What is Clinical Reasoning?
There are numerous definitions of Clinical Reasoning in the literature:
- The process by which the a health professional collects cues, processes the information, comes to an understanding of a patient problem or situation, plans and implements interventions, evaluate outcomes and reflects on and learns from the process
- Involving more than the ability to offer explicit reasons that justify clinical decisions because it is based on tacit understanding and habitual knowledge gained through experience
- A skill to be learnt rather than a concept to be understood
- The process of using thinking, interpersonal and clinical skills and knowledge in order to acquire, evaluate and make sense of the mass of clinical information available to the health carer during interactions with clients
Defining a clinical question from a ‘mass of information’ provided about or by a client in a clinical setting is a complex process. This involves an interaction of the therapist’s evaluation of cues, the task, the context, utilising of skills, knowledge, metacognition and cognition, with the output being communication with the client or education to the student. A reflective framework using key occupational models of practice, can provide a framework for communicating clinical reasoning with a student.
Common themes in all definitions seem to be that it is a process which is multidimensional and complex which involves planning, intervention and reflection.
How can I facilitate clinical reasoning with students?
UBC School of Audiology and Speech Sciences suggest the following ideas:
- model reflective practice/clinical reasoning/mindfulness by explicitly talking through your thought process as you assess and treat clients
(examples of questions - Why did you select particular goals, teaching strategies, test etc.? What was successful about your session & why? What will you change for the next time & why?)
- tell client stories (past and present, successful /unsuccessful) and your decision-making process
- ask students to tell you their thinking process as you plan sessions together
- ask students how you can help their learning as you observe their sessions (e.g. What objective data would the student like you to record?)
- in following sessions, ask students to reflect on what succeeded and why, what they would change and why, what professional skills have improved as a result of this session and why and how they will use these reflections in planning future sessions. Allow students time to reflect, for example, give the student 15 minutes after the sessions to write notes or questions about the session to then bring to the post-session discussion, encourage the student to keep a journal and / or to keep a list of things learned
- continue to provide students opportunities to observe you (and other clinicians) throughout the placement and continue to share your reflections of your own work with the student
At all times, it is important to consider that the students are at the beginning of their career/their learning in this field. Pathways or ways of thinking which are everyday for you are unlikely to be simple for the student. They will require the process to be broken down into multiple steps to assist.
Development of Clinical Reasoning/Reflection Sheets to guide the student through the process can be valuable. It is essential that they are relevant/individual to your profession and the practice context. They can be used as a tool to prompt the student to think about the process in a step by step way.
Approaches to Clinical Reasoning
Higgs and Jones(2000) outline the following approaches to Clinical Reasoning.
Hypothetico-deductive reasoning – The clinician formulates a hypothesis after observing their patient/client and combines this with their existing knowledge. Than they aim to confirm diagnosis with further tests.
Pattern Recognition - The clinician relies on knowledge and experience of common presentations which they recognise in a new patient/client.
Knowledge reasoning integration - The integration of a clinicians knowledge/cognitive skills with reasoning
- Interpretive reasoning styles:
- Diagnostic reasoning - Aims to reveal the patients/clients impairments
- Interactive reasoning – Developed from patients/clients interactions
- Narrative reasoning – Reasoning based on stories which give us an understanding of the patient/clients motivations and actions.
- Collaborative reasoning – Shared decision making
- Predictive or conditional reasoning – Predicting what will occur based on information collected
- Ethical reasoning – Reasoning based on our ethical thinking
- Teaching as reasoning - Conscious use of advice, guidance and instruction to change patients' understandings, feelings and behaviours
It is generally recognised that most professionals will use a variety of approaches based on their individual circumstances.
Resources to support student clinical reasoning
- Christiansen, C., & Baum, C. (1997). Enabling function and well-being (2nd ed.). Thorofare: Slack
- Higgs and Jones (2000), Clinical Reasoning in the Health Professions. Woburn, MA. Butterworth-Heinemann.
Levett-Jones T, Hoffman K, Dempsey J, Yeun_Sim Jeong S, Noble D, Norton C, Roche J and Hickey N (2009), 'The five rights of Clinical Reasoning: An educational model to enhance nursing students ability to identify and manage 'at risk' patients'. Nurse Education Today. 30, 515 - 520.
- Linn A, Khaw C and Kildea H (2012) 'Clinical Reasoning, a guide to improving teaching and practice'. Australian Family Physician. 41(1), 18 - 20.
- Mattingley C (1991), 'What is Clinical Reasoning?' The American Journal of Occupational Therapy. 45(11), 979 - 986.
- UBC School of Audiology and Speech Sciences (2009) 'Fostering Reflective Practice and Clinical Reasoning in Student Clinicians.' Retrieved from: http://www.audiospeech.ubc.ca/our-people/clinical-faculty/clinical-educators/clinical-education-strategies/strategy11/