This week we are taking a quick look at clinical reasoning and how it applies to prescription of wheelchair and seating items. Clinical reasoning is a tricky concept to define. While universal to all health professions, the exact process appears to vary a little between professions. There is some research available into clinical reasoning, however most of it involves clinical reasoning for medical professionals or exploring how clinical reasoning is taught to students.
Looking at the research does help give us a definition for clinical reasoning. Gummesson, Sunden and Fex (2018) state clinical reasoning may be explained as being the professional thought process, or the decision-making process, that a clinician undertakes when working with a person. Delany and Golding (2014) state that clinical reasoning involves gathering and analysing information as well as deciding on therapeutic actions specific to the patient’s circumstances and wishes.
Young and Thomas et al (2020) state clinical reasoning reflects the thinking or reasoning that a health practitioner engages in to solve and manage a clinical problem. Cited in Edwards and Jones et al (2004), clinical reasoning can be described as a process in which the therapist, interacting with the patient and others such as family members or caregivers, helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices and professional judgement and knowledge.
Clinical reasoning can differ between therapists of different levels of experience, for example students mainly use a more analytic way of reasoning, where they seek answers from their theoretical knowledge to explain their findings, while more experienced therapists tend to rely on patterns they recognise without full analytical thought process. However, experienced therapists will also engage in an analytical thought process when presented with something unfamiliar (Gummesson, Sunden and Fex 2018).
Edwards and Jones et al (2004) explored clinical reasoning processes in a group of experienced Physiotherapists with different specialties (musculoskeletal, neurology and community) and proposed that physiotherapists use a mixture of hypothetical-deductive reasoning, along with narrative reasoning, to acquire an understanding of the person as well as the disease
Hypothetical-deductive reasoning can also be known as diagnostic reasoning, where a therapist attempts to diagnose the underlying concern, and throughout the treatment process will continually evaluate as to whether this reasoning continues to hold true, such as assessing the impact of an intervention and checking whether the response is in keeping with the initial diagnosis.
Narrative reasoning on the other hand seeks to understand the unique lived experience of the person through their stories or narratives, to allow the therapist to gain insight into the person’s experience of pain or disability and their subsequent beliefs, feelings, and health behaviours.
The combination of these two models of clinical reasoning balance the need to optimally diagnose and manage person’s presentation but also understand and engage with the person’s experience of that disability and pain.
In our Funding 101 webinar we explored the use of the ICF framework as a means of collecting the wide range of information required to assist in writing a funding report. A funding report also requires us to demonstrate our clinical reasoning process. In other words, showing our thinking as to how the identified solution will meet the persons identified needs and goals. This clinical reasoning process needs to incorporate information obtained during our assessment process and may incorporate both a hypothetical-deductive reasoning approach and a narrative approach.
Clinical reasoning to support provision of a wheelchair is often the easy part – a person may have a complete spinal cord injury and is no longer able to walk, hence they require a wheelchair for all functional mobility. In addition to showing rationale for provision of a wheelchair, we also need to demonstrate clinical reasoning to justify additional features or the additional cost of a higher specification chair.
For example, our person with a complete spinal cord injury requires a scripted chair to allow for optimal configuration to maintain shoulder health (as per the RESNA position paper. They may also require a power assist device to allow them to continue to work in their large workplace, or to be independently mobile in their community to allow them to attend activities with their children.
This clinical reasoning process can help identify what parameters a solution requires, for example the person needs a power assist device that is easily transported in their standard car or a solution that works well on different terrain in their community. Identifying the parameters of a solution then matching a particular product to those parameters can assist with documenting our clinical reasoning, as opposed to just stating that a person requires a particular product.
Another component of clinical reasoning involves considering alternative solutions and weighing the benefits and challenges of each solution identified. For example, each power assist device comes with its benefits and challenges, not to mention an actual power wheelchair may be also be a potential option. This can be where our narrative reasoning can help us – for example incorporating a person’s desire to remain self-propelling or whether or not they are willing to change their vehicle to accommodate a proposed solution.
This narrative reasoning can also expose some challenging issues, such as the person who refuses to consider trialling a power wheelchair despite their lack of functional mobility in a manual wheelchair, or the person who wants to trial of a piece of mobility equipment that is potentially beyond their ability to safely manage due to their progressive condition.
When it comes to how we explain our clinical reasoning in our reports, a study by Delany and Golding (2014) provides a little insight. Delany and Golding looked at a group of educators working with students – these were educators from a variety of health professions, who explored their own clinical reasoning processes and looked at how to translate this into teaching of their students.
A point that emerged from this study was how the educators had to be more concrete and explicit about their knowledge and reasoning when describing their clinical thinking to a colleague from a different discipline. A Physiotherapist needed to explain their clinical reasoning clearly to an educator that had a Social Work background in order for the Social Worker to understand their clinical reasoning process. This might be something we need to keep in mind when writing our reports – in that the person reading the report and approving the funding may not have the same professional background as the person writing the report.
Where the trial occurs in the report writing process varies across funding options, however the trial does give us a chance to add information to our clinical reasoning process – for example if we are exploring use of a power wheelchair as a means of reducing fatigue, a trial will allow us to establish whether this proves to be true. A trial can also be a source of new information – for example a person’s cognitive abilities may become clear when trialling a power wheelchair, or new goals may emerge when a person realises what opportunities a change of mobility solution may offer them.
Many of us will have the clinical reasoning abilities discussed here. But how well we are able to articulate them, or document them in a report, will vary. A useful strategy for improving on your ability to articulate or document your clinical reasoning is to discuss your reasoning with a person who is not familiar with the person you are writing the report about. This can help identify any gaps in your reasoning or challenge any assumptions you have made. This is likely to result in a report that is easier for the funders to follow and reduce the time taken to get approval for a solution, allowing the person to receive their equipment and fulfill their goals sooner.
Gummesson, C., Sunden, A., & Fex A. (2018). Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews 23 (1) 29-34
Delany, C., & Golding, C. (2014). Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. BMC Medical Education 14 (20) https://doi.org/10.1186/1472-6920-14-20
Young, M.E., & Thomas, A. et al (2020). Mapping clinical reasoning literature across the health professions: a scoping review. BMC Medical Education20(107) https://doi.org/10.1186/s12909-020-02012-9
Edwards, I., & Jones, M. et al (2004). Clinical Reasoning Strategies in Physical Therapy. Physical Therapy 84 (4) 312-330
Clinical Education Specialist
Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.
Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.
Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.
Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.