Developing Solid Clinical Reasoning Skills in Occupational Therapy
Clinical reasoning in occupational therapy is a term that gets thrown around a lot in OT school and beyond. Professors say it’s something that will eventually come to you with practice and experience in the field. But, oftentimes, it’s not something you get a lot of direct training on.
Clinical reasoning is most frequently addressed by practicing case studies and problem-based learning scenarios where you need to plan your response to certain clinical situations. This is helpful, but we all know that being new in a setting like a hospital with flashing lights, machines beeping, and wires everywhere isn’t exactly stress-free.
This may lead to nerves, hesitation, and questioning everything you’ve learned. Having a solid foundation with plenty of practice will not only give you confidence in your skills but it will help you develop reasoning before you’re in a sink-or-swim type of situation.
Professors may give you the evaluation and treatment knowledge you need to develop clinical reasoning, but putting them into place appropriately and at the right time is usually less cut and dried. That’s why on-site experiences like fieldwork and shadowing are so crucial, because it gives us the chance to see things from the lens of a therapist rather than that of a student.
Students learn the concepts and foundations of OT in a very specific way for the first year or two of their program. But most of us can agree that, once you get to your first fieldwork setting, you quickly realize that there is a whole other type of learning that you’re only beginning to dip your toes in.
That’s why I like to define clinical reasoning as the marriage between those learned rudimentary OT concepts (like ROM and MMT levels) and what happens in the clinic.
Let’s put it this way : you can memorize every minute detail of the Rancho Los Amigos Levels, but none of that information is going to help if you’re not aware of how to use it. This is why fieldwork is such a crucial aspect of OT school. We need to go through some of those motions and begin building our clinical reasoning and judgment before we enter the field on our own.
So we know what clinical reasoning in occupational therapy is, but how exactly can we build it? Fieldwork and clinical experiences definitely help, but there are certain parts of a therapist’s job that specifically encourage clinical judgment:
It may seem that activity analysis is just busy work that supervisors use to occupy students when they run out of other work for them. But this is something that truly requires practice because therapists innately use activity analysis constantly . They may not even realize it until they slow down and go through each step individually to teach students the basics.
Some patient deficits may require small tweaks, whereas others may need a lot more strengthening and training to result in independence. The only way that therapists know what their plan of care (and each treatment) must target is by breaking the task down into smaller parts. This may seem difficult, but it actually makes things much simpler by giving us a clear idea of where the issue is!
Does a patient have mostly intact motor skills but lack the cognition to appropriately sequence each step of the task? This means they will need help knowing what to do and when rather than improving their dexterity to help hold the object.
The only way we can figure this out is to pick apart even the smallest of tasks, such as brushing your teeth. An intention tremor may prevent a patient from initiating the task by picking up the brush. But if we provide a stabilizing device, then they may be able to complete the rest of the task on their own.
If we didn’t identify initiation as the main issue, then we might have incorrectly assumed that the patient could not participate in the task at all . As you can see, an omission like this can change the course of the entire plan of care!
Adapting the environment to the patient may be another result of activity analysis. Sometimes therapists will find that a distracting, unsafe, or stressful environment is the center of a patient’s deficits.
An analysis may show that a patient can complete each component of an activity when they’re with you one-on-one in their room. But they may freeze and get tripped up on each step if they practice the same task in a crowded therapy gym with lots of noise, movement, and activity from other patients and therapists.
The patient’s surroundings can be altered to improve their chances of success. Use that clinical reasoning to dive into what the problem may be. It may be as simple as addressing basic safety issues like removing or affixing throw rugs and covering exposed wires in the home.
But it can also be less obvious. If there is a history of falls, does the patient have deep-set fears about this happening again and not being able to recover? Do they have an abusive family member that controls the patient’s every move and prevents them from doing certain things on their own?
These may sound like social barriers but they are also environmental obstacles that should be addressed to encourage patient independence.
Upgrading and Downgrading
Once you use activity analysis and environmental modification, you may still find that the patient has issues with task completion. This may mean that it’s appropriate to downgrade the task to make it a better fit for their needs or abilities. The same applies to patients who easily complete tasks right off the bat; they will benefit from a more difficult activity to challenge them and strengthen their skills.
Upgrading and downgrading is usually a big part of therapeutic activities and not necessarily functional tasks like dressing or completing hygiene tasks. However, it’s sometimes appropriate for patients to participate in a “downgraded” functional task, more commonly known as task modification.
This is when therapists can make functional tasks easier for patients by training them in the use of adaptive equipment, compensatory strategies, or other techniques to improve patient performance despite the presence of certain deficits.
Improving your Clinical Judgment
Clinical reasoning is at the heart of each of these central occupational therapy concepts. While these concepts are frequently taught in OT school, there are other ways to improve clinical reasoning outside of this:
Practice, practice, practice
A good example is running through case studies and problem-based learning scenarios. We mentioned that this is often how professors teach clinical reasoning, but getting even more practice in these areas is never a bad idea.
Run through a range of scenarios, especially ones that you may not see as often in clinical settings, such as mental health or burn-related cases. This is a good way to broaden your perspective while also getting some form of experience in areas you may not otherwise have exposure to.
Another way to improve your clinical reasoning skills is by asking for continual feedback. Practicing is certainly important, especially if you have an answer key to refer back to. But you can’t always ask for elaboration if you need more details on the rationale behind that answer.
This is why fieldwork and on-site visits are so important, because supervisors can provide real-time comments and critiques to shift your perspective. This encourages therapists to dig deeper for answers and end up with the option that’s most effective, safest, and the best fit for the patient.
If you haven’t taken the NBCOT exam yet, you will soon learn that coming up with the best and safest answer is a good way to problem solve those exam questions!
Higher-level thinking, also called metacognition , is another process that plays a big part in our own learning. It’s important to be continually aware of all the aspects that impact our patients’ performance.
This doesn’t mean that you need to constantly address all of a patient’s deficits because this can be impossible (and counterproductive) with some low-functioning patients. But you should always strive to increase your own perspective in an effort to give patients the best care possible.
You are likely already practicing metacognition in ways such as planning and preparation for treatment sessions, assessing your own comprehension of learning materials, adjusting your plan of care when you discover something doesn’t work as you thought, and monitoring your progress each step of the way.
The good news is that you’re likely well on your way to developing solid clinical reasoning skills, if you haven’t already! By combining your instincts with your OT training and experience, you will be able to reason your way through some of the toughest problems. Keep practicing and always be open to learning.
What is your favorite way to encourage clinical reasoning in OT? Let us know in the comments!
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- Aug 19, 2019
Case Study | Clinical Reasoning: Home or Hospital?
Updated: Nov 8, 2020
By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub
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Occupational Therapy: A Client Centered Analysis and Project Planning
Client Demographic and Medical Information
The client is a female who lives alone in her own apartment. She has had a post open reduction internal fixation on the right femur fracture and from it has developed respiratory abnormalities along the way. The said health status has been a result of a past accident while the client was on vacation. After the accident, the client had an operation on her right leg and was then transferred to another hospital later on due to the swelling of the operated leg. From there the swelling has imposed another form of problem which resulted to her respiratory function abnormalities.
Target Point of Development: Goal of Therapy (Daily Activities)
The client basically wants to function normally again especially when it comes to moving the legs freely and specifically breathing normally with no specific hindrances to the function of the respiratory system. Considerably, the process by which the therapy entails to respond to these problems is through imposing regular slow-walking activities that would gradually increase in time-length as the client begins to adapt to the therapy’s everyday nature. Along with that comes the daily breathing exercise that shall be imposed so as to make sure that the client’s breathing process would be further defined for improvement. Like the first type of development, the client’s breathing exercise shall first pick up from slow and short span of therapies towards longer spans hence increasing the capability of the client to perform long term breathing exercises.
Short Term Goals:
Activity: Assistance to patient when it comes to dressing herself up [this shall include a 20 to 30 minute dressing up so as to make a considerable approach in helping the patient train to do the task]
Rationale: Patient expresses her desire to dress on her own without assistance later on but accepts the fact that as of now she needs to practice regularly to be able to attain the said state.
Activity: Assistance to patient when walking to and from her own kitchen and dining room. [the distance is pretty close and the activity is expected to be held at least three times per day with at least 10 minute session each practice]
Rationale: The client asks that she be assisted to walk around the house freely after the therapy
Long Term Goals:
Activity: Walking outside the house within the neighborhood for at least 10 minutes each day
Rationale: The patient wants to be able to walk around the neighborhood freely as she follows the pattern of recovery that the therapy intends to impose on her current health status.
Activity: The therapy shall involve a more defined way of allowing the patient gain full control of herself especially when it comes to standing up. The activity shall involve points of development in a gradual manner that includes standing freely for three minutes and later on shall adjust up to five-ten minute practices.
Rationale: Patient asks for assistance in standing up for long minutes without the need to feel extensive pain.
Occupational Therapy Interventions
The client should be specifically prepared in three different aspects of development specifically considering physical, mental and emotional factors of individuality. This will help the client inhibit a positive outlook of the situation that she is supposed to undergo during the entire therapy session. With the assumption of mental preparedness, the OT attendant could provide a summation of the goals that are to be achieved in the course hence giving the client an overview of what she would expect to happen after the application of the process of development being imposed through the therapy. This ideal assumption of development could be further imposed in the aspect of emotional and physical preparedness.
In the process of preparation, it is important to have a correlative talk with the client which shall further help her redefine her being alongside the developments that she is supposed to incur through the time frame being completed for the therapy. The purpose of this approach is to make sure that the client knows what she is supposed to expect and further help her make a list of goals she herself would like to accomplish during and after the therapy sessions.
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Clinical Reasoning in Occupational Therapy: Case Studies Across the Lifespan
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Clinical Reasoning in Occupational Therapy
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Occupational therapy practitioners use clinical reasoning in all areas of practice to determine who needs intervention, the most effective interventions, and expected outcomes. Successful professionals also use clinical reasoning to confidently assimilate new information, make decisions, argue well, and advocate for clients.
A particular challenge facing occupational therapy students and novice practitioners is that actual clients do not always fit a typical clinical picture. This text guides readers in learning how to identify relevant clinical data among the diverse details of clients’ histories, interests, comorbidities, and lifestyles through fully developed case examples that guide reasoning through hypothesis refinement and changing situations.
This essential text is aligned with the Occupational Therapy Practice Framework and integrates frames of reference and evidence in practical ways. Learning activities challenge readers to thoughtfully integrate what they are learning into their own ways of reasoning. Designed with the belief that systematic use of clinical reasoning strategies streamlines and supports using responsible, cost-effective interventions, Clinical Reasoning in Occupational Therapy guides students and practitioners in thinking efficiently, flexibly, and critically, providing clients with the best possible care.
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Table of Contents
- Contents iii 4
- About the Authors v 6
- Figures, Tables, Exhibits, Case Examples, and Practice Wisdom vii 8
- Introduction ix 10
- PART I. Occupational Perspective for Clinical Reasoning 1 12
- PART II. Frames of Reference 65 76
- PART III. Intervention 143 154
- Citation Index 223 234
- Subject Index 227 238
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All Things OT
A collection of occupational therapy resources
Clinical reasoning is the thinking process used by occupational therapists as they interact with clients throughout the occupational therapy process. Seven different types of clinical reasoning are defined and discussed below.
This type of reasoning focuses on the facts such as impairments, disabilities, and performance contexts. It can be used to identify problems and to develop solutions.
This type of reasoning specifically relates to the client’s diagnosis and how that diagnosis affects the clinical picture. It is sometimes considered a component of scientific reasoning.
This type of reasoning focuses on the process of what, when, and how interventions and other solutions will be carried out. It focuses primarily upon the process of therapy.
Narrative and Interactive Reasoning
This type of reasoning relies on story telling in order to identify problem areas and solutions. It requires interaction between client and therapist in order to gain an understanding of the situation.
This type of reasoning focuses on logistics such as cost, time, therapist’s skills, client wishes, and physical location. It looks at the problems and the contexts and focuses on developing practical and realistic solutions.
This type of reasoning brings in the aspect of right and wrong as it looks at issues and aims to develop the best and most moral solution to a problem.
This type of reasoning is the most complex, and it encompases both an empathetic understanding of the situation, as well as a vision for its resolution. It incorporates the other types of reasoning into an integrated picture of the client and a framework for selecting the most appropriate course of action in order to achieve the ideal end goal.
References and Further Reading:
Krajnik, S. (2015). Clinical reasoning in occupational therapy [Handout].
Pendleton, H., & Schultz-Krohn, W. (2011). Pedretti’s occupational therapy for physical dysfunction (7th ed.). St. Louis: Mosby Elseiver.
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Clinical Reasoning in Occupational Therapy: A Comprehensive Guide
Clinical reasoning is the backbone of effective decision-making and problem-solving in occupational therapy (OT). It enables therapists to analyze complex situations, gather information, and develop tailored treatment plans for their clients. In this blog post, we will delve into the intricacies of clinical reasoning in occupational therapy, exploring its importance, key components, and practical strategies. Whether you’re a seasoned occupational therapist or a student just starting your journey, this guide will empower you to enhance your clinical reasoning skills and deliver optimal outcomes for your patients.
Important of Clinical Reasoning in OT
The Significance of Clinical Reasoning in Occupational Therapy At the core of occupational therapy lies the process of clinical reasoning. This cognitive process allows therapists to integrate knowledge, clinical expertise, and patient values to make informed decisions. Here’s why clinical reasoning is paramount in occupational therapy:
- Promotes Personalized Treatment: Clinical reasoning enables occupational therapists to individualize treatment plans based on the unique needs and goals of each client. By analyzing client factors, activity demands, and environmental considerations, therapists can tailor interventions to maximize functional outcomes.
- Enhances Problem-Solving Abilities: Occupational therapists face diverse challenges and must navigate complex client situations. Clinical reasoning equips them with the skills to identify problems, explore potential solutions, and make sound judgments that optimize intervention effectiveness.
- Facilitates Evidence-Based Practice: Clinical reasoning guides therapists in critically evaluating research evidence and integrating it with their clinical expertise. This ensures that therapeutic interventions are grounded in the latest scientific knowledge and align with best practices.
Components of Clinical Reasoning in OT
Components of Clinical Reasoning in Occupational Therapy To fully grasp clinical reasoning in occupational therapy, it’s essential to understand its core components. Here are the key elements involved:
Strategy of Clinical Reasoning for OT
Strategies for Enhancing Clinical Reasoning in Occupational Therapy
- Continual Professional Development: Engage in ongoing learning and attend relevant workshops, conferences, and seminars to stay updated with the latest evidence-based practices and research.
- Reflective Practice: Regularly reflect on clinical experiences, seeking to understand the reasoning behind your decisions and analyzing the outcomes. This introspection helps refine your clinical reasoning skills over time.
- Collaborative Approach: Foster open communication and collaboration with colleagues, clients, and other healthcare professionals to gain diverse perspectives and enhance your problem-solving abilities.
- Utilize Clinical Tools: Make use of standardized assessment tools, clinical guidelines, and evidence-based resources to support your clinical reasoning process.
FAQ: Frequently Asked Questions about Clinical Reasoning in Occupational Therapy
Q1: What role does clinical reasoning play in the occupational therapy process?
A1: Clinical reasoning serves as the foundation for decision-making in occupational therapy. It guides therapists in analyzing client information, identifying problems, setting goals, planning interventions, and evaluating outcomes.
Q2: How can I improve my clinical reasoning skills?
A2: Enhancing clinical reasoning skills requires a combination of ongoing learning, reflective practice, collaboration, and utilization of clinical tools. Engaging in professional development activities and
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Clinical Reasoning Case Studies as Teaching Tools
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Maureen E. Neistadt , Jennifer Wight , Shelley E. Mulligan; Clinical Reasoning Case Studies as Teaching Tools. Am J Occup Ther February 1998, Vol. 52(2), 125–132. doi: https://doi.org/10.5014/ajot.52.2.125
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Objective. Students are taught how to apply clinical reasoning methods through a variety of teaching methods, including the use of case studies. Various types of case studies have been described in the literature: paper cases, videotape cases, simulated client cases, and real client cases. This study examined the effectiveness of a new type of paper case study—the clinical reasoning case study—in teaching the clinical reasoning process to occupational therapy students .
Method. Four seniors in an undergraduate occupational therapy program completed intervention plans in response to both traditional medical model and clinical reasoning paper case studies. Qualitative methods were used to analyze intervention plans and videotaped discussion about this learning experience .
Results. Themes discovered in the data sources suggest that compared with traditional case studies, the clinical reasoning case studies increased the quality of participants’ intervention plans, participants’ confidence levels about their plans, and participants’ understanding of the clinical reasoning process. Participants also reported preferring clinical reasoning case studies over traditional paper case studies .
Conclusion. The clinical reasoning case studies are effective teaching tools because they provide students with a holistic picture of the client and his or her occupational therapy treatment. In addition, these case studies model the clinical reasoning process by organizing client information according to the types of clinical reasoning that would be used to gather that information. Occupational therapy educators may find this type of paper case study useful in introducing students to the intervention planning process .
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Clinical reasoning in occupational therapy: an integrative review
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- PMID: 8322880
- DOI: 10.5014/ajot.47.7.605
The occupational therapy literature has been comprehensively reviewed to identify various theoretical answers to the question of what is clinical reasoning. Authors to date have two primary answers to this question, which we labeled scientific reasoning and narrative reasoning. Additional literature addresses the influence of personal and practice contexts on clinical practice. These are labeled pragmatic reasoning and are proposed to be an integral part of clinical reasoning. Pragmatic reasoning considers issues such as reimbursement, therapists' skills, and equipment availability. To be comprehensive, further study of clinical reasoning should include these contextual issues as an inherent part of the clinical reasoning process.
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Learning and Development of Diagnostic Reasoning in Occupational Therapy Undergraduate Students
1 Department of Nursing, Physiotherapy and Occupational Therapy, University of Castilla-La Mancha, Talavera de la Reina, Toledo, Spain
2 Health Department, Faculty Human Rehabilitation, University of the Valle, Cali, Colombia
3 Integra Saúde Research Unit, Health Science Department, Faculty of Health Science, Universidade da Coruña, Campus de A Coruña, A Coruña, Spain
4 University School of Social Work, Universidade Santiago de Compostela, Santiago de Compostela, Spain
5 Faculty Padre Ossó, University of Oviedo, Oviedo, Spain
The data used and/or analysed during the current study are available from the corresponding author on reasonable request.
One way to facilitate occupational therapy undergraduate students transferring their academic skills of data gathering and analysis to professional settings is to ensure they can competently use diagnostic reasoning. Nevertheless, there are several obvious gaps in empirical evidence related to the learning and development of this style of reasoning in occupational therapy undergraduates. The most important are related to promoting higher-order thinking and the use of information to solve problems in the context of professional practice. This study analyses undergraduates' diagnostic reasoning and its changes during their education.
Materials and Methods
This multicentre study was conducted with a descriptive observational design. The study took place at the University of Coruña (Spain), University of Castilla-La Mancha (Spain), and University of el Valle (Colombia). The sample was n = 247. For data collection, a clinical case was specifically designed. IBM SPSS Statistics (v19) and EPIDAT 3.1 were used for the data analysis.
Participants identified and categorized occupational performance problems. However, they had difficulties when identifying and categorizing the occupational performance components (specifically, the symptoms and signs of the disease presented in the study case). They presented limitations to analyse and synthesize the information collected to develop an explanation of the occupational problems and their causes.
Undergraduate students' ability to analyse and synthesize information during data collection is poorly organized, so it makes the problem formulation difficult. This study contributes to the knowledge of undergraduates' diagnostic reasoning features, specifically the undergraduate students' capacities and limits to process information during the occupational assessment.
Encouraged by the studies on diagnostic reasoning done by the discipline of medicine since the early 1980s, the study of professional reasoning in occupational therapy has led to several lines of research [ 1 ]. One of the most important lines is the study of the information processing involved in diagnostic reasoning understood as a process of problem solving or decision making [ 2 – 7 ]. This area of research has provided ways to look at the competencies that occupational therapists need to handle information and arrive at an occupational therapy diagnosis in different practice fields [ 8 – 12 ].
Diagnostic reasoning examines and analyses cause(s) or nature of conditions requiring occupational therapy intervention and attempts to explain why a client is experiencing problems using a blend of scientific-based and client-based information [ 13 ]. When diagnostic reasoning is not well constructed, the causes of performance deficits could be misidentified, which could lead to the incorrect intervention principles being followed and thus lead to ineffective treatment [ 14 ].
According to Rogers and Holm [ 6 ], the problem-solving process that leads to the occupational therapy diagnosis is referred to as diagnostic reasoning. The occupational diagnosis usually consists of components: descriptive, explanatory, cue, and pathologic [ 6 ] ( Table 1 ).
Structural components of occupational therapy diagnosis [ 6 ].
Thus, the occupational therapy diagnosis is the product of diagnostic reasoning, the result of the problem-solving process during the initial assessment.
The information processing involved in diagnostic reasoning [ 10 , 15 , 16 ] implies two processes. The first is to acquire cues and recognise patterns during data collection to identify information on occupational performance areas, symptoms and signs, skills, performance patterns, and characteristics of the environment (hereafter, components of performance). This information is categorized thanks to a preselected theoretical framework of reference. The second is to formulate the problem, which allows analysing and synthesizing the information collected in an occupational therapy diagnosis to develop an explanation of the occupational problems and their causes. In this process, not only do experienced occupational therapists have a great deal more knowledge than novices but also their knowledge is more diverse, better organized, and in a more accessible way due to related prior experience [ 17 ]. Robertson [ 18 ] and Robertson et al. [ 19 ] looked at differences between novices and experts in occupational therapists' professional reasoning and found that undergraduate students and experts had access to the same information. However, the information was more clearly defined and highly organized by the experts who develop knowledge networks that are reinforced by working with similar cases over time. This repetition is essential for the development of useful knowledge networks and cannot be replicated by exercises in academic environments.
In the case of undergraduate students, the information was less defined than in the case of the experts due to the lack to domain-specific knowledge related to problem representation. Accordingly, the way in which the novices organize their knowledge to analyse and synthesize the information gathered during the initial assessment is an element of primary importance to acquire a proper professional reasoning during their academic education.
In occupational therapy, the line of research that focuses on the study of the differences between novices vs. experts in professional reasoning has been extensive [ 1 , 20 , 21 ]. However, there are several obvious gaps in empirical evidence, “but ones of such importance that they bear highlighting” are those related to information processing, fieldwork supervision, and personal variances in reasoning [ 22 ]. Particularly, those related to the learning and development of diagnostic reasoning of undergraduate students of occupational therapy (no specific references in the literature have been found for this topic). According to Farber and Koenig [ 23 ] for the future of the profession, “we need to strive toward facilitating the students' best clinical reasoning and to promote relevant problem-solving strategies.” As a result, to know the characteristics of the undergraduates' diagnostic reasoning is a prime objective.
From our point of view, although the body of knowledge on clinical reasoning in OT is extensive, it is still inadequate [ 24 ]. According with Schaaf [ 25 ], Rochmawati and Wiechula [ 26 ], and Bondoc [ 27 ], educators should start examining their practices and aligning those practices with the best evidence concerning instructional methods. We consider that this purpose fully justifies this research. The overall objective of this study is to analyse undergraduates' diagnostic reasoning and its changes during their education. The specific objectives are (a) to analyse the undergraduates' ability in identifying and categorizing information during data collection, (b) to analyse the undergraduates' ability in analysing and synthesizing information for problem formulation, and (c) to analyse the changes done during the undergraduates' education.
2. Materials and Methods
The study obtained the approval of the University of Valle Human Ethics Review Institutional Committee (ethics approval number VRI/1772); the Galician Network of Research Ethics Committees, attached to the General Technical Secretariat of the Department of Health (ethics approval number 2014/399); and the Healthcare Service of Castilla-La Mancha Clinical Research Ethics Committee (ethics approval number 2014/036).
2.2. Study Design
Multicentre study [ 28 ] was conducted in five phases (from October 2013 to September 2016) and involved three universities: the University of Coruña (Spain) (UDC), University of Castilla-La Mancha (Spain) (UCLM), and University of el Valle (Colombia) (UV). This study falls within the field of educational research [ 29 ]. It was conducted with a quantitative approach and a cross-sectional study design [ 28 ] ( Figure 1 ).
Flow chart of research stages and participants in the study.
After reviewing the bibliography, designing the study, getting approval by the Research Ethics Committees, and obtaining the authorization from the dean of each faculty ( Figure 1 , phase 1), the process to select the participants started. A meeting was organized with the undergraduates in three different programs: 53 students attended at the Universidad del Valle, 90 at the Universidad de A Coruña, and 104 at the Universidad de Castilla-La Mancha, in which research goals were explained and their voluntary participation in the study was requested. Those who agreed to participate signed informed consent (IC) forms. The universities' population of the three universities in the first, third, and fourth years was 460 undergraduates, with a female predominance n = 392 (85.2%).
Programs length is four years. Content and teaching strategies in the three universities are similar and ordered in the same way. The curricula in all institutions comply with standards from ENOTHE and WOFT [ 30 ], and their teacher continuing education criterion and teaching strategies are common and shared by the three universities. Professional reasoning is taught using lectures, reading, problem-based learning, tutorials, and case methods. These strategies are used in specific practice fields: mental health, geriatrics, paediatrics, physical and intellectual impairments, community, and education. The three institutions were actively engaged in the study. The principal researchers are professors from all three institutions, and participants were included from all university programs.
In the selection process, first-, third-, and fourth-year undergraduates were included. The second-year undergraduates were not selected because the contents of the syllabus from the first and second years are similar concerning professional reasoning skill learning. With the aim of contextualizing the findings of this study, the structure of occupational therapy programs is described as follows. Therefore, it will be possible to identify when the different elements of professional reasoning are taught and the students' level of expertise. The students acquire generic competencies associated with basic general knowledge of professional reasoning during the two first years of education, at the three universities ( Table 2 ).
The clusters of specific competences associated with occupational therapy process and professional reasoning at the different universities.
PD and PF: physical dysfunction and paediatric fields; TFound, model, and MB: theoretical foundations, models of practice, and methodological bases.
The basic assumption was that the undergraduate students will improve their ability to identify, categorize, analyse, and synthesize the information during their education. Those who were also enrolled in a related degree and those who were retaking subjects from previous academic years were excluded. Finally, after doing the pilot test and after excluding those undergraduates that voluntarily decided not to participate, the study sample was n = 247 participants, with an average age of 21 ± 1.5 and a female prevalence of n = 222 (89.9%) ( Figure 1 , phase 2).
2.4. Data Collection
For data collection, a clinical reasoning case study was specifically designed [ 28 ] which consisted of a description of the gathered data, step by step, during the initial evaluation process. According to Neistadt et al. [ 31 ], a clinical reasoning case study is a type of case method that “illustrate the occupational therapist's thought processes by providing specific client information.” This type of case study chunks client information the way an experienced therapist might. Therefore, a case study method is reliable to assess professional reasoning to the extent that it “uses a variety of reasoning skills critical to solving real clinical problems” [ 32 ].
This case study was validated during two years with a group of occupational therapists ( n = 150) who had more than five years of experience in different fields of practice, with a reliability coefficient of 0.98 (rxx′ = 0.98). Furthermore, it was conducted as a pilot study with students from two universities (UDC and UCLM). In this pilot study, we had 149 students from the first, second, third, and fourth academic years. The validity in the pilot study with the student's population achieved a reliability coefficient of 0.80 (rxx′ = 0.80) [ 28 ] ( Figure 1 , phase 2). The questions were formulated after reviewing the literature on similar studies [ 33 ]. All the questions at the end of the Figure 2 were checked by three experts (from each university), to make them easier to understand for the students. This consultation resulted in a further modification of the information contained in the case. So, it was culturally more valid for students at Universidad del Valle (Colombia). Finally, five open questions were developed for each participant to answer ( Figure 2 ).
Case study. PP: performance problem; PC: performance components; PP1: instrumental activities of daily living (IADL); PP2: social participation; PP3: sleep and rest; PP4: leisure.
According to the previous questions, the participants were requested (a) to read the case in order to identify and categorize the occupational performance problems, (b) to identify and categorize the components of performance associated with the identified occupational performance problems, and (c) to formulate the problem, according to an occupational therapy diagnosis. Open questions were used to obtain the data related with the study variables, basing on the analysis of the student's answers, as described in Table 3 . Each participant received the same instructions before solving the case. The test was conducted in a single room, which was large enough to keep participants working individually in small groups of five undergraduate students. After presenting the study, the authors distributed the booklets to the participants. The participants worked with the same booklet throughout the test. Time and progress throughout the sequence of steps were controlled. The case resolution time was about 60 minutes.
2.5. Data Analysis
The established variables for the assessment of the undergraduates' answers about the case resolution are found in Table 3 .
A descriptive study of the variables registered in the study was carried out. The variables were expressed by measures of frequency and percentage. The chi-square test was used to test the null hypothesis of equality of proportions, with a confidence interval of 95%. The analysis was carried out using IBM SPSS Statistics (v19) and EPIDAT 3.1.
The percentage of participants that identified and categorized information related to performance components was significantly lower than the percentage of participants that identified and categorized occupational performance problems. It should be noted that the lowest percentage was symptoms and signs ( Table 4 ).
Results regarding identifying and categorizing information ∗ .
∗ Results for the group of participants from the three universities (UV, UDC, and UCLM). Percentages are based on the total sample ( n = 247). CI: confidence interval; PP: performance problem; PC: occupational performance components.
Regarding the knowledge organization of the undergraduates for analysing and synthesizing information for problem formulation, most participants in the study did not associate any symptoms or signs as a probable cause of performance problems. Only 4.9% of the participants associated one symptom or sign, and only three participants in their fourth year associated two or more symptoms or signs. In addition, the percentage of participants that associated only one component of performance as a probable cause of performance problems was higher than the percentage of participants that associated two or more components of performance. In short, the ability of students to analyse information was poor ( Table 5 ).
Results regarding analysing information ∗ .
∗ Results for the group of participants from the three universities (UV, UDC, and UCLM). AY: academic year. Percentages are based on the total sample ( n = 247). ∗∗ Statistically significant variables ( p < 0.005) are highlighted in italics.
In relation to synthesizing information in an occupational therapy diagnosis, the results show that none of the undergraduate students made a complete occupational diagnosis. Nevertheless, less than half of the participants made a partial occupational diagnosis. In this partial diagnosis, 16% identified only one variable to explain the performance problems described whereas 27% identified two or more variables (three variables were expected for a totally correct response). In summary, students showed very low percentages of occupational therapy diagnosis.
Regarding the changes during the undergraduates' education, there was a significant increase in the identification of performance problems in the IADL and social participation areas ( p = 0.005) between academic years (hereafter, AY) 1 and 4. The increase in the identification of occupational performance problems in the leisure area was constant throughout academic education ( p = 0.001). The comparison of the other academic years did not reveal any significant differences. With respect to the development in categorization of the identified performance problems, when AY1 vs. AY4 and AY3 vs. AY4 are compared, a significant increase in all the occupational performance areas can be identified ( Table 6 ).
Comparison of differences among academic years: identification and categorization of problems/components of occupational performance ∗ .
Comparison and estimation of differences among academic years in the identification and categorization of each area and components of occupational performance. ∗ Results for the group of participants from the three universities (UV, UDC, and UCLM). AY: academic year. Percentages are based on the total number of participants in each academic year. S/S: symptoms/signs; PS: performance skills; IADL: instrumental activities of daily living; SP: social participation; RS: rest and sleep; PP: performance patterns. ∗∗ Statistically significant variables ( p < 0.005) are highlighted in italics.
An increase in the identification of the performance components was also identified, specifically in the signs and symptoms, in the performance patterns, and in the environment ( p = 0.001) when comparing the first and fourth academic years. Also, when the first and third academic years were compared, a significant increase in the categorization of the performance components was identified, specifically in the signs and symptoms ( p = 0.004) and in the performance patterns ( p = 0.001) ( Table 6 ).
In summary, a significant improvement was identified in the identification and categorization of information into performance areas and performance components (symptoms/signs, performance patterns, and environment) throughout the students' academic education.
On the other hand, a statistically significant improvement in analysing information throughout the students' education was found in symptoms/signs and performance patterns ( p = 0.001) and environment ( p = 0.004), as well as an improvement in synthesizing information using an occupational therapy diagnosis. The comparison between the academic years AY1 vs. AY4 and AY3 vs. AY4 yielded a chi-square of p = 0.001 ( Table 6 ).
The results of this research show that participants identified and categorized occupational performance problems. However, they had difficulties when identifying and categorizing the occupational performance components (specifically, the symptoms and signs of the disease presented in the study case). In addition, they showed poor capacity in analysing and synthesizing the information collected to outline the problem formulation. As a result, undergraduate students have difficulty processing the occupational performance components during the initial evaluation to articulate a satisfactory explanation of the occupational problems presented in the case.
The previous considerations arise from the two findings that were obtained. The first of them is related to the undergraduate's knowledge in identifying and categorizing information during data collection. According to the literature review, undergraduate students of occupational therapy historically have difficulties in identifying and describing problems in occupational performance. However, they do not have those difficulties when it comes to describing medical and psychosocial conditions [ 3 , 6 ]. Contrary to what might be expected from the literature review [ 34 , 35 ], a high percentage of the participants in this research were able to identify the information related to the performance areas presented in the case study. However, they found it more difficult to identify the signs, symptoms, skills, patterns, and environmental characteristics related to such performance problems. They also found it difficult to categorize them according to a theoretical reference framework or practice model.
Although various studies [ 36 , 37 ] emphasize the primacy of psychological and medical models in the education of undergraduates, this finding obtained from the study participants is contrary to that thesis. This fact may be related to (a) the strengthening of practice models in our discipline, which are focused on the study of performance and occupational participation and which are organized around the evaluation of the areas of occupational performance, and (b) the weakening of education in basic knowledge of medicine and psychology [ 38 ].
This interpretation is confirmed when the facility of participants to identify and categorize problems in performance areas is compared with the facility to identify signs, symptoms, skills, patterns, and characteristics of the environment. The latter was significantly lower, particularly in the case of pathological conditions. The percentage of participants who identified the signs and symptoms of the disease presented in the case was minimal. These facts question central aspects of occupational therapy undergraduates' education since it is a health science, and therefore, the knowledge of pathological conditions and their influence on occupational performance and participation are decisive. Strengthening our practice models should not lead to underestimate medical and psychological knowledge because they assist in the elaboration of an occupational therapy diagnosis [ 39 ].
In this regard, we advocate for reinforcing the acquisition of knowledge related to medical and psychological conditions and for consolidating the undergraduate students' education to identify and categorize this kind of data collected during the evaluation.
In the second finding, although an improvement of the knowledge organization of the undergraduates for problem formulation is identified, it is found that undergraduate students present limitations in analysing and synthesizing the information collected in order to develop an explanation of the occupational problems.
On the one hand, none of the participants elaborated a complete occupational diagnosis. In addition, although a small number of participants made a partial occupational diagnosis, this is characterized by relating a single variable to explain the identified performance problems. It seems that despite finding improvements in the clinical reasoning of students when they increase their experience and advance in their courses, this improvement is not reflected in their ability to synthesize information collected during the initial assessment. The analysis of more than one variable to explain the causes of performance problems is very low among the participants. There is a predominance of reductive explanations, focusing on performance patterns and skills as the only causes of performance problems at the expense of explanations examining the complex and changing dynamics of factors that affect occupational performance and participation [ 40 ]. In other words, they tend to make reductive interpretations of performance problems instead of doing multifactorial interpretations, which would be more aligned with the theoretical assumptions of our discipline.
This study confirms the participants' limitations in organizing their knowledge according to an occupational therapy diagnosis. As they have these difficulties, they rely on other areas of knowledge, such as medicine and psychology to elaborate an occupational therapy diagnosis [ 37 ].
Previous research findings emphasize the importance of carrying out a problem formulation, encompassed by an occupational therapy diagnosis [ 18 , 41 ]. Thus, an occupational therapy diagnosis makes easier to understand the complex and dynamic interaction among symptoms/signs, performance skills, performance patterns, and environments, along with the activity demands of the occupation being performed [ 38 ]. Therefore, the causes of performance problems can be identified better, leading to the correct intervention principles being followed and thus leading to effective intervention.
The findings of this research show that participants had difficulties to elaborate an occupational therapy diagnosis. This limitation might be related to the reductive interpretation of occupational performance problems. So, interpretation moves away from the ontological exegesis of the performance problems and occupational participation that define our discipline [ 42 ].
The participants' interpretation is based fundamentally on medical and psychological variables derived from a health exegesis of individual nature. It is the opposite of other broader interpretations that relate the health of individuals, groups, and communities to environmental, social, and cultural factors. These interpretations argue that the conditions of injustice, deprivation, alienation, imbalance, and occupational apartheid have determinant effects on the capacity for performance and occupational participation of individuals, groups, and communities [ 43 ].
The difficulty to elaborate an occupational therapy diagnosis could create a gap in the understanding of the new theoretical contributions in occupational therapy.
We strongly advocate promoting the organization of knowledge brought by occupational therapy diagnosis. Strengthening the undergraduate students' education to reason professionally is the best way to progress our knowledge.
An overview of our results shows a progression in the ability of students to identify, categorize, and analyse case information. When we compared responses between first- and fourth-year students, first- and third-year students, and third- and fourth-year students, we found that the higher the year, the better is their identification of relevant information and the information analysis is more complete and diverse [ 41 ]. This finding might be explained by students increasing experience and learning who are developing more knowledge and diverse knowledge. However, results do not show a similar progression in student's ability to elaborate an occupational diagnosis. This last fact might indicate that despite the education received, students have difficulties to synthesize information, because of their difficulties to represent the problem [ 18 , 19 , 23 ]. Probably, this difficulty is related with the fact that the students do not have their knowledge organized well because they do not have prior experience. It would be necessary to strengthen the learning of the occupational therapy diagnosis.
In conclusion, the findings of this research with respect to undergraduate students' knowledge related to the identification and categorization of information, as well as its analysis and synthetisation, question the undergraduate's ability to carry out efficient diagnostic reasoning. This fact could lead to the incorrect intervention principles being followed and thus lead to ineffective treatment.
4.1. Study Limitations
Due to the characteristics of the research design, it was not possible to establish control procedures for potential confounding variables to avoid potential bias in results. However, the study does make it possible to establish the possible relationship between the variables involved to conduct analytical studies.
4.2. Future Lines of Research
Our results suggest reinforcing students' professional reasoning learning by improving theoretical knowledge and practical skills related to problem representation and occupational diagnosis. It should be noted that research on undergraduates' professional reasoning from English-speaking countries predominates. This suggests that this research area in developing countries has not been sufficiently studied. Therefore, further research should be undertaken to analyse in depth the cultural relevance of knowledge involved in the undergraduates' learning process of professional reasoning.
Undergraduate students' ability to analyse and synthesize information during data collection is poorly organized, so it makes the problem formulation difficult. Although an improvement was observed in the knowledge and its organization throughout education, the limitations on processing information when making an occupational therapy diagnosis are evident.
This study contributes to the knowledge of undergraduates' diagnostic reasoning features, specifically the undergraduate students' capacities and limits to process information during the occupational assessment.
In addition, it may have implications for the education of occupational therapy undergraduates in (a) the modification of the curricula contents to promote the knowledge related to diagnostic reasoning, (b) the consolidation of the skills to analyse and synthesize the information collected during the assessment, and (c) the promotion of the learning of an occupational therapy diagnosis scheme as the best way to consolidate the professional reasoning. A key message from the study is that an inadequate organization of the undergraduate's knowledge to process the data collected during the occupational evaluation can make the learning of an appropriate diagnostic reasoning difficult.
We wish to thank the undergraduate participants and the Clinical Epidemiology and Biostatistics Unit, Spanish Clinical Research (SCReN) for their technical support. This research was funded by grants from the University of Valle bank of projects (Cod. 21-2014).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of Interest
The authors declare that there are no conflicts of interest regarding the publication of this paper.
What are the types of clinical reasoning in occupational therapy?
Different types of clinical reasoning used by occupational therapists have been identified, including scientific, procedural, interactive, narrative, conditional, and pragmatic reasoning.
What is clinical reasoning?
1 ( p . 204 ) Clinical reasoning is defined by Simmons as “a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information and weigh alternative actions”.
What is pragmatic clinical reasoning occupational therapy?
Pragmatic reasoning considers issues such as reimbursement, therapists’ skills, and equipment availability. To be comprehensive, further study of clinical reasoning should include these contextual issues as an inherent part of the clinical reasoning process.
What are the three elements of clinical reasoning?
Clinical reasoning may be characterized into three elements: scientific, ethical, and artistic.
Why do occupational therapists use clinical reasoning?
Clinical reasoning is crucial in occupational therapy because it is the means by which therapists identify clients’ problems accurately and determine effective treatment protocols. The extent to which a therapist is able to use clinical reasoning skills effectively determines the quality of care given to a client.
What are the types of clinical reasoning?
Seven different types of clinical reasoning are defined and discussed below.
- Scientific Reasoning. This type of reasoning focuses on the facts such as impairments, disabilities, and performance contexts. …
- Diagnostic Reasoning. …
- Procedural Reasoning. …
- Narrative and Interactive Reasoning. …
- Pragmatic Reasoning. …
- Ethical Reasoning.
Why is clinical reasoning important?
Why is clinical reasoning important? … The benefits of having sound clinical reasoning include making timely diagnoses, making prompt life-saving treatment plans, avoiding unnecessary investigations which reduces cost for the patient, and ultimately improving the patient’s health condition.
What factors influence clinical reasoning?
The factors affecting clinical reasoning include not only the individual mental processes of therapist but also the specific tools of practice and subtle influences such as cultural expectations embedded in the practice settings and client perceptions of what constitutes “good therapy” (21, 22).
How do you improve clinical reasoning?
Top 10 Strategies for Building Clinical Reasoning Skills
- Prioritize. Apply. …
- Use formative assessment. …
- Work around clinical shortages. …
- Personalize the experience. …
- Tell a story. …
- Maximize manikin-based simulations. …
- Apply real-world, evidence-based scenarios. …
- Flip the classroom and the sim lab.
How is clinical reasoning cycle used?
Various Phases of the Clinical Reasoning Cycle
- Consideration of facts from the patient or situation. This is the phase where you are first presented with a clinical case. …
- Collection of information. …
- Processing gathered information. …
- Identify the problem. …
- Establish goals. …
- Take action. …
- Evaluation. …
What is clinical reasoning model?
Six models of clinical reasoning were identified including hypothetic-deductive model, pattern recognition, a dual process diagnostic reasoning model, pathway for clinical reasoning, an integrative model of clinical reasoning, and model of diagnostic reasoning strategies in primary care.
How can occupational therapy improve clinical reasoning skills?
Improving your Clinical Judgment
- Practice, practice, practice. A good example is running through case studies and problem-based learning scenarios. …
- Get feedback. Another way to improve your clinical reasoning skills is by asking for continual feedback. …
- Use metacognition.
What are the five stages of clinical reasoning?
Clinical reasoning is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process.
What is clinical reasoning and why is it important?
Clinical reasoning is an important aspect of advanced practice and involves the use of problem-solving to establish differential diagnoses for patients’ presenting medical conditions. A stages approach to clinical problem-solving provides a clear structure for developing coherent clinical reasoning strategies.
What is the first stage of the clinical reasoning cycle?
During the first stage of the clinical reasoning cycle, the nurse begins to gain an initial impression of the patient and identifies salient features of the situation.
What is diagnostic reasoning in occupational therapy?
Diagnostic reasoning examines and analyses cause(s) or nature of conditions requiring occupational therapy intervention and attempts to explain why a client is experiencing problems using a blend of scientific-based and client-based information [13.
What is clinical reasoning in medicine?
A definition of clinical reasoning includes an ability to integrate and apply different types of knowledge, to weigh evidence, critically think about arguments and to reflect upon the process used to arrive at a diagnosis.
What is conditional reasoning in occupational therapy?
Conditional reasoning involves the understanding of. clients’ disabilities in specific life contexts. Therapists using conditional rea- soning need to integrate clients’ deficits in each performance component, each occupational performance area and each environment with their needs.
What is OT process?
The occupational therapy process is the client-centered delivery of occupational therapy services. The process includes evaluation and intervention to achieve targeted outcomes. The stages of the process and the dynamic interactions among the different aspects of the process are emphasized.
What is narrative clinical reasoning?
Narrative reasoning is a central mode of clinical reasoning in occupational therapy. … 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.
What is the therapeutic reasoning process?
Therapeutic reasoning is the cognitive thought process that guides planning, directing, per- forming, and reflecting on client care (Schell & Schell, 2007).
What is clinical reasoning and why is it important in nursing?
Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010).
What are good clinical skills?
They are confident, knowledgeable, able to prioritise information, flexible and competent in basic clinical skills by the time of graduation. They are fluent in medical terminology while retaining the ability to communicate effectively and are genuine when interacting with patients.
What is the difference between clinical reasoning and critical thinking?
Critical thinking is the cognitive processes used for analyzing knowledge. Clinical reasoning is the cognitive and metacognitive processes used for analyzing knowledge relative to a clinical situation or specific patient.
How do you assess clinical reasoning skills?
Assessment of clinical reasoning abilities should be done throughout the training course in diverse settings. Use of scenario based multiple choice questions, key feature test and script concordance test are some ways of theoretically assessing clinical reasoning ability.
What are steps in clinical reasoning quizlet?
clinical reasoning cycle
- Consider the patients situation.
- Collect cues/information.
- Process information.
- Identify problems/issues.
- Establish goal/s.
- Take action.
- Evaluate outcomes.
- Reflect on process and new learning.
What is clinical decision making?
The developed definition was Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action. A contiguous framework for clinical decision making specific for nurse practitioners is also proposed.
How can DCE improve clinical reasoning skills?
In addition to replicating a clinical experience, the DCE increases student engagement, provides opportunities for reflection in the development of clinical reasoning skills, and it provides immediate feedback of performance.
How do nurses develop clinical reasoning skills?
To further develop critical thinking skills outside of clinical areas, nurse managers can adopt the following habits:
- Suspend judgment, and demonstrate open-mindedness for other departments and other views. …
- When confronted with a problem or situation, seek out the truth by actively investigating a problem or situation.
What is clinical reasoning and decision making in nursing?
Clinical reasoning and decision-making are the thinking processes and strategies we use to understand data and choose between alternatives with regard to identifying patient problems in preparation for making nursing diagnoses and selecting nursing outcomes and interventions.
Graduated from ENSAT (national agronomic school of Toulouse) in plant sciences in 2018, I pursued a CIFRE doctorate under contract with Sun’Agri and INRAE in Avignon between 2019 and 2022. My thesis aimed to study dynamic agrivoltaic systems, in my case in arboriculture. I love to write and share science related Stuff Here on my Website. I am currently continuing at Sun’Agri as an R&D engineer.
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This article reports on a single case study of an occupational therapist working in a plastic surgery unit at an Australian public hospital. A phenomenological approach was used to explore the therapist's clinical reasoning in depth. Data were gathered over a 3–week period through semi-structured interviews with the informant and through participant observation of therapy sessions with patients and associated activities engaged in by the informant. The resulting narrative data were analysed inductively. The focus of this discussion is on the aspects of personal interactions that influence clinical reasoning. The article examines how such constructs as power, responsibility, caring and competence combine to influence clinical reasoning.
British Journal of Occupational Therapy – SAGE
Published: Feb 1, 1997
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