the assessment of needs, planning of intervention, dissemination and evaluation of health care. It is important because it facilitates understanding of the complexities of practice. It considers decision-making during practice and reflection about this decision-making process can enhance practice and improve outcomes ( 1 , 2 ).

For nearly three decades since Rogers and Masagatani (1982) first described clinical reasoning in the occupational therapy literature, many studies have attempted to explore this phenomenon. Although clinical reasoning is generally defined as the numerous modes of thinking that guide clinical practice, little is known about supportive as well as restricting factors that influence the quality of practice. The context of occupational therapy practice is generally regarded as significantly influencing clinical reasoning ( 3 ). Mattingly (1991) noted that the effectiveness of the clinical reasoning process largely depends on the therapist’s skill at interpreting context. Fleming (1993) stated that clinical reasoning observed in occupational therapy was continuous and evolving, focusing more on individual clients and contextual factors that could influence the outcome ( 4 - 7 ).

There are an increasing number of professional, organizational, socio-cultural and political/economic factors influencing everyday clinical practice. Therefore these factors and solutions to the challenges associated with these factors influence practice regardless of the setting ( 8 ).

The results of some research suggest a diverse range of client and therapist-related factors within the social and physical environment influence the clinical decisions of occupational therapists ( 9 - 11 ). A well-organized rehabilitation team structure, political forces ( 7 , 12 , 13 ), and organizational considerations ( 12 ) are environmental factors that influence clinical decision making. Client-related factors include age; illness severity; lifestyle motivation; the client-therapist relationship ( 14 ), their economic resources ( 15 ), values and beliefs and client attributes ( 16 , 17 ).Therapist-related factors are professional experience and worldview ( 1 , 14 , 18 - 20 ), along with personal style and values ( 16 ).

The factors affecting clinical reasoning include not only the individual mental processes of therapist but also the specific tools of practice and subtle influences such as cultural expectations embedded in the practice settings and client perceptions of what constitutes “good therapy” ( 21 , 22 ).It is important to identify such factors, in order to avoid pitfalls that can limit the outcomes of therapy. Additionally, research in this area has provided the basis for educational approaches that assist practicing therapists and students to develop skill in clinical reasoning ( 6 ).

Clinical reasoning is a complex process. Occupational therapists are required to make decision considering multiple variables and factors in dynamic contexts. Therefore, perception and understanding of the factors influencing the clinical reasoning enables the occupational therapist to provide relevant services producing desirable outcomes. The purpose of this article is to identify and evaluate the factors affecting the clinical reasoning of occupational therapists in clinical settings.

This article contributes to a PhD research thesis using grounded theory methodology. It was supported by the Faculty of Rehabilitation, Tehran University of Medical Sciences and seeks to explore the clinical reasoning of local occupational therapists.

A qualitative content analysis method was used in this study to enable researchers to explore the factors that might influence clinical decision-making in occupational therapists who work in different clinical settings. Content analysis is a research method for drawing repeated and valid inferences from data that is relevant to their context, with the purpose of producing knowledge; and facts; new insights, and a guide for action ( 23 ). Qualitative content analysis is designed to reduce and categorize raw data into themes based on reasonable inference and interpretation. In this process the researcher uses inductive reasoning and careful examination to identify themes and subthemes in the data ( 24 ).

Participants

The participants in the study were twelve occupational therapists. All participants volunteered for the study, forming a convenience sample from three private rehabilitation centers and three university hospitals and day centers. All participants were key informants. Six participants were female and six were male with between 3 and 22 years of experience (with an average of 8.8 years). Four occupational therapists were PhD students; five participants had Masters Degrees while the remaining three had Bachelor degrees in occupational therapy. Five participants worked with physical dysfunction, six in pediatric centers and one worked in a psychiatric center. They were interviewed at their workplace or at the Occupational Therapy department in school of Rehabilitation, Tehran University of Medical Sciences. Recruitment continued until achieving data saturation or redundancy was achieved.

Data collection

Data was gathered through interviews with each participant. The interviews followed a semi-structured interview guide and interviews began with two open-ended questions “How do you begin with a new client? What factors influence your decision-making during your work with clients? The interviews were audio taped and transcribed verbatim. They took between 25 and 55 minutes.

Data analysis

The interview transcriptions were read thoroughly several times and reduced into meaning units (threads of meaning found throughout the transcriptions). The condensed meaning units were conceptualized and labeled with a code. The various codes were compared based on differences and similarities and classified into the subthemes and each cluster of similar sub- themes produced themes ( 25 ).

Strategies for trustworthiness

Maximum variation of sampling (choosing different participants from different settings, different academic degrees, and different job experiences) has been employed to enrich data. Member checking; peer checking; writing memo notes and reflexivity were used as strategies to increase trustworthiness. To increase data transferability all research processes have been clearly documented and 30-40% of the transcripts were peer reviewed by qualitative research specialists. Subthemes and themes were discussed and revised by three supervisors and a qualitative researcher and the participants.

Ethics approval for the study was sought and obtained from the ethics committees at the Faculty of Rehabilitation, Tehran University of Medical Sciences. All participants were assured of confidentiality of data and of their anonymity when reporting findings. Prior to data collection, each participant signed an informed consent letter explaining the purpose and procedure of the study and was thereafter identified with a number. Participants were also informed that their participation was completely voluntary and they could withdraw from the study at any time. Each interview transcript was de-identified, coded and stored securely.

Analysis revealed three themes, socio-cultural conditions, individual attributions and environmental conditions. Each theme had either two or three sub-themes, identifying the conditions and factors influencing the Clinical Reasoning Process ( Table 1 ).

Socio-cultural Conditions

This theme includes three subthemes. These include the beliefs of the client about their disease and the role of the therapist; the attitude and confidence of the occupational therapist, and social attitudes to disability.

Client beliefs

The participants in this study believed that the awareness and belief of clients about their disease and their understanding of their problems influences the initial clinical reasoning of the occupational therapist. In such circumstances, occupational therapists need to provide an explanation about the disease and its effects. "That how much the patient has accepted his/her illness and how much he/she is familiar with the situation, how much information he/she has about his/her illness…what’s willing to help himself/herself this issue is so important and can influence our clinical reasoning ".

They also felt the acceptance of the problem by the client can influence the type of clinical reasoning and cooperation with the therapist. "That how much the patient has accepted his/her illness and how much he/she is familiar with the situation, how much information he/she has about his/her illness…. Sometimes denial is so serious in the patient that we cannot commence our main treatments from the very beginning. A part of the problem is that how much of the treatment the patient wants to undertake… this issue is so important and can influence our clinical reasoning ".

The belief of the client and the family about occupational therapy services and their trust in the therapist are the facilitating factors affecting continuation of treatment and thus clinical reasoning.

"The belief of the family about occupational therapy is so important. Families are often unaware of rehabilitation services…they think occupational therapist is like a doctor….they come in five sessions and they are going to be good”.

Therapist values and beliefs

The belief and confidence of the therapist in his/her capabilities and ability to attend to the demands of the client is an important factor affecting interaction with clients and evaluation and planning for him/her.

“The first and most important thing is that the therapist believes he/she can assist the client”.

More experienced participants believed considering and assessing client needs and priorities increase client participation in the treatment process.

“First … we are trying to see the real complaint, and then with respect to client’s complaint do an assessment, goals and treatment plan according to the problem and we will fix the problem so the client can trust the therapist”.

The participants working in community-based centers believe they need to view their clients with a holistic perspective. This holistic approach is effective in increasing client satisfaction with the treatment process.

“Depends on therapist’s perspective…. treatment can continue because our patient not only have physical problems but also they have some problems in emotional, mental and social components ,therefore , treatment program can continue to solve these problems.”

The participants working in hospital state that they have to treat their client with a medical perspective. This is effective in decreasing their job satisfaction.

“… our medical doctors and expect me to do movement therapy as physiotherapists and just decrease physical problems but this is not my job. Increasing abilities and autonomy of the patient are not important”.

Social attitude to disability

The interviewees suggested that the community has shortcomings in understanding disabled people and their problems. This indicates the situation of the client in the society should be considered when prescribing assistive equipment. Otherwise, because of the attitude of the society this device may be a barrier to participation in daily life in public places.

"…. our society has contradictory attitudes where things are different….and inevitably this makes the individual face challenges. When the disabled person wants to go to a party, for example it is not acceptable for him/her to appear at that party wearing ‘medical’ shoes. This fact relates to the understanding of the community…..If the therapist fails to consider the social attitudes to disability their reasoning and clinical decision-making may result in lack of participation in life.”

Individual attributions

The second theme: individual attributions include two sub-themes: Client and therapist attributions.

Client attributions

Most participants stated the financial status of the clients was the important demographic feature influencing their clinical reasoning. The financial status of the clients can determine the number of sessions, use of assistive devices and the interventions. "I believe the financial status of the family highly affects the treatment. If he/she can attend regularly he/she can achieve a good result, but unfortunately some cannot continue because of their financial status"

The education level of the client or family is a factor participants felt influenced the treatment plan, efficiency, and treatment results.

“Parent who is a doctor or educated and has more information…. should be treated differently from the parents with little information, namely it affects the weight of my speech”.

Diagnosis was another factor, considered important by most participants, in beginning clinical reasoning to determine the occupational therapy frame of reference and model.

"One of the main problems we have is the diagnosis. I should know my goal, because I have to do something with them. However I do my best to satisfy myself and get good results"

The participants suggested that the honesty of the client and their family with the therapist influences the collection of data and planning. "The honesty of the client toward us, sometime I have to ask the patient and I cannot evaluate all patients objectively (using standardized assessments), and this can affect the treatment".

Therapist attributions

In the sub-theme of therapist attributions, the participants mentioned the competence and experience of the therapist as well as access to current knowledge all of which they felt could influence their clinical reasoning.

All participants considered the competence and experience of the therapist important in diagnosing the effect of problem on performance and developing the therapeutic relationship. "Due to my good experience, when I see the patient's hand, even if I do not see the graphs and the doctor's instruction, from the cleft areas I can guess what kind of surgery has been done"

All the participants indicated enjoying current knowledge and using modern methods are significant factors influencing their reasoning and their clinical decisions. "All subjective and objective information I get from the patients, for example the Para-clinical information, I match them with the data I already have. Sometimes I match them with other information to gain a series of objectives and plans.

”In this way I could be a person with up to date knowledge. Maybe it is clinical reasoning".

Participants working in hospitals stated

“… Should have updated information. Least what I have experienced, and I think we need to know the new research papers. If not read the new articles and updated here soon realize that you do not know anything .You must be prepared to respond to any question”.

According to the participating occupational therapists, their reasoning in clinical tasks is affected by numerous factors such as their personal attitudes, the support of the health environment and financial constraints. "For example an important thing is the financial condition. More important is the therapist. I found out in my task that many therapists work to have an income.”

Another participant added: “For example, I myself do not like the diagnosis of Down’s syndrome… Often I prefer not to visit a patient because I do not have a good attitude".

Another therapist insisted it is important to love your work. “What I have experienced is when you love working with the patients; this makes it a very different and gives positive result.”

The Workplace Environment

This theme labeled environmental conditions has three sub-themes including knowledge of the managers and directors of centers, teamwork and facilities.

Knowledge of managers of rehabilitation services

The lack of knowledge of the managers of services is the first sub-theme relating to the workplace environment of the therapist. Lack of understanding and recognition of occupational therapy by hospital directors potentially affects reasoning and clinical decision-making.

The factors relating to this subtheme include: inappropriate expectations of occupational therapy services and considering Occupational Therapy the same as medicine or physiotherapy. "Hospital centers instead of paying attention to quality see the daily figures booklet (income & numbers treated). This changes our treatment plans. Absolutely the quality will decrease. I have to devote less time to the patients. I often tend to consult."

Working in an inter-professional team

How to work in a team is the second sub-theme influencing the clinical reasoning of the occupational therapist.

Lack of knowledge about Occupational Therapy and lack of cooperation from the physicians, unrealistic expectations beyond the role of the occupational therapist and lack of timely referral to occupational therapy are some of the issues influencing the reasoning and planning of the occupational therapist.

"One of our problems is that the patients are not referred in a timely manner…. Another is the lack of knowledge of our physicians about occupational therapy. Naturally, the understanding of the role of the occupational therapist is ambiguous in the treatment team."

Cooperation or non-cooperation of physiotherapists and other members of the rehabilitative team and even occupational therapists with each other in clinical environments are also factors that impede or facilitate clinical reasoning.

"The patient refers to the physiotherapists and physiotherapist says to patient that you does not need occupational therapy services…patient comes to occupational therapists and occupational therapist says to patient that you doesn't need physiotherapy and this reduces the teamwork at least between physiotherapist and occupational therapist."

Limited clinical facilities and resources

Clinical facilities and resources is the third sub-theme of workplace environments.

The limited number of occupational therapy clinics in the community is a factor that impedes occupational therapist's clinical reasoning. Occupational Therapy clinics available in capital cities either depend on public and academic centers or are administered privately. Many clients have to travel long distance to access occupational therapy services. This fact influences planning and implementation of interventions in clinical reasoning process.

"Sometimes the distance is so far and we only visit once a week… We have educational consultancies for example for the patients in other cities. They contact to the clinic in the morning. Many take cameras… they take films and then I explain for them and answer their questions".

The existence or lack of physical facilities in occupational therapy clinics can facilitate or impede the reasoning and decision-making of the occupational therapist. Some participants mentioned environmental conditions that are crowded and noisy affected their reasoning. "The noise… disrupts the concentration… when you are evaluating, the noise bothers you. The environment should be quiet and appropriate in terms of light, moisture, no heavy traffic so that the patient can give information easily."

One participant identified the lack of recognition of Occupational Therapy had an effect on their reasoning. "What affects the treatment is that insurance department (health cover) does not recognize our treatment and it is a catastrophe. Shockingly this old necessary field is not covered by insurance coverage."

This study explored the factors influencing clinical reasoning of occupational therapists. The factors influencing the clinical reasoning of the participants as mentioned above are threefold. The socio-cultural theme includes the subthemes of client beliefs; therapist values and beliefs along with the social attitudes to disability.

The occupational therapists participating in this study stated that the knowledge and belief of the client and their family about the disease and occupational therapy influences the clinical reasoning process of the occupational therapists. Many clients when coming for occupational therapy deny their problem and/or have limited information about it. Further research is required about why the clients deny their problems. From the perspective of the participants, evaluating the knowledge and acceptance of the client in relation to the disease and occupational therapy services may indicate the expectations of the clients from such services. That is consistent with Coply ( 26 ) and other researcher findings ( 17 , 27 , 28 ) in which occupational therapists can identify achievable goals and outcomes with clients if they explore and perceive their unique values and beliefs about his/her conditions. Participants believed that to encourage the cooperation of clients and their families, it is important to consider their beliefs, for example respecting their religious beliefs. These results emphasize the importance of a ‘client-orientation’ and interactional reasoning. According to the studies done by Mattingly and Fleming study ( 1 ) and others ( 29 , 30 ) considering the spiritual aspects of clients and respecting the associated values and beliefs is essential for successful treatment.

When considering the second sub-theme the therapists in this research considered confidence in their abilities as the necessary prerequisite to achieving their clinical objectives. Participants in this study stated that therapist experience, access to new/current professional knowledge and the clinical situation or context: such as expectations of clients or physicians affect the confidence of individual occupational therapists in his/her abilities. According to Chapparo ( 16 ) therapist perceptions of their ability to complete planned actions has a direct effect on their feeling of self-efficacy and self-confidence. When therapists, because of organizational constraints, have a tenuous sense of self-efficacy, their actions do not always result in appropriate reasoning and thus positive therapy outcomes.

Experienced participants who were faculty members or clinical supervisors indicated considering all relevant aspects of a problem and presenting plans pertinent to the situation; attending to the wants and priorities of the clients and their families; not acting with prejudice and finally reflection about feedback influences the satisfaction of clients with occupational therapy services and their continued cooperation with occupational therapy.This result support Hooper (1997) and Unsworth (2004) and Rassafiani (2009) studies that worldview of the therapist affects thinking and clinical reasoning. The worldview of therapists may be positive or negative effects on clinical reasoning ( 1 , 19 , 20 , 22 ).

The sub-theme of social attitudes to and acceptance of disability is a factor affecting the formation of therapeutic plans, their implementation and follow-up. The participants in the research stated that traditional beliefs and limited awareness in society about disability, limits the clinical reasoning of the therapists within their clinical environment. Disabled people in Iranian society are either isolated or pitied ( 31 ). Consequences of such an attitude include a limited number of support services such as vocational education centers, life skills services, and recreation centers that could empower and increase participation of disabled people.

Individual attributions are the second theme found in this study. The first subtheme demographic features of clients such as the financial situation, diagnosis and severity of the disability, age of client, and geographical position of the clients are important in clinical reasoning. All participants highlighted the significance of economic status and diagnosis upon clinical reasoning especially relating to assessment, planning and implementation of therapeutic interventions. Many clients of private occupational therapy centers cannot afford therapy due to lack of health insurance coverage for occupational therapy. In addition, many occupational therapists provide or limit their services in proportion to the financial status of the clients. Kuipers ( 14 ) and Lutfey ( 15 ) argued that some demographic features of clients influence health professional decision making. Further research is required about the importance of this factor in clinical reasoning.

The second sub-theme in individual characteristics relates to the therapist. The participants consider therapist experience as one of the most important factors influencing the diagnosis of problem-effects on function; type of evaluation, planning method, and performance of therapeutic interventions. They emphasized that many of the reasoning mistakes in the process of treatment are due to the lack of experience of the therapist in clinical tasks. Being updated and taking advantage of recent knowledge were the factors related to this sub-theme of characteristics of the therapist. Well-developed therapist knowledge influences the development of trust of clients and their families, thereby influencing planning. According to the participants, therapist motivation to work is another factor influencing clinical reasoning. They also indicated that therapist interest in his/her specialization and particular diagnosis, along with salary can influence the therapist reasoning and thus performance. According to the Schell and Cervero ( 10 ) study the beliefs of therapists regarding occupational therapy, the ability of occupational therapists in treating their clients, their knowledge, comments and interests in their profession and client and the motivation of occupational therapists affects the process of clinical reasoning. A component of treatment is related to whether the therapist is able and wants to enable the client. These factors are also present in this study.

The third theme discussed in this article is the workplace environment. Lack of knowledge of managers and the policies applied to the organizations providing rehabilitative services have negatively influenced the process of clinical reasoning, including the expectation of providing services similar to medical and physiotherapy services; income generation regardless of the quality of services, allocating limited facilities and space to the occupational therapy sector and not employing enough occupational therapists for the number of clients. Rogers and Massagatani have also emphasized that the expectations of the therapeutic environment can influence the clinical reasoning of the therapists ( 32 ). Brace (1987) in his studies also identified the influence of the number of clients, physical facilities and the prevailing traditions of the department on therapist reasoning ( 32 ). Another sub-theme identified in this meaning unit was teamwork. The cooperation or non-cooperation of team members and the specialists with the occupational therapist is another condition influencing on the clinical reasoning process of the occupational therapists participating in the study. Lack of knowledge of physicians or their neglect of occupational therapy services and consequently, their lack of cooperation are other impediments affecting the clinical decisions of occupational therapists. The participants also emphasized the overlaps in some tasks between physiotherapists and occupational therapists, resulting in negative effects on teamwork and also the competition between occupational therapists to gain higher income are other reasons affecting the clinical decisions. Studies suggest that many therapists enter negotiations with other specialists of the treatment team when decision-making is difficult and examine their decisions ( 33 ). Support of colleagues, teamwork, and less competition between team members could lead to use of desirable therapeutic methods by the therapists ( 11 ).

Availability or lack of appropriate physical facilities can facilitate or impede the clinical reasoning of occupational therapists. Limited facilities and equipment for conducting interventions and lack of culturally appropriate tests are barriers to appropriately evaluating therapy results .According to the participants most of the clients face financial difficulties and lack of health insurance is another factor limiting the clinical reasoning of occupation therapists. Various studies support these findings. Schell (2005) and Unsworth (2004), in their studies, found that insurance and what the client can afford are factors influencing the reasoning of the therapist when providing services ( 1 , 34 ). Another study supporting these findings indicates that the physical environment and accessible facilities influence clinical decisions ( 8 ). This study indicates that therapists base their clinical reasoning upon the available devices, space and the geographical location of their clinics.

Results of this research indicate that numerous complex factors can influence the clinical reasoning of occupational therapists. The knowledge and situation of the clients; the attributions of the therapists, social attitudes to disability and the workplace conditions of the therapists can positively or negatively influence reasoning and clinical decisions. In this study, the influence of the attitudes and beliefs upon reasoning was different to other studies. Understanding these factors, especially the socio-cultural basis can play a significant role in the quality of occupational therapy services and has a role in training occupational therapy students in clinical reasoning in this social context. Correct understanding of these influential factors requires more extensive qualitative and quantitative studies with occupational therapists working in specialized clinical settings.

Limitation of research and suggestions

In this study, participants mainly worked at academic and state hospitals and/or clinics in pediatrics or with physical dysfunction. To increase the credibility of the findings of this research, it is necessary to explore the reasoning of therapists working in other contexts.

Acknowledgments

The authors would like to extend their sincere thanks to all participants in the School of Rehabilitation at Iran University of Medical Sciences and Tehran University of Medical Sciences, Shaheed Behshti and Welfare University.

Cite this article as: Shafaroodi N, Kamali M, Parvizy S, Hassani Mehraban A, O’Toole G. Factors affecting clinical reasoning of occupational therapists: a qualitative study. Med J Islam Repub Iran 2014 (19 Feb). Vol. 28:8.

• DOI: 10.5014/AJOT.47.7.605
• Corpus ID: 13157023

Clinical reasoning in occupational therapy: an integrative review.

• B. Schell , R. Cervero
• Published in American Journal of… 1 July 1993
• Education, Medicine

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Clinical reasoning: how do pragmatic reasoning, worldview and client-centredness fit.

• 10 Excerpts

Clinical Reasoning, Looking Back

Using cultural-historical activity to study clinical reasoning in context, employing service learning to promote student self-efficacy in occupational therapy education, effect of personal and practice contexts on occupational therapists’ assessment practices in geriatric rehabilitation, perceptions of health professionals about effective practice in falls prevention, using cultural-historical activity theory to study clinical reasoning in context, the nature of clinical reasoning with groups: a phenomenological study of an occupational therapist in community mental health., 14 references, clinical reasoning process for service provision in the public school., the classroom as clinic: applications for a method of teaching clinical reasoning., staff development through analysis of practice., what is clinical reasoning, how high do we jump the effect of reimbursement on occupational therapy., seeking a relevant, ethical, and realistic way of knowing for occupational therapy., values influencing clinical reasoning in occupational therapy: an exploratory study, cognition in practice: outdoors: a social anthropology of cognition in practice, ethical considerations in clinical reasoning: the impact of technology and cost containment., classroom as clinic: a model for teaching clinical reasoning in occupational therapy education., related papers.

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Developing Solid Clinical Reasoning Skills in Occupational Therapy

Clinical reasoning in occupational therapy is a term that gets thrown around a lot in OT school and beyond. Professors say it’s something that will eventually come to you with practice and experience in the field. But, oftentimes, it’s not something you get a lot of direct training on.

Clinical reasoning is most frequently addressed by practicing case studies and problem-based learning scenarios where you need to plan your response to certain clinical situations. This is helpful, but we all know that being new in a setting like a hospital with flashing lights, machines beeping, and wires everywhere isn’t exactly stress-free.

This may lead to nerves, hesitation, and questioning everything you’ve learned. Having a solid foundation with plenty of practice will not only give you confidence in your skills but it will help you develop reasoning before you’re in a sink-or-swim type of situation.

Professors may give you the evaluation and treatment knowledge you need to develop clinical reasoning, but putting them into place appropriately and at the right time is usually less cut and dried. That’s why on-site experiences like fieldwork and shadowing are so crucial, because it gives us the chance to see things from the lens of a therapist rather than that of a student.

Students learn the concepts and foundations of OT in a very specific way for the first year or two of their program. But most of us can agree that, once you get to your first fieldwork setting, you quickly realize that there is a whole other type of learning that you’re only beginning to dip your toes in.

That’s why I like to define clinical reasoning as the marriage between those learned rudimentary OT concepts (like ROM and MMT levels) and what happens in the clinic.

Let’s put it this way : you can memorize every minute detail of the Rancho Los Amigos Levels, but none of that information is going to help if you’re not aware of how to use it. This is why fieldwork is such a crucial aspect of OT school. We need to go through some of those motions and begin building our clinical reasoning and judgment before we enter the field on our own.

So we know what clinical reasoning in occupational therapy is, but how exactly can we build it? Fieldwork and clinical experiences definitely help, but there are certain parts of a therapist’s job that specifically encourage clinical judgment:

Activity Analysis

It may seem that activity analysis is just busy work that supervisors use to occupy students when they run out of other work for them. But this is something that truly requires practice because therapists innately use activity analysis constantly . They may not even realize it until they slow down and go through each step individually to teach students the basics.

Some patient deficits may require small tweaks, whereas others may need a lot more strengthening and training to result in independence. The only way that therapists know what their plan of care (and each treatment) must target is by breaking the task down into smaller parts. This may seem difficult, but it actually makes things much simpler by giving us a clear idea of where the issue is!

Does a patient have mostly intact motor skills but lack the cognition to appropriately sequence each step of the task? This means they will need help knowing what to do and when rather than improving their dexterity to help hold the object.

The only way we can figure this out is to pick apart even the smallest of tasks, such as brushing your teeth. An intention tremor may prevent a patient from initiating the task by picking up the brush. But if we provide a stabilizing device, then they may be able to complete the rest of the task on their own.

If we didn’t identify initiation as the main issue, then we might have incorrectly assumed that the patient could not participate in the task at all . As you can see, an omission like this can change the course of the entire plan of care!

Environmental Modifications

Adapting the environment to the patient may be another result of activity analysis. Sometimes therapists will find that a distracting, unsafe, or stressful environment is the center of a patient’s deficits.

An analysis may show that a patient can complete each component of an activity when they’re with you one-on-one in their room. But they may freeze and get tripped up on each step if they practice the same task in a crowded therapy gym with lots of noise, movement, and activity from other patients and therapists.

The patient’s surroundings can be altered to improve their chances of success. Use that clinical reasoning to dive into what the problem may be. It may be as simple as addressing basic safety issues like removing or affixing throw rugs and covering exposed wires in the home.

But it can also be less obvious. If there is a history of falls, does the patient have deep-set fears about this happening again and not being able to recover? Do they have an abusive family member that controls the patient’s every move and prevents them from doing certain things on their own?

These may sound like social barriers but they are also environmental obstacles that should be addressed to encourage patient independence.

Upgrading and Downgrading

Once you use activity analysis and environmental modification, you may still find that the patient has issues with task completion. This may mean that it’s appropriate to downgrade the task to make it a better fit for their needs or abilities. The same applies to patients who easily complete tasks right off the bat; they will benefit from a more difficult activity to challenge them and strengthen their skills.

Upgrading and downgrading is usually a big part of therapeutic activities and not necessarily functional tasks like dressing or completing hygiene tasks. However, it’s sometimes appropriate for patients to participate in a “downgraded” functional task, more commonly known as task modification.

This is when therapists can make functional tasks easier for patients by training them in the use of adaptive equipment, compensatory strategies, or other techniques to improve patient performance despite the presence of certain deficits.

Improving your Clinical Judgment

Clinical reasoning is at the heart of each of these central occupational therapy concepts. While these concepts are frequently taught in OT school, there are other ways to improve clinical reasoning outside of this:

Practice, practice, practice 

A good example is running through case studies and problem-based learning scenarios. We mentioned that this is often how professors teach clinical reasoning, but getting even more practice in these areas is never a bad idea.

Run through a range of scenarios, especially ones that you may not see as often in clinical settings, such as mental health or burn-related cases. This is a good way to broaden your perspective while also getting some form of experience in areas you may not otherwise have exposure to.

Get feedback

Another way to improve your clinical reasoning skills is by asking for continual feedback. Practicing is certainly important, especially if you have an answer key to refer back to. But you can’t always ask for elaboration if you need more details on the rationale behind that answer.

This is why fieldwork and on-site visits are so important, because supervisors can provide real-time comments and critiques to shift your perspective. This encourages therapists to dig deeper for answers and end up with the option that’s most effective, safest, and the best fit for the patient.

If you haven’t taken the NBCOT exam yet, you will soon learn that coming up with the best and safest answer is a good way to problem solve those exam questions!

Use metacognition

Higher-level thinking, also called metacognition , is another process that plays a big part in our own learning. It’s important to be continually aware of all the aspects that impact our patients’ performance.

This doesn’t mean that you need to constantly address all of a patient’s deficits because this can be impossible (and counterproductive) with some low-functioning patients. But you should always strive to increase your own perspective in an effort to give patients the best care possible.

You are likely already practicing metacognition in ways such as planning and preparation for treatment sessions, assessing your own comprehension of learning materials, adjusting your plan of care when you discover something doesn’t work as you thought, and monitoring your progress each step of the way.

_______________

The good news is that you’re likely well on your way to developing solid clinical reasoning skills, if you haven’t already! By combining your instincts with your OT training and experience, you will be able to reason your way through some of the toughest problems. Keep practicing and always be open to learning.

What is your favorite way to encourage clinical reasoning in OT? Let us know in the comments!

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Using the case method to develop clinical reasoning skills in problem-based learning

Affiliation.

• 1 Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque 87131-5641, USA.
• PMID: 7785717
• DOI: 10.5014/ajot.49.4.349

Clinical reasoning is increasingly recognized as a crucial component of the occupational therapy process. Different types of clinical reasoning used by occupational therapists have been identified, including scientific, procedural, interactive, narrative, conditional, and pragmatic reasoning. This article describes the use of the case method in the University of New Mexico undergraduate occupational therapy curriculum to facilitate development of occupational therapy students' problem-solving and reasoning abilities. The case method is a component of problem-based learning that emphasizes small group work to solve clinical problems that are presented as case studies. Students are presented with a variety of case formulas including paper or written cases, videotape cases, simulated client cases, and real client cases to promote the development of specific types of clinical reasoning. Problem-based learning may also hold promise as an educational strategy for fieldwork students and clinicians.

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• Effects of problem-based learning on clinical reasoning in occupational therapy. Scaffa ME, Wooster DM. Scaffa ME, et al. Am J Occup Ther. 2004 May-Jun;58(3):333-6. doi: 10.5014/ajot.58.3.333. Am J Occup Ther. 2004. PMID: 15202631
• Clinical reasoning case studies as teaching tools. Neistadt ME, Wight J, Mulligan SE. Neistadt ME, et al. Am J Occup Ther. 1998 Feb;52(2):125-32. doi: 10.5014/ajot.52.2.125. Am J Occup Ther. 1998. PMID: 9494633
• Analysis of the orthopedic content in an occupational therapy curriculum from a clinical reasoning perspective. Neistadt ME, Atkins A. Neistadt ME, et al. Am J Occup Ther. 1996 Sep;50(8):669-75. doi: 10.5014/ajot.50.8.669. Am J Occup Ther. 1996. PMID: 8863940
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• Learning and Development of Diagnostic Reasoning in Occupational Therapy Undergraduate Students. Moruno-Miralles P, Reyes-Torres A, Talavera-Valverde MÁ, Souto-Gómez AI, Márquez-Álvarez LJ. Moruno-Miralles P, et al. Occup Ther Int. 2020 Aug 19;2020:6934579. doi: 10.1155/2020/6934579. eCollection 2020. Occup Ther Int. 2020. PMID: 32934612 Free PMC article.
• Clinical reasoning in massage therapy. Lemoon K. Lemoon K. Int J Ther Massage Bodywork. 2008 Aug 20;1(1):12-8. doi: 10.3822/ijtmb.v1i1.2. Int J Ther Massage Bodywork. 2008. PMID: 21589814 Free PMC article.
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Clinical Reasoning in Occupational Therapy: Case Studies Across the Lifespan

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Jacob A – 02/21/2019

Very interesting content and thank you.

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It summarizes each chapter on the first page to grasp the subject matter well.

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• Aug 19, 2019

Case Study | Clinical Reasoning: Home or Hospital?

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By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub

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