1.8 Clinical reasoning
In the previous chapters you learned about the ICF and importance of evidence-based practice (EBP), and how we need to integrate consideration for all components of the ICF and a range of evidence-related factors in our decision making. But how do we actually make these decisions? Clinical reasoning is about how clinicians go about making the decisions they do and involves the integration of information from the four components of EBP. Clinical reasoning is a logical, systematic and cyclical process that guides our decision making.
Clinical reasoning, or problem solving, is a complex concept involving cognitive processes and has been described as “the often intangible, rarely explicated thought processes that lead to the clinical decisions” that clinicians make on a daily basis when providing services to individuals, families and communities in specific practice contexts (McAllister & Rose, 2000, p. 205). Effective and robust clinical reasoning is associated with improved client care and outcomes (Ginsberg Friberg & Visconti, 2016). Clinical reasoning comprises two interactive elements: 1) Diagnostic reasoning (i.e. collecting and analysing information); and 2) Therapeutic reasoning (consideration for the client’s circumstances, values and goals).
The video below provides a useful overview of clinical reasoning, and how critical thinking applies to the clinical reasoning process.
Critical thinking vs Clinical reasoning by American Council of Academic Physical Therapy
As a student speech pathologist you will not have, at your stage of learning and expertise, the same skills in clinical reasoning that an experienced clinician possesses. Your clinical reasoning skills and knowledge will be developed over time through a combination of formal education, case-based learning, learning activities, application of skills and knowledge in a range of clinical settings, and clinical reflection.
As outlined above, clinical reasoning is a logical, systematic and cyclical process. As such, to support development of your clinical reasoning skills, it is useful to use clinical reasoning models for guidance in the clinical reasoning process. There are a number of theoretical models and processes that help to describe and explain various clinical reasoning approaches. For example, Yazdani, Hosseinzadeh and Hosseini (2017) outline several models of clinical reasoning associated with medicine in their critical review paper. Some of the models outlined include hypothetic-deductive and pattern recognition.
For our purposes, we will use the clinical reasoning cycle below in Figure 4 (Levett-Jones et al., 2010). This evidence-based theoretical model of clinical reasoning is used extensively in nursing, medicine and allied health professions globally. As depicted in Figure 4, clinical reasoning is described across eight phases:
- Consider the patient situation.
- Collect cues and information.
- Process information.
- Identify problems/issues.
- Establish goal(s).
- Take action.
- Evaluate outcomes
- Reflect on process and new learning.
Below are examples of the application of the clinical reasoning cycle to speech pathology contexts:
| Clinical reasoning cycle phase | Description | Example: Speech and swallowing difficulties following stroke |
| Consider the patient situation | Engage the person, their family/carers to learn about their situation and describe or list facts, context, objects or people. Check and reflect on your assumptions or preconceptions. | 65 yo man is in the acute stroke unit because he had a left hemisphere MCA ischaemic cortical stroke 2 days ago. |
| Collect cues/information | Review current information (e.g. handover reports, patient history, patient charts, results of investigations, previous assessments, patient/carer reports, reports from others etc) | He has a history of hypertension. He takes beta blockers.
He is on a soft and bite-sized and slightly fluids. He has a right-sided mild paresis of all limbs. He can follow simple directions and is talking in grammatically correct sentences. Nurses reports his speech is difficult to understand. |
| Gather new information (e.g. undertake patient assessment, patient/carer interview) | An OME, patient interview and communication screener (WAB Bedside) was undertaken.
Overall unilateral (right sided) weakness and reduced ROM of articulators (particularly tongue, face and lips). Imprecise articulation; slow speech rate; speech intelligibility approx. 60%; anterior spillage of bolus; increased oral transit time of bolus; mild oral pocketing of bolus in buccal cavity on right side. Language appears intact. Likely dysarthria and dysphagia |
|
| Recall knowledge (e.g. physiology, anatomy, neuroanatomy, epidemiology, therapeutics, context of care, ethics, law etc) | Upper motor neuron (UMN) involvement – motor speech, voice, swallowing……..
Acute hospital setting Consider nutrition/hydration needs; immediate communication needs. |
|
| Process information | Interpret: analyse data to come to an understanding of signs or symptoms. Compare typical vs not typical | His presentation is consistent with UMN damage. Moderate severity.
Not consistent with pre-morbid function. |
| Discriminate: distinguish relevant from irrelevant information; recognize inconsistencies, narrow down the information to what is most important and recognise gaps in cues collected | He’s on a modified diet/fluids but food intake chart & dietitian indicates his intake is meeting nutritional needs – patient reported modified diet/fluids is preferable at present. His speech is quite unintelligible (approx. 60% intelligibility) and he is having difficulty participating in his healthcare due to his communication difficulties. He is also very frustrated at his inability to communicate. | |
| Relate: discover new relationships or patterns; cluster cues together to identify relationships between them | Speech impairment clusters/patterns (imprecise articulation, tongue/lip/face hypotonia, slow speech rate, fatigue) could be indicators of unilateral upper motor neuron dysarthria. These clusters and links to anatomical function likely contributing to dysphagia. | |
| Infer: make deductions or form opinions that follow logically by interpreting subjective and objective cues; consider alternatives and consequences | Speech impairment/dysphagia clusters & patterns indicate common cranial nerve involvement (VII, XII) | |
| Match current situation to past situations or current patient to past patients (usually an expert thought process) | L-MCA cortical strokes often result in varying severities of dysarthria and dysphagia | |
| Predict an outcome (usually an expert thought process) | Education and treatment may improve function. | |
| Identify problem/issue | Synthesise facts and inferences to make a definitive diagnosis of the patient’s problem | XX presents with moderate UUMN dysarthria and moderate oral phase dysphagia characterized by reduced speech intelligibility, slow speech rate, anterior spillage of bolus, increased oral transit time of bolus, and mild oral pocketing of bolus in buccal cavity on right side. Presentation consistent with right-sided lip, tongue and facial weakness. |
| Establish goals | Describe what the person, their family/carers/supporters/stakeholders want to happen, and a desired outcome, a timeframe | Ensure adequate nutrition and swallow safety.
Reduce communicative frustration and facilitate active healthcare participation. Improve speech intelligibility. Improve swallowing function to return to normal diet and fluids. |
| Take action | Select a course of action between different alternatives available | Develop communication board in collaboration with patient.
Provide communication partner training. Provide safe swallowing strategies. Daily speech and swallow rehabilitation. |
| Evaluate | Evaluate the effectiveness of outcomes and actions. Ask: “has the situation improved?” | Monitor patient chart notes
Review baseline in one week. Ask patient/others for feedback on progress. |
| Reflect on process and new learning | Contemplate what you have learnt from this process and what you could have done differently. Engage and reflect with the person, their family/carers/stakeholders to see what they’ve learnt, what they’d have liked to be different and what else they need to know. | What worked well/didn’t work well?
Next time I would….. I should have….. If I had….. I now understand….. |
Clinical reasoning, or problem solving, is a complex concept involving cognitive processes and has been described as “the often intangible, rarely explicated thought processes that lead to the clinical decisions” that clinicians make on a daily basis when providing services to individuals, families and communities in specific practice contexts (McAllister & Rose, 2000, p. 205).
