Clinical Reasoning Introduction & Differences Between Novice/New Grads vs Expert/Experienced Occupational Therapists

Clinical Reasoning Definition

Compared to other healthcare professions, PT and OT are more likely to use the phrase ‘clinical reasoning’. This is likely due to the explicit definitions for this term. There is also variability used to describe CR across the healthcare professions.((Young, M. E., Thomas, A., Lubarsky, S., Gordon, D., Gruppen, L. D., Rencic, J., … & Durning, S. J. (2020). Mapping clinical reasoning literature across the health professions: a scoping review. BMC medical education, 20(1), 1-11.))

Components of Clinical Reasoning

  • Narrative Reasoning – the use of storytelling to describe and convey events in therapy for clients, families, and colleagues. Understands the problems from the client’s perspective.
  • Procedural Reasoning – the ‘why’ for assessments are chosen and the treatments are used with clients; thinking about the problems in terms of disease within the context of OT performance.((Mattingly C, Fleming M H 1994 Clinical reasoning: forms of
    inquiry in a therapeutic practice. F A Davis, Philadelphia))
    • Data-gathering with a focus on the parts; not necessarily the entire person.
    • Focuses on the diagnosis, identification of the problem, and planning interventions.
  • Interactive Reasoning– goal is to understand the client as a person.
    • Includes the use of therapeutic use-of-self and forming therapeutic relationships.
  • Conditional Reasoning – considers the client’s condition and its impact on their broader contexts for future outcomes.
  • Ethical Reasoning– when the occupational therapist determines if values are violated and balance values against each other.
  • Pragmatic Reasoning – addresses the practical context in which therapy occurs such as organizational constraints, values, resources, practice trends, and reimbursement issues.((Chapparo, C., & Ranka, J. (2008). Clinical reasoning in occupational therapy. Clinical reasoning in the health professions, 3, 265-277.))

Factors that Impact CR

  • Organizational (Work cultural)
  • Client’s needs
  • Client’s expectations
  • Theoretical and scientific knowledge of disease and human occupations
  • Personal skill
  • Personal beliefs
  • Personal knowledge((Chapparo, C., & Ranka, J. (2008). Clinical reasoning in occupational therapy. Clinical reasoning in the health professions, 3, 265-277.))

Stages

  1. Novice
  2. Advanced Beginner
  3. Competent
  4. Proficient
  5. Expert((Benner PE. From novice to expert: Excellence and
    power in clinical nursing practice. Menlo Park, CA:
    Addison-Wesley, 1984.))((Benner PE, Tanner C. Clinical judgement: How expert nurses use intuition. Am J Nurs 1987; 87: 23–31.))

Novice vs Experienced Clinical Reasoning

 

Novice Expert
Considers each component distinctly and separately. Considers components together simultaneously.
Lacks a knowledge base. Has a better knowledge base.
Often uses irrelevant information. Uses the most relevant information.
More difficulty recalling critical cues. Recalls critical cues better.
Confirms a hypothesis by collecting information. (Confirmation Bias) Tests a hypothesis using disconfirming hypothesis.
Takes more time to solve clinical problems. Solves clinical problems faster.
Less advanced problem-solving and clinical reasoning. Better problem-solving and clinical reasoning.
Less client-centered More client-centered
Places more value in knowledge and understanding of client problems. Places more value on good communication skills.
Developing understanding of the client. Excellent understanding of the client.
Focuses on a primary aspect or association. Focuses on multiple aspects and associations.
Reasons using step-by-step thinking process. Reasons more holistically and efficiently.
Less likely to make changes on the spot. More likely to make changes.
   
Unsworth, C. A. (2001). The clinical reasoning of novice and expert occupational therapists. Scandinavian Journal of Occupational Therapy, 8(4), 163-173.