American Journal of Occupational Therapy

This paper describes the research process and methodology used in the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. This study examined the clinical reasoning of occupational therapists through a 2-year ethnography of therapists at one hospital site. The research was innovative in several important respects. One important innovation was a combined ethnographic and action research design that involved collaboration between the research team and those therapists being studied. Therapists who were research subjects became actively involved in examining and reflecting on their own practice through group analysis of videotaped sessions with clients. One outcome of this action research component was that the study served as both a research and a staff development project.

This paper offers a concept of clinical reasoning that differs from many of the traditional definitions of clinical reasoning in occupational therapy and the health professions in general. Here, clinical reasoning in occupational therapy is described as a largely tacit, highly imagistic, and deeply phenomenological mode of thinking. It is argued that clinical reasoning involves more than the ability to offer explicit reasons that justify clinical decisions because it is also based on tacit understanding and habitual knowledge gained through experience. Clinical reasoning also involves more than a simple application of theory, particularly theory as understood in the natural sciences, because complex clinical tasks often require that the therapist improvise a treatment approach that addresses the unique meaning of disability as it relates to a particular patient.

This article highlights some observations made in the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study, an ethnographic study of 14 occupational therapists working in a large teaching hospital. Concepts and premises that frequently appear in the clinical reasoning in medicine literature are discussed and compared and contrasted to observations and interpretations made of the practice and reasoning strategies of the occupational therapists who were participants in the Clinical Reasoning Study. It is postulated that similarities in the reasoning strategies of the members of the two professions are a result of use of the scientific model that calls for hypothetical reasoning. Differences, it is proposed, are accounted for by the difference in the particular focus, goals, and tasks of the two professions and the nature of the practice in those arenas. Five hypotheses are proposed as questions for further research in clinical reasoning in occupational therapy.

Narrative reasoning is a central mode of clinical reasoning in occupational therapy. Therapists reason narratively when they are concerned with disability as an illness experience, that is, with how a physiological condition is affecting a person’s life. In this paper, narrative reasoning is contrasted with propositional reasoning, and two kinds of narrative thinking are examined. The first is the use of narrative as a mode of speech that can be contrasted with biomedical discourse, in which disability is framed as physical pathology. The second involves the creation rather than the telling of stories. Therapists try to “emplot” therapeutic encounters with patients, that is, to help create a therapeutic story that becomes a meaningful short story in the larger life story of the patient.

This article reports some of the results of the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. Therapists are thought to use three different types of reasoning when solving problems in day-to-day practice. Procedural reasoning guides the therapist in thinking about the patient’s physical performance problems. Interactive reasoning is used when the therapist wants to understand the patient as a person. Conditional reasoning is used to integrate the other two types of reasoning as well as to project an imagined future condition or situation for the person. Experienced occupational therapists seem to shift smoothly from one mode of thinking to another in order to analyze, interpret, and resolve various types of clinical problems.

Occupational therapists, like other health care professionals, must balance their application of treatment techniques with an understanding of their patients’ life experiences. This paper reviews the literature from interpretive and medical sociology regarding the interplay between professional power and the achievement of an understanding of another person. It analyzes how an occupational therapist, during a single treatment session, enters into her patient’s life-world and simultaneously controls and manages the treatment process. The concepts of knowledge schemata (the expectations and beliefs people bring to a situation) and footings (the shifts in alignment, or focus, that occur during interaction) are central to this analysis. The process of achieving a balance between professional power and an understanding of the patient’s experience may be fostered in education and in clinical supervision through increased emphasis on the importance of understanding the values and beliefs of patients and on the development and refinement of interactive skills.

The recent focus on clinical reasoning in occupational therapy, specifically on how therapists solve complex problems, has stimulated interest in how master clinicians think in practice. By gaining insight into how clinicians think and what they think about when they identify and solve problems, we may be able to identify clinical reasoning patterns and processes that occupational therapy students and novice therapists need to experience in order to progress in their practice or to emerge as leaders in their field. Observation of the way in which clinical masters and leaders view challenges and solve problems as manifested in their clinical reasoning may provide new and potential therapists with clues as to how to best hone their skills and knowledge for future success in practice.

This paper describes a study that examined the relationship of mastery, excellence, and leadership in occupational therapy. Ten master clinicians were interviewed to determine the characteristics of their mastery and excellence in practice and to explore the degree to which they engaged in leadership behavior. The findings revealed that mastery, excellence, and leadership are independent of one another but that some characteristics are common to all of these phenomena.

Some recent research efforts have been focused on the attainment of a better understanding of intelligence and reasoning. One such study is the Clinical Reasoning Study funded by the American Occupational Therapy Association and the American Occupational Therapy Foundation. Other studies have been conducted by theorists of human development. The findings of both groups reveal three common themes: the multiple aspects of intelligence, the importance of understanding the patient’s story, and the use of the caring perspective. This article examines these shared themes and discusses their implications for new directions in occupational therapy curricula.

Dreyfus and Dreyfus’s (1986) five-stage model of skill acquisition is integrated with findings from the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. This model is presented as an organizing framework for staff development. Strategies for the recognition and retention of experienced clinicians who can serve as mentors for newer colleagues are identified.

The occupational therapy process involves the assessment and treatment of problems in occupational status. Assessment entails the sensing and defining of patients’ problems and is accomplished through diagnosis. As a process, diagnosis involves the creation of a clinical image of the patient through cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation. This sequence of cognitive activities is called diagnostic reasoning. As a product, diagnosis summarizes a patient’s occupational deficits in terms of occupational role performance, occupational performance, and the components of occupational performance. To serve adequately as a basis for planning intervention, the occupational therapy diagnosis describes the problem, explains the potential cause of the problem, gives the cues whereby the problem is recognized, and names the pathologic agent. Occupational therapy assessment is broader than diagnosis and includes a delineation of the patient’s assets as well as deficits. In the resolution of problems in occupational status, assets may be used to offset deficits. The clinical image represents a balanced view of occupational status by reflecting assets and deficits.