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Terminology used in OT literature to describe the process of making a choice in a clinical context varies. The following chapter offers operational definitions, provides the main types of clinical decision making in OT, and explores the thought processes that underpin clinical judgements in OT. Some discussion is also offered as to whether these might differ in the area of paediatrics, as exploring what informs clinical decision making when working with children born preterm was one of the study objectives. The literature in this chapter relates to the seventh section of the questionnaire where participants were asked to provide information relating to the factors informing their clinical decision making when evidence about occupational therapy's effect on this population may be lacking.

Terms such as clinical reasoning, clinical judgement, clinical decision making or problem solving are often used interchangeably. As exploring dictionary definitions and semantics were not the purpose of the thesis, no lexical denotations are presented here. The definitions provided by Fleming (1991) and Unsworth (2008) have been adopted. Reasoning appears to be a broader term that “refers to the many ways in which a person may think about and interpret an idea or phenomenon”

(Fleming, 1991, p.989), and involves, according to Unsworth (2008), intuition, judgement, empathy and, common sense. Decision making on the other hand, within a clinical context, equals the formal, professional decision making, the “science of practice”, and involves making a choice between alternatives (Unsworth, 2008). It becomes therefore apparent that reasoning is a broader term and, covers more aspects of thinking. Decision making is somewhat narrower as a term as it entails the process of reaching a certain decision, a product, something that reasoning does not necessarily translate into. Decision making is according to Mattingly and Fleming (1994), cited in Kuipers et al (2006) embedded within the broader process of reasoning. In this sense “clinical decision making” was the term used from the beginning of this study, when its objectives were formulated (Chapter I). Clinical

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reasoning (or decision making) is, according to Munroe (1992) cited in Munroe (1995): “A complex and multidimensional activity involving the use of a wide range of cognitive strategies and mental processes which underpin the judgements and decisions made by clinicians in the context of clinical practice” (p313).

Occupational therapy literature is presented here that relates to both terms, i.e.

clinical reasoning and clinical decision making, as the definitions adapted by each author were not always clear, or at times even arbitrary, a fact that did not allow the setting exclusion criteria.

Chapparo and Ranka (2000) claim that there is a wide array of factors that influence OTs’ thinking when making certain decisions during the course of therapy. One of those is the therapeutic context. This might involve organisational values, policies and, financial or human resources. The client and client’s life are other factors and might involve knowledge of their wishes and values, knowledge of their abilities, knowledge of the environment they live in etc. Scientific and theoretical knowledge, but also tacit, practical professional knowledge, informed by experience in clinical situations, might also inform OT decision making. Finally, the therapist’s personal beliefs and fundamental assumptions are often elements that can inform the process.

Kuipers’ and Grice’s (2009) study, which employed repertory grid interviews to investigate the clinical reasoning of experienced occupational therapies in neurology, similarly, revealed an array of themes across the interviews such as the importance of theoretical frameworks and practice models, the significance of clinical expertise, as well as client-related aspects of the clinical situation, which guide clinical practice in neurological rehabilitation.

It becomes, therefore, apparent that synthesising all these factors, which might often be conflicting in nature, is a very challenging process. During this “synthesis”, which is according to Higgs (2003), a key procedure of advanced practice, the clinician draws all these elements together. Pedretti (1982), cited in Chapparo and Ranka (2000), claims that it is probably this that defines the professional identity of OTs more than anything else as “our real identity and uniqueness lies not as much in what

109 we do, but in how we think” (p.130).

Fleming (1994a) and Roberts (1996) stress that there are several modes of clinical reasoning that OTs use, and which very much depend on the purpose and the special aspects of the clinical situation (Table 9).

Table 9: Types of Clinical Reasoning

Definitions of Modes of Clinical Reasoning

Narrative: use of stories from past or present clients to understand a clinical situation; creating images of the future for the client

Ethical: Balancing one value against another; used for moral or ethical dilemmas

Conditional or Predictive: Projecting an imagined future for the client; clients participate in the construction of the image; social and physical contexts in which the person lives are very important Interactive: Creating a dialogue to better understand the context in which the client’s

problem exists; understanding how client might be experiencing disability; taking into account his point of view with regards to certain treatments

Pragmatic: Goes beyond therapist-client relationship; practical action and what is achievable in terms of resources, financial constraints, practice trends etc

Procedural: Problem identification->goal setting->treatment planning; resembles medical model of reasoning (diagnosis-prognosis-prescription);

Hypothetico-deductive: generation of hypotheses based on clinical data and further testing of those, through further enquiry

(Higgs, 2003; Chapparo and Ranka, 2000; Flemming, 1994a; Fleming, 1994b, Mattingly, 1994; Schell, 1998)

An exploration of the OT-specific literature on decision making did not reveal research which was particularly related to the topic of this study. Studies which explored the decision making processes of OTs in paediatric areas of interest were also limited (Rigby & Schwellnus, 1999; Clark & Miller, 1996), and did not reveal any particular idiosyncrasies in the ways paediatric OTs reach certain decisions. What was found in the literature were rather descriptions of the factors that inform OT’s decision making, comparisons between the medical model of clinical hypothetico-deductive reasoning and the clinical reasoning of OTs, or, the decision strategies OTs use before selecting from alternative plans of action e.g. intuition,cross validation etc.

Lee and Miller (2003) supported the importance of evidence as a major informant of everyday clinical decision making. The idea of evidence-based practice is certainly not a new one. Clinicians engage with appraising available research in order to find

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examples of “best” research. What the authors highlighted, however, was the importance of incorporating a “diverse variety” of evidence into the process of decision making. Without ignoring the importance of scientific method as the one which “overcomes the accidental and capricious element” (Pierce, 1877 quoted by Lee & Miller, 2003), the authors suggest that there is no golden standard, and no evidence should be dismissed as it could add to a fuller understanding of OT practice.

The authors looked at evidence as a broader term which goes beyond anything stemming from the pure scientific method. They did, for example, stress that a priori sources of evidence such as clinical experience and expertise can also be invaluable informants of decision making. The opinions of peers, and especially specialists’ and individuals’ of a high calibre, as well as, institutional guidelines and policies could also be viewed as evidence of an authoritarian status which could also play an important role in decision making. Finally, the core values of the profession were viewed as a framework for decision making.

Bennett and Bennett (2000) refer to “hierarchies of evidence”, and research methodologies such as randomised controlled trials (RCTs) and systematic reviews, being viewed as those producing “best” evidence. They do, however, suggest caution when interpreting the clinical importance of any study’s findings. They stress that placing faith on the strength of a study findings should very much relate to the clinical question(s) the practitioner is formulating when seeking evidence. As such, RCTs produce “strong” findings when investigating the effectiveness of a treatment;

however, qualitative research methodologies might be rather suitable when exploring how a client or a client group experiences this treatment or the illness. It is therefore stressed that “disciplines should not be disadvantaged by the rigid application of a hierarchy of evidence” (National Health and Medical Research Council, 1998 in Bennett and Bennett, 2000, p.176).

Grime (1990) who looked at how initial decisions are made after a client is referred to community OT services, did, like Lee and Miller (2003), agree on the importance of evidence as an informing factor to decision making. Grime (1990) referred to Hammond’s cognitive continuum, which proposes ways that the task of making a

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decision should be approached. These ways vary from intuitive or peer judgements to scientific methods of enquiry, e.g. controlled trials, informing decision making. This author also stressed that there does not seem to be a uniform opinion in the OT community, and opinions vary from those of “theorists” who claim that the higher someone moves along Hammond’s continuum the more improved the quality of a decision is, whereas others believe that such an approach could undermine the holistic, individualised OT approach, which could equally value individual meaning.

The latter seems to agree with the claim of Lee and Miller (2003) who suggested that no type of evidence should be dismissed, as evidence leads to fuller understanding of the client and their needs.

Fleming (1991) attempted to elucidate the nature of the thinking (reasoning) processes occurring when OTs come to make certain decisions. The American OT Foundation Clinical Reasoning Study was an ethnographic study that investigated the clinical reasoning strategies of 14 OTs working in a large hospital by employing observations, videotaped treatment sessions and interviews with the participants who were asked to identify these strategies. These were subsequently compared to the clinical reasoning employed by the medical profession. In contrast to the linear process of decision making adopted by the medical profession based on the formulation of a hypothesis for a diagnosis, the prediction of a prognosis and, the assessment of the outcome of specific treatment, OTs did not identify similar distinctive “clear cut decision points” (p.992). They rather described an iterative process with the formulation of hypotheses on what the problem might be and the devising of action plans occurring simultaneously, and several times throughout the OT process. Moreover the notion of diagnosis appeared to be for OTs of a lesser significance as they were rather preoccupied with functional outcome and occupational performance. Therapists perceived aetiology as important but not necessary. In a similar fashion, the notion of prognosis was for OTs not a fixed outcome, but a strong possibility depending on a number of other factors such as the individual and his wishes, and/or his environment. As these variables can vary greatly the clinicians engaged often in “visualisation” possibilities in the client’s future, resembling the conditional mode of reasoning that was described earlier (Table 9).

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Fleming (1991) reported that the participants, without dismissing the importance of the scientific method and prediction based on statistical values, tended to place equal importance on the particulars of the client e.g. the variations on the clinical picture of his disease which in combination with personal circumstances could lead to a different outcome and therefore demand an individualised treatment. Prediction was not only viewed in relation to statistical information but also experience and acquired knowledge, which the author referred to as “clinical prediction”.

The qualitative study of Roberts (1996), who looked at the content and process of OT reasoning, reported similarly the thinking strategies of 38 OTs, who had a higher degree in OT and at least two years of post-qualification experience. The participants were presented with specific practice scenarios that they had to comment upon by providing written responses/ commentaries. As the content of these responses was not specifically related to paediatrics it is not presented here. With regards to the process of reaching a specific decision, an iterative, non-linear process resembling the one described by Fleming (1991) was described in this study. Similarly to the type of reasoning by the medical profession, problem formulation, cue acquisition and eventual problem solution were identified as steps in the reasoning process, with these however, not necessarily following a sequential mode.

A direct comparison between the studies of the American OT Foundation Clinical Reasoning Study (Fleming, 1991) and the one of Roberts (1996) might not be possible as the methodologies deployed varied greatly. The first study used a variety of methods to elucidate the reasoning process (e.g. observations, videotaped treatment sessions, interviews), whereas a uni-method (written response) was used for the latter. Some commonalities are, however, evident with regards to the way OTs reason in the light of a pertinent clinical decision. Roberts (1996) stressed that despite this common pattern in the reasoning process, some variations existed across the participants’ responses representing “diverse individual schemata” (p.375) due to different and unique experiences each one of them has had. In this sense some clinicians were capable of a “rapid”, almost automatic or intuitive formulation of the potential problem, something that according to the author might have had to do

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with longer experience. This experience could permit pattern recognition. This probably explains the reliance of non experienced, “novice” clinicians on the hypothetico-deductive reasoning. Area of expertise could also be crucial. Paediatrics may pose unique issues in terms of clinical reasoning. For example, some function might have never been gained rather than having been “lost”. Moreover, client input is different.

Several other, often diverse, factors are reported to influence the decision making of therapists in the OT literature. Kuipers et al (2006) explored whether these factors differed when making certain decisions for adult or paediatric client populations with brain injury. Eleven occupational therapists, six with experience in working with children, and five with experience working with adults with a brain injury, were recruited to participate in two focus groups in order to investigate the elements that affect decision making. The analysis of the focus groups revealed a relative consistency in the views of the participants irrespective of the population they worked with. The factors were categorised as intrinsic or extrinsic to the client. Intrinsic factors included the client’s personal characteristics such as age, motivation, compliance and wishes, the client’s condition and, the client’s occupational performance needs. The importance of the intrinsic factors seems to agree with Lee and Miller (2003) and Fleming(1991) who referred respectively to “intrinsic potential of each client to determine what is meaningful to them” and the importance of taking into consideration “the particulars of the each person”, including variations in the clinical manifestations of the condition. Extrinsic factors deemed to be of importance for decision making were knowledge of the therapist and/or her clinical experience and “preference” of particular methods and interventions, or, environmental factors such as organisational culture and context of service provision, technical and professional resources, peers’ opinions, time use etc.

Although, the listing of these factors and their subsequent categorisation is interesting, the study design does not permit any discussion on whether the factors had a different weighting. The authors acknowledged this limitation by suggesting future quantitative research. It remains, however, unclear how this might be feasible

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given the “particularity” of each case. Ranking these factors could for example pose challenges even when the diagnoses would be the same, as they could differ for each client.

When considering the “intrinsic to the client” factors, the role of the family and the importance of family-centred practice have to be mentioned. Especially, when considering paediatric practice, the role of family in understanding the children’s roles and occupational performance and, subsequently, collaborating when designing intervention is pivotal (Darlington and Rodger, 2006). “Family-centred practice (FCP) means that professionals value, encourage and commit to the meaningful involvement of families in the planning and implementation of services” (Salisbury and Dunst, 1997 in Rodger and Ziviani, 2006, p.30). Darlington and Rodger (2006) present the recognition of the importance of family values, wishes, and willingness to engage to therapy as a core requirement of family-centred practice. They also stress that family members should have the opportunity to decide their level of involvement in decision making.

Rigby and Schwellnuss (1999) have also explored issues that resemble the

“extrinsic” factors of Kuipers et al (2006), and relate to the therapist’s knowledge or expertise when deciding on specific assessment and intervention procedures.

Although their study focused on the written productivity of school-aged children with cerebral palsy (CP), the study is mentioned here as its findings were used as preliminary steps towards developing “OT Decision Making Guidelines” for children with problems in written productivity. Four video-taped case examples of children with CP experiencing handwriting problems were sent to 26 paediatric OTs who were asked to comment on assessment and intervention procedures they would use for these children. They were also asked to comment on what grounds they would base these decisions. According to the authors the therapists’ clinical choices were based on their experience and/or the theoretical assumptions about these procedures, even when empirical support would be lacking. This somewhat agrees with Lee and Miller (2003) and Grime (1990) who, without disregarding the scientific method and evidence stemming from it, supported the importance of knowledge and expertise of

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clinicians as equally valuable evidence in the process of decision making. According to Rigby and Schwellnuss (1999), even in the absence of empirical evidence OTs seem to use the principles of certain assessments and intervention by using it as

“direction and rationale for OT decisions” (p.24). The process of deciding upon a certain intervention method in particular, was thought to very much depend on assessment findings. As the process of assessment consisted of multiple rather than one procedure, findings suggested that, rather than linking one assessment finding to one intervention, OTs viewed all assessment findings together, looked for patterns and then decided upon the intervention.

Referring to the, “extrinsic” to the client, factors that might affect decision making, Grime (1990), whose work focused on the decision making process of community OTs in Oxfordshire, UK, when receiving referrals for new clients, suggested that clinicians often face constraints with resource allocation and time. According to Grime (1990), this inevitably influences decisions, and presses for prioritisation of “urgent”

over “non-urgent” needs. A similar pragmatic constraint is that of a limited budget to facilitate the best approach for clients. This could relate either to purchasing specific equipment or funding for acquiring specialised training in new treatment approaches.

These could pose challenges when OT practitioners come to balance the individualised approach with “distributional efficiency”. This decision can, according to Grime (1990), even take ethical dimensions when pressure for cost efficiency from external services such as local councillors could trivialise provision of individual care.

This prioritisation of “urgent” over “non-urgent” needs, stemming from pragmatic constraints, does very much relate to the topic of prematurity and the children who might not present with obvious disabilities from an early point onwards as this could result into their “non –urgent” needs being “overlooked”.

Although not necessarily related to paediatrics, some ways have been suggested in the literature of establishing rigour and consistency in the process of clinical decision making. Campbell (1999), cited in Kuipers et al (2006) suggested the use of systematic clinical reasoning protocols and the use of algorithms, whereas Sinclair (2004) proposed a matrix that breaks the reasoning process into facets,