"Instead of your voice, raise your reasoning..."

April 03, 2019

"...Flowers bloom because of rain, not thunder."

This is a very important lesson that any health practitioner must learn, as your opinion is only valid if it is backed by clinical reasoning. For critical reasoning to occur, critical thinking needs to take place first.

What is critical thinking? To give you a summarised version – “It refers to the ability to analyse information objectively and make a reasoned judgment. Critical thinking involves the evaluation of sources such as data, facts, observable phenomenon, and research findings.” ("Why Employers Value Critical Thinking", 2019)

I know this looks like A LOT of words and therefore a lot of work involved in critical thinking, but once it is broken down into a couple of steps, it becomes a bit simpler.

The above picture is what is known as the clinical reasoning cycle. This helps us upcoming health professionals to break down the process and do it step by step until it becomes second nature.

To make this a bit more story like than lecture like (cause I feel like I am planning a lecture speech on clinical reasoning) I am going to relate each step to my client and how I used clinical reasoning to narrow down what treatment to start with and how to continue further.

STEP 1 – consider the patient situation.

As one of my lecturers used to say – context, context, CONTEXT. You might think this is self-explanatory, but sometimes you are so excited about a planned activity, that you don’t realise that the activity or treatment does not necessarily match the treatment goals or the client’s situation. It’s all good and well you teach the client how to go up and down ramps, but then they do not have ramps at home. It is integral to plan treatment according to home and work context so that they are as independent as possible before discharge.

STEP 2 – collect cues/information

This step involves collecting information from the therapists at the facility, the patient file, assessment findings and observations.

I read the patient file to gain insight into his condition and how it has affected him, as spinal cord injuries manifest in so many different ways. He is a T3 SCI which means he would have full upper limb sensory and motor function, but that his trunk and lower limbs will have decreased motor control or decreased sensation, or both – all to varying extents. I also spoke to the occupational therapist and physiotherapist about the client’s progress so far.

STEP 3 – Process information.

This involves researching aspects that you don’t understand, relating problems to prognosis, researching co-morbidities and their effect on the prognosis, as well as precautions relating to the diagnosis.

For my client, I needed to research precautions for 2 months post-surgery. I needed to research prognostic factors and co-morbidities such as hypertension, diabetes.

STEP 4 – Identify problems/issues

When you have assessed your patient and spoken to the therapists who have had contact with your client, you then need to identify all the problems. In terms of OT, we have a prioritized problem list which consists of every problem the client has – physically and psychosocially – and put them in order of importance. This can be determined by looking at factors that would inhibit the client from coming to therapy, or looking at what problem is most affecting the client.

With regards to my client, after assessing him, I saw that his biggest problem is that his lower limbs are weak and he needs to improve his standing tolerance. By doing this, the client will be able to improve his standing balance.

STEP 5 – Establish Goals

By establishing goals, we are able to implement methods to achieve these goals. In OT, we call them aims. We have different aims with different cut-off points – short term, intermediate term and long term aims.

For my client, my aim was to improve his lower limb strength, improve his standing tolerance and improve his ability to transfer from sit to stand (very summarised.)

STEP 6 – Take Action

Once you have a plan, you obviously need to act on your plan.

I have been implementing my aims of improving standing tolerance by making use of a standing frame. A standing frame helps the client to weight bear onto the feet, which helps to activate the muscles.

STEP 7 – Evaluate Outcomes

You always need to evaluate how effective your plan is, to ensure that the client is receiving therapy that is beneficial. If not, then a new plan needs to be established.

Fortunately, the therapy I have given my clients has been beneficial and I can see results. My client who was unable to walk or stand unsupported, is now walking using a standing frame and has a standing tolerance of 28 seconds.

STEP 8 – Reflect on process and new learning.

This is a necessary step as it not just helps you to ascertain what works and what doesn’t, but it also gives you an idea of how far you have come. I have reflected on all my therapy sessions over the past few weeks in my blogs, which has been a good way of keeping track of progress.

I have found it to be a very helpful cycle that is easy to implement and has for the most part, become second nature. It has helped me narrow down assessment lists and provide more effective treatment.

So to end off like I do every week…