Chapter 1 Professional Reasoning as the Basis of Practice

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 1 Professional Reasoning as

the Basis of Practice

Barbara A. Boyt Schell

John W. Schell


History of Professional Reasoning ResearchHistory of Professional Reasoning Research

• Rogers & Masagatani (1982): Research how clinical decisions were made

– Therapists often could not explain what they had done (or why)

• Rogers’ Eleanor Clark Slagle Lecture at AOTA (1983)

– Aware of emerging research in cognitive science & medicine


History of Professional Reasoning Research (Con’t)History of Professional Reasoning Research (Con’t)

• AJOT Special Issue on Clinical Reasoning (1991)

– Enlarges research focus in OT field

• Based on Schön (The Reflective Practitioner, 1983)

– Commonalities in practice among professions

– AOTF & AOTA funded the Clinical Reasoning Study (Mattingly & Fleming, 1994)

• Mattingly & Fleming (1994) publish

– Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice


History of Professional Reasoning Research (Con’t)History of Professional Reasoning Research (Con’t)

• More than 50 books & articles published in recent years

• The current text

– Unit I – Describes the nature of clinical and professional reasoning

– Unit II – Summarizes clinical & professional reasoning in OT

– Unit III – Identifies implications for OT education for: curriculum planning, classroom teaching, fieldwork education, & professional development

– Unit IV – Summarizes the state of literature, identifies future directions for research


Thinking About ThinkingThinking About Thinking

“There is a high hard ground where practitioners can make…use of…theory & technique, & there is the swampy lowland where…confusing “messes” [are] incapable of technical solution. The…problems of the high hard ground…are…relatively unimportant…while in the swamp are…problems of greatest human concern”

(Schön, 1983, p. 42)


Definitions of Clinical & Professional Reasoning (C&PR)Definitions of Clinical & Professional Reasoning (C&PR)“The process used by practitioners to plan, direct, perform

& reflect on client care”

(Schell, 2003, p. 131)

• Professional reasoning is added because:

– It broadens the discussion to:

• Nonmedical environments such as schools & community settings

• Reasoning done by supervisors, fieldwork educators, & OT managers


Thinking in ContextThinking in Context

• The thinking that guides practice is:

– The interplay among the person, the context, & specific therapy tasks

• Theories about C&PR are focused on therapists & how they provide therapy


Thinking in Context (Con’t)Thinking in Context (Con’t)• Some practice decisions are easy:

– Scientific or technical information is applied

• Most decisions require nuanced decisions & actions

• C&PR research attempts to:

– Identify the “high hard ground” of therapist thinking

– Surface the “swampy lowland” where most live

• Current research does not reach the complexities of C&PR in real life


Thinking in Context (Con’t)Thinking in Context (Con’t)

• This book seeks to promote C&PR research using:

– “Hard” &

– “Soft ground” methodologies


Views of Clinical & Professional ReasoningViews of Clinical & Professional Reasoning

• C&PR topical areas are:

– Scientific reasoning

– Diagnostic reasoning

– Procedural reasoning

– Narrative reasoning

– Pragmatic reasoning

– Ethical reasoning

– Interactive reasoning

– Conditional reasoning

Many different perspectives exists on the nature & process of C&PR

(Rogers, 1983; Mattingly & Fleming, 1994; Schell & Cervero, 1993; Rogers & Holms, 1991)


Scientific ReasoningScientific Reasoning

Description & Focus Clues for Recognizing in Therapist Discussions

Reasoning involving the use of applied logical & scientific methods, such as hypothesis testing, pattern recognition, theory-based decision making, & statistical evidence

Impersonal; focused on the diagnosis, condition, guiding theory, or evidence from research or what “typically” happens with clients like the one being considered


Diagnostic ReasoningDiagnostic Reasoning


Investigative reasoning & analysis of cause or nature of conditions requiring occupational therapy intervention; can be considered one component of scientific reasoning

Uses both personal & impersonal information; therapists attempt to explain why client is experiencing problems using a blend of science-based & client-based information


Procedural ReasoningProcedural ReasoningDescription & Focus Clues for Recognizing in

Therapist Discussions

Reasoning in which therapist considers & uses intervention routines for identified conditions; may be science based or may reflect the habits & culture of the intervention setting

Characterized by therapist using therapy regimes or routines thought to be effective with problems identified & that are typically used with clients in that setting; tends to be more impersonal & diagnostically driven


Narrative ReasoningNarrative Reasoning


Reasoning process used to make sense of people’s particular circumstances; prospectively imagine the effect of illness, disability, or occupational performance problems on their daily lives; & create a collaborative story that is enacted with clients & families through intervention

Personal; focused on the client, including past, present, & anticipated future; involves an appreciation of client culture as the basis for understanding client narrative; relates to the “so what” of the condition for the person’s life


Pragmatic ReasoningPragmatic ReasoningDescription & Focus Clues for Recognizing in


Practical reasoning that is used to fit therapy possibilities into the current realities of service delivery, such as scheduling options, payment for services, equipment availability, therapists’ skills, management directives, & the personal situation of the therapist

Generally not focused on client or client’s condition, but rather on all the physical & social “stuff” that surrounds the therapy encounter, as well as the therapist’s internal sense of what he or she is capable of & has the time & energy to complete


Ethical ReasoningEthical Reasoning


Reasoning directed to analyzing an ethical dilemma, generating alternative solutions, & determining actions to be taken

Systematic approach to moral conflict; tension is often evident as therapist attempts to determine what is the “right” thing to do, particularly when faced with dilemmas in therapy, competing principles, risks, & benefits


Interactive ReasoningInteractive Reasoning


Thinking directed toward building positive interpersonal relationships with clients, permitting collaborative problem identification & problem solving

Therapist is concerned with what client likes or doesn’t like; use of praise, empathetic comments, & nonverbal behaviors to encourage & support client’s cooperation


Conditional ReasoningConditional ReasoningDescription & Focus Clues for Recognizing in


A blending of all forms of reasoning for the purposes of flexibly responding to changing conditions or predicting possible client futures

Typically found with more experienced therapists who can “see” multiple futures, based on therapists’ past experiences & current information


Putting Reasoning in a Larger ContextPutting Reasoning in a Larger Context

• Brief overview of selected C&PR contributors

– Purpose is to highlight key researchers & concepts shaping current C&PR thinking


Key Selected ContributorsKey Selected Contributors

• Aristotle

• Darwin

• Gestalt & Bruner

• Paget

• Vygotsky

• Lave & Wenger


Key Contributor: Aristotle Key Contributor: Aristotle

• Artisans’ work involved thinking & reasoned action

– Actions taken within artisan’s “praxis”

– Praxis is reasoned actions taken to accomplish a specific task


Key Contributor: DarwinKey Contributor: Darwin

• Theory of evolution

– Humans as “biologically continuous” with animal kingdom

– Human progression as basis of learning & thinking

– Strong influence on development of behaviorism & developmental psychology


Key Contributors: Gestalt & BrunnerKey Contributors: Gestalt & Brunner

• Classical theories of psychology emerged

– Gestalt theories focused on patterns & structured experiences

– Brunner introduced schemes to illustrate cognitive structures


Key Contributor: PiagetKey Contributor: Piaget

• Assumed learning as an artifact of biologic functioning

– Research focused on “mental or cognitive structures” as the way children organize their minds

– Stages of human development


Key Contributor: Vygotsky Key Contributor: Vygotsky

• Examined the use of knowledge within social structures

– Human development as social interaction

– Zones of proximal development (ZPD)


Key Contributors: Lave & Wenger Key Contributors: Lave & Wenger

• Emphasis on context & social engagement

– Situated cognition

– Communities of practice


Reasoning in a Social WorldReasoning in a Social World

• 20th-century researchers: Social relationships form basis of human thinking & reasoning

– Ricœur influenced Heidegger, Gadamer, Merleau-Ponty, Sartre, & Schütz

• Examined conscious existential experience for understanding actions of individuals

– Schütz emphasized “lived experiences” through “flowing consciousness” as they passed from experience into memory


Reasoning in a Social World: SchönReasoning in a Social World: Schön• Reflective practice & organizational “systems of

learning”

– An avid jazz musician

• Jazz improvisation perhaps led to ideas about “thinking in the moment”

• Origins of “reflection in action” & “reflection on action”


Reasoning in a Social World: Dreyfus & Dreyfus (Athanasiou)Reasoning in a Social World: Dreyfus & Dreyfus (Athanasiou)

• Mind over Machine (1986)

– Influenced researchers in many professions

• How experts shape novices who become experts

• Five stages of expertise:

– Novice

– Advanced beginner

– Competent

– Proficient

– Expert


Reasoning in a Social WorldReasoning in a Social World

• Many writers have influenced present-day thinking

– Dewey, Lewin, Rogers, & Kolb have significantly contributed

– “Thinking about thinking” has been handed down by several generations of researchers & practitioners

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Chapter 1 Professional Reasoning as the Basis of Practice

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