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Case Study | Clinical Reasoning: Home or Hospital?

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By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub

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Clinical Reasoning

clinical reasoning case study examples occupational therapy

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.

Scientific Reasoning

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.

Diagnostic Reasoning

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.

Procedural 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.

Pragmatic Reasoning

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.

Ethical Reasoning

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.

Conditional Reasoning

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 case study examples occupational therapy

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.

ot clinical reasoning

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.

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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 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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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:

Activity Analysis

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!

Environmental Modifications

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.

clinical reasoning ot

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.

Get feedback

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!

Use metacognition

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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The Clinical Reasoning of an Occupational Therapy Assistant

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Kathleen Doyle Lyons , Elizabeth Blesedell Crepeau; The Clinical Reasoning of an Occupational Therapy Assistant. Am J Occup Ther September/October 2001, Vol. 55(5), 577–581. doi: https://doi.org/10.5014/ajot.55.5.577

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This qualitative case study focused on the clinical reasoning of a certified occupational therapy assistant who had 16 years of practice experience. Observation and interview methods were used to collect data. Transcripts and field notes were coded using a priori codes of the forms of clinical reasoning of occupational therapists identified in published research. The study participant demonstrated the use of pragmatic, procedural, interactive, conditional, and narrative reasoning. We encourage further research to support these findings and to increase the understanding of the forms of clinical reasoning used by occupational therapy assistants.

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Professional Reasoning in Occupational Therapy: A Scoping Review

Luis-javier márquez-Álvarez.

1 Universidad de Salamanca, Salamanca 37007, Spain

José-Ignacio Calvo-Arenillas

2 Department of Nursing and Physiotherapy, Universidad de Salamanca, Escuela Universitaria de Enfermería y Fisioterapia, Salamanca 37007, Spain

Miguel-Ángel Talavera-Valverde

3 Integra Saude Unit Research, Department of Health Science, Facultad de Ciencias de la Salud, Universidade da Coruña, Faculty of Health Science, A Coruña 15570, Spain

Pedro Moruno-Millares

4 Department of Nursing, Physiotherapy and Occupational Therapy, Universidad de Castilla-La Mancha, Toledo, Talavera de la Reina 45600, Spain

Background/Aim

Professional reasoning in occupational therapy is the process used by practitioners to plan, direct, perform, and reflect on client care. The professional's ability to manage the process of the intervention is structured around it, thereby influencing the effectiveness of the work carried out. The objectives of this research were to identify and describe (a) the historical development of this area of research from 1982 to 2017 and (b) the nature and volume of the scientific literature on professional reasoning in occupational therapy and the evidence that exists today.

A scoping review method was used to carry out an historical mapping of research on professional reasoning and to summarise the lines of research explored to date. The review was conducted in five stages following the PRISMA guidelines. After applying the selection criteria, the search identified 303 references.

The results are presented under three headings: (a) nature and volume of publications on professional reasoning in occupational therapy according to number and year of publications, journal, country, author, and line of research; (b) historical trends in the scientific literature on professional reasoning in occupational therapy since 1982; and (c) methodological aspects of the research. Each of them is discussed through statistical analysis.

Conclusions

The research about professional reasoning in occupational therapy is a field of empirical nature, in which qualitative studies predominate. Principal lines of research are focused on specific fields of practice, undergraduates, and theoretical aspects of professional reasoning. There were identified three historical phases with common features in terms of objectives and research methods.

1. Introduction

In occupational therapy, professional reasoning can be defined as the process used by practitioners to plan, direct, perform, and reflect on client care [ 1 , 2 ]. Its importance in professional practice is fundamental given that the professional's ability to manage the process of assessing, planning, and implementing the intervention is structured around it, thereby influencing the effectiveness of the work carried out [ 2 – 4 ].

Currently, the scientific literature on professional reasoning in occupational therapy describes it as a highly complex mode of thought that “involves all the thinking processes of the clinician as s/he moves into, through and out of the therapeutic relationship and therapy process with a client” [ 4 ]. It is characterised as a mode of tacit, highly creative and deeply phenomenological thinking [ 5 , 6 ], aimed at determining the focus of care for a given client or group of clients [ 1 ]. It is studied using a range of approaches, in terms of both focus and method [ 7 ].

Despite its importance in our discipline, the body of knowledge on professional reasoning in occupational therapy is still inadequate [ 8 , 9 ]. To date, there has been no full, comprehensive review of the scientific literature that would allow us to define and summarise existing scientific evidence in the area of professional reasoning in occupational therapy. Previous reviews of the literature on clinical reasoning in occupational therapy limited the databases selected, the languages of the studies, and the analyses carried out. They were therefore subject to possible biases in the information gathered. [ 4 , 10 , 11 ].

For this reason, we conducted a scoping review to identify and describe the scientific publications on professional reasoning and to analyse the historical development of this area of research from 1982 to 2017 and the nature and volume of the scientific literature on professional reasoning in occupational therapy and the evidence that exists today.

2. Materials and Methods

A scoping review method [ 12 – 14 ] was used to carry out an exploratory historical mapping of research on professional reasoning and to summarise the lines of research explored to date. The review was conducted in five stages [ 14 ] following the PRISMA guidelines [ 15 ].

2.1. Review Question and Relevant Papers

The research questions that guided the review were as follows: (a) What is the nature and volume of the literature on professional reasoning in occupational therapy? (b) How has research on professional reasoning evolved over time? In the first stage, a two-step search strategy was employed for this review. First, an initial search strategy (January 11, 2018) was created for Medline (using Ovid) and was adapted to each search: (1) reasoning.af (16,579); (2) occupational therapy/(12,440); (3) occupational therap∗.ab,ti (10,234); (4) allied health occupations/(547); (5) allied health personnel/(11,272); (6) 2 or 3 or 4 or 5 (27,348); (7) 6 and 1 (218). In this way, we established if the terms contained in the title, abstract, or keywords of the retrieved citations allied with the planned search terms. Finally, the keywords used are classified in Table 1 .

List of descriptors and keywords used in the search.

Second, the formal literature search was conducted across the selected databases: OTDBase, CINAHL, Medline, WOS, Embase, Scopus, ISOC, Latindex, LILACS, LivRe, ProQuest, CSIC (Spanish National Research Council), and Dialnet. The results were actualized on February 15, 2019. In addition to the abovementioned databases, a search was also carried out on Google Scholar ( https://scholar.google.es/ ) and the catalogue of the Network of Spanish University Libraries ( http://rebiun.org/ ) in order to identify further references from magazines, books, book chapters, and theses for their possible inclusion. With this search strategy, we have tried to gather information in the most thorough way possible, without limiting the language of the documents and by incorporating databases that have not been used in previous literature reviews. Our aim was to avoid any bias that could diminish the information obtained.

2.2. Selection of Relevant Studies

In the second stage, we proceeded to identify and select the relevant studies. The following selection criteria were established.

  • Inclusion criteria: any article, book (publications dealing with professional reasoning in all their chapters), book chapter (publications that, while appearing in a book on various subjects, specifically cover the subject in question), or doctoral thesis in which any of the keywords appear in the title, keywords list, abstract, or headings of the document. Material in any language was included
  • Exclusion criteria: documents that did not contain any of the keywords were excluded. Furthermore, after removing any duplicate documents, we excluded studies that did not focus on professional reasoning in occupational therapy or in health professions that would include occupational therapists

These inclusion and exclusion criteria were refined as we gained familiarity with the literature [ 12 ].

2.3. Data Charting

In the third stage, carried out simultaneously with stage two, the data were extracted from each 303 references and included in a data extraction table developed by the research team. This data extraction table was developed using the programme IBM SPSS Statistics (V.25). The data extraction process was carried out by researchers L.M. and M.T. independently. It was subsequently reviewed by researchers C.A. and P.M.

2.4. Data Sorting and Analysis

The fourth stage consisted of sorting the data following an iterative process and using the following categories: title, author, characteristics of the publication (journal or publisher, year of publication, publication type, and language), objectives of the study, and study design (type of method, type of study, methodological design of the study, and subject of the study). Our aim was to identify parameters for analysing the literature that would enable us to carry out a detailed critical review. The fifth stage involved a comprehensive review of the selected documents. After reading and analysing the articles published in indexed journal, the historical research trends since the publication of the first article in 1982 were identified [ 16 ]. Lastly, a descriptive and inferential statistical analysis was performed by applying the chi-square test to the different categories of scientific articles published between 1982 and 2014. In addition, Fisher's exact test was applied to scientific articles included in the same period with a frequency below n = 5 to analyse the statistically significant relationships between the variables selected in cases where the chi-square test was not representative. To carry out the statistical analyses detailed above, the articles were grouped into 10-year periods in order to compare the different phases statistically. Therefore, articles published between 2015 and 2017 were not considered in these statistical analyses.

The search strategies retrieved 1,632 references (890 once duplicates were removed). After applying the selection criteria, we identified 303 references ( Figure 1 ).

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PRISMA flow diagram [ 15 ].

The results are presented under three headings: (a) nature and volume of publications on professional reasoning in occupational therapy according to number of publications, year of publication, journals, country, author, and line of research; (b) historical trends in the scientific literature on professional reasoning in occupational therapy since 1982; and (c) methodological aspects of the research.

3.1. Nature and Volume of Publication

Of the 303 references analysed, the largest percentage corresponds to articles published in indexed journals (original studies and reviews): n = 208 (68.6%). The remaining references are editorials, opinion articles, and commentaries in scientific journals, with n = 37 (12.2%); doctoral theses, n = 22 (7.3%); books, n = 7 (2.3%); popular science publications, n = 5 (1.7%); conference proceedings, n = 12 (4%); and book chapters, n = 12 (4%). With regard to the languages used by the authors, English predominates with n = 280 (92.4%), followed by Spanish, n = 14 (4.6%); German, n = 5 (1.7%); and French, Polish, Portuguese, and Hebrew, n = 1 (0.3%).

Since 1982, a gradual and steady increase can be observed in the number of documents published ( Figure 2 ).

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Comparison between number of documents published and articles published in indexed journals (original studies and reviews) 1982-2017.

The analysis reveals that the articles published in indexed journals (original studies and reviews) were published in 49 different journals, with publications in English predominating ( n = 195; 93.8%). The journals with the largest number of articles are the American Journal of Occupational Therapy , with n = 42 (20.2%), and the British Journal of Occupational Therapy , with n = 32 (15.4%). These are followed by the Australian Journal of Occupational Therapy , with n = 18 (8.7%); Occupational Therapy in Health Care , with n = 17 (8.2%); the Scandinavian Journal of Occupational Therapy , with n = 15 (7.2%); and the Canadian Journal of Occupational Therapy , with n = 10 (4.8%). The rest of the journals fell short of 10 articles published. With regard to non-English-language journals, the greatest number of publications was found in the Spanish-language TOG (A Coruña), with n = 4 (1.9%).

With regard to the 439 authors, English-speaking authors overshadow the rest with n = 414 (94.3%). No author, except for C.A. Unsworth, with nine empirical articles and one nonempirical article, reaches a total of 10. This author is followed by Neistadt, with seven empirical articles, and Rodger and Ziviani, with five empirical articles. With regard to non-English-speaking authors, only two appear among the top 29: Talavera, with four empirical articles, and Moruno, with two.

In addition, four major lines of research were identified in the analysis of the articles published in indexed journal (original studies and reviews) ( Table 2 ).

Number of articles published in indexed journal (original studies and reviews) published between 1982 and 2017 by line of research.

The percentages were calculated on the basis of the sample of articles published in indexed journals (original studies and reviews) ( n = 208).

With regard to the books and book chapters published from 1982 to the present, an irregular pattern can be observed when compared to the scientific articles published in indexed journals. Books (57.1%) and book chapters (50%) of a theoretical nature predominate. Since 1995, the year in which the first doctoral thesis on professional reasoning in occupational therapy was published, there has been a gradual increase in the publication of doctoral theses similar to the increase observed in articles published in indexed journals. With regard to the methodology of the doctoral theses, in contrast to the articles published in indexed journals, quantitative studies predominate (57.1%; n = 13), followed by qualitative studies (38.1%; n = 8) and mixed studies (4.8%; n = 1). The main lines of research among the doctoral theses are student reasoning ( n = 8; 38.1%), specific professional fields ( n = 3; 13.6%), and novice/expert reasoning ( n = 3; 13.6%).

3.2. Historical Trends

The first article focused on the study of clinical reasoning was published in 1982 [ 16 ] and aimed to define this area of study within the field of occupational therapy. The first review of the literature on clinical reasoning in occupational therapy was published in 1993 [ 17 ].

On the basis of the analysis of the articles published in indexed journals (original studies and reviews) published between 1982 and 2017 ( n = 208), it was identified that n = 149 (71.6%) are empirical studies and n = 59 (28.4%) do not have an empirical basis. It should be noted that between 1982 and 1993, there are a similar number of nonempirical articles n = 10 (4.8%) and empirical ones n = 11 (5.3%). In that period, the articles are mainly exploratory and descriptive ( Table 3 ).

Number of articles published in indexed journal (original studies and reviews) published between 1982 and 2017 by study type.

In more recent periods, an increase can be observed in the publication of both empirical and nonempirical articles, and in the variety of methodological approaches used in the studies. The majority of the explanatory studies ( n = 4) converge in the period 2004-2014, as does a large share of the empirical scientific output n = 67 (32.2%).

Figure 3 shows an increase in both trends. The empirical trend is more dominant in recent years. By calculating their linear average, we can observe how the gap widens between the two trends, with the nonempirical trend making more limited progress.

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Object name is OTI2019-6238245.003.jpg

Evolution of the number of articles published in indexed journals (original studies and reviews) according to method.

When comparing the first three periods, which last the same amount of time ( n = 175), a statistically significant relationship ( p < 0.05) is found between the periods and the methodology used in the articles. There is a statistically significant relationship between nonempirical articles and the period 1982-1992 ( p < 0.05), when compared with the other periods. Furthermore, there is a statistically significant relationship between empirical articles and the period 2004-2014 ( p < 0.05), when compared with previous periods.

3.3. Methodological Aspects of the Research

The descriptive analysis of the methods used in the empirical articles is summarised in Table 4 .

Number of articles published in indexed journals (original studies and reviews) using empirical methods published between 1982 and 2017 by study design.

The percentages were calculated on the basis of the sample of empirical articles ( n = 149).

Overall, the percentage of qualitative articles published n = 72 (48.3%) exceeds the percentage of quantitative articles, mixed articles, and reviews.

During the years 1982 to 1992, we can identify a greater number of qualitative studies ( n = 8) based on ethnographic and phenomenological approaches in comparison to quantitative and mixed studies ( n = 3). In the case of articles using quantitative methodology, we find the same number of experimental studies and observational studies. In this period, a study categorised as “qualitative and experimental” was identified, which from our point of view is a clear methodological error, because the description provided (qualitative and experimental) does not reflect the methodology used.

During the years 1993 to 2003, an increase is observed in both quantitative studies and in reviews and mixed research designs ( n = 17). Nevertheless, a greater number of qualitative articles ( n = 32) continue to be published, particularly ones using a phenomenological approach ( n = 13).

However, during the years 2004 to 2014, the trend from the previous period reverses. Quantitative studies ( n = 29) outweigh qualitative ones ( n = 23), and the number of literature reviews increases significantly.

In terms of possible correlations, we performed Fisher's exact test (due to the existence of values n < 5 in some categories) to analyse the major design approaches (quantitative, qualitative, mixed, and review) in relation to the first three periods described ( n = 127). We can confirm that there is a significant relationship between qualitative methodology and publications during the years 1993 to 2003 ( p < 0.01) and between quantitative methodology and publications with respect to the period 2004-2014 ( p < 0.05).

4. Discussion

The results obtained in this scoping review allow us to answer the research questions posed at the outset of this paper. Regarding the first question, we have been able to describe the nature and volume of the research carried out on professional reasoning in occupational therapy. Since 1982, there has been a gradual and steady increase in the number of research articles on professional reasoning in occupational therapy, which may indicate a growing interest in this area of knowledge. In relation to this fact, it is fair to say that professional reasoning in occupational therapy has become a consolidated and ongoing line of research during the period studied.

Overall, research on professional reasoning in occupational therapy is empirical. Furthermore, qualitative research predominates, with the number of qualitative articles published exceeding the number of quantitative and mixed methodology articles and reviews. This dominance of qualitative research on this topic is likely because qualitative techniques are appropriate to the nature of research questions about clinical reasoning because they allow in-depth responses and field notes on observations of clinical reasoning in practice. In addition, it may be also related to the predominance of qualitative research in our discipline during the eighties and the nineties. There has been only one systematic review with methodological rigour, conducted by Unsworth and Baker [ 4 ]. However, it did not involve a detailed analysis of the scientific rigour of the studies.

By mapping the research topics associated with professional reasoning, we have been able to identify three major lines of study: (a) professional reasoning in specific fields of practice, (b) professional reasoning among undergraduates, and (c) theoretical aspects of professional reasoning. Other relevant lines of study include modalities of reasoning and the differences in professional reasoning between novices and experts.

In light of these results, it appears that research on professional reasoning in occupational therapy is especially concerned with the particularities of reasoning in specific professional fields, to the detriment of the study of information processing that takes place in practice and that shapes professional reasoning in general [ 18 ]. This fact is reflected in the 25 articles classified under this category (information processing). We agree with Schell et al. [ 19 ] when they suggest that research on information processing could: “…help the occupational therapy community understand the applicability and limitation of information-processing models that are borrowed from research in other professions.” (p. 410). Furthermore, there is a lack of studies focused on the distinctive and unique modalities of reasoning that occur among occupational therapists [ 19 ]. In this scoping review, only 18 papers were identified in which the different modalities of professional reasoning were the focus of research. Despite the fact that these modalities of reasoning are frequently referred to in scientific literature [ 17 ], it appears that in-depth study of procedural, interactive, conditional, ethical, and pragmatic reasoning has not yet occurred. Therefore, we call on occupational therapists to continue to move beyond the limits established by information-processing models taken from other professions and to explore in more depth the unique and distinctive characteristics of professional reasoning in occupational therapy.

It should also be noted that publications from English-speaking countries predominate, particularly the United States, Britain, Australia, and Canada, followed by publications in Northern European and Spanish-speaking countries. This suggests that the clinical reasoning of OTs in developing countries has not been sufficiently studied, which is likely to limit the progression of OT practice in these countries [ 20 – 22 ]. This scoping review has broadened the search criteria of previous literature reviews to try to correct this bias.

With regard to the second research question, we have been able to describe how research on professional reasoning in occupational therapy has evolved. Our findings point to three historical periods with distinct characteristics: (a) exploratory phase (1982-1993), (b) transition phase (1994-2003), and (c) consolidation phase (2005-present).

In the exploratory phase (1982-1993), the scope of the research that would be developed in later literature is defined, described, and explored. This phase is characterised by nonempirical qualitative studies based on ethnographic and phenomenological approaches, which seems to indicate an exploratory perspective [ 23 ]. This thesis is consistent with the findings of Unsworth and Baker [ 4 ] and Harries and Harries [ 24 ], and with the statistically significant relationship we have identified between the nonempirical articles published and the period 1982-1993, when compared with the other periods.

In the transition phase (1994-2003), the number of studies increases considerably, the types of studies carried out diversify and there is also a significant increase in empirical studies, which outweigh nonempirical studies during these years. This increase in empirical studies is probably related to the need to support occupational therapy with more rigorous scientific research. However, among the empirical articles published during this period, qualitative articles with a phenomenological approach predominate. According to the data analysed, this theory is consistent with the statistically significant relationship found between this phase and the use of qualitative methodology. It is likely that, although researchers were still seeking to develop a rich descriptive image of professional reasoning, the available scientific methods at that time were becoming more rigorous in the field of health sciences. These findings seem to indicate a transition period in the research, during which new research perspectives are developed, while the earlier ones continued to predominate [ 24 ].

In the consolidation phase (2005-present), the research trend is clearly reversed, with a quantitative approach predominating and an increase in the number of literature reviews. These findings indicate that, in recent decades, research on professional reasoning has reached a period of consolidation, adopting a variety of both qualitative and quantitative approaches, although qualitative studies still predominate [ 25 ]. This thesis is consistent with the statistically significant relationship found here regarding empirical articles using quantitative methodology and the period 2004-2014, when compared with previous years. In addition, almost a third of the studies published during that period were reviews and experimental designs, which indicates a research trend to achieve a higher level of scientific evidence.

4.1. Limitations

A detailed analysis of the findings of the papers included in this review was beyond the scope of this study. Moreover, this scoping review did not assess the scientific quality of the literature analysed, which may be considered a limitation of the study.

4.2. Future Research

Future lines of research need to assess the methodological quality and scientific evidence arising from studies on professional reasoning in occupational therapy. From our point of view, conducting a study to assess the quality of the publications and the existing evidence is imperative.

It would be interesting for research in this area to encompass a greater number of non-English-speaking countries in order to gather information about the cultural and ethical particularities of professional reasoning [8, 19, 26].

5. Conclusions

Research and literature about professional reasoning in occupational therapy is a rising field of knowledge, through which occupational therapists increase their understanding of the mechanisms that regulate the selection and evaluation of occupational therapy interventions. The research about professional reasoning in occupational therapy has increasingly involved empirical research, in which qualitative studies predominate. However, there is still a relative lack of quantitative and mixed methods studies, as well as a dearth of systematic reviews about the quality of existing studies. Principal lines of research focus on specific fields of practice, undergraduates, and theoretical aspects of professional reasoning. There are relatively few studies focused on information processing, modalities, and unique characteristics of professional reasoning in occupational therapy. Three historical phases were identified with common features in terms of objectives and research methods: (a) exploratory phase, characterised by nonempirical studies; (b) transition phase, in which there is a considerable increasing diversification of the lines and methods of research; and (c) consolidation phase, in which evidence-based research perspectives and more quantitative studies emerge. Overall, the research about professional reasoning in occupational therapy during the next years should target the in-depth study of the basic process of information processing and the reasoning modalities that define the occupational therapy professional reasoning.

Acknowledgments

We would like to thank the University of Salamanca and the support on the elaboration of the manuscript.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

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Clinical Reasoning in Occupational Therapy: Case Studies Across the Lifespan

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Thinking in Stories: Narrative Reasoning of an Occupational Therapist Supporting People with Profound Intellectual Disabilities' Engagement in Occupation

Affiliations.

  • 1 School of Sport and Health Sciences, University of Brighton, Brighton, UK.
  • 2 Occupational Therapy, University of Brighton, Brighton, UK.
  • PMID: 34965831
  • DOI: 10.1080/07380577.2021.2022260

This article illustrates narrative reasoning using the findings from research into an occupational therapy intervention promoting changes in the ways a staff team facilitated meaningful engagement in occupation. Qualitative critical ethnographic case study research explored a single case over one year of an occupational therapist working with five people with profound intellectual disabilities and their support network. Data were collected using participant observation, interviews and document analysis. Illustrated by an ethnodramatic vignette, the findings demonstrate how the occupational therapist reasoned narratively by eliciting, telling and creating stories and how this supported individualization of her intervention to the specific context. Creation of a prospective story that the support network were invited to share, guided and propelled the intervention toward its hoped-for ending. Narrative reasoning was particularly apparent in opportunities to reflect aloud, supporting occupational therapists' need of opportunities for reflection through story-sharing and story-making. Case study and ethnographic research methodologies may be useful in further clinical reasoning research to better understand narrative reasoning.

Keywords: Case study methodology; clinical reasoning; ethnodrama; ethnography; narrative reasoning; occupational therapy; qualitative.

  • Intellectual Disability*
  • Occupational Therapists
  • Occupational Therapy* / methods
  • Occupations
  • Prospective Studies

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COMMENTS

  1. Case Study

    Case Study | Clinical Reasoning: Home or Hospital? By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub.

  2. Thinking in Stories: Narrative Reasoning of an Occupational Therapist

    Critical ethnographic case study research methods. With few examples of narrative reasoning in clinical reasoning research findings since Mattingly's original research, it may be that certain aspects of this study's design were key in highlighting how Esther thought in stories. ... The clinical reasoning of an occupational therapy assistant ...

  3. Clinical Reasoning

    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. Scientific Reasoning. This type of reasoning focuses on the facts such as impairments, disabilities, and performance ...

  4. Clinical Reasoning in Occupational Therapy: A Comprehensive Guide

    26/06/2023 by ot. 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 ...

  5. Clinical Reasoning in Occupational Therapy

    Figures, Tables, Exhibits, Case Examples, and Practice Wisdom vii 8; Introduction ix 10; PART I. Occupational Perspective for Clinical Reasoning 1 12; 1. Overview of the Clinical Reasoning Process 3 14; 2. Clinical Reasoning and Occupational Therapy's Domain of Practice 21 32; 3. Hypothesis Generation and Refinement 37 48; PART II. Frames of ...

  6. PDF Occupational Therapy Case Study Examples

    Occupational Therapy Case Study Examples Jennifer L. Theis Case Studies Through the Healthcare Continuum Patricia Halloran,Nancy A. Lowenstein,2000 This phenomenal new text focuses on assisting students in learning that there can be many possible choices in the clinical decision making process, and

  7. Clinical Reasoning Case Studies as Teaching Tools

    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 ...

  8. The Fieldwork Case Study: Writing for Clinical Reasoning

    Occupational therapy literature suggests several methods of fostering clinical reasoning skills with Level II fieldwork students. Buchanan, Moore, and van Niekerk (1997) propose using a revised ...

  9. Clinical Reasoning in Occupational Therapy

    Clinical Reasoning in Occupational Therapy is a key text for occupational therapy students and practitioners. Written by an internationally renowned group of clinicians, educators and academics and with a central case study running throughout, the book covers the theory and practice of the following key topics: Working and Thinking in Different Contexts; Teaching as Reasoning; Ethical ...

  10. Using the Case Method to Develop Clinical Reasoning Skills in Problem

    Abstract. Clinical reasoning is increasingly recognized as a crucial component of the occupational therapy process. Different types of clinical reasoning used by occupational therapists have been identified, including scientific, procedural, interactive, narrative, conditional, and pragmatic reasoning. This article describes the use of the case method in the University of New Mexico ...

  11. Developing Solid Clinical Reasoning Skills in Occupational Therapy

    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.

  12. The Clinical Reasoning of an Occupational Therapy Assistant

    Abstract. This qualitative case study focused on the clinical reasoning of a certified occupational therapy assistant who had 16 years of practice experience. Observation and interview methods were used to collect data. Transcripts and field notes were coded using a priori codes of the forms of clinical reasoning of occupational therapists identified in published research. The study ...

  13. Clinical Reasoning in Occupational Therapy

    This is a dummy description. Clinical Reasoning in Occupational Therapy is a key text for occupational therapy students and practitioners. Written by an internationally renowned group of clinicians, educators and academics and with a central case study running throughout, the book covers the theory and practice of the following key topics ...

  14. Clinical reasoning and the occupational therapy curriculum

    The type of clinical reasoning style used by therapists could be influenced by several factors: 1) the theoretical framework used; 2) the application of theory; and 3) the level of experience. The first two factors are related to the design of the occupational therapy curriculum, and the last relies on thera-pists' accumulation of clinical ...

  15. A Q-method approach to perceptions of professional reasoning in

    Background. In occupational therapy, professional reasoning is defined as the process by which professionals plan, direct, carry out and reflect on the client's treatment [1, 2].Its importance is based on its relationship with professional practice, which gives the professional the ability to manage the process of assessment, planning and implementation of the intervention, structuring it ...

  16. Learning and Development of Diagnostic Reasoning in Occupational

    1. Introduction. 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 [].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 ...

  17. (PDF) Thinking in Stories: Narrative Reasoning of an Occupational

    Case study and ethnographic research methodologies may be useful in further clinical reasoning research to better understand narrative reasoning. Discover the world's research 25+ million members

  18. How Qualitative Case Study Methodology Informs Occupational Therapy

    The strength of case study methodology is its flexibility to capture the complexity of the phenomenon under study and take into account the context in which it is situated (Hyett et al., 2014; Stake, 1995).As a result, case studies are well suited to exploring a variety of complex research questions such as the development and evaluation of programs, interventions, and theories (Baxter & Jack ...

  19. Clinical reasoning in occupational therapy: an integrative review

    This work has suggested that pragmatic reasoning, which considers issues such as reimbursement, therapists' skills, and equipment availability, should be an integral part of clinical reasoning. 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 ...

  20. Professional Reasoning in Occupational Therapy: A Scoping Review

    1. Introduction. In occupational therapy, professional reasoning can be defined as the process used by practitioners to plan, direct, perform, and reflect on client care [1, 2].Its importance in professional practice is fundamental given that the professional's ability to manage the process of assessing, planning, and implementing the intervention is structured around it, thereby influencing ...

  21. PDF Thinking in Stories: Narrative Reasoning of an Occupational Therapist

    Discussion. Narrative reasoning by thinking in stories as envisioned by Mattingly and Fleming (1994) is referred to theoretically, but rarely seems visible in clinical reasoning research findings outside of Mattingly's original work. This study supports this claim that occupational therapists reason in this way.

  22. Clinical Reasoning in Occupational Therapy: Case Studies Across the

    ISBN 10: 1-60797-761-3 ISBN 13: 978-1-60797-761-2 . By Emmy Dagnan, Debra Gibbs & Lorry Liotta-Kleinfeld $ 60.00

  23. Thinking in Stories: Narrative Reasoning of an Occupational ...

    Narrative reasoning was particularly apparent in opportunities to reflect aloud, supporting occupational therapists' need of opportunities for reflection through story-sharing and story-making. Case study and ethnographic research methodologies may be useful in further clinical reasoning research to better understand narrative reasoning.