Clinical Reasoning: How do Pragmatic Reasoning, Worldview and Client-Centredness Fit?

Abstract

Using both clinical reasoning data and literature from the past 20 years, this paper sought to examine the relationship between client-centred practice and clinical reasoning, to explore the concept of pragmatic reasoning and to present a diagrammatic conceptualisation of our knowledge of clinical reasoning in occupational therapy. The clinical reasoning literature published between 1982 and 2001 was reviewed and this information was combined with the findings from a study which used a head-mounted video camera to collect data and then explore the clinical reasoning of 13 experienced occupational therapists. The data were collected and analysed within a focused ethnographic framework. The findings showed that clinical reasoning occurred in the context of client-centred practice, but that a reciprocal relationship appeared to exist between client-centred practice and interactive reasoning. It also appeared that pragmatic reasoning was related only to the therapist's practice context and that all forms of reasoning were influenced by the therapist's worldview. A diagram was developed to depict this current understanding of the modes of clinical reasoning. While clinical reasoning has been described as the guiding force in a therapeutic practice, we are only just beginning to understand the nature of reasoning and reflection and how clinicians think. Further research is required to build and test the emerging theory of clinical reasoning in occupational therapy.

First Year Occupational Therapy Students’ Clinical Reasoning Approach to Addressing Challenging Behaviors Related to Sensory Processing Using a Simulated Case Study

“…Though more difficult to extrapolate, participants evaluated A SECRET strategies to determine if they were fair to the client in question or the other children within the case scenario. Unsworth (2004) concluded that participants' (occupational therapists) personal motivations, values and beliefs influenced their clinical reasoning within pragmatic reasoning. In another study, Hooper (1997) reported that occupational therapists' worldviews influence how therapists reasoned through clinical challenges.…”

A Novel Approach to Study Medical Decision Making in the Clinical Setting: The “Own‐point‐of‐view” Perspective

“…31,32 This idea of ethnography, which developed particularly during the 1970s, is used to collect a large quantity of data within a limited time, when it is coupled with video, thus facilitating the observer's work.…”

“…Therefore, according to Unsworth, "focused ethnography is an ideal method to study clinical reasoning, given the emphasis on understanding what participants think that they are doing and why they are doing it." 32 The use of video is a core feature of methods used to investigate clinical reasoning in an authentic setting (i.e., actual clinical environments where physicians manage patients in their everyday practice). According to Wears and Schubert, 30 "Video-reflexive ethnography is particularly well suited to illuminate the intricate relationships that emerge in the context of interprofessional clinical work.…”

“…32,35 This bulky recording device is likely to disturb the relations between the physician and the patient 36 and thus affect the physician's reasoning. It may also disturb cranial movement and the accomplishment of certain technical operations, especially those performed in emergency medicine.…”

Insights into emergency physicians’ minds in the seconds before and into a patient encounter

“…As there is no accepted definition of expertise, we developed a list of selection criteria (Table 1) [23,30,31]. We sought diversity in our sample [32].…”