Clinical reasoning underlying acute care occupational therapists' assessment of rehabilitation potential after stroke or brain injury : a constructivist grounded theory study

Introduction In acute care hospitals, clinicians are expected to rapidly provide recommendations regarding patients' rehabilitation potential and candidacy for postacute rehabilitation. Some studies have investigated factors influencing referral to rehabilitation, but few have examined clinical reasoning underlying referral decisions. This study aimed to investigate what occupational therapists were thinking about (factors influencing reasoning), how they reasoned (thought processes) when evaluating stroke or traumatic brain injury patients' rehabilitation potential, and how they decided on referral to postacute rehabilitation. Methods Using a constructivist grounded theory approach, the clinical reasoning of 10 acute care occupational therapists working in a large Canadian city was examined. Participant recruitment, data collection, and analysis were performed simultaneously following theoretical sampling procedures. Therapists' thoughts on patients' rehabilitation potential were collected twice (during chart consultation and initial patient assessment) using think-aloud protocols and semi-structured interviews. Constant comparison, memoing, and diagramming methods were employed during coding to help categorisation and conceptualisation. Findings Numerous patient, clinician, and organisation-related factors were found to influence clinical reasoning. Occupational therapists interpreted these factors in an attempt to (1) predict recovery, (2) estimate rehabilitation potential, and (3) determine rehabilitation candidacy. They used two types of thought processes: (1) building a representation of patients' rehabilitation potential (involving eight steps including gathering and interpreting factors); (2) activating bottom-up and top-down scripts (comparing the expected impact of impairments on activity performance to behaviours observed during activity performance). Furthermore, an algorithm was developed describing how occupational therapists decide on referral to postacute rehabilitation. Conclusion Findings can be used to teach students and novice occupational therapists how to identify and interpret key factors in the assessment of stroke or traumatic brain injury patients' rehabilitation potential. Results also provide insight on cognitive processes that can be taught for efficient assessment of rehabilitation potential and decision-making regarding referral to postacute rehabilitation