Clinical/Professional Reasoning

Professional Reasoning & Ethics in OT Practice

Terminology

• Clinical Reasoning/Professional Reasoning/Therapeutic Reasoning

• Types

  • Scientific Reasoning

    • Diagnostic Reasoning

    • Procedural Reasoning

  • Narrative Reasoning

  • Pragmatic Reasoning

  • Ethical Reasoning

  • Interactive Reasoning

  • Conditional Reasoning

• Embodied processes

• Knowing more than we can tell

• Cognitive Processes

  • Memory, Meta-Cognition

• Whole-Body Process

• Occupational storytelling

• Occupational story making

• Therapeutic Employment

• Reflective practitioners

  • Reflect in action

  • Reflect on action

Professional Reasoning Is

• A process used to plan, direct, perform, & reflect on client care

• How OT's think

• Completed in real time

• A skill that needs to be developed…

It requires meta-cognitive analysis- "thinking about thinking"

• Always needs to be done

Is based on assumptions

Schell’s Ecological Model of Professional Reasoning

1. OT is co-constructed process between the therapist & client

2. What actually happens in therapy is a result of transactions among the therapist, the client, & the practice context.

3. There are a number of personal & practice context factors that influence professional reasoning, the client & the therapy process. Some factors are known to the participants & some are unknown.

4. Therapy outcomes are affected by this nexus of factors, along with the nature of the occupational performance/ participation problem, & the client’s therapy-related actions outside of therapy.

Cognitive Processes Underlying Professional Reasoning

Cognitive neurosciences suggests that people have limited space in their working (short term) memories

• How can an OT process everything he/she needs to all at once?

• And over time & with experience, the OT develops & utilizes strategies

  • Chunking

  • Scripts

  • Frames

  • Procedural Rules

Aspects of efficient mental frameworks

• Cue acquisition: searching for helpful & targeted info through observation & questioning

• Pattern recognition: noticing similarities & differences among situations

• Limiting the problem space: using patterns to focus cue acquisition & knowledge application on most fruitful areas

• Problem formulation: developing an explanation of what’s going on, why it’s going on & what a better situation or outcome would be

• Problem solution: identifying courses of action based on the problem formulation

Creation of Frames or Scripts: Chunking

• Average person can recall

  • 7 +/- 2 bits of information

• Chunking helps organize info into familiar manageable units.

  • e.g. digit of phone # to 3 units

    • 978-531-6545

  • Relate to familiar memories

• OT’s with experience organize & store info in LTM

  • Create ‘built-in mental rules’ to

    • Categorize

    • Detect patterns & differences in patterns

Scripts & Procedural Rules

• Frames or Scripts are complex representations of simulations representing perceptions gained from our experiences.

• Experienced OT’s connect information together so they don’t have to juggle all the details

• Example: Client with a CVA often (not always)

  • Extensive prior medical history comorbidities (HTN, DM)

  • Patterns of effects on occupation

  • Patterns for L CVA vs. R CVA and CVA of different arteries

  • Patterns of impairments on body functions

• Guide thinking (Bruning et al., 1999; Carr & Shotwell, 2007).

• Organize common occurrences or events

• Based upon observations & experiences over time

• Help OT anticipate likely events

Together enhance processing of complex information

Professional Reasoning Develops Over Time

• Strategies are individually constructed

  • OT students & newer OT’s may struggle to retain & effectively use therapy knowledge

• Effective Reasoning: depends upon baseline knowledge/skills & it takes time and reflection and repetition of experiences and involves OT practitioners’ client factors, skills and contexts

  • Allows you as the OT, to target specific memories for use as therapy unfolds

• How to improve be a reflective practitioner:

  • Reflect in action: think about your thinking when in the midst of a situation

  • Reflect on action: apply critical thinking after the situation is over

    • What went well (why), what didn’t go well (why), what are other ways that

Developmental Process

• Interactive

• Non-linear

• In a therapeutic situation, the OT’s thought process moves between

  • Current situation

  • Information stored from prior learning experiences

Examples:

• What OT role involves

  • Respond to referral- see client

  • Write findings on correct form

  • Interventions used with X

  • Communicate with team

  • Develop discharge plans

• Implications for clients w/wo supportive families

  • Supportive family cares for client at home, regardless of resource

  • Clients with little family support likely to face institutional care

Professional Reasoning Continuum of Expertise

Clinical Reasoning Helps

Professional/clinical reasoning supports holistic problem-solving

• Each directs you to attend to different aspects of situations or different cues & patterns

• Consider how each type helps

  • Limit the problem spaces

  • Formulate problems

  • Explain what is going on &

  • Generate alternative solutions

  • Identify courses of action that might help solve the problem

Aspects of Professional Reasoning

1 Scientific Reasoning (It science)

• Involves use of applied logical & scientific methods

  • Hypothesis testing

  • Pattern recognition

  • Theory-based decision making

  • Statistical evidence

• Don’t stop here

  • It is impersonal & focuses on diagnosis/condition when guiding theory is used

  • Helps you anticipate what “typically” happens with clients like this, but will not tell you how your client will respond!

• OT uses selected theories to identify problems & to guide decision making.

  • Understand condition affecting client

  • Decide on interventions in client's best interest.

• Aka treatment planning

• Types of Scientific Reasoning

  • Diagnostic reasoning

  • Procedural reasoning

2 Diagnostic Reasoning (It science)

• This type of Scientific Reasoning

  • Starts prior to seeing client

    • i.e. referral

  • Concerned with

    • Clinical problem sensing

    • Problem definition

  • OT’s look primarily for occupational performance problems.

    • Influenced by referral information in the requests for services.

• Investigative reasoning

  • Analyzes of causes or nature of conditions requiring OT

• Uses both personal & impersonal information.

  • OT attempts to explain why (specific) client experiences specific problems

3 Procedural Reasoning (It science)

• OT considers & uses evaluation & intervention routines for identified conditions.

• Science-based & reflects habits & culture of practice setting

• Characterized by therapy regimes & routines

  • Evidence-based practices

  • Practices used with clients in that setting.

• Impersonal & diagnostically driven.

• OT: thinks about the disease or disability

• Decides which intervention activities (procedures) should be use to address client's issues

• May involve

  • Interview

  • Observation of the person engaged in a task

  • Formal evaluations using standardized measures.

• Procedural reasoning should be used, but can be a trap if it becomes an unquestioned implementation of therapy protocols & thus less scientific in nature

  • Routinely evaluate your ‘typical’ therapy approaches based upon data

4 Pragmatic Reasoning (It science)

Practical reasoning: Helps OT fit therapy possibilities into realities of service delivery within a particular context

• Scheduling options

• Payment for services

• Equipment availability

• Therapists' skills

• Management directives

• Personal situation of the therapist

• Generally not focused on client/client's condition

• Considers contextual factors involving OT & particular practice setting

  • Physical

  • Social

  • Therapist's internal sense of

    • What he/she is capable of

    • Has the time & energy to complete

5 Ethical Reasoning

• Ethical reasoning asks: What should be done?

• Analyzes ethical dilemmas

  • Generates alternative solutions & helps OT determine possible actions

• Systematic approach to moral conflict.

• OT attempts to determine the “right” thing to do

• Sounds easy… reality is soooooo different…

6 Narrative Reasoning (I science)

Makes sense of client's circumstances

• Personal: focused on client

  • Includes past, present, & anticipated future.

  • Appreciates client’s context as basis for understanding client’s story

  • Relates to the “so what” of condition for client’s life.

• Provides OT with way to understand or contextualize client's illness experience.

  • What does this sound like?

• Involves asking questions, attending to client & thinking in story form.

  • Understand the meaning that a disease, illness, or disability has for individual

• Necessary for client-centered practice

• Particularly important for considering how the person's life story can be constituted or reconstituted

  • Occupational Story-making…

The Narrative Process is Important

• Humanizes clients: They are mothers, brothers, teachers, comedians… not just “the CVA in room 20”

• Gives us insight into client’s perspective

  • Suffering, strengths, & triumphs

  • What is his/her worldview?

  • Values

  • Indicates range of responses to current situation…

  • Informs shape & implement OT intervention

Stories are “about someone trying to do something, & what happens to him/her & others as a result” (Mattingly, 1998, p. 7)

• How client makes sense of experiences

• Provides view of life & who client is

• Links story, act, & consequence

Story Telling in OT

• In health care: reaction to the dehumanization of people & “expert’ models & associated with qualitative research e.g. phenomenology…

• In OT: Flemming & Mattingly Clinical Reasoning Study: ethnographic study of OT’s in a teaching hospital

  • Methods: Observations, interviews with OT’s & clients & videotaped sessions

  • Findings: OT’s have different ways of working with clients

    • “Chart talk” for medical establishment

    • “Story telling” to interpret meaning in clients’ lives

    • Use collaborative approaches to create new/different meaningful life for client as part of recovery process

    • Think prospectively to envision the effects of illness, disability, or occupational performance problems on client’s daily life

    • Intervention involves collaboration to co-create a new life-story with client & family

Client's Stories

• OT practice provides many opportunities to

  • Listen to stories

  • Elicit stories from clients

  • Tell clients stories

  • Revise stories

Our clients' stories,

• Tell us about how they perceive their experiences

• Lend insight into their interpretations of experience

  • Help us begin to understand who they are

    • How they view illness or disability experience

    • How this shapes their daily occupations

• Provide clients with opportunities to process their lives AND

• Provide OT’s with opportunities to help shape meaning

Narrative as Interpretive Process

Narratives involve an interpretive process

• Person selects aspects of past experience(s)

• Chooses if & how to represent experiences to others in present time

Narratives evolve: Stories change in light of one’s present experiences

1. People attend to what is important or meaningful to them at that moment, which alters

2. Re-telling of the story construction & intent

3. Experience shapes interpretive lens

4. Listeners are involved as they often help interpret the story

• When listening to a story, attend to

  • What client attends to about experience in moment

  • Telling of this experience

    • How do they tell it?

    • Word choices matter

  • Editorial processes

    • Does client change or omit aspects?

    • Affective tone

  • Interpretations: how does the person interpret the story?

  • When possible what do significant others say?

Stories are used in OT

• Occupational Story-Telling

  • Stories are sources of motivation

  • Stories help person see self in particular ways

  • Stories as socialization

  • Stories can be strategy for problem-solving

    • Process (make sense of what happened)

    • Procedural: (determine how or where to go with a particular client)

  • Stories can persuade others (team or family) toward a particular point of view or insight about a client

• Occupational Story-Making

  • Narratives can be used to shape (present & future) actions

  • OT intervention involves a prospective “therapeutic employment”

    • Clients & OT co-create new narratives for client’s lives so clients can envision moving from where/who they are to where/who they want to be

  • OT’s weave stories & occupations to rewrite, revise, & re-create life stories

7 Interactive Reasoning (I science)

• Focuses on building inter-personal relationships with clients

• Permits collaborative problem identification & problem solving.

• OT concerned with what client likes or does not like.

  • Asks how can I motivate this person?

• OT must gain client’s trust

• “Doing with” vs. “doing to” clients

• Enters the client's life world

• Conscious Thoughts: e.g. Selecting which mode to use

• Automatic: Type of touch

• Needs to be intentional: mistakes may mean you need to rebuild therapeutic relationship.

8 Conditional Reasoning

• Blends all forms of reasoning to be provide a flexible responsive approach to client & possible changes

• Found with more experienced OT’s who can “see” multiple futures, based on therapists past experiences & current information.