clinical reasoning occupational therapy2

Developing Solid Clinical Reasoning Skills in Occupational Therapy

Clinical reasoning in occupational therapy is a term that gets thrown around a lot in OT school and beyond. Professors say it’s something that will eventually come to you with practice and experience in the field. But, oftentimes, it’s not something you get a lot of direct training on.

Clinical reasoning is most frequently addressed by practicing case studies and problem-based learning scenarios where you need to plan your response to certain clinical situations. This is helpful, but we all know that being new in a setting like a hospital with flashing lights, machines beeping, and wires everywhere isn’t exactly stress-free.

This may lead to nerves, hesitation, and questioning everything you’ve learned. Having a solid foundation with plenty of practice will not only give you confidence in your skills but it will help you develop reasoning before you’re in a sink-or-swim type of situation.

Professors may give you the evaluation and treatment knowledge you need to develop clinical reasoning, but putting them into place appropriately and at the right time is usually less cut and dried. That’s why on-site experiences like fieldwork and shadowing are so crucial, because it gives us the chance to see things from the lens of a therapist rather than that of a student.

Students learn the concepts and foundations of OT in a very specific way for the first year or two of their program. But most of us can agree that, once you get to your first fieldwork setting, you quickly realize that there is a whole other type of learning that you’re only beginning to dip your toes in.

That’s why I like to define clinical reasoning as the marriage between those learned rudimentary OT concepts (like ROM and MMT levels) and what happens in the clinic.

Let’s put it this way: you can memorize every minute detail of the Rancho Los Amigos Levels, but none of that information is going to help if you’re not aware of how to use it. This is why fieldwork is such a crucial aspect of OT school. We need to go through some of those motions and begin building our clinical reasoning and judgment before we enter the field on our own.

So we know what clinical reasoning in occupational therapy is, but how exactly can we build it? Fieldwork and clinical experiences definitely help, but there are certain parts of a therapist’s job that specifically encourage clinical judgment:

Activity Analysis

It may seem that activity analysis is just busy work that supervisors use to occupy students when they run out of other work for them. But this is something that truly requires practice because therapists innately use activity analysis constantly. They may not even realize it until they slow down and go through each step individually to teach students the basics.

Some patient deficits may require small tweaks, whereas others may need a lot more strengthening and training to result in independence. The only way that therapists know what their plan of care (and each treatment) must target is by breaking the task down into smaller parts. This may seem difficult, but it actually makes things much simpler by giving us a clear idea of where the issue is!

Does a patient have mostly intact motor skills but lack the cognition to appropriately sequence each step of the task? This means they will need help knowing what to do and when rather than improving their dexterity to help hold the object.

The only way we can figure this out is to pick apart even the smallest of tasks, such as brushing your teeth. An intention tremor may prevent a patient from initiating the task by picking up the brush. But if we provide a stabilizing device, then they may be able to complete the rest of the task on their own.

If we didn’t identify initiation as the main issue, then we might have incorrectly assumed that the patient could not participate in the task at all. As you can see, an omission like this can change the course of the entire plan of care!

Environmental Modifications

Adapting the environment to the patient may be another result of activity analysis. Sometimes therapists will find that a distracting, unsafe, or stressful environment is the center of a patient’s deficits.

An analysis may show that a patient can complete each component of an activity when they’re with you one-on-one in their room. But they may freeze and get tripped up on each step if they practice the same task in a crowded therapy gym with lots of noise, movement, and activity from other patients and therapists.

clinical reasoning ot

The patient’s surroundings can be altered to improve their chances of success. Use that clinical reasoning to dive into what the problem may be. It may be as simple as addressing basic safety issues like removing or affixing throw rugs and covering exposed wires in the home.

But it can also be less obvious. If there is a history of falls, does the patient have deep-set fears about this happening again and not being able to recover? Do they have an abusive family member that controls the patient’s every move and prevents them from doing certain things on their own?

These may sound like social barriers but they are also environmental obstacles that should be addressed to encourage patient independence.

Upgrading and Downgrading

Once you use activity analysis and environmental modification, you may still find that the patient has issues with task completion. This may mean that it’s appropriate to downgrade the task to make it a better fit for their needs or abilities. The same applies to patients who easily complete tasks right off the bat; they will benefit from a more difficult activity to challenge them and strengthen their skills.

Upgrading and downgrading is usually a big part of therapeutic activities and not necessarily functional tasks like dressing or completing hygiene tasks. However, it’s sometimes appropriate for patients to participate in a “downgraded” functional task, more commonly known as task modification.

This is when therapists can make functional tasks easier for patients by training them in the use of adaptive equipment, compensatory strategies, or other techniques to improve patient performance despite the presence of certain deficits.

Improving your Clinical Judgment

Clinical reasoning is at the heart of each of these central occupational therapy concepts. While these concepts are frequently taught in OT school, there are other ways to improve clinical reasoning outside of this:

Practice, practice, practice 

A good example is running through case studies and problem-based learning scenarios. We mentioned that this is often how professors teach clinical reasoning, but getting even more practice in these areas is never a bad idea.

Run through a range of scenarios, especially ones that you may not see as often in clinical settings, such as mental health or burn-related cases. This is a good way to broaden your perspective while also getting some form of experience in areas you may not otherwise have exposure to.

Get feedback

Another way to improve your clinical reasoning skills is by asking for continual feedback. Practicing is certainly important, especially if you have an answer key to refer back to. But you can’t always ask for elaboration if you need more details on the rationale behind that answer.

This is why fieldwork and on-site visits are so important, because supervisors can provide real-time comments and critiques to shift your perspective. This encourages therapists to dig deeper for answers and end up with the option that’s most effective, safest, and the best fit for the patient.

If you haven’t taken the NBCOT exam yet, you will soon learn that coming up with the best and safest answer is a good way to problem solve those exam questions!

Use metacognition

Higher-level thinking, also called metacognition, is another process that plays a big part in our own learning. It’s important to be continually aware of all the aspects that impact our patients’ performance.

This doesn’t mean that you need to constantly address all of a patient’s deficits because this can be impossible (and counterproductive) with some low-functioning patients. But you should always strive to increase your own perspective in an effort to give patients the best care possible.

You are likely already practicing metacognition in ways such as planning and preparation for treatment sessions, assessing your own comprehension of learning materials, adjusting your plan of care when you discover something doesn’t work as you thought, and monitoring your progress each step of the way.


The good news is that you’re likely well on your way to developing solid clinical reasoning skills, if you haven’t already! By combining your instincts with your OT training and experience, you will be able to reason your way through some of the toughest problems. Keep practicing and always be open to learning.

What is your favorite way to encourage clinical reasoning in OT? Let us know in the comments!

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