11
CLINICAL REASONING:
THE BASIS OF PRACTICE
Clinical Reasoning: A Whole Body Process
Theory and Practice
Cognitive Processes Underlying Clinical Reasoning
Aspects of Clinical Reasoning
Scientic Reasoning
Narrative Reasoning
Pragmatic Reasoning
Ethical Reasoning
Clinical Reasoning: A Process of Synthesis
Interactive Process
Conditional Process
Conclusion
C linical reasoning is the process used by practitioners to
plan, direct, perform, and reect on client care. It is a
complex and multifaceted process. To consider clinical rea-
soning requires engaging in a metacognitive analysis. In
simple terms, that means thinking about thinking. This is
important, because newcomers to the eld may incorrectly
understand clinical reasoning as something that practition-
ers choose to do or consider it a form of occupational
therapy intervention theory. It is neither of those things.
Whenever you are thinking about or doing occupational
therapy for an identied individual or group, you are en-
gaged in clinical reasoning. It is not a question of whether
you are doing it, only a question of how well. Furthermore,
there are many practice theories discussed throughout this
text that will inform your clinical reasoning. However, the
BARBARA A. BOYT SCHELL
theories about clinical reasoning discussed in this chapter
are theories about occupational therapy practitioners and
their reasoning processes, not about clients. Keep in mind
these important distinctions as you become mindful of your
own clinical reasoning processes.
This chapter examines clinical reasoning from several
perspectives. The case study presented in Whats a Practi-
tioner to Do? 11-1adapted, with name changes, from a
situation I actually observedprovides an example of an
encounter between an occupational therapist, Terry, and
her client, Mrs. Munro. Read this case study before contin-
uing with the text, paying special attention to the different
kinds of issues and problems that the occupational therapy
practitioner has to address.
CLINICAL REASONING: A WHOLE
BODY PROCESS
With the case study in mind, lets explore the nature of
clinical reasoning. Perhaps one of the rst things to note is
that clinical reasoning is a whole body process. That is one
reason it is a different experience to read a case study than
to be the practitioner in the situation. Some clinical rea-
soning involves straightforward thinking processes that the
practitioner can easily describe. Examples include assessing
occupational performance, such as daily living skills and
work behaviors. Occupational therapy practitioners use
their observations and theoretical knowledge to identify
131
132 UNIT THREE: Occupational Therapy Practitioners
WHATS A PRACTITIONER TO DO? 111
Determining Appropriate Recommendations
Terry, an occupational therapist, goes up to a clients
room in the neurology unit of a regional medical center.
Along the way, she shares her thoughts with Barb, a re-
searcher who is observing her practice. Terry lls Barb
in on the client they are about to see. The client,
Mrs. Munro, is a widow who lives alone in a house in
town. A couple of days earlier, she suffered a strokea
right cerebrovascular accident (CVA)and was brought
by a neighbor to the hospital. Mrs. Munro has made a
rapid recovery and demonstrates good return of her mo-
tor skills. She still has some left-sided weakness and in-
coordination, along with some cognitive problems. She
is a delightfully pleasant older woman and is anxious to
return home.
Terry is seeing this client for the third time, and her
primary concern is to assess whether Mrs. Munro has any
cognitive residual effects from her stroke that would put
her at serious risk if she returned home alone. Terry plans
to do some more in-depth activities of daily living
(ADL) with her to see how well Mrs. Munro demon-
strates safety awareness. Terry thinks she will probably
have Mrs. Munro get out of bed, obtain her clothing and
hygiene supplies, perform her morning hygiene routines
at the sink, and then get dressed. Terry wants to see the
degree to which Mrs. Munro is spontaneously able to
manage these tasks as well has how good her judgment
appears to be. Terrys thought is that if she can engage
Mrs. Munro in several multistep activities that also re-
quire her to perform in different positions Terry should be
able to detect any cognitive and motor problems that
pose a serious safety threat.
When Terry arrives at the room, she greets Mrs. Munro
who says, I am so excited. The doctor says I can go home
tomorrow.
Terry turns to Barb and raises her eyebrows, as if to say,
I told you so. On the way to the room, Terry had told
Barb that she was worried that the physician managing
Mrs. Munros case tended to think that as soon as clients
can physically get up, they can go home. Terry went on
to defend the physician by saying that in todays cost-
conscious environment, doctors were under a lot of pres-
sure to not keep clients in the hospital.
As Terry converses with Mrs. Munro about generali-
ties, she notices that Mrs. Munro is already dressed in
her housecoat. When she talks to Mrs. Munro about do-
ing some self-care activities, it becomes apparent that
the client has already completed her bathing and dress-
ing routines, with help from nursing. When Terry sug-
gests that she perhaps brush her teeth and comb her hair,
Mrs. Munro is happy to get up out of bed, but notes that
her neighbor never did bring in her dentures. Mrs. Munro
sits on the edge of the bed, and after a reminder from
Terry, puts on her slippers. She then stands and walks to
the nearby sink, nds her comb, and combs her hair.
While she is doing this Terry looks around for some
other ideas about what to do, since Mrs. Munro has
already completed the self-care tasks Terry had planned
to do with her.
Terrys eyes light on some wilted owers by the bed.
She suggests to Mrs. Munro that she might want to dis-
pose of the owers and clean the vase so it will be ready
to pack when it comes time to go home. Mrs. Munro
agrees and proceeds to walk somewhat unsteadily over to
the vase. Picking it up, she carries it to the sink, where
she pulls out the dead owers. Terry follows her, staying
slightly behind and within reach of Mrs. Munro. When
Mrs. Munro stops after removing the owers, Terry sug-
gests she rinse out the vase, which she does. She then dries
it and returns the vase to the bedside table. Terry reminds
her to throw out the dead owers. While Mrs. Munro
does this, they begin to talk some more about her plans to
return home.
Mrs. Munro tells Terry that she has lived in her home
for 40 years, and even though her husband died over
10 years ago, she still feels his presence there. He used to
love her cooking, and she still cooks three meals a day for
herself. She starts to cry when they talk about cooking,
but then cheers up. Terry tells her that it might be safer if
she had someone around the house for a few weeks, until
she recovers a bit more from her stroke. Mrs. Munro
thinks she can get some help from her neighbor. Terry
says she is also going to suggest some home-care therapy,
just to make sure she is safe in the kitchen, bathroom,
and so on, noting, We sure dont want to see you have a
bad fall just when you are doing so well after your stroke.
After reviewing some coordination exercises for
Mrs. Munros left hand, Terry says good-bye. Terry and
Barb leave the room. Terry stops at the nurses station to
note in the chart that Mrs. Munro demonstrated good
safety awareness in familiar tasks at her bedside but did
require cuing to complete multistep tasks. Terry also
notes some motor instability in task performance during
ambulation. Terry recommends a referral to a home
health occupational therapy practitioner to assess safety
and equipment needs during bathroom activities, meal
preparation, and routine homemaking tasks. Terry com-
ments to Barb, as they walk off the unit, that she thinks
Mrs. Munro did pretty well, but Terry remains concerned
about the risks once Mrs. Munro goes home and particu-
larly when she is tired. Terry wants someone to monitor
Continues

Mrs. Munro in a familiar setting to see if she handles her
daily routines adequately. Terry would really like to see
Mrs. Munro go to a rehab center, but the client has no in-
surance funding to support that. Terry believes that she
might at least be able to get some home care, because
there are a few programs around that provide some serv-
ices to indigent elderly. Staying in her own home seems
to be Mrs. Munros major goal, and Terry is going to do
what she can to try to help her attain that goal. Terry will
catch up with the social worker later to discuss the need
relevant client factors that contribute to occupational
performance problems. Practitioners also attend to the con-
textual factors affecting performance. For instance, Terry
was able to describe her concerns about Mrs. Munros safety
in returning home. In particular, Terry was addressing self-
care and homemaking activities. She had analyzed relevant
contextual factors about the home setting and Mrs. Munros
social and nancial situation. Terry had identied some im-
pairments in cognition and motor control that were affect-
ing her clients occupational performance skills. This was
all information that Terry could readily share with Barb.
However, there was more knowledge from the therapy
session that Terry either did not or could not put into
words.
Part of Terrys clinical reasoning involved body-based
knowledge that she gained from her senses. For instance,
Terry used her sense of touch to feel the muscle tension (or
lack of tension) in Mrs. Munros affected arm when she was
doing an activity or home exercise program. During her
evaluation, Terry did some quick stretches to Mrs. Munros
elbow and wrist to see if she could feel evidence of spastic-
ity, an abnormal reex response commonly found in indi-
viduals recovering from a stroke. When Mrs. Munro stood
up, Terry carefully gauged the distance she stood from
Mrs. Munro, because Mrs. Munro was at some risk of falling.
Terry was careful to stand not so close that she crowded or
overprotected Mrs. Munro but close enough to protect her
should she lose her balance. While close to Mrs. Munro,
Terry could smell her, gaining a quick sense of possible hy-
giene or continence problems. Terry used her voice quality
to display encouragement and support. Terry watched and
listened carefully for clues about the nature of Mrs. Munros
emotional state. In particular she watched facial expres-
sions and listened for evidence of fear or insecurity during
Mrs. Munros performance of activities. All of these sensa-
tions contributed to an image of Mrs. Munro that inuenced
Terrys practice.
There are other aspects of the clinical reasoning process
that are even harder to describe. Fleming (1994a) described
this as knowing more than we can tell (p. 24). She ex-
plained that much of the professions knowledge is practical
CHAPTER 11: Clinical Reasoning: The Basis of Practice 133
for Mrs. Munro to have good support from any neighbors,
friends, or relatives.
QUESTIONS AND EXERCISES
1. How did Terry develop her concerns about Mrs. Munro?
2. How did Terry know what to do when her initial
plans didnt work out?
3. What factors seem to guide Terrys recommendations
at the end?
knowledge, which is seldom discussed and rarely described
(p. 25). This tacit knowledge, combined with the rich
sensory aspects of actual practice, help explain why reading
about therapy and doing therapy are such different experi-
ences.
THEORY AND PRACTICE
There has been a long-standing discussion in many professions
about the role of theory in professional practice (Kessels &
Korthagen, 1996). Theories help practitioners make decisions,
although Cohn (1989) noted that the problems of practice
rarely present themselves in the straightforward manner de-
scribed in textbook theories. Clinical reasoning involves the
naming and framing of problems based on a personal under-
standing of the clients situation (Schn, 1983). In problem
identication and problem solution, practitioners blend theo-
ries with their own practice experiences to guide their actions.
Theoretical knowledge aids the practitioner to avoid unjusti-
ed assumptions or the use of ineffective therapy techniques
and to reect on how the clinical experience is similar to or
different from theoretical understandings (Parham, 1987).
This issue is discussed further in Chapters 12 and 17.
COGNITIVE PROCESSES UNDERLYING
CLINICAL REASONING
In the case study, Terry had to remember, obtain, and
manage a great deal of information quickly to provide ef-
fective and efcient intervention. How did she do it?
Research ndings from the eld of cognitive psychology
help explain how practitioners think and how experience
combined with reection fosters increasing expertise. In-
dividuals receive, store, and organize information in
schemata, or chunks, which are complex representations
of phenomena (Bruning, Schraw, & Ronning, 1999). For
example, in school, Terry probably learned many of the
134 UNIT THREE: Occupational Therapy Practitioners
common problems associated with someone who has had
a stroke. She also has seen perhaps 100 people with
strokes over the past several years. She has built up a gen-
eral representation in her mind of what to expect when
she receives a referral for someone who has had a stroke.
She anticipates that many of these individuals will have
thick medical charts, because they almost always have
prior medical problems, such as diabetes and high blood
pressure. She wont be surprised if the person is over-
weight. She expects to see impairments in cognition that
often affect the persons ability to do everyday tasks, such
as dressing, cooking, and driving. As part of her schema,
Terry has built-in mental rules that help her categorize and
detect differences. For instance, although she knows that
many people who have strokes have movement impair-
ments, she knows that not all do. Furthermore, when
movement is impaired, she expects individuals with a left
cerebrovascular accident (CVA) to have right-sided
weakness and those with a right CVA to have left-sided
weakness. She knows a persons social support systems are
critical for promoting an adaptive response to disability.
She may use certain cues, such as the presence or absence
of frequent family visits, to prompt her to categorize a
family as supportive or nonsupportive.
In addition to chunking information into schemata,
Terry also creates and uses scripts or procedural rules that
guide her thinking (Bruning et al., 1999). Just as her
schemata help her organize and retrieve her knowledge
about common aspects of stroke, scripts help her organize
common occurrences or events. For instance, she under-
stands that her role involves responding to the referral by
seeing the client, writing her ndings on the correct form,
providing interventions, communicating verbally with the
other team members, and developing discharge plans. Terry
likely has scripts about the implications for clients with
supportive families and those without. In her experience, a
supportive family cares for its family member at home, re-
gardless of the familys nancial resources. Alternatively,
clients with little family support are more likely to face in-
stitutional care. Again, these scripts are formed by Terrys
observations and experiences over time and serve the pur-
pose of helping her anticipate likely events.
Schemata and scripts support effective processing of in-
formation by providing efcient mental frameworks for
handling complex information. Each person individually
constructs them. It is no surprise that students and new
practitioners often struggle to retain and effectively use
their therapy knowledge. It takes time and repetition of ex-
periences to develop effective schemata and scripts. Impor-
tant aspects of the process are as follows (Bruning et al.
1999; Robertson, 1996; Roberts, 1996):
Cue acquisition: Searching for the helpful and targeted
information through observation and questioning.
Pattern recognition: Noticing similarities and differences
among situations
Limiting the problem space: Using patterns to help focus
cue acquisition and knowledge application to the most
fruitful areas.
Problem formulation: Developing an explanation of
what is going on, why it is going on, and what a better
situation or outcome might be.
Problem solution: Identifying courses of action based on
the problem formulation.
These cognitive processes are interactive and rarely oc-
cur in a linear fashion. Rather, the mind jumps around
between the information at hand and that which has been
stored up from prior learning while attempting to make
sense of the situation.
ASPECTS OF CLINICAL REASONING
Although there appear to be common processes underly-
ing clinical reasoning, the focus of that mental activity
appears to vary with the demands of the problems to be
addressed. Fleming (1991) was the rst within occupa-
tional therapy to describe how occupational therapists
seemed to use different thinking approaches, depending
on the nature of the clinical problem they were address-
ing. She referred to this process as the therapist with the
three-track mind (p. 1007). Since that time others have
examined the different aspects of occupational therapy
clinical reasoning. The vast majority of this research has
been done with occupational therapists, although recent
explorations (Lyons & Crepeau, 2001) suggest there is
some application for occupational therapy assistants as
well. These aspects of clinical reasoning are scientic,
narrative, pragmatic, and ethical reasoning. Table 11-1
lists some of the typical questions of the different aspects
of clinical reasoning.
Scientic Reasoning
Scientic reasoning is used to understand the condition that
is affecting an individual and to decide on interventions
that are in the best interest of the client. It is a logical
process that parallels scientic inquiry. Two forms of scien-
tic reasoning described in occupational therapy are diag-
nostic reasoning (Rogers & Holm, 1991) and procedural
reasoning (Fleming, 1991, 1994b). Scientic reasoning may
also be referred to as treatment planning (Pelland, 1987), in
which the therapist uses selected theories both to identify
problems and to guide decision making.
Diagnostic reasoning is concerned with clinical prob-
lem sensing and problem denition. The process starts in
advance of seeing a client. Occupational therapy practi-
tioners, because of their mind-set, primarily look for occu-
pational performance problems. Furthermore, the nature
of the problems they expect to nd are inuenced by the
 CHAPTER 11: Clinical Reasoning: The Basis of Practice 135

TABLE 111. ASPECTS AND EXAMPLES OF THE CLINICAL REASONING PROCESS

Primary Clinical Reasoning Concerns

What are the persons occupational performance concerns?

What is the persons occupational performance status and potential?
What will be done to improve occupational performance?
How are effective are interventions?
When and how should interventions stop?

Scientic Narrative Pragmatic Ethical

Used to understand the
nature of the condition
What is the nature of the
illness, injury, or develop-
ment problem?
What are the common
disabilities resulting from
this condition?
What are the typical
impairments associated
with this condition?
What are the typical
contextual factors that
affect performance?
What theories and research
are available to guide
assessment and interven-
tion?
What intervention protocols
are applicable to this
persons condition?
Used to understand the Used to understand the Used to choose morally defensible
meaning of the condition practical issues affecting actions, given competing interests
to the person clinical action What are the benets and risks to
What is this persons life Who referred this person the person related to service
story? and why? provision and do the benets
What is the nature of this Who is paying for services warrant the risks?
person as an occupational and what are the expec- In the face of limited time and
being? tations? resources, what is the fairest way
How has the health condition What family or caregiver to prioritize care?
affected the persons life resources are there to How can the OT balance the goals
story or ability to continue support intervention? of the person receiving services
his or her life story? What are the expectations with those of the caregiver when
What occupational activities of the OTs supervisor they dont agree?
are most important to this and workplace? To what degree should the OT
person? How much time is there to customize documentation of serv-
What occupational activities see this person? ices to improve reimbursement?
are both meaningful to this What therapy space and What should the OT do when other
person and useful for meet- equipment are available? members of the treatment team
ing therapy goals? are operating in ways that the OT
What are the OTs clinical
feels conict with the goals of
competencies?
the person receiving services?

OT, occupational therapist.

information in the requests for services. Some of Terrys
diagnostic reasoning, described earlier, included informa-
tion about the typical impairments associated with having
a stroke.
Procedural reasoning occurs when practitioners are
thinking about the disease or disability and deciding which
treatment activities (procedures) they might employ to re-
mediate the persons functional performance problems
(Fleming, 1991, p. 1008). This may involve an interview, an
observation of the person engaged in a task, or formal eval-
uations using standardized tools. In the case study, Terry
used a combination of interview and observation, both of
which were guided by her working hypothesis that
Mrs. Munro had cognitive problems that might affect her
safe performance at home. As intervention begins, more
data are collected and the occupational therapy practi-
tioner gains a sharper clinical image. This clinical image is
the result of the interplay between what the occupational
therapy practitioner expects to see (such as the usual course
of the disease or disability) and the actual performance of
the client. In the case study, there was congruence between
Mrs. Munros abilities and problems in performing activities
of daily living and Terrys expectations of someone making a
good recovery from a stroke.
Mattingly (1994a) made the point that occupational
therapists have a two-body practice (p. 37). By that she
meant that occupational therapy practitioners view a per-
son in two ways: the body as a machine, in which parts
may be broken, and the person as a life, lled with per-
sonal meanings and hopes. Much of the procedural rea-
soning in occupational therapy addresses issues related to
the body as machine. The next form of clinical reasoning,
136 UNIT THREE: Occupational Therapy Practitioners
narrative reasoning, provides the occupational therapy
practitioner with a way to understand a persons illness
experience.
Narrative Reasoning
Understanding the meaning that a disease, illness, or dis-
ability has to an individual is a task that goes beyond the sci-
entic understanding of disease processes and organ systems.
Rather, it requires that practitioners nd a way to under-
stand the meaning of this experience from the clients
perspective. Mattingly (1994b) suggested that practitioners
do this through a form of reasoning called narrative reason-
ing. Narrative reasoning is so named because it involves
thinking in story form. It is not uncommon for an occupa-
tional therapy practitioner who is preparing to substitute for
another with a client to ask, So what is her story? As Kiel-
hofner (1997) noted, narrative reasoning becomes particu-
larly important for considering how the persons disrupted
life story can be constituted or reconstituted (p. 316).
In the case study, part of Terrys clinical reasoning was
concerned with making decisions in light of what was im-
portant to Mrs. Munro. This process of collaboration and
empathy has been described as building a communal hori-
zon of understanding (Clark, Ennevor, & Richardson,
1996, p. 376). Terry gained understanding by listening at-
tentively to Mrs. Munros stories about her husband and
how he loved her cooking. It is apparent from this session
that Mrs. Munros home is more than just a house. It is the
place in which she lived with her husband, where he died,
and where she still felt his presence. Part of Mrs. Munros
story is that going home is going back to her husband.
Should this stroke prevent that, Mrs. Munro would lose
more than her independence; she would lose symbolic
connections to her husband. Although a logical case
might be made that Mrs. Munro should start considering a
more supportive living environment, Terry understands
that for Mrs. Munro this would not be an acceptable end-
ing. Consequently, Terry worked hard to obtain the sup-
port systems that would be necessary for Mrs. Munro to
function in her chosen environment, where she will con-
tinue her life story.
Often, occupational therapy practitioners work with
individuals whose life stories are so severely disrupted that
they cannot imagine what their future will look like.
Mattingly (1994b) believes that in these situations, skillful
practitioners help their clients invent new life stories. To
some degree, these stories become visible as the occupa-
tional therapy practitioner and the client develop goals to-
gether. The use of life stories is also apparent when activities
are selected both for their healing potential and their par-
ticular signicance to the person. To do this, one must rst
solicit occupational stories from the individual (Clark et al.,
1996). With an understanding of clients past occupational
stories, practitioners can help individuals create new stories
and new futures for themselves. If Mrs. Munro were more
signicantly disabled, and in a more extended therapy
process, Terry might explore her interest in cooking as an
activity that Mrs. Munro liked and that offers many thera-
peutic opportunities. Further, Mrs. Munro might nd that
she could express her pleasure in cooking for others by
making special treats, rst for other clients and then perhaps
for neighbors in exchange for their help with chores. During
this process, Mrs. Munro would not only be regaining coor-
dination and dexterity, she would be regaining her sense of self
as a productive person. This narrative aspect of clinical rea-
soning, which ultimately focuses on the person as an occu-
pational being, provides a link between the founding values
of the profession and current practice demands (Gray, 1998).
Pragmatic Reasoning
Pragmatic reasoning is yet another strand of clinical reason-
ing that goes beyond the practitioner-client relationship
and addresses the world in which therapy occurs (Schell &
Cervero, 1993). This world is considered from two perspec-
tives: the practice context and the personal context. Be-
cause clinical reasoning is a practical activity, there are a
number of everyday issues that have been identied over the
years that affect the therapy process. These include treat-
ment resources, organizational culture, power relations
among team members, reimbursement issues, and practice
trends in the profession (Barris, 1987; Howard, 1991;
Neuhaus, 1988; Rogers & Holm, 1991). Studies examining
clinical reasoning conrm that occupational therapy practi-
tioners both actively consider and are inuenced by their
practice contexts (Creighton, Dijkers, Bennett, & Brown,
1995; Schell, 1994; Strong, Gilbert, Cassidy, & Bennett,
1995). An example of pragmatic reasoning in the case study
was Terrys use of immediate resources (the ower vase) in
Mrs. Munros room as a therapy tool. Although Terry had
thought of appropriate activities related to self-care, she
had to identify practical alternatives quickly when it turned
out that Mrs. Munro was already dressed. Practical con-
straints for Terry included (1) the time it would take to
move Mrs. Munro to the clinic, where there might be more
resources; (2) the need to get the required information on
that day, since Mrs. Munro was going home; and (3) the
physical constraints of what was available within the room.
Terrys invention of a feasible alternative was a product of
both her therapeutic imagination and the cues provided
within her practice setting.
Terrys attention to the inuence of team members
demonstrates pragmatic reasoning directed to interpersonal
and group issues. She knew the physician had the power to
make discharge decisions. She was aware of the pressures on
the physician by third-party payers to discharge clients as
quickly as possible. Practice requires that practitioners rea-
son about negotiating their clients interests within the
practice culture.
Similar to the practice context, the practitioners per-
sonal situation also is part of the pragmatic reasoning

process. A persons clinical competencies, preferences, com-
mitment to the profession, and life role demands outside of
work all affect the therapy choices considered and thus en-
ter into the clinical reasoning process. For instance, if a
practitioner does not feel safe helping a client stand or
transfer to a bed, he or she is more likely to use tabletop ac-
tivities, which can be done from a wheelchair. Or another
occupational therapy practitioner may feel uncomfortable
dealing with individuals who have depression and, there-
fore, may be quick to suggest that such clients are not moti-
vated for therapy. Furthermore, if a practitioner has a young
family to go home to, he or she may opt not to schedule
clients late in the day, so as to get home as soon as possible.
These simple personal issues result in clinical decisions that
affect the scope and timing of therapy services. Hooper
(1997) suggested that fundamental issues, such as a practi-
tioners values and general worldview, strongly affect the
way an individual constructs his or her clinical reasoning.
Such worldviews play an important role in the next kind of
reasoning, ethical reasoning.
Ethical Reasoning
All of the forms of reasoning described so far help the prac-
titioner respond to the following questions: What is this
persons current occupational situation? What can be done
ETHICS NOTE 111
What Are the Ethical Obligations of
Roberts Therapist?
PENNY KYLER and RUTH ANN HANSEN
Robert is 25 years old and has sickle cell (SC) anemia. He
volunteers at a local SC community program, delivering
bottled water to other people who have SC. Medicaid
provides coverage for his health care. He has been in the
hospital 11 times in the past year with severe abdominal
pain and joint pain. During each hospitalization, he re-
ceives occupational therapy instructions in energy con-
servation and joint protection. Today, the occupational
therapist walks into the clinic and sees Robert waiting.
She turns and walks out mumbling to herself, Its a
waste of my time to treat him. He doesnt follow through
on any of my suggestions.
QUESTIONS AND EXERCISES
1. What are some of the possible reasons that the
practitioner is reluctant to treat Robert? Can you
justify any of them either ethically or legally?
2. Are Roberts goals important? Should his priorities
make a difference in setting treatment goals?
3. What are possible reasons for Roberts lack of
compliance?
CHAPTER 11: Clinical Reasoning: The Basis of Practice 137
to enhance the persons situation? Ethical reasoning goes
one step further and asks the question, What should be
done? Rogers (1983) framed these three questions (here par-
aphrased) in her Eleanor Clark Slagle Lecture and went on
to state: The clinical reasoning process terminates in an
ethical decision, rather than a scientic one, and the ethical
nature of the goal of clinical reasoning projects itself over
the entire sequence (p. 602). In the case study, Terrys eth-
ical dilemma is to understand Mrs. Munros personal wishes
and to honor them when developing a therapy plan that re-
alistically addresses her limitations. This can be particularly
challenging when the pressures of nancial realities (such as
Mrs. Munros lack of insurance) affect available options. A
number of occupational therapy authors have addressed the
ethical aspect of clinical reasoning (Fondiller, Rosage, &
Neuhaus; 1990; Howard, 1991; Neuhaus, 1988; Peloquin,
1993), and Chapter 52 of this text is devoted to the issue of
the ethics of the profession. The purpose here is to intro-
duce ethical reasoning as yet another of the components of
clinical reasoning in occupational therapy.
CLINICAL REASONING: A PROCESS
OF SYNTHESIS
The preceding section described the aspects of clinical rea-
soning separately to illustrate the different parts of the
process. However, these facets of clinical reasoning are not
separate or parallel processes; rather, the opposite appears to
be the case. Virtually all the research about clinical reason-
ing suggests that these different forms interact with each
other.
Interactive Process
Scientic, narrative, pragmatic, and ethical reasoning
processes are intertwined throughout the therapy process.
Indeed, each perspective informs the other. In the case
study, Terrys understanding of medical science helped her
know what might be potential impairments and perform-
ance problems, but her narrative reasoning helped her un-
derstand the importance for Mrs. Munro of returning home.
Put together, these two forms of reasoning help Terry to an
unsaid understanding that there would be a high risk for de-
pression (which could worsen her clients medical condi-
tion) if Mrs. Munro did not return to her home, which
means so much to her. Furthermore, the practical con-
straints associated with the setting and Mrs. Munros reim-
bursement prompted Terry to reason about the ethics of
referring Mrs. Munro to a rehabilitation center (which she
couldnt afford), to home alone (where she might not be
safe), and nally to home with the support of home health
care and neighbors.
Underlying the view of clinical reasoning as an interac-
tive process is the communicative nature of occupational
138 UNIT THREE: Occupational Therapy Practitioners
therapy practice. This is because occupational therapy
involves doing with as opposed to doing to clients meaningful occupations.
(Mattingly & Fleming, 1994, p. 178). Practitioners must
gain the trust of their client and those persons important
in the clients world. They do this by entering the life
world of the client (Crepeau, 1991). Once they are in that
life world, occupational therapy practitioners can better
understand how to help the individual resolve perform-
ance problems.
Conditional Process
Not only must practitioners blend different aspects of clini-
cal reasoning in order to interact effectively with their
clients but also they must exibly modify interventions in
response to changing conditions. Terry showed her exibil-
ity by inventing an activity with the ower vase when her
plan to work with Mrs. Munro on bathing and dressing did
not pan out. Creighton et al. (1995) noticed that occupational
therapy practitioners preplanned treatments in a hierarchi-
cal manner. They observed that practitioners typically
brought several sets of supplies to a treatment session. One
set would be directed to the expected level of performance,
the others to a stage higher and lower than the expected
performance. As an example, one practitioner, in prepara-
tion for a writing activity with a client who had a spinal
cord injury, brought a short writing splint and unlined paper.
This practitioner also brought a longer splint to provide
wrist support (in case the clients hand control was worse
than expected) and lined paper, which required more preci-
sion (in case the hand control was better than expected).
This practitioner blended scientic and pragmatic concerns
in a way that anticipated several possible situations that
might occur.
On a larger scale, Fleming (1994c) described the abil-
ity of skilled occupational therapy practitioners to form
an image of future life possibilities for the person (p. 234).
The ability to form these images (or schemata, using cog-
nitive terms) seems to require a blend of all the forms of
clinical reasoning, along with sufcient clinical experi-
ence to have seen a variety of different outcomes with
former clients. These images help practitioners select
therapeutic activities on a day-to-day basis. For instance,
the writing activity for the client who had a spinal cord
injury not only is a good activity for increasing coordina-
tion but also presages occupations that will enable him to
regain control of his life through writing his own checks,
signing his name on legal documents, and using various
forms of technology for work and play. If this client was an
accountant, these would be powerful images. Conversely,
if the client was a professional athlete, the occupational
therapy practitioner might have to create different activities
to allow the client to develop a vision of himself as a fu-
ture coach or teacher. The activities used in occupational
therapy can help meet specic short-term goals and shape
long-term expectations. It is in this way that practitioners
help individuals reengage in their lives through the use of
CONCLUSION
Clinical reasoning is the process used by practitioners to
plan, direct, perform, and reect on client care. It is a whole-
body and multisensory process that requires complex cogni-
tive activity. Practitioners develop schemata and scripts as
they gain experience, forming the basis of professional
knowledge and action. Clinical reasoning is multifaceted
and enables practitioners to understand client issues from
different perspectives. Practitioners use the logical processes
associated with scientic reasoning to understand the clients
impairments, disabilities, and performance contexts and to
predict the impact these have on occupational performance.
Narrative reasoning helps practitioners appreciate the mean-
ing of occupational performance limitations to the client,
thus supporting client-centered care. Practitioners use prag-
matic reasoning when they address the practical realities as-
sociated with service delivery. All of these forms of reasoning
lead to an ethical reasoning process by which practitioners
select the best therapy action to respond to the clients occu-
pational performance needs.
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