Chapter 24 Clinical reasoning in occupational therapy
Occupational therapy (OT) in the 21st century is a complex and changing profession whose service provision has extended from medically based institutions to a variety of community, educational and social service agencies and private practice. Demands of consumer groups, expectation of documentation, the need for accountability of services and government intervention in service delivery have made an impact on every therapist. Within this context occupational therapists have a mandate to develop and implement therapy programmes aimed at promoting maximum levels of independence in life skills and optimal quality of life. The process of occupational therapy in this context consists of problem solving under conditions of uncertainty and change (Mattingly & Fleming 1994, Rogers & Masagatani 1982). Therapists collect, classify and analyse information about clients’ ability and life situation and then use the data to define client problems, goals and treatment focus. The fundamental process involved is clinical reasoning.
The importance of reasoning in occupational therapy has been clearly established (Mattingly & Fleming 1994, Parham 1987, Rogers 1983, Unsworth, 2005). However, several questions remain unanswered in seeking to understand the nature of clinical reasoning. What personal and contextual elements are involved in the reasoning process? How do therapists combine science, practical knowledge and their personal commitments to make decisions about their actions? What is the range of elements involved in making judgements? Why do therapists make decisions the way they do?
In this chapter we examine clinical reasoning from three perspectives. First, a historical perspective of clinical reasoning in occupational therapy is outlined, and parallels with the development of the profession are drawn. Second, elements of therapist knowledge that have been found to influence the process of reasoning and ultimately determine occupational therapy action are examined. Third, alternative notions about the process of thinking that results in clinical decision making in occupational therapy are explored.
Throughout the development of the occupational therapy profession, elements of what is termed clinical reasoning have been referred to as: treatment planning (Day 1973, Pelland 1987); the evaluative process (Hemphill 1982); clinical thinking (Line 1969); a subset of the occupational therapy process (Christiansen & Baum 1997); and problem solving (Hopkins & Tiffany 1988). The clinical reasoning process has been described as a largely tacit, highly imagistic and deeply phenomenological mode of thinking, ‘aimed at determining “the good” for each particular client’ (Mattingly & Fleming 1994, p. 13), ‘thinking about thinking’ (Schell 2003), and an example of behavioural intention that is based on salient beliefs, attitudes and expectancies held by the therapist (Chapparo 1999). Current descriptions and definitions of clinical reasoning have been influenced by the diverse nature and goals of occupational therapy practice, the philosophy of the profession itself, and the various epistemologies of individual researchers. A brief review of the development of the profession illustrates how its history has influenced various reasoning strategies in current practice as well as the methods that have been employed for studying them.
Occupational therapy was founded on humanistic values (Meyer 1922, Slagle 1922, Yerxa 1991). The view of occupation that was accepted by the profession early in its development centred around the relationship between health and the ability to organize the temporal, physical and social elements of daily living (Breines 1990; Keilhofner & Burke 1977, 1983). This view of occupation and occupational therapy treatment was influenced by the theories and beliefs of the moral treatment movement of the 18th and 19th centuries (Harvey-Krefting 1985) which acknowledged people’s basic right to humane treatment (Pinel 1948). A client-centred philosophy evolved which placed emphasis on the rights of all people to develop the skills and habits required for a balanced, wholesome life (Shannon 1977).
The profession subscribed to a belief in the unity of mind and body in action, and developed a philosophical approach to health through active occupation (Breines 1990). Influential in the creation of treatment principles was a thinking mode described by pragmatic theorist, John Dewey (1910), who claimed that actions of professionals depended on a unique mental analysis through which they sought to obtain an understanding of the significance and meaning in a person’s everyday life. The criteria for judging this significance, meaning and worth were practical, largely arbitrary, qualitative rather than quantitative, non-specialized and purposive (Stanage 1987). Clinical reasoning of the time took the form of commonsense inquiry and was structured around the goal of normalizing the activities and environments of people who had problems in daily living. This early pragmatic view of the subjective and individual reality of knowing is mirrored not only in contemporary occupational therapy practice (Yerxa 1991) but also in contemporary methods employed to study clinical reasoning which have focused on the examination of personal meaning of illness, disability and therapy action (Chapparo 1999, Crepeau 1991, Mattingly & Fleming 1994).
Remnants of past humanistic views of health are found in today’s social theories of health and disability. Social disability theory lies at the heart of contemporary moves to redefine occupational therapy service delivery systems in community practice. It moves the focus of reasoning away from medical impairment by defining disability as a rights issue, locating the cause of disability and illness in exclusionary social, economic and cultural barriers to human occupation (Chapparo & Ranka 2005, Peters 2000, Sherry 2002). The original humanistic values on which the professional thinking developed are seen in contemporary therapist thinking that is related to social and occupational justice (Wilcock 1998). Health and ability for all is conceptualized in this century as an issue that is not simply the concern of people with disabilities or those who are ill (Fawcett 2000). Therapists now think about social health and optimal occupational opportunities for all, thereby placing their reasoning within the realm of public health. Social justice is a vision of everyday life in which ‘people can choose, organize and engage in meaningful occupations that enhance health, quality of life and equity in housing, employment and other valued aspects of life’ (CAOT 1997, p. 182). Decision making focuses on issues such as maintaining well-being through occupation, enhancing people’s unique capacities and potential, scaffolding occupational and social support for all people and communities, and advocating for politically supported and social valued occupational opportunities. Increasingly, therapists are required to think about structural social barriers in communities rather than behaviours in individuals. Public policy has become an everyday working arena for occupational therapists, who must use their reasoning skills to determine how occupational performance fits with social need.
During its early years, occupational therapy quickly expanded its services to a variety of medical facilities. Although everyday occupations remained the focus of therapy (Anderson & Bell 1988), there was an increased alliance to medical trends that focused on isolated cause-and-effect principles of illness. Growing pressure from medicine for a more scientific rationale for practice (Licht 1947) resulted in specialized interventions where scientific explanations and medical parallels existed (Keilhofner & Burke 1983). Occupational therapists turned to kinesiologic, neurophysiological and psychodynamic explanations of human function and dysfunction (Barris 1984, Keilhofner & Burke 1977). During this period, medical diagnosis permeated all aspects of occupational therapy decision making. Clients’ problems were viewed in terms of physical or psychiatric diagnosis rather than occupational need (Spackman 1968). Intervention focused on internal mechanisms (Jacob 1964). Clinical decision making became reductionistic, as evidenced by stated goals for intervention which were aimed at improving isolated units of function, such as particular physical or psychological attributes. The central concept of caring for self through a balanced sequence of activity found no place in the medical model and was discarded for many years. This type of reductionistic focus persists in a number of current clinical reasoning practices (Keilhofner & Nelson 1987, Neistadt & Crepeau 1998, Rogers & Masagatani 1982).
Elements of contemporary views of procedural reasoning emerged and reflected the scientific influence of the time. Reilly (1960), for example, proposed an early model of clinical reasoning for occupational therapy that was a type of procedural thinking process. She described its components using the formula: treatment plan equals the sum of the related raw data drawn from the data collecting instruments of observation, testing, interview and case history (Day 1973, Reilly 1960). During the 1970s this formula became formalized into the assessment and treatment planning part of the occupational therapy process.
From Reilly’s work, and in keeping with the adoption of more scientific modes of thinking, systems approaches were applied to clinical reasoning (Line 1969, Llorens 1972). Day (1973), for example, created a model of decision making with the components of problem identification, cause identification, treatment principle or assumption selection, activity selection and goal identification. The circular model created depended on generating and testing a series of hypotheses about client problems and reactions to intervention, and contributed to our understanding of procedural reasoning today (Bridge & Twible 1997, Dutton 1996, Rogers & Holm 1991).
The last decade has seen a resurgence of scientific and reductionist thinking through the evidence-based practice movement (Taylor 2000). Contemporary authors lament the lack of appropriate evidence on which to base reasoning in occupational therapy (McCluskey 2003). Use of evidence in decision making is based in medicine. The original intention was that evidence-based medicine should base decisions on ‘knowledge of individual client characteristics, and preferences in the formulation of clinical decisions’ (Dubouloz et al 1999, p. 445), ‘clinical experience’ and ‘clinical research’ (Sackett et al 1996, p. 71). The reality, however, is that the current evidence-based practices demonstrate the dominance of reductionist science across health and disability services, including occupational therapy (Chapparo & Ranka 2005). Australia’s National Health and Medical Research Council (1999), for example, outlined dimensions of evidence that call for and favour randomized controlled trials and statistical measurement (Dixon & Sibthorpe 2001). Assumptions that underpin this view of evidence include that health is a universal perfection and can be measured the same way for all people; that ill health and disability can be reduced to small units of measurement that accurately reflect a larger problem; and that what science chooses to and is able to measure is of primary relevance to people who experience complex problems of ill health and disability. The influence upon occupational therapy thinking is clear. Contemporary writers exhort a preferred thinking stratagem, with the systematic review of sanctioned information as its basis. This is reminiscent of the scientific dogma that ‘derailed’ the focus of the profession in the 1950s, 1960s and 1970s (Shannon 1977), leading therapists to think of client problems as single factors, and constraining therapy practice towards outcomes that can be precisely defined and statistically justified.
Occupational therapy practice since the 1970s has been characterized by theoretical conflict, as the profession universally re-examined its direction and focus. A number of theories, models and frames of reference emerged to explain the purpose of occupational therapy, with some emanating from other professions (Hagedorn 1992, Reed 1984). The result of this theoretical explosion is contemporary practice wherein various frames of reference are valued by different and substantial segments of the profession.
If theories, models and frames of reference are indeed the ‘tools of thinking’, as suggested by Parham (1987), the impact of this theoretical diversity on clinical reasoning is clear. By adhering to a specific frame of reference, therapists follow a particular line of thinking that translates knowledge into action. This specialized style of reasoning and action has been supported and fostered by current trends in health care and its specialties. Occupational therapists may refer to themselves variously as psychosocial therapists, physical disabilities therapists, hand therapists, or sensory integration therapists, to designate the area of specialty (Schkade & Schultz 1992). The existing pluralism appears to have defied attempts at synthesis (Katz 1985) and creates problems for those who seek an encompassing view of occupational therapy practice (Christiansen 1990, Van Deusen 1991). The present position is perhaps best described by Henderson (1988, p. 569) who urged the profession to ‘be unified in … [its] fundamental assumptions, but diverse in … [its] technical knowledge’.
In summary, the nature of occupational therapy and the clinical reasoning processes that continue to form a basis for its identity are founded in the history and humanistic philosophy that shaped the profession’s beginning. Continuation of the profession’s original belief in health through occupation is reflected in preoccupation with the form, function and meaning of doing in contemporary clinical reasoning (Zemke & Clark 1996). The original belief in clients’ rights to choice and autonomy is reflected in current phenomenological approaches to studying clinical reasoning (Chapparo 1999, Mattingly & Fleming 1994, Neistadt & Crepeau 1998).
The continuing impact of the reductionist and analytic orientation of medicine on current clinical reasoning in occupational therapy is illustrated by the prominent place of diagnosis and disease in the clinical reasoning process that is organized around notions of acceptable evidence (Bridge & Twible 1997, Rogers & Masagatani 1982, Taylor 2000). The influence of modes of scientific inquiry is reflected in a clinical reasoning style that involves systematic conceptualization and examination of clinical situations. Early scientific dogma has been tempered by the profession’s emerging rejection of scientific dependency (Yerxa 1991, Zemke & Clark 1996), resulting in modification of current concepts of clinical reasoning as being more than applied science (Mattingly & Fleming 1994).
Clinical reasoning is recognized as the core of occupational therapy practice. As a phenomenon for study, its contribution lies in describing the diversity, commonalities and complexities of therapists’ thinking. Its importance in defining the professional identity of occupational therapy was summed up by Pedretti (1982, p. 12) who stated, ‘perhaps our real identity and uniqueness lies not as much in what we do, but in how we think’.
The therapy context, the client situation, theory, the identity of the therapist, attitudes about therapy and expectancies of OT outcomes impose powerful internal and external influences on the decisions therapists make about their actions. One way to describe these influences is to consider them as sources of knowledge and motivation for decision making (Chapparo 1997).
The organizational context contains powerful factors that establish conditions (e.g. organizational values) and constraints (e.g. human and financial resources, policies) on therapy. In many situations these elements determine therapy action (Schell & Cervero 1993). Within therapy contexts, therapists view themselves as autonomous individuals and reason according to their internalized values and theoretical perspectives, which may be consistent or at odds with the organizational influences. If practice beliefs and values of therapists fail to account for prevailing institutional contexts, therapy goals can come into direct conflict with organizational goals. The resulting dilemma for clinical reasoning is one of conflict between what therapists perceive should be done, what the client wants done, and what the system will allow.
Therapy experiences, including the organizational elements of therapy, contribute to the practical knowledge schemata that therapists develop. Therapy experiences are remembered by therapists as total contextual patterns of what is possible, involving people, actions, contexts and objects, rather than as decontextualized elements or rules (Gordon 1988, Schön 1983). Contextual patterns contribute to therapists’ perceptions of the amount of control they have over their ability to carry out planned actions. These perceptions have a direct effect on their feelings of efficacy, self-confidence and autonomy (Ajzen & Madden 1986, Bandura 1997), all essential attributes for effective and creative reasoning. When therapists, because of organizational constraints, have a tenuous sense of efficacy and control, they have difficulty constructing images of how their actions can lead to a positive therapy outcome, and they will reason accordingly (Chapparo 1997, Fidler 1981).