10th Anniversary Meeting of ENOTHE

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10th Anniversary Meeting of ENOTHE

• Workshop
• Clinical Reasoning

David Robertson Robert Gordon University david.rob
ertson_at_rgu.ac.uk
Dr Bhoomiah Dasari University of
Southampton B.D.Dasari_at_soton.ac.uk
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Plan

• Introductions?
• Project introduction learning plan
• Development of clinical reasoning skills
• Things we learned
• How do you foster the development of clinical
  reasoning skills within your students?
• How can we improve our project?

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THE MARY STUART PROJECT
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Learning Plan

• Keynote lecture on clinical reasoning
• PBL introduction
• PBL assessment strategy
• PBL treatment strategy
• PBL resettlement strategy
• Videoconference
• Review, debrief, reflect

Participants are in year 3 of a 4-year BSc(Hons)
in Occupational Therapy
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Project Steps

• Released Students Return
• Initial interview history
• Assessment plan
• Sample assessment
• Treatment plan
• Sample discharge summary home environment
• Discharge strategy

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Videoconferencing
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Virtual Community

• Send and receive messages
• Post and read messages on a group forum
• Reading and resource room
• Download case documents

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What is Clinical Reasoning?

• Clinical Reasoning refers to the thinking and
  processes associated with the clinical practice
  of health care providers (Higgs Jones, 1995)
• Clinical reasoning is a specialized cognitive
  process that uses thinking and sometimes talking
  (narrative) to facilitate effective problem
  solving and decision making (Reed, 1999)
• Clinical reasoning is depicted as a non-linear,
  goal-directed process that involves the therapist
  in making sense of the patients condition while
  establishing a collaborative relationship with
  the patient.

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Why Teach Clinical Reasoning?

• As clinical reasoning is a fundamental component
  of occupational therapy clinical practice,
  teaching clinical reasoning is vital to the
  professional preparation of occupational therapy
  students.
• (Dutton, 1995 Royeen, 1995 VanLeit, 1995
  Schell Cervero, 1993 Higgs, 1992 Fleming,
  1991a, 1991b Rogers Holm, 1991, Cohn, 1989
  Neistadt, 1987))

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Types of clinical reasoning identified in the
contemporary literature

• Procedural Reasoning
• Scientific Reasoning
• Diagnostic reasoning
• Hypothetico-deductive reasoning
• Interactive reasoning
• Narrative reasoning
• Collaborative reasoning
• Conditional reasoning
• Predictive reasoning
• Pragmatic reasoning
• Interactive reasoning
• Procedural reasoning
• Ethical or moral reasoning

Clinical Reasoning
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The Dreyfus Model of Skill Acquisition(Dreyfus
Dreyfus, 1980 Dreyfus, 1981)
In the acquisition and development of a skill, a
professional passes through five levels of
proficiency
Novice Advanced beginner Competent Proficient
and Expert
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Developmental Stages and Characteristics of
Clinical Reasoning

• Novice
• No experience, dependent on theory to guide
  practice.
• Uses rule-based procedural reasoning to guide
  actions and not skillful in adapting rules to fit
  situations.
• Narrative reasoning used to establish social
  relationships.
• Pragmatic reasoning stressed in terms of job
  survival

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Developmental Stages and Characteristics of
Clinical Reasoning

• Advanced beginner (lt 1 years of experience)
• Incorporates contextual information into
  rule-based thinking.
• Recognizes differences between theory and
  practice.
• Limited experience in prioritizing problems well.
  
• Begins to gain skills in pragmatic and narrative
  reasoning skills.

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Developmental Stages and Characteristics of
Clinical Reasoning

• Competent (3 years of experience)
• Automatically performs more therapeutic skills
  and attends to more issues.
• More experience in sorting out relevant data and
  able to prioritize treatment goals in the light
  of discharge plan.
• Treatment planning is deliberate, efficient and
  responsive to contextual issues.
• Uses conditional reasoning to upgrade treatment
  and anticipate discharge needs, but lacks
  flexibility of more advanced practitioners.
• Recognizes ethical dilemmas but less sensitive to
  justifiably different ethical responses.

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Developmental Stages and Characteristics of
Clinical Reasoning

• Proficient (5 years of experience)
• Brings deeper store of experience and perceives
  situations as wholes..
• Evaluations are more targeted and shows
  flexibility in treatment.
• Flexibility and creativity demonstrates different
  diagnostic and procedural approaches.
• More attentive to patient/client needs and more
  skillful in negotiating resources to meet
  patient/client needs.
• Increased awareness to ethical dilemmas with more
  sophistication in recognizing situational nature
  of ethical reasoning.

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Developmental Stages and Characteristics of
Clinical Reasoning

• Expert (10 years of experience)
• Clinical reasoning becomes quick intuitive
  process which is deeply internalized and embedded
  in an extensive store of clinical experience..
• Becomes highly skillful in the use of narrative
  and makes appropriate intervention strategy to
  promote long term performance satisfaction..
• More Flexibility and creativity of an experienced
  practitioner which permits practice with less
  routine analysis.

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Clinical Reasoning

• Videoconferences were videotaped and transcribed
• Student statements demonstrating clinical
  reasoning were identified.
• Classification of the statements was undertaken
  by two researchers following reliability testing
  (inter-rater reliability 91)
• These statements were classified according to
  Mattingly Fleming (1994).

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Clinical Reasoning

• Procedural reasoning (61 of statements)
• focuses on the process used to maximize clients
  functioning. (deficits and disabilities)
• Conditional reasoning (27 of statements)
• focuses on understanding of clients feelings
  about themselves and about the intervention they
  receive. (understanding and feelings)
• Interactive reasoning (12 of statements)
• Focuses on the understanding of clients
  disabilities in specific life contexts. (needs,
  occupational performance and environment)

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Clinical reasoning discussion

• Students were utilising clinical reasoning
  extensively during consideration of the case.
• Novices largely adopt procedural reasoning in
  practice, (Paper cases facilitate procedural
  reasoning).
• Reduced opportunity for patient/client
  interaction therefore interactive reasoning.
• Differences between Scottish and US students.
• Exposure to the clinical setting.
• Exposure to MS.

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Discussion

• How is this topic considered in your curriculum?
• What are successful strategies in teaching and
  learning clinical reasoning?

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In Conclusion

• Introductions?
• Project Introduction?
• Things we learned?
• Mistakes we made?
• What do you do/would you do differently?
• How will we move things on?

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References

• Mary Stuart Project
• McCannon, R., Robertson, D., Caldwell, J., Juwah,
  C. Elfessi A. (2004a), The effectiveness of
  problem based learning to achieve targeted case
  specific learning objectives, Occupational
  Therapy in Health Care 18(4) 13-28.
• McCannon, R., Robertson, D., Caldwell, J., Juwah,
  C. Elfessi A. (2004b), A comparison of clinical
  reasoning skills in occupational therapy students
  in the USA and Scotland, Occupational Therapy
  International, 11(3) 160-76.
• Robertson, D., McCannon, R., Caldwell, J., Juwah,
  C. Elfessi A. (2005), Transatlantic
  collaborative teaching and learning via
  information and communications technology.
  British Journal of Occupational Therapy in press.