Putting Clinical Reasoning into Practice

It is a truth universally acknowledged that there needs to be some method to one’s madness when practicing OT; through use of clinical reasoning one can justify one’s actions and approaches. Clinical reasoning is an essential skill that has to develop in order to be taken seriously as not only a student, but as a professional too. If you cannot justify your actions and intervention planning, you cannot be expected to be taken seriously by your peers or your client.

As a student, the one question you dread is “why are you doing this?”. We shouldn’t dread it. We know what we’re doing and have a plan, but the pressure weighs heavy on your shoulders and a cold sweat creeps down your spine. We know we’re right! But we can’t risk being wrong! Mattingly (1991) expressed this so perfectly when she said “words always fall short of practice” and went on to explain how our eyes and ears have the knowledge, but we struggle to translate this into words. I’ve often been asked to justify why I’ve decided to perform a particular session and why I’ve structured an activity in a certain way; these questions are necessary, and do not serve as a way to embarrass or trick me, these are the questions that allow my fellow rehab team members and supervisors to gain insight into my line of thinking. From there, suggestions are made, and I develop as an OT. But what leads to my decisions in the first place? And why is it so difficult to explain my clinical reasoning to another?

I employ clinical reasoning throughout fieldwork, and with increased experience, my decisions have become clearer and easily justifiable. This week, I received two new clients, Client C and Client D. Both clients are mothers who have suffered left CVAs resulting in right hemiplegia, speech deficits and difficulties with motor planning. Before I even met with my clients, I used their diagnosis to narrow down which assessments I would perform. Upon meeting them and assessing, my observations and findings are used to generate a treatment plan. Fleming (1991) describes the beforementioned process as “Procedural Reasoning” whereby the therapist decides on intervention based on the physical ailments of the client and what procedures are appropriate to alleviate these. In my case, my theoretical knowledge about trunk weakness in CVA clients and my physical assessment which confirmed trunk weakness, was used as justification for performing an activity with my client seated unsupported and reaching to her side to activate and strengthen her trunk. According to Fleming (1991) this sequence of reasoning is “problem identification, goal setting and treatment planning”. I’ve discovered that Procedural Reasoning has become my go-to response when decision-making, though it allows for a clearer picture in my mind- if I set the wrong goal or incorrectly identify a problem, my reasoning is flawed.  

According to Chris Cabellero’s article for Forbes.com (https://www.forbes.com/sites/forbescoachescouncil/2018/04/20/the-seven-key-steps-of-critical-thinking/#f71fa3f6a528) , there are six steps to improving critical thinking. The steps I tend to follow when reasoning, align well with the article’s content but I’ve found that there is room for improvement in considering more points of views through conducting holistic and thorough research, as well as improving in communication of findings and results. I find that relaying information and being able to communicate my reasonings has become essential for my growth as a student. In order to relay my reasoning I need to have a thorough understanding of my client’s capabilities and my capabilities. In order to describe my aims for a session I need to do more than just write them down in a SMART aim template, instead being able to explain my session verbally is a skill I need to improve. Not many people will have the time to read through pages of my reasoning, being able to relay my reasoning succinctly and with confidence is something I strive for. To achieve this, I need to run through sessions in my head (and practically!) and be able to verbalize my justifications in order to develop the ability to answer questions pertaining to my treatment confidently when on fieldwork.

This week, I feel like I was able to convey my clinical reasoning appropriately when explaining my sessions to my supervisor and peers. When conducting a dressing session with Client C, I deviated from the recommended norms for posture by having my client’s feet placed on a wedge. This caused around 45⁰ of dorsiflexion and slight hip flexion, instead of the recommended 90-90-90 position when seated. I was able to use my clinical reasoning here by explaining to my supervisor that the angle I had placed Client C’s feet at was relieving pain in her hip and promoting increased weight-bearing through the leg. This was a proud moment for me because my knowledge was able to come across practically and I could explain my thoughts clearly.

So yes, it is a truth universally acknowledged that there needs to be some method to one’s madness when practicing OT, and that through use of clinical reasoning one can justify one’s actions and approaches. We must acknowledge that as fledgling OTs this is easier said than done and, putting practice into words is rather difficult. However with experience will come more confidence and wisdom. Eventually, we’ll be responding to queries without a blink of an eye and clinical reasoning will come effortlessly. For now, we research, plan, and demonstrate good understanding.

Until next week,

Kaylee

An insightful investigation into the minds of therapists:

Unsworth, C. A. (2005). Using a head-mounted video camera to explore current conceptualizations of clinical reasoning in occupational therapy. The American Journal of Occupational Therapy, 59(1), 31-40.

References:

Fleming, M. H. (1991). The therapist with the three-track mind. The American Journal of Occupational Therapy, 45(11), 1007-1014.

Higgs, J., Jones, M. A., Loftus, S., & Christensen, N. (Eds.). (2008). Clinical Reasoning in the Health Professions E-Book. Elsevier Health Sciences.

https://www.forbes.com/sites/forbescoachescouncil/2018/04/20/the-seven-key-steps-of-critical-thinking/#f71fa3f6a528

Mattingly, C. (1991). What is clinical reasoning?. The American Journal of Occupational Therapy, 45(11), 979-986.

Pictures:
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