1. Purpose – This is the goal which needs to be realistic and achievable. The range of the purpose can be significant to trivial, and it needs to be consistent and not be contradictory.
   
2. Question at issue – This is the problem to be solved. The importance of the problem needs to be considered as well as the requirements for solving the problem.
   
3. Assumptions – These are the things taken for granted. When looking at assumptions, they need to be recognised and articulated clearly and considered as to whether they are justifiable or not, crucial or extraneous, or consistent or contradictory.
   
4. Implications – Further implications and consequences will always arise no matter where the reasoning is ended. It is necessary to identify whether the implications are significant and realistic.
   
5. Inferences – These are the steps of reasoning. This refers to the logical progression of ‘since this happens, that will also occur’.
   
6. Point of view – This is a frame of reference. The point of view is aimed at being broad, flexible or fair and adhered to consistently.
   
7. Concepts – This is the conceptual dimension of reasoning, including theories, principles, axioms and rules implicit in the reasoning.
   
8. Evidence – This is the empirical dimension of reasoning, namely, the experiences, data or raw material. This needs to be reported clearly, fairly and accurately (Figure 5.1).

With critical thinking, this process is easily illustrated with a riddle.

You cradle me, when you pick me up I purr for you, sometimes I cry, I enjoy being talkative, most times I am quiet, I can be very useful. What am I?

The purpose is to solve the riddle by integrating all the information. The question at issue is ‘what is the answer’? These two steps are very similar. The assumptions are that a cat purrs and a baby is cradled and cries. The implications are that the answer cannot be both a cat and a baby. The inferences are that since cats cannot talk, it must be a baby. The point of view relates to the frame of reference that the answer to the riddle is functional. The concepts relate to it not being an occupational therapy theory, but that metaphors are being used. The integration of these concepts needs to combine the metaphors and use lateral thinking to solve the riddle. Finally, the evidence is the culmination of the information of the metaphors. (Cradle = cradle a baby and a phone has a cradle on which to hang the hand piece, and a mobile phone is cradled in the hand. Purr = a cat purrs and a phone purrs with a dialling tone. Cry = baby cries and a phone cries when it rings.) The evidence is integrated through prior knowledge and experience. Cats do not cry or talk. Babies are not useful, and usefulness suggests that it is an object. This then changes the mindset to think laterally and solve the riddle to answer it as ‘a telephone’ or a ‘mobile phone’. These critical thinking processes are not often consciously thought about when solving the riddle.

When assessing critical thinking, it is important to note:

• How clearly and completely the problem is stated
  
• How logically and consistently a position is defended
  
• How flexible and fairly other points of view are articulated
  
• How significant and realistic the purpose is described
  
• How precisely and deeply the question at issue is articulated (Paul 1996).

Clinical reasoning

The evidence of a clinical case using the bio-psycho-social model is the factual information of the person, his/her illness, his/her mental and emotional state, his/her social and cultural context and his/her functional development into the future. An additional level of spirituality could also be included, especially when terminal illness is diagnosed. This is what is used for the clinical reasoning process.

Mattingly and Fleming (1994) describe the therapist’s three-track mind model with the procedural, interactive and conditional tracks:

• The procedural track is the thinking about the illness/condition/disability and its effect on the occupational performance together with what actions are needed to perform effective treatment. Gilsenan et al. (in Robertson 2012) challenges the ideas that procedural reasoning is overemphasised in practice and needs to have more meaningful emphasis on the cultural context.
  
• The interactive track is thinking about the client as an individual and trying to see the illness/disability/situation from his/her point of view, also incorporating the client’s illness experience. This relates to the interaction between the therapist and the client and the therapist’s empathy. This also includes the client’s values and beliefs.
  
• The conditional track is thinking about the client and his/her condition within the broader social and temporal contexts. This includes the meaning attribution of the illness to the client as well as to the family, social and physical contexts. The temporal context implies how the illness could change/develop over time and the future potential of the client (Mattingly & Fleming 1994; Neistadt 1998).

Case Smith (2001) describes clinical reasoning as having four parts, procedural, interactive, conditional and intuitive reasoning.

• Intuitive reasoning is the occupational therapist’s understanding of the client’s mood, interests and intentions. This intuitive reasoning is the intrinsic motivational factor that the occupational therapist recognises in the client and may differ as the activity progresses.

Neistadt (1998) includes also narrative reasoning and pragmatic reasoning.

• Narrative reasoning includes the occupational story of the client and the shared story of the client and occupational therapist of how the client’s preferences are incorporated into the therapy to build a meaningful future. Narrative reasoning needs to be repeated over time as new goals are set when progress fulfils set goals.
  
• Pragmatic reasoning considers all the practical issues that will have an influence on the occupational therapy intervention. This includes ‘the treatment environment, the therapist’s values, knowledge, abilities and experiences; the client’s social and financial resources; and the client’s potential discharge environment’ (Neistadt 1998, p. 228). Pragmatic reasoning is very important in the developing countries as resources and finances are often severely lacking in the rural or informal settlements in the urban areas. The First World hospital setting and the Third World rural setting that the client returns to are also a consideration with pragmatic reasoning. The desires of the client and the constraints of the environment need to be balanced (Robertson 2012).

Various authors in (Robertson 2012) include other reasoning aspects.

• Ethical reasoning is included by Butler in Robertson (2012) which considers the human rights, ethical (beneficence, non-maleficence, veracity, justice and autonomy) and moral responsibilities, accountability and professionalism of all involved.
  
• Contextual reasoning is included by Robertson (2012), which gives meaning attribution to the mix. Contextual reasoning takes into consideration the cultural and spiritual beliefs, traditional healers and healing beliefs.
  
• Abductive reasoning (Thompson in Robertson 2012) is when descriptions of patterns (pain, behaviour, relapse) are used to work backwards to obtain assessment information or explanations for the patterns exhibited. This works from patterns to the explanations that are possible, giving a larger scope to the reasoning.

Personal contexts are described by Ryan and Hills in Robertson (2012) and Robertson in Robertson (2012) as personal knowledge of values, levels of professional competence and the influences of life experience and life roles. Personal contexts influence the occupational therapist’s approach to clinical reasoning, and there are many layers of personal contexts.

Tacit knowledge uses all the clinical reasoning constructs to view the occupational therapy intervention in a holistic manner. Data analysis used in clinical reasoning needs to ensure that the information is consistent through different data gathering methods, settings and times, resulting in ‘triangulation’ (Robertson 2012). Triangulation can be used between all the nine clinical reasoning tracts. This informs ‘best practice’ in occupational therapy. Neistadt (1998) discusses that the acquiring of a thinking frame for clinical reasoning needs an explicit explanation of that frame and inclusion of clinical reasoning is needed in the varied practical applications of the occupational therapy fieldwork. Thus, it is imperative for universities to engender a culture of clinical reasoning early in the curriculum. The occupational therapist needs to use metacognition (thinking about their own thinking) to reflect and complete self-evaluation of their clinical reasoning in their reflection about the client. A rating scale is also effective, using a nine-pronged diagram (Figure 5.2).

Fitzgerald in Robertson (2012) states that teams, colleagues, clinical reasoning models and managerial styles all operate in a broader sociopolitical context and a national health context and that different matrices may be formulated. These external ideologies influence and mould the clinical reasoning styles of the occupational therapist in different countries. Managerialism has emerged in some countries, initiated by New Zealand with the United Kingdom, Australia and the Scandinavian countries following suit (Robertson 2012). Managerialism is a new style of civil service, which is a reorganisation so as to increase the transparency of public accounting and to use outsourcing. Managerialism focuses on customer service and monitors customer satisfaction. This focuses on measurable outputs and occupational performance. Managerialism’s long-term change in the health profession arena is the transferring of power to managers rather than to the professionals in the delivery of health care services. These managers do not necessarily have the training or the experience of the health professional in the clinical reasoning process. All referrals go through the manager.

Reflective journals

The value of reflection is that it guides and informs the clinical reasoning process. Reflection assists in increasing the awareness of the practitioner to question the validity of actions within practice. Reflection contributes to professional development by learning and developing from experience. A reflective journal may be used as a measure over time to record and evaluate self-development, and due to the metacognition about the experiences, it enhances the learning curve for the practitioner. For the occupational therapy student, a reflective learning journal can assist the development of clinical reasoning. The students need time allocated in the curriculum to develop their clinical reasoning skills and reflective journals. This may take the form of an ‘interactive journal’ between a student and a tutor/mentor, where the student can respond to the tutor/-mentor comments (Tryssenaar 1995). When considering the academic merit of a reflective journal, it is important to consider that the experiences and feelings may be negative and that the student–tutor/-mentor’s relationship creates constraints. Students feel guarded about disclosing personal revelations to fellow students and to the tutor/mentor. Formal marking of reflective journals makes students anxious about how their performance might affect their marks at the end of the year. Thus, reflective journals for students should be rated and not marked so that a deep learning approach is encouraged rather than only an achieving learning approach (Alers & Smuts 2002). The rating scales could include comments such as ‘vague, incomplete, coherent, thorough’ or ‘superficial, adequate, sophisticated’. Student’s reflective journals need to be incorporated into the clinical practice or fieldwork as a compulsory task although a formal mark is not allocated. A reflective diary can be a useful tool to ensure that reflection becomes part of the work ethic in the workplace. Reflection relates to interpreting experiences rather than analysing them. Reflective practice certainly encourages analytical thinking, learning and subsequent clinical credibility. Tryssenaar (1995) found that interactive journals in academic courses promote reflection and increase the student’s awareness and openness, showing positive changes in attitude associated with new knowledge and experiences.

According to Sinclair (2003), in order to become a reflective expert practitioner, questions and challenges need to be set to promote ethical and creative ways of improving intervention quality:

Student learning should take place in the context of a supportive teaching and learning environment and in a curriculum which allows for development of clinical reasoning. Interactive teaching and learning must provide support to the development of cognitive skills, knowledge and experience (Sinclair 2003, Chapter 11, p. 227).

A current trend in medical education around the world is to move away from the didactic type of curriculum to a problem-based learning (PBL) curriculum. The key concepts underpinning the PBL approach is ‘lifelong learning’ and that the student takes a greater responsibility for his or her own learning. This ‘lifelong learning’ concept has been further incorporated in many countries where practitioners need to comply with rules relating to continued professional development (CPD). Professional skills, personal values and ethical practice contribute expertise to practitioners who are confident, competent and creative in their occupational therapy practice.

A useful format for students to progress through when compiling a reflective journal includes:

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