Aug 10 / Kimberly Breeden, MS, OTR/L

Occupational Therapy Clinical Reasoning 101

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I have found that in the last several years of my clinical practice, I feel much more confident in my ability to provide effective occupational therapy treatment. Many of you may feel that I should be more confident after 28 years of practice and I agree. I am much more confident than I was as a new practitioner. My years in practice have provided me with the opportunity to experience failure and know that it is not the end of the world. I have acquired a significant amount of knowledge regarding diagnoses and treatment interventions over the years, mind you much of that information is now outdated. I remember when I started practicing as an OTA, there was no internet. If I needed information on a diagnosis, I had to go to the hospital library and look it up. If I wanted to learn more about treatment interventions I searched through AJOTs and textbooks. I relied heavily on my fellow OT practitioners for advice and to answer my questions. I relied on all of these information sources to guide my practice. 

I thought that if I gained more medical and treatment information, I would provide better treatment. I see a lot of posts from new graduates reflecting this same thought. I have come to believe this is not true. Now, I definitely feel that we as OT practitioners should be informed to the evidence and clinical knowledge. But I don’t think that confidence should come only as a result of more information. I see this clearly in my own practice. Seven years ago I accepted the challenge to develop an outpatient occupational therapy pain program. I had zero experience working specifically in pain, of all the settings I have worked in, I had the least amount of experience in outpatient. This was my very first job as an OT. Niccole joined the program shortly after; she too had no experience working in pain. So how did we make it work? Some may think it is by learning more about pain, and that would be a part of it. However, what really guided our process and continues to guide my process is clinical reasoning.  

The Occupational Therapy Practice Framework: Domain and Process, Fourth Edition does not use the term clinical reasoning but instead professional reasoning, which is defined as "the process that practitioners use to plan, direct, perform and reflect on client care" (2020, p, 81). For me it is my professional reasoning process that actually leads to me identify what information I have, and what I need to seek out. This process allows me to confidently navigate new challenges.  

Before we go on, I want to take a minute to discuss why I feel that it is important to share this information. I have come to know so many amazing new grad OTs and OTAs entering our field who talk about lacking confidence in their ability and skills to provide excellent OT services to their clients. This grieves my heart, because every year I am more impressed by the knowledge and skills that our newest colleagues bring to our field. Our profession desperately needs our new practitioners' knowledge to best practices and the most current emerging trends. In my opinion, new practitioners should be confident that they are equipped with all of the skills they need to successfully help individuals, groups, and populations engage in meaningful occupations. They may need more knowledge, but all practitioners need more knowledge, because it is ever changing. I think that it would be helpful to distinguish the difference in having knowledge and having a strategy.  

A good strategy is based on clinical or professional reasoning. I think that there is no one right way to apply professional reasoning. Many practitioners may choose a specific occupational therapy model or theory to guide their reasoning. Several occupational therapy models include specific assessment tools and/or a reasoning process such as the Model of Human Occupation (MOHO) and the Canadian Model of Occupational Performance and Engagement (CMOP-E).  

I have found that as a practitioner, I often make things much more complicated than they need to be. I also have relied too heavily on medical information in the past, For example I have read a medical chart and felt overwhelmed by an individual's medical complexity but walked into the room to find the client sitting in the chair fully dressed in street clothes with a good understanding of how to manage their condition. At other times, I have reviewed a chart and felt confident that I already knew what areas would need to be addressed. I would then proceed into the home to find a myriad of unexpected issues that made the situation extremely complex. It is easy to get lost in all the details, especially when they are regarding medical conditions. Having a process to organize the details and develop a plan of action can be extremely helpful. 

I will briefly share my process in hopes that it may help you develop one that works for you. To keep it simple I have condensed the process down to 5 steps.
 
1. Information Gathering - Safety

2. Information Gathering - Identify what occupations are meaningful to the client, this may include previous occupational engagement

3. Assessment- Identify current occupational engagement and performance.
 
4. Occupational analysis
 
5. Develop goals and a plan. 

It really is that simple. Focusing on occupation first helps me better sort through the details. 
There are definitely a lot of considerations within each of these points, but I will try to keep it brief for this blog. 

1. Information Gathering - Safety:
 - What do I need to know or do to keep this client safe? 
 
Prior to seeing the client:
 
I thoroughly read the medical chart before I see a client. For me the most important information is to make sure I keep my client safe:
- What precautions do they have?  
- Do they have allergies?
- Activity Restrictions
- Diet Restrictions
 
This may be the point that you realize you need to obtain some additional information regarding a diagnosis. Take a minute to look it up, if you can't look it up now, plan to look it up later. It's ok to not know everything during a session, but also be prepared that there may be some things that cannot be safely carried out until that information is obtained. 
 
Now I go and see my client and obtain the following information
 - Clarity any precautions and restrictions
   "Is there anything I need to know to keep you safe?"
 
This may be another point where you identify that you need to research more about a specific condition or treatment. Don't panic, know what you don't know and have a plan to find out more. If in doubt, don't do anything you aren't comfortable with. You can always defer a part of the assessment or treatment such as range of motion or strength testing until you clarify precautions.  


 2. Information Gathering - Identify previous engagement in occupations or what occupations are meaningful to the client:
   
- What occupations have been the most meaningful to them?  
- How have they identified themselves (career, roles, service)? 
- What occupations do they want to engage in that they have not previously been able to? Hint: this is part of the occupational profile. You can also check out my previous blog about how I use the occupational profile. 
 

3. Assessment - Identify current occupational performance: (also part of the occupational profile)
 
 - Most importantly: identify what the client is most concerned about in regards to their current occupational performance. 
 - Assess current occupational engagement: what occupations are impacted? 
 - Assess performance skills, patterns, client factors, and contexts that could be impacting current occupational performance? 

This is where I complete my assessment of MMT, ROM, coordination, balance, cognition, sensory processing, pain, psychosocial, readiness for change, environment, social supports 

4. Occupational Analysis: 
 
 - First I focus on what occupations are most important to the client
- Safety: what needs to be done to ensure the client is safe in all occupations 
- What do they need to do for their health management
- Now identify what factors are impacting or impairing occupational performance in the identified occupations to be addressed 

Tip: I may identify many areas that are not within the normal limits, however that does not mean that they need to be addressed if they are not impacting occupational performance and they are not a concern for the client. Someone may have weakness, limited range of motion or impaired coordination, but they may be able to dress, bathe, toilet, cook and garden to their satisfaction.  
 
I utilize a top down approach. I focus on the factors that impact the client's ability to do the things they want to do. Often times clients may have some weakness but that is not what is keeping them from doing what they want to do, as a matter of fact helping them do what they want to do may help them gain strength. 
 
5. Develop goals and a plan in collaboration with client:  Goals should be directed at occupations that client wants to address and the plan should be developed with the client, not for the client.
 
 - This is where you determine what approach will be best to help the client achieve their goals 
   
Identify if you are going to work to restore skills or adapt tasks to complete occupations, or both.

Conclusion:

This process can be applied to every session, you may focus more on just one or two steps and that is ok.  

I know that the occupational therapy process is complex, but I hope that this blog has helped you to realize that you already have the training and skills no matter how much experience you have. The key is having a process to apply those skills and training and to identify what knowledge is required. Feel free to reach out to us with any questions you may have. 


American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

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