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Scandinavian Journal of
Occupational Therapy
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Differences in Clinical Reasoning between Occupational
Therapists working in Rheumatology and Neurology
Gunilla Svidn; Marlene Hallin

Online Publication Date: 10 June 1999

To cite this Article: Svidn, Gunilla and Hallin, Marlene , (1999) 'Differences in
Clinical Reasoning between Occupational Therapists working in Rheumatology and
Neurology', Scandinavian Journal of Occupational Therapy, 6:2, 63 - 70
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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 1999;6:6369

Differences in Clinical Reasoning between Occupational Therapists working in

Rheumatology and Neurology
GUNILLA SVIDEN and MARLENE HALLIN
From the Uni6ersity College of Health Sciences, Jonkoping, Sweden

Sviden G, Hallin M. Differences in clinical reasoning between occupational therapists working in rheumatology
and neurology. Scand J Occup Ther 1999; 6: 6369.
The purpose of this study was to explore whether clinical reasoning of occupational therapists varied
depending on their field of practice. The subjects were six occupational therapists working in rheumatology
and six working in neurology who individually viewed a videofilm showing either a patient with rheumatoid
arthritis or a hemiplegic patient in three different situations. While watching each situation, the participants
were asked to think aloud or reflect on action. Comments were tape-recorded and transcribed. The
analyses, using a phenomenographic approach, focused on how participants reason in order to make sense
of the situation. Five qualitatively different groups of comments were identified: confident, tentative,
understanding, generalized and teaching. The results showed both qualitative and quantitative differences
between the two groups of therapists. In conclusion, differences in clinical reasoning may influence
patientoccupational therapist interaction. Key words: interaction, reflection on action, specialized fields of
practice.

INTRODUCTION Every profession has its own frames of reference

This study investigated whether specialization in a
particular area influences the ways in which occupa-
tional therapists reflect on their clinical work. A
starting point for the study was the assumption that
different types of clinical problems arise depending
on which category of patients the occupational thera-
pist encounters. In order to deal with these varied
problems, occupational therapists may employ differ-
ent types of clinical reasoning.
As has been pointed out by Schon [1], Fleming [2,
3] and Rogers & Holm [4], an integral part of profes-
sional development is the ability to distinguish and
organize phenomena in order to make situationally
appropriate decisions. This requires an individualized
approach to a patients reactions to physical prob-
lems, illness, trauma and handicap as well as the
ability to focus on common elements characteristic of
a particular diagnostic group. According to Mat-
tingly [5, 6], the occupational therapist needs to at-
tend to both the biomedical aspects of a clients
disability and the illness experience. An understand-
ing of the experience of living in a disabled body is
central to understanding the patients life-world. The
therapist must interpret observations of the patients
behaviour and actions in order to enter the patients
life-world and establish a collaborative process [7, 8].
This collaborative approach requires that the occupa-
tional therapist be sensitive to what is happening in
specific situations. A prominent feature of clinical
reasoning is the ability to combine sensitivity to what
is happening, or, to use Gibsons [9] term, attunement
to situationally relevant cues, with knowledge on a
general thematic and theoretical level.
for understanding what is important and relevant in
the work. These frames of reference are not only
established by the profession itself, but also by the
institutional context, which sets the limits within
which the professional can act. Healthcare is an
institutional context characterized by a hierarchical
organization. Physicians represent the most influen-
tial group in this organization, and thus the biomedi-
cal model, which is reflected in the voice of
medicine, prevails [10, 11]. Physicians indicate their
expectations and requirements to the occupational
therapist by prescribing certain types of treatment. In
an attempt to adapt to the demands of an essentially
biomedical cultural context, the occupational thera-
pist may be reluctant to report impressions of the
patient in terms of what Mishel [11] refers to as the
voice of the life-world.
Information is not passively absorbed, but is ac-
tively selected and should, like all human activity, be
viewed as socially and culturally situated. This means
that in social cognition there is an interplay between
cognitive processes, knowledge structures and be-
haviour, in that knowledge guides how behaviour is
produced and interpreted, and behaviour is used to
update and modify knowledge through cognitive pro-
cesses [12]. This perspective implies that the individ-
ual adapts to and develops forms of thought and
modes of understanding the world that are prevalent
in the cultural context in which the individual be-
comes involved [1315].
As occupational therapists practising in neurology
and rheumatology encounter different types of prob-
lems in their treatment of patients, they must be

1999 Scandinavian University Press. ISSN 1103-8128

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64 G. S6iden & M. Hallin
sensitive to different biomedical aspects as well as
different types of illness experiences. Against this
background, we were interested in exploring if exposure
to different occupational therapy specialities within the
healthcare system would influence the ways in which
occupational therapists reflect on their clinical work.
This question was explored using a phenomenographic
approach [16]. The focus of this approach is on how
participants decide to talk about their impressions of
a patient who is representative of a speciality, i.e.
neurology or rheumatology. Thus, this study focuses
on how participants say they reason or make sense of
a situation. The aim is to describe whether there are
qualitatively different ways in which participants say
they make sense of a situation, rather than to present
an account of specific knowledge regarding aspects of
treatment.
Although there is a difference between talking about
and actually communicating/interacting with a patient,
we assumed that how therapists talked about their
impressions and actions would provide clues to what
they observed in patients and how they reflect upon
these impressions and respond to them in practice.
METHOD
Subjects
Participants in this study were six female occupational
therapists who had been working in rheumatology
4 16 years (Group A) and six occupational therapists
who had been working in neurology 8 15 years (Group
B). All participants were working in either neurological
or rheumatological hospital clinics.
Materials
We used videotapes to portray clients, one of whom
was of a 50-year-old woman with a 20-year history of
rheumatoid arthritis. The other videotape showed a
49-year-old man with left-sided hemiplegia, who had
had a stroke one year ago. Both videotapes began with
the patients introducing themselves and describing their
families, their professions and their interests. Following
the introduction the videotapes were silent, portraying
patients performing personal hygiene and dressing
(self-care), preparing and eating breakfast (kitchen)
and showing the patients environments both in and out
of doors (home visit).
Procedure
Members of Group A individually viewed the videofilm
showing the RA patient and those in Group B the
videofilm showing the hemiplegic patient. Participants
were informed that they would be asked to think
aloud while watching each of the (self-care, kitchen
and home visit) sequences in order to voice their
impressions. After watching a sequence, the videotape
was stopped and the participant was asked: Have you
anything to add and can you summarize your impres-
sions? That gave participants an opportunity to
explain and clarify earlier comments made during the
viewing and to express additional thoughts. No further
questions were asked. The interviews were conducted
by one of the authors, who is also an occupational
therapy lecturer. The interviews were tape-recorded
and then transcribed.
Data analysis
The first step of the analysis involved reading through
each participants account several times in order to
identify comments. Each comment was considered a
unit of analysis and the number of comments was
calculated. A comment is defined as an utterance that
provides new information about the participants im-
pressions and opinions. For example, each comment in
the excerpt below is identified by slashes:
I doubt whether or not he will be independent/ I think
he will need some help in the future/ his neglect is not
6ery pronounced/ his left arm is one of the problems/ and
the fact that he is not quite able to organize his morning/
dressing/ and hygiene/ he needs some help.
The total number of comments in this excerpt is eight,
each adding new content. Comments which exactly
repeated previous comments in terms of their content
were counted only once, and comments which were
merely remarks, e.g. He is washing his hands, were
not counted.
The second step of the analysis categorized com-
ments as either related to patient assessment or to
treatment. The third step of the analysis examined the
qualitative differences in comments between the two
groups. Five qualitatively different categories were
identified: confident, tentative, understanding, general-
ized and teaching comments. The statistical calcula-
tions of differences were performed using SPSS. When
inter-rater reliability of these categorizations between
the two authors was tested on 20% of the comments,
89% agreement was reached for Group A and 85% for
Group B.
RESULTS
Assessment 6s. treatment
The total number of comments categorized as assess-
ment or treatment for the three different sequences is
presented in Table I. Most comments related to as-
sessment in both groups of participants.
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The MannWhitney test revealed that Group A
made a statistically significantly larger number of
comments on assessment (p = 0.004), while there was
no significant difference regarding comments on
treatment between the two groups.
Qualitati6e differences in comments for the fi6e
categories
Confident comments. Most comments were expressed
confidently and were formulated as statements of
fact. The comments did not indicate that a particular
aspect could be interpreted in more than one way, or
that the information was incomplete or insufficient.
Instead, comments of this type expressed partici-
pants certainty about the correctness and appropri-
ateness of what they had said. When making
confident comments, participants usually did not
refer to the grounds on which they were based. This
means that participants did not link confident com-
ments to references to theoretical knowledge or ob-
servations of the patients behaviour. Thus, it was not
possible to describe the ways in which they justified
and supported their comments as it would have been
if, for example, they had specified which cues they
had selected and how these were interpreted in order
to arrive at a certain comment.
The following excerpts are examples of confident
comments. (A) refers to comments on assessment and
(T) refers to treatment:
He has no difficulties with spatial relations/ his balance
is good. (A)
It is difficult for her to dress herself. (A)
I would mo6e the bed to the ground floor. (T)
I would find out which home alterations she needs. (T)
The MannWhitney test revealed no statistically sig-
nificant differences in the number of confident com-
ments between the two groups (see Table II).
When participants made confident comments, they
did not seem to feel the need to explain or justify how
they had arrived at their impressions. However, par-
ticipants also made comments which were less certain
and more tentative.
Table I. Number of comments on participants categorized as assessment or treatment in three different situations
Group A
Total Mean SD
Assessment 1128 188 45.2
Treatment 418 69.7 103
** pB0.01.
Clinical reasoning 65
Tentati6e comments. Some comments suggested that
the participant was not certain that her impressions
or judgement were correct. These tentative com-
ments were frequently linked to observations of the
patients behaviour. They suggested that the partici-
pant was trying out different interpretations of the
observed situation. When a participant tried different
interpretations, she argued for and against a certain
opinion. This also indicated the participants concern
for making explicit the grounds on which she was
making her comments. Tentative comments were fre-
quently linked to comments indicating that the par-
ticipant would have reformulated the problem if she
had more information. In some cases, participants
indicated that the information on the videofilm was
insufficient and that they had resorted to guessing.
These different features of tentative comments are
illustrated in the following excerpts, which show rea-
soning for, against and how observations constitute a
foundation for the expressed opinions.
I do not know if on the one hand he has neglect/ or if
his perception is affected in any other way/ but on the
other hand he seemed to be aware of his arm and hand/
and he could read when his book was to the left side.
(A)
Perhaps I should start with the arm/ try and stretch the
fingers a little. (T)
Perhaps she needs to ha6e her bed ele6ated. (T)
Tentative comments frequently indicated why the
participants were uncertain. This extra information
added coherence to the accounts and showed partici-
pants concern for making explicit their reasoning, i.e.
the grounds for the uncertainty. The MannWhitney
test revealed that Group A made a significantly larger
number of tentative comments (p= 0.004) (see Table
II).
Understanding comments. Understanding comments
indicated that the participants were trying to under-
stand the patients emotional reactions, or that the
patient had developed his/her own way of performing
an activity. Some of the understanding comments
were expressed in relation to emotional reactions the
patients or members of their family may have experi-
Group B
Total Mean SD p-value
506 84.3 20.2 0.004**
351 58.5 40.9 n.s.
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66 G. S6iden & M. Hallin
Table II. Number of qualitati6ely different comments
Group A
Total Mean SD
Tentative 356 59.3 13
Understanding 227 37.8 25.2
Generalized 289 48.1 30.5
Teaching 31 5.1 3.6
** pB0.01.* pB0.05.
enced. This means that the participants made infer-
ences regarding emotional reactions. In addition,
comments were made in relation to observations,
which showed that the patient was not performing
daily activities in the usual/expected manner. In this
type of comment, the participants expressed that they
accepted the ways in which the patients solved their
problems. Participants also made inferences regarding
the patients personal characteristics, e.g. persever-
ance, patience, etc. The following excerpts are exam-
ples of understanding comments.
It must be terrible to be sitting like that/ and to be
dependent on others for help/ e6en on the toilet. (A)
I think it must be awful for the relati6es/ the uncer-
tainty regarding the future/ and how they will be able
to manage/ will he be able to return home/ and how
will we be able to cope (A)
She was a positi6e person/ acti6e/ wanting to manage
self-care without assistance/ maintaining her integrity
is important to her. (A)
That is a cle6er solution to the problem of drying
between the toes. (A)
I would ask her about her habits and routines/ and
discuss with her how much she needs to ha6e adapted/
and how much she wants to do without adaptations. (T)
He could ha6e pulled it o6er his head/ but he seems to
be used to doing it his own way/ and that is OK. (T)
I ha6e to strike a balance between making alterations/
and accepting the patients way of doing things/ e6en if
these are not always the best for her joints. (T)
I would ne6er stop somebody from doing something/ if
the person thinks it is of importance to him. (T)
Understanding comments indicated that the partici-
pants were taking the patients perspective into con-
sideration, and that they had faith in the patients
personality and ability to solve problems. The
MannWhitney test revealed that Group A made a
significantly larger number of understanding com-
ments (p=0.04) (Table II).
Group B
Total Mean SD p-value
143 23.8 5.9 0.004**
72 12 9.97 0.04*
104 17.3 24.97 n.s.
76 12.7 14.98 n.s.
Generalized comments. In contrast to understanding
comments, which were related to a specific patient,
other comments expressed a generalized view of the
patient. Generalized comments were made in the light
of a general framework consisting of elements com-
mon to a category of patients. Thus, these comments
indicated that the participants were comparing the
patient in the videofilm with others within that diag-
nostic group. Consider the following excerpts:
The tendency to forget is common among these pa-
tients. (A)
This lack of concentration is typical of this category of
patients. (A)
Ordinarily I 6isit the patients home early during the
treatment. (T)
I usually recommend putting on larger buttons/ bits of
Velcro. (T)
First of all we ask what the problems are/ then I begin
by attending to the problems according to the patients
priorities. (T)
As generalized comments were made in relation to a
general framework, the type of reasoning they used
may be called deductive. The MannWhitney test
revealed no significant differences between groups,
but there was a strong tendency for Group A to
make a larger number of generalized comments (p=
0.06) (Table II).
Teaching comments. Teaching comments were those
that showed that participants intended to teach the
patient certain procedures. This means the patients
behaviour was evaluated in relation to a certain
standard. When this standard was not attained, the
teaching comment indicated the change the occupa-
tional therapist would have implemented. Teaching
comments were used to promote implementation of
what the participants considered the correct proce-
dure. They imply that a certain agenda or plan must
be followed. Consider the following excerpts:
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Clinical reasoning 67

He could be taught to do it according to the Bobath DISCUSSION

method/ and see if he can manage that. (A) A disadvantage of the research design in this study
She has probably been taught to use aids/ but in spite was that to respond to a patient on a videotape is not
of that she does not use any aids/ when dressing. (A) a natural situation. This means that a certain amount
of spontaneity may be lost, as participants were not
To begin with I would teach him to stand up/ and then
in direct interaction with the patient. Thus, partici-
sit on an ordinary chair/ when trying to put on his
pants may not have been sufficiently stimulated to
socks. (T)
express how they would interact with a real patient.
On the days she feels worse/ she could learn to use They may have expressed fewer understanding com-
shoes with Velcro fastenings/ instead of shoelaces. (T) ments than they might have if they had been in direct
The MannWhitney test revealed no statistical differ- interaction with the patient. However, other studies
ences between groups (see Table II). concerning clinical reasoning among occupational
therapists, e.g. those of Fleming [2, 3], Sviden & Saljo
[17] and Alnervik & Sviden [18], have shown that
Comments in relation to situation comments related to insight into the patients per-
In relation to self-care, there was no statistically spective, empathy, or in Flemings terms, interaction
significant difference between groups regarding differ- reasoning, were present only to a small extent.
ent types of qualitative comments, except for tentati6e The differences in clinical reasoning reported here
comments. The Mann Whitney test revealed a statis- between occupational therapists working in rheuma-
tically significant difference between groups (p= tology and neurology as reflected in their comments
0.01). In relation to the kitchen situation, there was a may to some extent be explained by differences in
significant difference regarding tentati6e comments institutional frameworks, which set the limits within
between groups (p = 0.004). In the situation showing which the professionals can act. Townsends ethno-
the home 6isit, there were no differences between graphic study [19] showed how the organizational
groups except for generalized comments, where there context invisibly shapes occupational therapy prac-
was a statistically significant difference between tice. In addition, Bellner [20] illustrated how occupa-
groups (p = 0.03) (see Table III). tional therapy ideas about occupation can be seen as
organizationally subordinated to fit prevailing medi-
cal ideas.
As is evident from Table I, Group A made a
significantly larger number of comments on assess-
Table III. Qualitati6ely different types of comments in ment. This result may to some extent be explained by
relation to different treatment situations the fact that the videotape showed a female patient,
Group A Group B while Group B watched a male patient. It is possible
that to watch another woman put on make-up, comb
Mean SD Mean SD p-value her hair, put on jewellery, etc. may have stimulated
participants in Group A to make more comments on
Self-care
Confident 52 25 35 9 n.s. assessment than Group B who were watching a male
Tentative 21 8 7 5 0.01* patient. Thus, the results suggest that participants in
Understanding 15 11 5 6 n.s. Group A may have identified more with the patient
Generalized 26 16 12 22 n.s. than Group B.
Teaching 1 2 9 11 n.s.
Kitchen The results also show that Group A made signifi-
Confident 35 20 22 4 n.s. cantly more understanding comments (cf. Table II).
Tentative 20 7 5 3 0.004** This suggests that participants working in rheumatol-
Understanding 13 12 3 2 n.s. ogy were more sensitive to the patients attempts to
Generalized 8 12 1 2 n.s.
Teaching 3 4 2 3 n.s.
develop strategies and competencies in adapting to
Home visit disability. They expressed faith in the patients abili-
Confident 21 10 10 15 n.s. ties and the fact that the patient was learning a new
Tentative 18 7 12 5 n.s. identity as a person with a long-term disability. The
Understanding 10 10 4 7 n.s.
patient is seen as a person engaged in an ongoing
Generalized 14 8 4 4 0.03*
Teaching 1 2 1 2 n.s. process involving the use of competencies, interests,
roles and values in order to connect that individuals
* pB0.05.** pB0.01. future and past to the present.
Downloaded By: [EBSCOHost EJS Content Distribution] At: 15:42 19 July 2007
68 G. S6iden & M. Hallin
As many authors have pointed out (e.g. Rosa &
Hasselkus [21], Crepeau [7] and Mattingly [5]), the
therapist needs to be able to enter the patients
life-world in order to develop the collaborative ap-
proach. It is interesting to note that results reported
by Spencer et al. [22] show that staff intent on
teaching the patients new skills often failed to help
the patients connect their future life story to their
past. The use of a teaching approach does not neces-
sarily exclude a collaborative approach, but is based
on an unequal relationship, i.e. an expert layperson
interaction.
Both teaching and generalized comments were fre-
quently linked to theoretical or practical knowledge,
which was either explicitly or implicitly expressed. As
indicated above, confident comments implied that
participants did not question the content of their
comments. Instead, they said that this is the way we
always do it or the patient should learn to do it expand their repertoire of different types of reasoning
another way. Benner [23] found that to some extent
this feature is typical of experts in many professional
areas in the sense that when things proceed normally,
experts do not solve problems and make decisions.
They do what normally works, i.e. they use a rou-
tinized approach.
In contrast, the tentative comments gave insight
into the clinical reasoning processes and indicated an
individualized approach, as the reasoning took its
starting point in comments related to the individual
patient. This feature is also present in the understand-
ing comments. As is shown in Table II, Group A
made significantly more tentative and understanding
comments, thus indicating the participants were try-
ing to gain insight into the patients life, which ac-
cording to research mentioned above [5, 7, 21], is
related to the collaborative approach.
Differences in clinical reasoning can to some extent
be explained by the fact that the RA patient had been
ill for several years, and had thus had more time to
develop problem-solving strategies of her own, which
the stroke patient had not had time to develop. In
addition, occupational therapists working in neurol-
ogy may have interpreted the demands of her institu-
tional training to mean that she should train the
patient as quickly as possible to become independent
in performing daily activities so that the patient could
be discharged quickly.
As research [5, 7, 21 23] indicates, differences in
clinical reasoning influence patient occupational
therapist interaction. The results reported in this
study suggest that further research is necessary to
investigate how, for example, generalized, teaching
and confident comments and tentative and under-
standing comments may influence patient therapist
interaction.
Furthermore, to promote professional develop-
ment, it is important to determine whether there are
differences in clinical reasoning between different spe-
cialities in occupational therapy, as these differences
may influence patientoccupational therapist
interaction.
The exploratory nature of this study necessitates
caution in interpreting the results, but some of the
observations indicate that further research is neces-
sary to elucidate how differences in clinical reasoning
may affect patientoccupational therapist
interaction.
Thus, the relationship between clinical reasoning
and patientoccupational therapy interaction in rela-
tion to different types of patient problems and differ-
ent therapeutic goals must be investigated. If these
relationships are investigated and described, both
clinicians and students will be able to develop and
in order to select the most appropriate mode of
reasoning in relation to their interactions goals.
ACKNOWLEDGMENTS
This study was supported by a grant from the scientific
committee of Jonkoping County Council, Sweden.
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Accepted February 3, 1999
Address for correspondence:
Gunilla Sviden
University College of Health Sciences
P.O. Box 1038
SE-551 11 Jonkoping
Sweden
Tel: + 46 36 32 48 62
Fax: + 46 36 32 49 39