CLINICAL REASONING IN REHABILITATION

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What is it and why should i care about my actions?

You will get to know everything after reading this article. In our day to day life, we hear people telling others "to think twice or thrice before doing or saying anything" so that any action which we/others take in life is right and should not harm others or self.

Similarly, Clinical Reasoning (CR) in rehabilitation is an evidence based thinking process, related to therapy, which helps us in making decisions during practice and reflection about this decision- making process can enhance practice and improve outcomes. It guides us to take ethical decisions and select appropriate intervention type for patients and bring improvement in them. Clinical reasoning now a days is also called as Professional reasoning. 

Thus, clinical reasoning in an essential part of healthcare practice for making decisions about which assessment and evaluation needs to be done, which intervention protocol to implement and how it will prove effective. It facilitates therapists in understanding complexities of practice thus making them more efficient and competent in their work skills. Clinical reasoning forms the base for planning effective treatment strategies for patients. These 'effective treatment strategies' are decided based on available evidence related to specific intervention type. (Click on the below link to understand evidence based practice in Rehabilitation and it's importance : https://otpthealthcarerehab.blogspot.com/2020/06/purpose-of-evidence-based-practice-in.html )

    Fig: What is clinical reasoning and why we need it.

NEED FOR CLINICAL REASONING

• Decreases misdirection and misbelieves.
• Increases thinking ability
• Increases safety of practise.
• Professional autonomy, competence, and accountability

WHAT IS CLINICAL REASONING?

• Ways of thinking that therapist use to understand clients and their problems in doing routine occupations. (Reed & Sanderson 1999)
• The cognitive process whereby conclusions can be reached on the basis of information available. ( Hagedorn 1995).

COGNITIVE PROCESS UNDERLYING CLINICAL REASONING OR PROFESSIONAL REASONING.

• CR requires efficient mental work (working memory) for handling complex information. We have observed that students and new practitioners often face difficulties in retaining and effectively using their therapy knowledge. 
• To be a competent therapist (who takes right and quick decisions with respect to patients condition in therapy program) it takes time and lots of experiences to develop effective reasoning based on efficient storage in long-term memory and allowing for use of short-term memory during therapy.
• Cognitive process involves cue acquisition, pattern recognition, limiting the problem space to focus on targeted areas, problem formulation, problem solutions and implementation.

TYPES OF CLINICAL REASONING

1. NARRATIVE

2. INTERACTIVE

3. PROCEDURAL and DIAGNOSTIC

4. PRAGMATIC

5. CONDITIONAL

6. ETHICAL

1) NARRATIVE REASONING:

• Helps to get all history ,medical, psychosocial activities, habits, roles.
• Provides ways of learning about person’s life story.
• Storytelling: practitioners tell stories about clients to each other.(informally during breaks or formally through case studies.)
• Create stories: Make clients visualize- therapy program by mentioning stories about past clients.

2) INTERACTIVE REASONING

Used to:

• Individualize the therapeutic approach and to understand client as a human being.
• Engage client in the intervention.
• Impart a sense of trust and acceptance to the client.
• Try to understand the extent and limitation to occupational performance from the client’s perspective.
• Relieve tension by using humor.

3) PROCEDURAL REASONING and DIAGNOSTIC REASONING

• Involves thinking about the client’s performance.
• Used to think about disability level (diagnosis) focusing mainly on the body and occupational performance problems in activities of daily living.
• Using this reasoning one would choose specific occupation based intervention activities to maximize the function while addressing clients performance problem.
• Procedural reasoning involves interview, observation of person engaged in task, or formal evaluation using standardized assessment tools.
• Diagnostic reasoning is concerned with clinical problem sensing and problem definition. The process starts in advance of seeing a client after referral.

4) PRAGMATIC REASONING

• Management reasoning
• Therapist use this to decide what is realistically possible to do for a particular client in a particular environment and time.
• Factors influence clinical decision like : Space, materials availability, financial obligation, therapist personal value and style, time constraints, the organizational structure, clients social and financial issues, client’s discharge environment etc.

• Therapist must weigh and balance these factors when we try meeting client’s demand within boundaries of particular delivery system.

5) CONDITIONAL REASONING

• Used to review/ re-evaluate therapy plans regularly to meet the client’s need.
• This is done by keeping client’s present and possible future context in mind.
• Using a “what if?” or conditional approach, the therapist imagines possible scenarios for the client.

6) ETHICAL REASONING

• Used to make sure one selects the morally justifiable choices for therapy.
• What should be done in the best interest of the person and the family.
• Taking into consideration of benefits to risks ratio. Patients should get more benefit from the therapy rather than facing risks.

DEVELOPMENT OF CLINICAL REASONING SKILLS

According to the DREYFUS MODEL OF SKILL AQUSITION a professional passes through 5 level :

of proficiency.

1. Novice

2. Advanced Beginner

3. Competent

4. Proficient

5. Expert  

COMMON ERRORS IN CLINICAL REASONING

• Vagueness
• Narrowness of knowledge
• Rigidity or not trying newer approaches or intervention in therapy.
• Irrationality thinking
• Wastefulness

ANSWER TO “WHY SHOULD I CARE”

• Care ,because clinical reasoning is the backbone of our profession.
• Care, because CR is not just logic.
• Care, because CR is what makes our use of occupation, therapeutic, enabling activities different from the average person just doing activities.
• Care ,because devaluing CR belittles our profession.
• Care, because CR gives words to what goes in our mind.
• Care, because without CR we, and others will see OT in a fragmented way.

Thankyou for reading!!!

( Dr.Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe)