The Narrative Nature of Clinical Reasoning

Abstract

Narrative reasoning is a central mode of clinical reasoning in occupational therapy. Therapists reason narratively when they are concerned with disability as an illness experience, that is, with how a physiological condition is affecting a person's life. In this paper, narrative reasoning is contrasted with propositional reasoning, and two kinds of narrative thinking are examined. The first is the use of narrative as a mode of speech that can be contrasted with biomedical discourse, in which disability is framed as physical pathology. The second involves the creation rather than the telling of stories. Therapists try to "emplot" therapeutic encounters with patients, that is, to help create a therapeutic story that becomes a meaningful short story in the larger life story of the patient.

The role of clinician emotion in clinical reasoning: Balancing the analytical process

“…Evaluative work surrounding expertise and novice practice shows similarities between professions, especially in common decision-making skills (Curran et al 2006;Hoben et al 2007;Mattingly 1991). Expert practice in physiotherapy has been proposed to involve a combination of knowledge, clinical reasoning, movement and virtues (Jensen et al 2000), whilst "master" or expert practice when compared to novice has been shown to be separated by the ability to use time, develop frameworks, communicate, teach, and predict clinical outcomes (Jensen et al 1992).…”

“…The musculoskeletal physiotherapy literature surrounding therapists and reasoning suggests that clinicians commonly may generate initial hypotheses and subsequently test them via questioning or physical examination procedures (hypotheticodeductive) in a deductive way from a general presentation resulting to one that is more specific (Jones 1995;Loftus and Smith 2008). They attempt to recognise clinical patterns that have been experienced before (pattern-recognition) (Patel et al 1997), clinicians may create an understanding of the patient story (narrative reasoning) (Mattingly 1991;Mattingly and Fleming 1994) or identify a number of clinical variables that when presented together suggest a treatment plan (clinical prediction) (Childs et al 2004). In addition to these commonly cited musculoskeletal models there are other less familiar methods of reasoning identified such as ethical and procedural: Ethical reasoning requires the knowledge of ethical principles, codes of conduct and professional standards and applies these when confronted by a clinical dilemma (Barnitt & Partridge 1997;Edwards and Delaney 2008).…”

“…The emotional component that inter-links with the cognitive element of the clinical examination is generated by the clinicians' empathy and the ability to interpret and appreciate the patient experience enhancing the patients' sense of being listened to and understood (Mattingly 1991;Orme and Maggs 1993). This clinician and patient relationship has been described as intuitive practice (English 1993;Gore & Sadler-Smith 2011;Smith et al 2004) and is well documented in nursing literature.…”

Clinical reasoning in osteopathy – More than just principles?

“…16 Importantly, clinical reasoning encompasses more than just the process of reaching a diagnosis, which while pivotal, is just part of a range of clinical reasoning strategies at a clinicians' disposal. 17,18,19,20,21 Research in the health sciences has identified the clinical reasoning strategies used in different health professions. While all health professions tend to share common core compo-nents (such as diagnostic, procedural and narrative reasoning), the approach each profession takes to clinical reasoning varies, and a number of different clinical reasoning strategies have been identified though research or proposed theoretically: in nursing; 13,22 in occupational therapy; 17,18,19 and in physiotherapy.…”

“…17,18,19,20,21 Research in the health sciences has identified the clinical reasoning strategies used in different health professions. While all health professions tend to share common core compo-nents (such as diagnostic, procedural and narrative reasoning), the approach each profession takes to clinical reasoning varies, and a number of different clinical reasoning strategies have been identified though research or proposed theoretically: in nursing; 13,22 in occupational therapy; 17,18,19 and in physiotherapy. 10,20,21,23 Table 1 illustrates the clinical reasoning strategies identified in a range of health professions.…”