SETTING THE CONTEXT

Clinical reasoning is the core of clinical practice; it enables practitioners to make informed and responsible clinical decisions and address problems faced by their patients or clients. Around 20 years ago Schön (1987) pointed out that when a practitioner deals with new professional problems the first issue is ‘problem setting’. This means choosing and naming the things that will be noticed and the things that will be ignored, which he described as ‘naming and framing’ (p. 4). The naming and framing process is essentially linguistic and discursive; it depends on factors such as ‘disciplinary backgrounds, organizational roles, past histories, interests and political/economic perspectives’ (p. 4). Schön indicated that this process of problem setting is also an ontological process. The professional is engaged in a localized and specialized form of world making and world interpretation. From this point of view, professional practice is much more than a straightforward epistemological or knowledge framing task, and practice involves much more than acquiring and mastering a body of propositional knowledge and learning how to apply it. From the interpretive viewpoint, mastering and applying a body of knowledge are still important, but being a professional such as a dentist or a physiotherapist is a much greater challenge. It is a way of being in the world.

This ontological idea of professionalism is echoed in the work of others, such as Thomas Kuhn (1996). Kuhn described how professionals (scientists, in his case) live in the world, and perceive it, in a way that is radically different from non-professionals, and that this comes about because they have internalized a particular way of perceiving the world. A layperson might see lines on paper whereas a cartographer instantly perceives a terrain (Kuhn 1996, p. 111). Kuhn also wrote that when scientists undergo a paradigm shift, that is, a radical change in the sets of ideas and assumptions they use to perceive and conceptualize the world, they talk of life after this experience as being like living in a new world.

Vygotsky (1978) noted that this internalization of particular ways of perceiving the world is true of all humans, starting at an early age. He used the example of a clock. When we see a clock, we learn to perceive it instantly as a clock, not something round and black-cased with hands, which is then consciously and deliberately interpreted as being a clock. If there is interpretation it is instantaneous and unconscious. Shotter (2000) realized that professional ways of seeing the world are extensions of this. Professional socialization shapes our attention and makes us see things in particular ways. For example, one medical student in a research project on learning clinical reasoning (Loftus 2006, p. 199) spoke of being able to instantly recognize ‘glaring cardiac signs’ in a patient. Shotter (2000), following Vygotsky, maintained that it is through our language that this process occurs. These ways of responding to situations become embodied within us, and are therefore ontological rather than purely epistemological (i.e. words and knowledge). Professional ways of seeing the world are included among what Vygotsky (1978) described as higher mental functions. Such functions are the more complex and intellectually demanding skills that humans can develop, such as clinical reasoning, and they are qualitatively different from the lower mental functions or component cognitive skills (e.g. analysis) which they may incorporate.

THE CHANGING SHAPE OF RESEARCH QUESTIONS IN CLINICAL REASONING RESEARCH

Historically, in the majority of clinical reasoning research, researchers have stood outside the phenomenon of clinical reasoning, looking in, and addressed three key questions:

Not surprisingly, given the historical context of the scientification of health care and the dominance of medicine, these questions fit the expectations of the empirico-analytical research paradigm and the biomedical model. In both cases hypothetico-deductive reasoning or hypothesis generation and testing is the dominant mode of reasoning and decision making. The empirico-analytical research paradigm adopts a positivist philosophical stance where objectivity is the key issue and sense data determine reality; its goal is to measure, test hypotheses, discover, predict, explain, control, generalize and identify cause–effect relationships. Within the biomedical model the body is seen as a machine that can be adjusted or treated in seeking to cure (a person’s condition) or restore the body to normal functioning. If this restitution narrative fails (which is common in chronic conditions) the patient may be labelled ‘failed’ or ‘failing’ or ‘noncompliant’ (Alder 2003). In the wellness model, in comparison, which fits with the interpretive and critical paradigms, the patient – the person – has greater initiative and support to write a different (e.g. ability) narrative.

When clinical reasoning research entered the interpretive paradigm the philosophical stance turned to idealism. In this philosophy the emphasis is on the actors’ ideas or embodied knowing as the determinant of social reality, and multiple constructed or storied realities of the social world are recognized and acknowledged. Within this paradigm researchers seek to understand, interpret, seek meaning, describe, illuminate and theorize about lived experiences and actions. The context of human actions (including decision making) is seen as a vital influence on these actions and experiences. Hence, the way clinical reasoning came to be viewed changed towards a greater valuing of the narrative, contextual, conditional and interpersonal dimensions of practice. And the focus shifted onto the larger interactive phenomenon of making clinical decisions in the context of people with healthcare needs, their interests and concerns, their families, and the healthcare team.

Research in the interpretive paradigm has been conducted by Benner (1984) in nursing (with an emphasis on seeking understanding of behaviours and context), by Crepeau (1991) and Fleming (1991) in occupational therapy (with an emphasis on structuring meaning and interpreting the problem from the patient’s perspective) and by Jensen et al (1992, 2007) in physiotherapy (with a focus on elucidating the complex and unknown processes that occur during therapeutic interventions). The clinical reasoning processes which such approaches describe focus on seeking a deep understanding of patients’ perspectives and the influence of contextual factors, in addition to the more traditional and clinical understanding of the patient’s condition. The relevance of this broader perspective is evident in the growing body of research demonstrating that the meaning patients give to their problems (including their understanding of and feelings about their problems) can significantly influence their levels of pain tolerance, disability and eventual outcome (Borkan et al 1991, Feuerstein & Beattie 1995, Malt & Olafson 1995). As the volume and depth of research into clinical reasoning expands, it is becoming more and more apparent that traditional clinical reasoning models do not encompass the varying dimensions or reflect the diverse discipline-specific practice paradigms that exist across the health professions.

New questions being addressed in interpretive research include:

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