Clinical Reasoning: How do Pragmatic Reasoning ...

Using both clinical reasoning data and literature from the past 20 years, this paper sought to examine the relationship between client-centred practice and clinical reasoning, to explore the concept of pragmatic reasoning and to present a diagrammatic conceptualisation of our knowledge of clinical reasoning in occupational therapy. The clinical reasoning literature published between 1982 and 2001 was reviewed and this information was combined with the findings from a study which used a head-mounted video camera to collect data and then explore the clinical reasoning of 13 experienced occupational therapists. The data were collected and analysed within a focused ethnographic framework. The findings showed that clinical reasoning occurred in the context of client-centred practice, but that a reciprocal relationship appeared to exist between client-centred practice and interactive reasoning. It also appeared that pragmatic reasoning was related only to the therapist’s practice context and that all forms of reasoning were influenced by the therapist’s worldview. A diagram was developed to depict this current understanding of the modes of clinical reasoning. While clinical reasoning has been described as the guiding force in a therapeutic practice, we are only just beginning to understand the nature of reasoning and reflection and how clinicians think. Further research is required to build and test the emerging theory of clinical reasoning in occupational therapy.

Clinical Reasoning: How do Pragmatic Reasoning, Worldview and Client-Centredness Fit? Carolyn A Unsworth

Introduction In the 20 years since Rogers and Masagatani (1982) first described clinical reasoning in the occupational therapy literature, many studies have attempted to explore this phenomenon and a language has evolved to articulate what clinical reasoning is (Rogers and Masagatani 1982, Rogers 1983, Schön 1983, Mattingly and Fleming 1994). Although clinical reasoning is generally defined as the many modes of thinking that guide clinical practice, much work has still to be done to explore this phenomenon further. In a recent review of the clinical reasoning literature, Leicht and Dickerson (2001) concluded that it was timely to expand occupational therapists’ knowledge of this building block for the profession. A literature search was conducted to identify all the articles on clinical reasoning published in English in occupational therapy journals from 1982 to 2001, using the search programmes OTDBASE, AMED and CINAHL. This search yielded a total of 65 articles. The literature review and findings/interpretation sections of this paper are

10

British Journal of Occupational Therapy January 2004 67(1)

based on literature from this search as well as on key papers from other disciplines. This paper is also written from the premise that it is important to build on the foundation of clinical reasoning as laid by Mattingly and Fleming (1994). Many occupational therapy writers from the United States (Schell and Cervero 1993, Hooper 1997), Sweden (Alnervik and Sviden 1996), Australia (Strong et al 1995, Crabtree and Lyons 1997, Unsworth 2001a, 2001b, 2004) and most notably from the United Kingdom (McKay and Ryan 1995, Fortune and Ryan 1996, Medhurst and Ryan 1996, Roberts 1996, Barnitt and Partridge 1997, Harries and Harries 2001) have contributed to the understanding of clinical reasoning. Many of these researchers used Mattingly and Fleming’s (1994) framework, which attempted to describe both scientific and phenomenological forms of reasoning. However, other frameworks focus on scientific or diagnostic reasoning (Rogers and Masagatani 1982, Rogers 1983) which draws heavily on a cognitive process approach to describing clinical reasoning, or draw on concepts such as situated cognition which has been described as the basis for

pragmatic reasoning (Schell and Cervero 1993, Schell 1998). A review of these different approaches to understanding reasoning may be found in Leicht and Dickerson (2001). Rather than fragment research in this area by deliberately seeking out new approaches to classifying new forms of clinical reasoning, this paper also seeks to build on Mattingly and Fleming’s (1994) framework. Mattingly and Fleming (1994) found that therapists often think in narratives when working with clients and when describing or creating therapy stories with colleagues. Fleming (1991) identified that therapists seemed to think in three tracks, which were named procedural, interactive and conditional. Procedural reasoning is described as the thinking surrounding the evaluations and interventions adopted by therapists. This mode of reasoning has its roots in scientific reasoning. In contrast, narrative reasoning, which is based on a more phenomenological approach to client care, forms the basis for interactive and conditional reasoning. Described as more than just the reasoning related to the therapist’s interactions with the client and significant others, interactive reasoning is concerned with understanding the client as a person and his or her perceptions of the events that have led him or her to see the therapist. Finally, conditional reasoning is described as the most complex form of reasoning and is related to the therapist’s understanding of the client’s condition, how changes in the condition are dependent on the client’s participation in therapy and, most importantly, the temporal aspects of the client’s story or an understanding of the client’s past, present and possible futures. The author’s research (Unsworth 2001a, 2001b, 2004) supported the notion of the three-track mind and provided examples of how therapists used these modes of thinking in isolation, in rapid succession or simultaneously. This was illustrated using a venn diagram where procedural, interactive and conditional reasoning in all combinations were represented by overlapping circles (Unsworth 2004). The overlapping nature of these forms of reasoning was also recognised by Mattingly and Fleming (1994, p125): ‘In senior therapists, procedural and interactive forms seemed to flow together, each enhancing the other.’ In addition, the author’s research revealed a subcategory of clinical reasoning which was termed ‘generalisation reasoning’ (Unsworth 2004). Generalisation reasoning seems to be used by therapists when they reason initially about a particular client issue, then reflect on their broader experiences and refocus their thinking on the client. This subcategory of reasoning was found to be used within procedural, interactive and conditional reasoning tracks. The author’s research, however, questioned the addition of components of pragmatic reasoning, as described by Schell and Cervero (1993), to Mattingly and Fleming’s (1994) clinical reasoning framework. In addition, further examination of the data was required to elucidate the relationships between clinical reasoning and client-centred practice. The literature concerning the relationship between clinical reasoning and client-centred practice, and pragmatic reasoning, is now reviewed.

Literature review The relationship between clinical reasoning and client-centred practice Although a client-centred approach to practice has permeated the occupational therapy literature for over 20 years, the Canadians adopted a definition of client-centred practice in 1995 as part of the philosophy supporting the Canadian Model of Occupational Performance (Law et al 1995). In 2000, Sumsion developed an operational definition of client-centred practice through focus group work with 67 British occupational therapists. In clientcentred occupational therapy, a partnership is formed between the client and the therapist to use their combined skills to work towards client-driven occupational performance goals. The key concepts that underpin a client-centred approach to practice include partnership and collaboration, autonomy and choice, enablement, contextual congruence, respect, responsibility, and an acknowledgement of the client’s strengths, experience and knowledge (Canadian Association of Occupational Therapists [CAOT] 1997, Fearing et al 1997, Sumsion 1999, 2000). Mattingly and Fleming’s (1994) descriptions of clinical reasoning included many of the concepts of client-centred practice, although their work predated widespread use of this term. The relationship between clinical reasoning and clientcentred practice, however, is not clear. Fondiller et al (1990) found that patient-centred treatment was one of 18 core values that supported therapist reasoning. Similarly, Higgs and Jones (2000) theorised that clinical reasoning occurred in the context of a client-centred practice. It is also possible that client-centred reasoning is a separate mode of reasoning (Ersser and Atkins 2000); that effective interactive and conditional reasoning are the means through which a truly client-centred practice is achieved; or that a reciprocal relationship exists between clinical reasoning and client-centred practice. Further examination of the nexus between these constructs is required.

Pragmatic reasoning Schell and Cervero (1993) described pragmatic reasoning as resulting from the therapist’s personal and practice contexts. The therapist’s practice context includes organisational and political environments, and economic influences such as resources and reimbursement. Lyons and Crepeau (2001) labelled this kind of reasoning as ‘management reasoning’. Schell and Cervero (1993) described a therapist’s personal context as including his or her motivation, negotiation skills, repertoire of therapy skills, ability to read the practice culture and what Törnebohm (1991) described as life knowledge and assumptions. To date, there has been little empirical evidence to support personal-context-related pragmatic reasoning. More recently, work by Hooper (1997) has empirically supported the influence of the therapist’s personal context on clinical reasoning. Hooper (1997) argued that a therapist’s clinical reasoning was shaped by his or her worldview. Worldview is defined in philosophy as ‘a global outlook on life and the world’ (Wolters 1989, p15). Although the influence of personal and practice contexts on clinical


11

reasoning was not directly labelled by Mattingly (1994a, 1994b) or Fleming (1994), the influences of both the environment and the therapist’s personal values and beliefs on reasoning were evident in their work. Using the occupational therapy literature on clinical reasoning and a set of clinical reasoning transcripts obtained through the use of a novel form of video-assisted data capture and debriefing, this research aimed to explore qualitatively the relationship between clinical reasoning and the client-centred practice of occupational therapy; to examine the concept of pragmatic reasoning as conceived by Schell and Cervero (1993); and to present a diagrammatic conceptualisation of clinical reasoning drawing on both the research literature from the past 20 years and the findings of the present study.

Method Design Debriefing interviews were used to gain insights into occupational therapists’ clinical reasoning. These interviews were conducted within a focused ethnography (Morse 1987, Spencer et al 1993, Muecke 1994). Focused ethnography is an ideal method to study clinical reasoning, given the emphasis on understanding what participants (therapists) think that they are doing and why they are doing it (Morse and Field 1995). Focused ethnography was first described in nursing to develop knowledge and practice in specific areas of the discipline (Morse 1987). Classical or anthropological ethnography aims to provide a comprehensive description of people’s material constructions and perspectives through the researcher spending a considerable period of time engaged in the culture under study. In contrast, focused ethnographies are time-limited studies within a specific community or organisation (Muecke 1994). A focused ethnography seeks to explore a particular problem or answer a specific question, gathering data with a small number of participants with experience relative to the problem through selected episodes of participant observation and/or interview (Muecke 1994). Although the method for the study was fully documented in Unsworth (2004), brief details are provided below.

(1996), the occupational therapists were nominated as experienced therapists by their occupational therapy manager, had practised as an occupational therapist for more than 3 years and possessed a higher level of formal training than they did upon graduation. The occupational therapists were all female and had a mean of 7.85 ± 4.78 years’ experience in rehabilitation. Each therapist made a video tape of an evaluation, an intervention and a discharge planning session with her client and provided the reasoning for each of these three sessions as described below.

Video instruments A novel method involving the use of a head-mounted video camera to capture data, and the opportunity for therapists to watch the video to assist them to recall their reasoning, was used in this research (Unsworth 2001b). In summary, this approach involves asking therapists to wear a small headmounted video camera attached to a video recorder which is worn in a waist pouch and to record the therapy session, as shown in Fig. 1. When viewing footage from a head-mounted video camera, the therapist ‘sees’ exactly what he or she saw as therapy unfolded (that is, has the same visual and cognitive perspective), which is believed to enhance reasoning recall significantly (Omodei and McLennan 1994). Fig. 1. A therapist, not a participant in the research, wearing the head-mounted camera and the video recorder in a waist pouch. (Published with permission.)

Participants Thirteen experienced occupational therapists and 13 of their clients formed the participants in the study. All the participants volunteered for the study and were a convenience sample from three physical rehabilitation centres in a large metropolitan city. The 13 clients who participated in the study had experienced a stroke (one male and seven females all aged 50 years or more) or head injury and orthopaedic injuries (three males and one female aged under 25 years and one male aged in his 60s). The therapists selected clients for inclusion in the study based on their anticipated length of stay and the 18-month time frame for data collection and on their willingness to participate. Based on the selection approach used by Embrey et al

12


Procedure Ethics approval for the study was sought and obtained from La Trobe University and the ethics committees at the participating rehabilitation centres. Both clinicians and clients were assured of the confidentiality of the data and of their anonymity when findings were reported. Each clinician nominated a client for inclusion in the study and was requested to undertake the usual evaluation, intervention and discharge sessions and not to be influenced in this by

Table 1. Coding examples for pragmatic, procedural, interactive, conditional and generalisation reasoning, based on Schell and Cervero (1993), Mattingly and Fleming (1994) and Unsworth (2004) Type of Examples of the types of statements and quotes reasoning from therapists Pragmatic Limited time available: I’m spending a bit more time with Jenny … sometimes it’s

Data transcription and analysis

just like … what do I do! It’s just [like I’m] running …

Thirty-nine therapy debriefing sessions (13 clinicians with three therapy sessions each) were professionally transcribed from the video tapes and verified by the researchers. This generated approximately 390 pages of double-spaced transcript. Since English was not the first language of one of the therapists, minor grammatical corrections were made to her transcripts to increase ‘readability’. Initially, the author and the research student reviewed four transcripts and independently coded these with coloured markers, using Schell and Cervero’s (1993) pragmatic reasoning and Mattingly and Fleming’s (1994) categories of procedural, interactive and conditional reasoning. Since therapists recounted the ‘story’ of the therapy session, narratives were viewed as a way of expressing the other forms of reasoning (particularly interactive and conditional) and were not coded as a separate form of reasoning. This a priori approach to coding, and the non-inclusion of narrative reasoning as a separate category, was also used by Lyons and Crepeau (2001) and Alnervik and Sviden (1996). Since discrepancies between the coding sets were found, the two researchers spent time together going through samples of the different modes of reasoning and developing a coding guideline. Table 1 provides an example of each mode of reasoning from the coding guideline. The two researchers then independently coded two more transcripts and almost perfect agreement was found. The remaining transcripts were then coded by the researchers. In a second layer of analysis, the author then analysed an unmarked set of transcripts by reading them over several times, looking for new patterns, themes or relationships between the reasoning modes (Miles and Huberman 1994) and for reasoning that reflected client-centredness. Since the participants were not directly interviewed concerning client-centred practice, the author attempted to investigate the relationship between clinical reasoning and client-centred practice through participant practice narratives. The difficulties associated with this are described in the limitations section. To ensure the trustworthiness of the data, the findings were reviewed by the members of the research team and by graduate research students also undertaking clinical reasoning studies (three therapists) and were sent to five of the participating therapists for review and confirmation. At the time of data analysis, three of the participating therapists were on maternity leave and two had left their positions and could not be located. Hence, five of the remaining eight therapists were randomly selected to review and comment on the findings.

Following hospital protocol: [I used the] mini mental assessment because it’s a standard assessment that we have to complete

Procedural

Discussing why a particular procedure / action was undertaken: I stopped here as she became distracted and I was worried she might fall …

Describing adaptive equipment or services to be used: It was time to introduce her to the modified cutlery …

Interactive

Individualising treatment: Normally I’d do a warm up, but I didn’t think he needed one …

Showing an understanding of the client as a person: She’s one of those people who likes to have things her own way …

Conditional

During these debriefing sessions, a new video tape was made. This showed the original picture and the original soundtrack (soft) of the therapy session, and the new clinical reasoning soundtrack (loud) of the clinician describing the reasoning that supported the session. This new video tape contained the data for analysis.

Considering the client’s family life: She’ll be moving in with her sister initially, which will be good …

Assisting the client to imagine a possible future for himself or herself: I’m telling him that lots of people have discount taxi vouchers because I think that’s an option for him, and I would like him to consider it …

Generalisation Considering what it’s like for clients in general (subcategory of with a particular problem: the other types I mean often, you know, people with brain injuries of reasoning) they just request a lot of unnecessary assistance … Consider the client and then what it’s like for clients in general: There’s probably not a great deal of need for him to be in his own room, he’s not in PTA [post-traumatic amnesia] … we sort of keep private rooms for people who are in PTA or who have special social needs or who just can’t tolerate … having other people in the room with them …

the study. The use of the three sessions was chosen to ensure a balanced sample of therapy encounters. Immediately after each therapy session, a member of the research team (either the author, the research assistant or the research student) and the therapist watched the video footage on a television monitor and the clinician described the therapy session and the supporting reasoning (Ericsson and Simon 1993). The researcher guided these interview sessions with non-directive prompts, such as ‘Can you say some more about what is happening here?’ or ‘What else are you thinking about here?’ (Kagan 1976).


13

Findings The therapists who reviewed the preliminary analyses as part of the member-checking process were supportive of the interpretations and no changes were made. The findings are illustrated with transcript excerpts from the participating therapists. The names of all therapists and clients have been changed to maintain anonymity.

The relationship between clinical reasoning and client-centred practice Prior to investigating the link between clinical reasoning and client-centred practice, it needed to be established if therapists were practising in a client-centred way. A review of the transcripts suggested that the degree to which the therapists practised in a client-centred way seemed to fall along a continuum, with some therapists more willing and/or able to embrace and implement the principles than others, as was also found by Wilkins et al (2001). For example, while Louise (therapist) used the Canadian Occupational Performance Measure (COPM) (Law et al 1994) to assist set goals with the client, it was found that Louise and the team made the discharge housing plan for Gillian (client) with little client input. This suggests that Louise had not fully embraced a client-centred approach to practice: Louise and Gillian – Discharge planning session … the discharge planning has been an ongoing [process] and we discuss it with our team members formally and informally and especially at the team meeting. We also decided that it is better for Gillian to go to a hostel … although she wants to go home …

The clinical reasoning transcripts from the three clinicians who worked at a facility specialising in the longterm rehabilitation of clients with head injury, however, all indicated a high degree of client-centredness. It is possible that the departmental culture at this centre facilitated a client-centred practice. In the following transcript excerpt, Jacinta (therapist) grades the involvement of her cognitively impaired client in care-related decision making in the manner advocated by Hobson (1996): Jacinta and Joshua – Intervention session … so I’ve got lots of things that we probably won’t have time to do in our session, he’ll get too tired for a start with. [I always] give him the choice of what we can do as well … to start with, Joshua could only cope cognitively, with a choice between two things, either do you want to do this or do you want to do that. Now he is coping with a number of choices, so we grade what choices we give him. If he was someone who couldn’t cope with a choice of activities, I would introduce a specific activity with a rationale behind it.

Finally, in contrast to Louise above, Ellen (therapist) ensures that the client is fully involved in making the discharge plan. This transcript excerpt shows a relationship between client-centred practice, interactive reasoning and conditional reasoning:

14


Ellen and Libby – Discharge planning session I think … [Libby] is happy if her parents are happy, but I want to include her as much as possible in the discharge planning because she is the one who is going to be living her life when she is discharged, you know. So I’m trying to give her a little bit more autonomy there, trying to get her to give some input and for her to feel a part of it because often I think – the parents are lovely, they are very, very supportive and, you know, … but … I want Libby to take a lot more responsibility as well for what is going on …

Pragmatic reasoning Therapist transcripts provided many examples of pragmatic reasoning related to insurance or reimbursement issues, the kinds of service and equipment that could be provided, whether the client could afford to purchase equipment, the kinds of service available in the community for the client on discharge and the impact of time on therapy (for example, individual session time and the client’s length of stay). These instances of pragmatic reasoning appeared to interface with therapists’ procedural, interactive and conditional reasoning (Unsworth 2004). In the first example of pragmatic reasoning, Ellen (therapist) is also considering Libby’s (her client’s) future using conditional reasoning and the physical aspects of the driveway and Libby’s mobility skills using procedural reasoning. In the second example, Sally (therapist) reasons procedurally about increasing Sam’s (her client’s) endurance, but pragmatically recognises that Sam’s ‘best times’ must be shared by the different therapists: Ellen, Libby and Parents – Discharge planning session [In this example, the client lived in a different state, so another therapist undertook a home visit and sent notes and photos to the treating therapist.] We’re trying to work out whether Libby would be able to negotiate that driveway because there are some potholes there … She is going to be walking using a stick by the time she goes home. The parents are quite concerned that it will not be suitable, that there is a gradient right down the end. The [insurance organisation] are saying to me that they will not fund it, that it’s something that they don’t think it’s bad enough to resurface the whole lot, so the parents are just explaining to me here that they think it needs to be done, but they also said that if the [insurance organisation] would not fund it, then they might be willing to actually do it. Sally and Sam – Evaluation session [We are trying] to gradually increase his endurance but you get to the stage where his face is going to fall into his cereal [and] there’s no point. You just have to sort of respect that fatigue and also respect the role of the other therapists because if I see him first it’s not fair if I exhaust the guy and everyone else gets nothing out of him, either in physical therapy or neuropsych. assessment or whatever it may be.

In another example of Sally (therapist) and Sam, Sally presents the pragmatics of Sam’s living situation and the effect of his drug-taking habits on his housing options:

Sally and Sam – Discharge planning session I suppose the other thing that we are touching on … is his residential situation and it’s really hard because a lot of the residential settings are too low level for him or the ones that he could live in and have day to day contact with someone in attending care support, there’s no vacancies or he doesn’t like them and the other issue with him is if he goes into a group home other people are at risk. He actually, unfortunately, shares his drugs around and being people with brain injuries we have a responsibility to ensure, you know – they can’t obviously make a sensible decision. With Sam it’s a premorbid thing and essentially we have come to the realisation he is not going to change. He’s tried [everything to stop taking drugs] but can’t resist the temptation …

Although examples of pragmatic reasoning relating to the therapist’s practice context were found throughout the data, there were very few examples of pragmatic reasoning relating to the therapist’s personal context. In fact, only two of the sample therapists briefly articulated such thoughts. The following example follows on from Sally’s (therapist’s) earlier comments about Sam’s housing options. In this excerpt, she provides a brief insight into her personal thoughts on the impact of Sam’s drug-taking. Sally reflects on her disappointment that drug use is hindering her client’s functional potential: Sally and Sam – Discharge planning session He’s really well exceeded all of our expectations for someone with such a serious brain injury … [he’s] just made such amazing gains. [But] when [he] uses drugs he just loses all his cognition, basically. He sits there and his mother reports [after weekend leave] that he spaces out for 24 hours at a time and it’s a real shame. I have seen this fellow going from being full assistance in absolutely every activity of daily living to being fully independent in personal care, basic domestic activities and basic community activities so he really has done remarkably so it’s a bit disappointing. You try not to dwell on it too much but it is disappointing from a therapist’s point of view because you think he could just keep on going so much but it’s holding him back, but at the same time, it’s his life.

Discussion The relationship between clinical reasoning and client-centredness A review of the data transcripts suggested that clientcentredness was not a separate form of clinical reasoning. Rather, as described by Higgs and Jones (2000), for many of the therapists, clinical reasoning occurred in the context of client-centred practice. In other words, the data transcripts did not contain examples of the therapists trying to reason about client-centredness. However, the data contained many examples of therapists’ reasoning being affected by the degree to which their practice was client centred. It was also apparent that client-centredness was most closely linked with the narrative/phenomenological mode of reasoning, specifically with interactive and conditional reasoning. However, of the transcript sections that revealed

that therapists were practising in a client-centred way, a greater number were also coded as demonstrating interactive reasoning rather than conditional reasoning. Many of the concepts underlying client-centred practice mirror those of interactive reasoning, as described by Fleming (1991). Both interactive reasoning and clientcentred practice view an understanding of and respect for the client’s values and beliefs as central to practice; have a focus on ‘doing with’ rather than ‘doing for’ the client; and perceive the client and the therapist to be equal partners in the therapy relationship (Mattingly and Fleming 1994, Law et al 1995). In addition, both interactive reasoning and client-centred practice require the therapist to think reflexively and recognise the influence of their own beliefs and values on the therapy process and also to be able to put these aside. In discussing the link between interactive reasoning and a client-centred approach to practice, Sumsion (1999) also concluded that more experienced therapists have a better understanding of the client’s point of view and, therefore, find it easier to allow the client to take charge of therapy than do novice therapists. The therapists’ capacity to reason interactively seemed to hold the key to the degree to which they were client centred in their practice, just as a departmental practice culture that engendered client-centred practice seemed to promote interactive reasoning in the therapists. Hence, a reciprocal relationship appeared to exist between interactive reasoning and client-centred practice. Since conditional reasoning also requires an understanding of the client’s situation and a shared view of the future (Mattingly and Fleming 1994, Unsworth 2001), it was interesting that client-centredness was not more closely linked with this mode of reasoning. This finding may, in part, be explained by the method used in the study, through the fact that it is more difficult for clinicians to use conditional reasoning and through the relative ‘newness’ of articulating a client-centred practice. Since the participants were asked to describe only their therapy sessions, it may be that they simply displayed their client-centredness more frequently when reasoning interactively than conditionally. If these clinicians had been interviewed and asked to elucidate the links between these two modes of reasoning and client-centred practice, then perhaps they would have linked the two modes of reasoning equally. It may also be that while the participants in this study were considered experts, it is quite difficult for therapists to use and articulate both conditional reasoning (Mattingly and Fleming 1994, Unsworth 2001) and a clientcentred approach to practice. It is really only over the past 3-5 years that therapists in the facilities studied have begun to embrace this approach to practice. Therefore, whereas therapists may be readily able to make links between clientcentred practice and interactive reasoning, the links between client-centred practice and conditional reasoning are more tentative and less well developed.

Pragmatic reasoning There is no doubt that therapy is conducted under the


15

influence of the therapist’s own personal motivation, values and beliefs (Eisenberg 1979, Hooper 1997) and the findings from this research lend some support to Schell and Cervero’s (1993) assertion that personal context influences clinical reasoning. However, the absence of pragmatic reasoning examples related to personal context from the transcripts was significant. It is possible that these kinds of influences on a clinician’s reasoning could not be easily gleaned from the methods used in this research. Perhaps interviewing clinicians directly about the influence of their personal context on the therapy process may yield better results. For example, Barris (1987) used interviews as well as transcript analysis to examine the influence of personal and environmental contexts on clinical reasoning. However, in the absence of data concerning the therapist’s personal paradigm, Barris (1987) concluded that the environment was a more pervasive influence on clinical reasoning than personal beliefs and attitudes. In addition, Fondiller et al (1990) interviewed nine therapists (who were all Fellows of the American Occupational Therapy Association) concerning the values that influenced their clinical reasoning in relation to a hypothetical case study. These authors also found that while some responses clearly indicated values, others merely implied values so that ‘the researchers needed to interpret them in the context in which they were stated’ (Fondiller et al 1990, p47). More recently, Hooper (1997) interviewed one therapist to determine the internal beliefs or commitments held that influenced the delivery of occupational therapy services. However, the therapist interviewed was selected on the basis of her ability to articulate underlying philosophical assumptions. Hence, while interviewing clinicians has led to small increases in the understanding of the influence of personal context on the clinical reasoning of articulate expert therapists, there is still relatively little information about the influence of this on clinical reasoning in the ‘trenches of everyday practice’ (Fondiller et al 1990, p52). It seemed that for the majority of the therapists in this study, fundamental beliefs and values in relation to the delivery of therapy were rarely brought to a conscious level, let alone articulated. Even if this were possible, social mores and notions of political correctness may have prevented individuals from voicing their thoughts (Schön 1983). As pointed out by Fondiller et al (1990), the values and beliefs that are articulated can be examined but it is unclear if these values are employed or merely espoused. Hence, in the context of everyday practice, it seems unlikely that a therapist’s values and beliefs are brought to a conscious level where they can be reasoned with. In addition, the term ‘pragmatic’ was derived from the Greek pragmatikos which meant ‘relating to fact’ and is today defined as ‘dealing with things sensibly and realistically in a way that is based on practical rather than theoretical considerations’ (Britannica 2001). Given this definition, it is difficult to view a therapist’s deeply held, socioculturally based values and beliefs as pragmatic. It is argued, therefore, that the therapist’s personal context is not a form of

16


pragmatic reasoning, but that this creates the environment in which all modes of reasoning occur. This personal context was referred to by Hooper (1997) as a therapist’s ‘worldview’ (Wolters 1989).

Worldview As described by Hooper (1997), ‘worldview’ is a useful conceptualisation of the influence of a therapist’s personal context on thinking and reasoning. Worldview is commonly understood as an individual’s underlying assumptions about life and reality. These assumptions are shaped by the individual’s personal-cultural-historical context and produce a global outlook on the world and on life (Van Belle 1980, Wolters 1989). Hence, worldview encompasses the therapist’s ethics, values and beliefs, faith and spirituality, and motivation. A therapist’s worldview may positively or negatively influence his or her reasoning. Mattingly and Fleming (1994) described many situations where therapists’ skills were believed to be linked to or influenced by the therapist’s personal abilities or style. In many cases, these authors found that therapists used personality traits, such as humour or gentleness, to maximise the client’s participation in therapy. This was often linked to the therapist’s interactive reasoning. It is also known that many therapists are intrinsically motivated to achieve the best possible outcomes for their clients and strive to attain excellence in their practice. However, it is possible that a therapist’s reasoning may also be influenced by other less desirable factors. For example, seminal research by Eisenberg (1979) demonstrated that patient personality and physical appearance had an impact on a variety of medical diagnostic and treatment decisions, in spite of protestations from clinicians that they do not discriminate between patients. Research has also indicated that some health professionals may devalue the skills of people with disabilities, misinterpret their behaviour, underestimate their capabilities (DeLoach and Greer 1981, Gething 1992) or be influenced in their decisions by the client’s socioeconomic status (van-Ryn and Burke 2000). Although research exploring negative influences on clinical reasoning has not been conducted specifically with occupational therapists, it must be acknowledged that these influences exist. Therefore, it is argued that an occupational therapist’s clinical reasoning (procedural, interactive, conditional and pragmatic modes) is modulated by the influence of his or her worldview.

Summary of findings To summarise the discussion above related to pragmatic reasoning and worldview, Table 2 presents a list of the kinds of factors that may produce pragmatic reasoning and those factors that constitute worldview. Furthermore, all the modes of clinical reasoning and their relationships as described in this paper are presented in Fig. 2. This diagram is based on the foundation of clinical reasoning as articulated by Mattingly and Fleming (1994) and incorporates ideas from many researchers as discussed

Table 2. Constituents of pragmatic reasoning and a therapist’s worldview Pragmatic reasoning Worldview The kind of reasoning the therapist

The influence of the following

uses when considering:

factors on the therapist’s

Fig. 2. Conceptualisation of clinical reasoning in the clientcentred practice of occupational therapy.

clinical reasoning:

Family requests or demands Organisational policy Department practice culture Liaison - With colleagues - With outside agencies Funding/ insurance/ reimbursement Equipment and other resources Temporal issues - Treating more than one client at a time - How much the therapist can fit into one session - Seeing the client at a time of day when he or she is not fatigued - Client’s length of stay - Pressure of other clients waiting to be seen

Values Beliefs and attitudes Ethics Faith and spirituality Personal style - Negotiation skills - Manner Views and ideas about occupational therapy Ability to read the practice culture Interest in the profession Repertoire of therapy skills Motivation, influenced by: - Stress - Tiredness - Interest in the client - Rapport with client - Attitude to disability

earlier, most notably Barris (1987), Hooper (1996) and Schell and Cervero (1993). In addition, Fig. 2 draws a simple analogy between the modes of clinical reasoning and the levels of brain function. At the top of the diagram is worldview, which influences and modifies all the other modes of reasoning. Drawing on a simplistic brain function analogy, worldview represents quite sophisticated ‘higher cortical function’, which includes one’s moral beliefs and sociocultural perspective. Similar to the large working areas of the parietal and temporal lobes, the middle level of the diagram contains the three main forms of reasoning: procedural, interactive and conditional. Each of these forms of reasoning may contain the use of generalisation reasoning. The fact that the therapists also seemed to use two or three forms of procedural/interactive/conditional reasoning simultaneously is presented by the use of a venn diagram (Unsworth 2004). These modes of reasoning are either more scientific (procedural reasoning) or more narrative/phenomenological in nature (interactive and conditional). Finally, the last level of the diagram contains pragmatic reasoning. Similar to basic brainstem functions such as breathing, over which we do not have voluntary control, pragmatic reasoning deals with what can be achieved in therapy given the practical constraints or benefits of the environment (for example, economic, clinic or client home). In contrast to scientific and narrative modes of reasoning which are client driven, pragmatic reasoning is context driven.

*(GR): denotes including Generalisation Reasoning.

The arrows that flow around Fig. 2 indicate that these modes of reasoning or influences on reasoning all have an impact on each other. Importantly, this representation of clinical reasoning operates in the client-centred practice of occupational therapy. Although client-centred practice seems most closely linked to interactive reasoning, these concepts imbue practice and are therefore not drawn separately in this diagram.

Limitations and directions for further research The data for this study relied on the use of retrospective reporting. The main disadvantage associated with this technique is the participants’ reliance on memories of their thoughts (Nisbett and Wilson 1977, Martin 1992). In addition, participants may reconstruct their reasoning based on what they think they were supposed to do, or what the researcher might like to hear, rather than what they were actually thinking (Ericsson and Simon 1993). To minimise this difficulty, the debriefing sessions were held immediately after the therapy session. Similar to Mattingly and Fleming’s (1994) research, this study used a relatively small number of therapists and further research with more therapists from a variety of practice settings is required. It was attempted to ‘understand’ the relationship between client-centred practice and clinical reasoning through participants’ narratives of therapy sessions. However, future studies should also interview clinicians specifically about clientcentred practice and its relationship with clinical reasoning to gain a fuller understanding of these two constructs.


17

Finally, the construction of pragmatic reasoning and worldview presented in this paper was based on the absence of data to support what Schell and Cervero (1993) described as the therapist’s personal context component of pragmatic reasoning. Further research is required to confirm the constituents of these constructs, as proposed in Table 2.

Conclusion This research aimed to consolidate our knowledge of the evolving theory of clinical reasoning in occupational therapy. Specifically, the study aimed to explore the relationship between clinical reasoning and the client-centred practice of occupational therapy, to examine the concept of pragmatic reasoning and to present a diagrammatic conceptualisation of clinical reasoning based on both the research findings and the clinical reasoning literature from the past 20 years. As theorised by Higgs and Jones (2000), it was found that for most of the therapists in this research, clinical reasoning occurred in the context of a client-centred practice. However, it was suggested that a reciprocal relationship seemed to exist between interactive reasoning and client-centred practice. Schell and Cervero (1993) theorised that pragmatic reasoning was concerned with the therapist’s thinking in relation to both practice and personal contexts. However, drawing on the research findings and the work of Hooper (1997), it was determined that pragmatic reasoning was primarily concerned with the therapist’s practice context. It was argued that the therapist’s personal context was not a form of reasoning, but that each therapist’s worldview influenced all of his or her thinking. Finally, while further empirical research is required to build and test this emerging theory of clinical reasoning in occupational therapy, it is advocated that, in practice, therapists use professional supervision to recognise and reconcile the sometimes competing nature of the different modes of clinical reasoning and the therapist’s worldview. Acknowledgements Thanks to Jenny Halliday, BAppSci (research assistant), and Laine Nesbit, BOT (research student), who assisted in some of the data collection and analysis, and my graduate students for their stimulating discussions and insights. Thanks also to Dr Mary Omodei, BSc, DipEd, PhD, School of Psychological Sciences, La Trobe University, for sharing the idea and development of the head-mounted video to study reasoning processes, and the team in the Faculty of Health Sciences Technical Services Unit at La Trobe University, Bundoora Campus, for building and maintaining the head-mounted camera system. The video and camera equipment were purchased and built with funds from a La Trobe University ‘Major Equipment Grant’, for which I am grateful. Finally, sincere thanks to all the clinicians who generously allowed entry to their domain, consented to wear the head-mounted video camera, and then shared the clinical reasoning that supported their practice.

18


References Alnervik A, Sviden G (1996) On clinical reasoning: patterns of reflection on practice. Occupational Therapy Journal of Research, 16, 98-110. Barnitt R, Partridge C (1997) Ethical reasoning in physical therapy and occupational therapy. Physiotherapy Research International, 2, 178-94. Barris R (1987) Clinical reasoning in psychosocial occupational therapy: the evaluation process. Occupational Therapy Journal of Research, 7, 147-62. Britannica (2001) Encyclopaedia Britannica. New York: Britannica. Canadian Association of Occupational Therapists (1997) Enabling occupation: an occupational therapy perspective. Ottawa, Ontario: CAOT. Crabtree M, Lyons M (1997) Focal points and relationships: a study of clinical reasoning. British Journal of Occupational Therapy, 60(2), 57-64. DeLoach CP, Greer BG (1981) Adjustment to severe physical disability: a metamorphosis. New York: McGraw-Hill. Eisenberg J (1979) Sociologic influences on decision making by clinicians. Annals of Internal Medicine, 90, 957-64. Embrey DG, Guthrie MR, White OR, Deitz J (1996) Clinical decision making by experienced and inexperienced paediatric physical therapists for children with diplegic cerebral palsy. Physical Therapy, 76, 20-33. Ericsson KA, Simon HA (1993) Protocol analysis: verbal reports as data. Revised ed. Cambridge, MA: MIT Press. Ersser SJ, Atkins S (2000) Clinical reasoning and patient-centred care. In: J Higgs, M Jones, eds. Clinical reasoning in the health professions. 2nd ed. Melbourne: Butterworth Heinemann, 68-77. Fearing V, Law M, Clark J (1997) An occupational performance process model: fostering client and therapist alliances. Canadian Journal of Occupational Therapy, 64, 7-15. Fleming MH (1991) The therapist with the three-track mind. American Journal of Occupational Therapy, 45, 1007-14. Fleming MH (1994) The therapist with the three-track mind. In: C Mattingly, MH Fleming, eds. Clinical reasoning: forms of inquiry in a therapeutic practice. Philadelphia: FA Davis, 119-36. Fondiller ED, Rosage LJ, Neuhaus BE (1990) Values influencing clinical reasoning in occupational therapy: an exploratory study. Occupational Therapy Journal of Research, 10, 41-55. Fortune T, Ryan S (1996) Applying clinical reasoning: a caseload management system for community occupational therapists. British Journal of Occupational Therapy, 59(5), 207-11. Gething L (1992) Judgements by health professionals of personal characteristics of people with a visible physical disability. Social Science and Medicine, 34, 809-15. Harries PA, Harries C (2001) Studying clinical reasoning, part 1. Have we been taking the wrong ‘track’? British Journal of Occupational Therapy, 64(4), 164-68. Higgs J, Jones M (2000) Clinical reasoning in the health professions. In: J Higgs, M Jones, eds. Clinical reasoning in the health professions. 2nd ed. Melbourne: Butterworth Heinemann, 3-14. Hobson S (1996) Being client-centred when the client is cognitively impaired. Canadian Journal of Occupational Therapy, 63, 133-37. Hooper B (1997) The relationship between pretheoretical assumptions and clinical reasoning. American Journal of Occupational Therapy, 51(5), 328-38. Kagan N (1976) Interpersonal process recall: a method of influencing human action. East Lansing, MI: University of Michigan.

Law M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock N (1994) Canadian Occupational Performance Measure. 2nd ed. Toronto: CAOT Publications ACE. Law M, Baptiste S, Mills J (1995) Client-centred practice: what does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62, 250-57. Leicht SB, Dickerson A (2001) Clinical reasoning, looking back. Occupational Therapy in Health Care, 14, 105-30. Lyons KD, Crepeau EB (2001) The clinical reasoning of an occupational therapy assistant. American Journal of Occupational Therapy, 55, 577-81. Martin J (1992) Intentions, responses, and private reactions: methodological, ontological and epistemological reflections on process research. Journal of Counseling and Development, 70, 742-43. Mattingly C (1994a) Occupational therapy as a two-body practice: the body as machine. In: C Mattingly, MH Fleming, eds. Clinical reasoning: forms of inquiry in a therapeutic practice. Philadelphia: FA Davis, 37-63. Mattingly C (1994b) The narrative nature of clinical reasoning. In: C Mattingly, MH Fleming, eds. Clinical reasoning: forms of inquiry in a therapeutic practice. Philadelphia: FA Davis, 239-69. Mattingly C, Fleming MH (1994) Clinical reasoning: forms of inquiry in a therapeutic practice. Philadelphia: FA Davis. Medhurst A, Ryan S (1996) Clinical reasoning in local authority paediatric occupational therapy: planning a major adaptation for the child with a degenerative condition, part 2. British Journal of Occupational Therapy, 59(6), 269-72. McKay EA, Ryan S (1995) Clinical reasoning through story telling: examining a student’s case story on a fieldwork placement. British Journal of Occupational Therapy, 58(6), 234-38. Miles MB, Huberman AM (1994) Qualitative data analysis. 2nd ed. Thousand Oaks, CA: Sage. Morse JM (1987) Qualitative nursing research: a free-for-all? In: JM Morse, ed. Qualitative nursing research: a contemporary dialogue. Thousand Oaks, CA: Sage, 14-22. Morse JM, Field PA (1995) Qualitative research methods for health professionals. Thousand Oaks, CA: Sage. Muecke MA (1994) On the evaluation of ethnographies. In: JM Morse, ed. Critical issues in qualitative research methods. Thousand Oaks, CA: Sage, 187-209. Nisbett RE, Wilson TD (1977) Telling more than we can know: verbal reports on mental processes. Psychology Review, 84, 231-40. Omodei MM, McLennan J (1994) Studying complex decision making in natural settings: using a head-mounted video camera to study competitive orienteering. Perceptual and Motor Skills, 79, 1411-25. Roberts AE (1996) Clinical reasoning in occupational therapy: idiosyncrasies in content and process. British Journal of Occupational Therapy, 59(8), 372-76. Rogers JC (1983) Eleanor Clarke Slagle Lectureship – 1983; Clinical reasoning: the ethics, science, and art. American Journal of Occupational Therapy, 37, 601-16. Rogers JC, Masagatani G (1982) Clinical reasoning of occupational

therapists during the initial assessment of physically disabled adults. Occupational Therapy Journal of Research, 2, 195-219. Schell BA (1998) Clinical reasoning: the basis of practice. In: M Neistadt, E Crepeau, eds. Willard and Spackman’s occupational therapy. 9th ed. Philadelphia: Lippincott, Williams and Wilkins, 90-100. Schell BA, Cervero RM (1993) Clinical reasoning in occupational therapy: an integrative review. American Journal of Occupational Therapy, 47, 605-10. Schön DA (1983) The reflective practitioner: how professionals think in action. New York: Basic Books. Spencer J, Krefting L, Mattingly C (1993) Incorporation of ethnographic methods in occupational therapy assessment. American Journal of Occupational Therapy, 47, 303-309. Strong J, Gilbert J, Cassidy S, Bennett S (1995) Expert clinicians’ and students’ views on clinical reasoning in occupational therapy. British Journal of Occupational Therapy, 58(3), 119-23. Sumsion T, ed (1999) Client-centred practice in occupational therapy: a guide to implementation. London: Churchill Livingstone. Sumsion T (2000) A revised occupational therapy definition of clientcentred practice. British Journal of Occupational Therapy, 63(7), 304-309. Törnebohm H (1991) What is worth knowing in occupational therapy? American Journal of Occupational Therapy, 45, 451-54. Unsworth CA (2001a) Clinical reasoning of novice and expert occupational therapists. Scandinavian Journal of Occupational Therapy, 8, 163-73. Unsworth CA (2001b) Using a head-mounted video camera to study clinical reasoning. American Journal of Occupational Therapy, 55, 582-88. Unsworth CA (2004) Using head-mounted video camera to explore current conceptualisations of clinical reasoning in occupational therapy. American Journal of Occupational Therapy, in press. Van Belle HA (1980) Basic intent and therapeutic approach of Carl Rogers. Burnaby, British Columbia: Academy Press, Wedge Publishing Foundation. van-Ryn M, Burke J (2000) The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science and Medicine, 50, 813-28. Wilkins S, Pollock N, Rochon S, Law M (2001) Implementing client-centred practice: why is it so difficult to do? Canadian Journal of Occupational Therapy, 68, 70-79. Wolters AM (1989) On the idea of worldview and its relationship to philosophy. In: PA Marshall, S Griffioen, R Mouw, eds. Stained glass: worldviews and social science. New York: University Press of America, 14-26. Author Carolyn A Unsworth, BAppSci(OccTher), PhD, OTR, AccOT, Associate Professor, School of Occupational Therapy, La Trobe University, Kingsbury Drive, Bundoora,VIC 3086, Australia. Email: [email protected]


19