Clinical Reasoning in

Clinical Reasoning in Occupational Therapy Co

ntro

versies in PraCtiCe robertson

Controversies in PraCtiCe

OccupationalTherapy

edited by Linda robertson

Clinical Reasoning in

Controversies in PraCtiCe

Occupational Therapyedited by Linda robertson

Occupational therapists work with a wide variety of patients with a multitude of conditions in a range of clinical practice environments. They must be able to work with the varied clinical presentations they encounter and take the most appropriate action for individual patients whilst responding to current practice demands.

This book defines clinical reasoning as a process in which the therapist structures meaning, goals and health management strategies based on clinical data, client choices and professional judgement and knowledge. It informs clinicians and undergraduate students about the latest research and thinking on the topic, and examines clinical reasoning as an important aspect of occupational therapy practice and an obligatory component of professional training and assessment.

Written by an internationally renowned group of clinicians, educators and academics, this is a valuable resource for students and practitioners which covers the theory and practice of all key topics within clinical reasoning.

RelaTed TiTles

Role emerging Occupational TherapyMaximising Occupation-Focused Practice Edited by Miranda Thew, Mary Edwards, Sue Baptiste and Matthew Molineux ISBN 978-1-4051-9782-3

Occupation analysis in PracticeEdited by Lynette Mackenzie and Gjyn O’TooleISBN 978-1-4051-7738-2

The ediTOR

dr linda Robertson, Principal Lecturer, Otago Polytechnic, New Zealand

Cover design: Meaden Creative

9 781405 199445

ISBN 978-1-4051-9944-5

Robertson__Clinical_9781405199445_pb.indd 1 18/01/2012 11:20

Robertson_ffirs.indd iiRobertson_ffirs.indd ii 1/28/2012 9:26:41 AM1/28/2012 9:26:41 AM

Clinical Reasoning in Occupational Therapy

Controversies in Practice

Robertson_ffirs.indd iRobertson_ffirs.indd i 1/28/2012 9:26:40 AM1/28/2012 9:26:40 AM

Robertson_ffirs.indd iiRobertson_ffirs.indd ii 1/28/2012 9:26:41 AM1/28/2012 9:26:41 AM

Clinical Reasoning in Occupational Therapy

Controversies in Practice

Edited by

Linda RobertsonPrincipal LecturerOtago Polytechnic

DunedinNew Zealand

A John Wiley & Sons, Ltd., Publication

Robertson_ffirs.indd iiiRobertson_ffirs.indd iii 1/28/2012 9:26:41 AM1/28/2012 9:26:41 AM

This edition first published 2012© 2012 by Blackwell Publishing Ltd

Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.

Registered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK2121 State Avenue, Ames, Iowa 50014-8300, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Clinical reasoning in occupational therapy / edited by Linda Robertson. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-9944-5 (pbk. : alk. paper) I. Robertson, Linda, 1947– [DNLM: 1. Occupational Therapy. 2. Clinical Competence. 3. Problem Solving. WB 555] 615.8′515–dc23 2011048895

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Set in 10/12.5pt Sabon by SPi Publisher Services, Pondicherry, India

1 2012

Robertson_ffirs.indd ivRobertson_ffirs.indd iv 1/28/2012 9:26:41 AM1/28/2012 9:26:41 AM

Contents

List of Contributors viiForeword ixPreface xiAcknowledgements xv

1 Problem Solving in Occupational Therapy 1

Linda Robertson and Siân Griffiths

2 Abductive Reasoning and Case Formulation in Complex Cases 15

Bronwyn Thompson

3 Ethical Reasoning: Internal and External Morality for Occupational

Therapists 31

Mary Butler

4 Occupational Therapists, Care and Managerialism 45

Ruth Fitzgerald

5 Context and How It Influences Our Professional Thinking 63

Susan Ryan and Carol Hills

6 The Novice Therapist 77

Linda Robertson

7 Artistry and Expertise 93

Margo Paterson, Joy Higgs and Catherine Donnelly

8 Kai Whakaora Ngangahau – Maori Occupational Therapists’

Collective Reasoning 107

Jo-Anne Gilsenan, Jane Hopkirk and Isla Emery-Whittington

9 Reasoning That Is Difficult to Articulate 129

Linda Robertson

Index 137

Robertson_ftoc.indd vRobertson_ftoc.indd v 1/28/2012 10:03:33 AM1/28/2012 10:03:33 AM

Robertson_ftoc.indd viRobertson_ftoc.indd vi 1/28/2012 10:03:34 AM1/28/2012 10:03:34 AM

List of Contributors

Dr Mary Butler

Injury Prevention Research UnitDunedin School of MedicineNew Zealand

Professor Catherine Donnelly

Occupational Therapy ProgramSchool of Rehabilitation TherapyQueen’s UniversityKingstonOntarioCanada

Isla Emery-Whittington

Occupational TherapistAucklandNew Zealand

Dr Ruth Fitzgerald

Senior LecturerSocial Anthropology ProgrammeUniversity of OtagoDunedinNew Zealand

Jo-Anne Gilsenan

Occupational Therapist/NASCCarelinkWest Coast DHBGreymouthNew Zealand

Siân Griffiths

Senior LecturerOccupational Therapy DepartmentOtago PolytechnicDunedinNew Zealand

Professor Joy Higgs AM

Strategic Research Professor in Professional PracticeThe Research Institute for Professional Practice, Learning & Education (RIPPLE)Director, The Education for Practice Institute (EFPI)Charles Sturt UniversityNorth ParramattaAustralia

Carol Hills

Occupational TherapySchool of Health SciencesFaculty of HealthUniversity of NewcastleNSWAustralia

Jane Hopkirk

Occupational TherapistIndependent PractitionerLower HuttNew Zealand

Robertson_fbetw.indd viiRobertson_fbetw.indd vii 1/28/2012 9:36:05 AM1/28/2012 9:36:05 AM

viii List of Contributors

Dr Margo Paterson

Professor and ChairOccupational Therapy ProgramSchool of Rehabilitation TherapyQueen’s UniversityKingstonOntarioCanada

Dr Linda Robertson

Principal LecturerOccupational Therapy DepartmentOtago PolytechnicDunedinNew Zealand

Professor Susan Ryan

Occupational TherapySchool of Health SciencesFaculty of HealthUniversity of NewcastleNSWAustralia

Bronwyn Thompson

Clinical Senior LecturerDepartment of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchNew Zealand

Robertson_fbetw.indd viiiRobertson_fbetw.indd viii 1/28/2012 9:36:05 AM1/28/2012 9:36:05 AM

While the literature on clinical reasoning is not prolific, writers from a background of health and social care have been consistent contributors since the early 1990s. Dr Linda Robertson was one of the first occupational therapists in the United Kingdom to research in this area and this book is a timely and valuable addition to the existing corpus of knowledge. As editor for the text, she has sought mainly contributors from New Zealand but also other key writers in this area who all explore, debate and challenge basic tenets of clinical reasoning. She has synthesised existing knowledge, highlighted unreported aspects of clinical reasoning and offered new insights. Linda’s signature is attention to the cognitive element of reasoning and, in particular, problem solving, which provides the conceptual structure for the book.

The book has a grounded quality to it where emerging ideas have been shared and rehearsed with learners at both undergraduate and postgrad-uate level. Each chapter has provided valuable vignettes for the reader to develop their understanding of the issues being considered. Important questions for future study are also raised in each chapter and in this way readers are engaged to reflect upon their own thinking processes.

C. Wright Mills (1959, p. 223), the eminent sociologist, asserted that ‘thinking was a struggle for order and at the same time for comprehen-siveness’. He stressed the necessity to appreciate the dynamics of thinking but also the influences of context in pursuit of sound decision making. In this text, context is well considered in terms of contemporary influences upon health and social care but also the underpinning cultural issues. As such, there is constant appreciation and negotiation of the dynamics which scaffold clinical reasoning. Of particular note is the unique inclusion of why collective reasoning is pivotal for Maori people.

Other key themes which reverberate throughout the text include ways of assisting occupational therapists to constantly question and be able to articulate their professional ideas and understandings. This applies to the essence of problem posing and interrogating the ethics of practice prior to decision making. In turn it leads into another prevailing theme con-cerning professional integrity to which almost all writers refer either implicitly or explicitly. At the heart of this theme are confidence in the

Foreword

Robertson_fbetw.indd ixRobertson_fbetw.indd ix 1/28/2012 9:36:05 AM1/28/2012 9:36:05 AM

x Foreword

contribution of occupation to health and well being and the shift in thinking from a biomedical imperative.

Constant self-evaluation and reflexivity is another theme in all chapters where the authors have personally revealed through the vignettes the importance of self-scrutiny to understanding how personal frameworks impact upon reasoning. It could be argued that when members of a profession devote time to the specific study of their own thinking in an attempt to truly understand inherent issues, this metacognitive process enhances practice.

Particular attention has been paid to new therapists and how they can be helped to develop their reasoning skills and ‘juggle’ more than one form of reasoning. As observed in the chapter about the novice therapist, the transition from ‘knowing about practice to knowing how to practise is a journey that takes time’. Equally, as we change roles within the profession, for example from practitioner to educator, we need to revisit elements of our own reasoning to appreciate unique dynamics that occur. We each experience being a novice countless times over our professional careers.

I have had the pleasure of being involved with this book from the initial stimulus of the idea, through reading some of the emerging chapters, to the final product. As such, I consider that this book has achieved its aims and makes a significant contribution to the profession and the literature on clinical reasoning. It will be of immense assistance to educators, students, practitioners, managers and researchers. I congratulate Linda as the editor and all the writers of the nine chapters for their unique insights into clinical reasoning, enthusiasm for analysing decision making and their contribution to both learning and professional practice.

Dr Sheena E. E. BlairEd D, M Ed, Dip COT, FHEA, FCOT

ReferenceWright Mills, C. (1959). The Sociological Imagination. London: Oxford

University Press.

Robertson_fbetw.indd xRobertson_fbetw.indd x 1/28/2012 9:36:05 AM1/28/2012 9:36:05 AM

Preface

Introduction

Occupational therapists have been challenged by health care imperatives such as evidence-based practice, accountability and client-centred practice. Autonomous practice has become more evident and has deprived therapists of the support of departments where daily contact with colleagues was taken for granted. Consultancy has also become more prevalent. These are some of the changes that have resulted in therapists modifying the ways they think about practice and then explaining what they do. For instance, passing on knowledge to others (e.g. technicians, carers, teacher aids) rather than a hands-on approach influences therapist thinking as to what problems might be addressed and which interven-tions are thought to be appropriate. Similarly, client-centred or family-centred practice has challenged notions of who has control. Knowledge sharing and negotiation have become expected, rather than the ther-apists’ ideas of ‘best’ practice being accepted as the only way. Practice that limits professional input (e.g. restricts funding, discharges patients early) challenges therapist thinking and presents ethical dilemmas that were not apparent in more traditional practice. Community-based prac-tice has moved therapists away from the biomedical influences and encouraged them to frame their practice in language that can be readily understood within community teams and by their clients. This area of practice has become increasingly orientated to working from the premise of people having deficiencies related to ‘occupation’ rather than a bio-medical problem. Clinical reasoning is dynamic and responds to current practice demands. The aims of this book are to inform clinicians and undergraduate students about the current literature on clinical reasoning and to stimulate critical thinking about issues related to reasoning in practice.

Organisation

This book begins with an overview of problem solving. Robertson and Griffiths explain that diagnostic reasoning is a fundamental method of clinical reasoning that describes a cognitive process common in all

Robertson_fpref.indd xiRobertson_fpref.indd xi 1/28/2012 9:36:38 AM1/28/2012 9:36:38 AM

xii Preface

problem solving. In Chapter 1 they point out the value of using this approach and challenge the tendency to replace ‘problems’ with ‘strengths’ to clarify the focus of occupational therapy practice. This chapter also draws on commonly used models of clinical reasoning (such as three-track mind) to suggest that problem solving is a framework that can complement these models and be used successfully in student learning as an anchoring device.

While diagnostic reasoning induces both inductive and deductive rea-soning, Thompson (Chapter 2) provides another way for occupational therapists to think about problem solving: abductive reasoning. She rec-ommends the use of case formulation to provide a depth of analysis. This approach argues for the value of taking time during complex cases to sort out the ‘real’ problem, thus reducing the complexity before intervention. It teases out levels of problems and warns against the human reaction of jumping to conclusions without thoroughly testing the hypotheses. The case analysis challenges the extent to which we use evidence to substantiate our intervention.

Using the context of the Accident Compensations Corporation in New Zealand (a private provider), Butler (Chapter 3) argues that prob-lems in practice may usefully be explored using the framework of inter-nal and external ethics. External morality refers to influential organisational requirements which may threaten the integrity of prac-titioners. Internal morality is explained as the way in which occupa-tional therapists work to maintain the integrity of their patients. Tensions may arise between these two types of morality and questions are raised about how well our profession recognises that therapists may be implicated in the processes that contribute to the oppression of disabled people.

Similarly, Fitzgerald (Chapter 4) focuses on influences in the work context that impact on practice. Managerialism leads to restrictions on service provision, and she suggests that the moral and ethical basis of professions will reduce as health professionals limit their practice to meet the demands of efficiency. Interestingly, this is in contrast to Butler (Chapter 3), who equates complexity with greater demands on moral questions. In her discussion of the sociopolitical context, Fitzgerald argues that external ideologies shape our reasoning as much as the procedural knowledge that we acquire in our training. She points to the confusions around the notion of care and how this can be misconstrued because of differences between managers and health professionals. Emotional labour is suggested as a core constituent of professional care because it has the potential to assist therapists in understanding their emotional responses to patients and to the context. Critical reflection is viewed as the means whereby the meaning of practice can be examined in  order to explore the impact of power dynamics and the nature of professional ambiguities.

Robertson_fpref.indd xiiRobertson_fpref.indd xii 1/28/2012 9:36:39 AM1/28/2012 9:36:39 AM

Preface xiii

Chapter 5 also addresses the impact of the work context as well as a myriad of other factors such as personal experiences, educational experiences and supervision that impact on how well the unwary student copes with the demands of practice. Ryan and Hills provide a contextual guideline for thinking about practice in order to assist the new therapist in situating reasoning within the realities of the particular work environ-ment. It challenges ways of orientating new practitioners and suggests that a focus on individual practice misses essential reasoning which grounds practice within a context, as does Chapter 4. The authors propose that learning about the contextual aspects should be a systematic process as it is fundamental to reasoning. For the therapist in a new situation, it is recommended that reflective practice should be directed towards how to practice effectively in the particular work environment rather than focusing primarily on specific interventions.

The realities of the contextual elements in reasoning are also addressed in Chapter 6 by Robertson, who compares the novice therapist to a juggling clown. Elements such as the role of the occupational therapist (and who defines this) and team-related challenges to practice are raised. Even following protocols is fraught with difficulty as the new graduate struggles to make sense of practice. Like Ryan and Hills, Robertson argues for time to allow for practice realities to be better understood and to have space to think through the application of theory to practice. Suggestions are made to ensure that accurate procedural reasoning is developed and empathic qualities are nurtured. Acculturation into a profession is considered to be a key issue, as is learning how to function within a team.

Chapter 7 addresses the topic of artistry and expertise in occupational therapy. Paterson, Higgs and Donnelly helpfully differentiate between the four concepts of experience, expertise, professional artistry and judgement artistry. They point out that not all practitioners become ‘expert’ despite being experienced and that little is known about the progress from novice to expert in occupational therapy. One concern presented is that the human aspects of reasoning and professional autonomy are often devalued in environments where accuracy and certainty have high value. Their argument is that professional judgement builds on, rather than disregards, the more procedural aspects of reasoning.

Chapter 8 also challenges ideas about procedural reasoning being overemphasised and asks us to consider the importance of the cultural context. Gilsenan, Hopkirk and Emery-Whittington describe collective Maori ways of decision making in New Zealand practice. So often rea-soning is addressed from the point of view of the dominant cultural group, so this is a refreshing overview of a different perspective. The orientation towards answering questions such as ‘Where do I come from?’ and ‘What are my connections to this person?’ as a starting point in decision making reminds us to be cognisant of human relations in

Robertson_fpref.indd xiiiRobertson_fpref.indd xiii 1/28/2012 9:36:39 AM1/28/2012 9:36:39 AM

xiv Preface

reasoning. In a Maori world, everything has a place and holds signifi-cance in that it is imbued with spiritual meaning – including occupation. This chapter is a reminder of the potency of the personal life experiences that we bring to our practice and the importance of enhancing cultural identity in client interactions.

In the final chapter, Robertson comments on topics that have been raised in this book and relates these to the persistent theme in occupa-tional therapy literature that we need to be more articulate about our practice. Reference is made to aspects such as the influences on our rea-soning, intuitive responses and the need for credibility in environments that do not necessarily embrace the values of our profession. She asks several questions related to understanding how occupational therapists reason and poses ideas for further research – in particular, the need to better understand cognitive processes as well as what we reason about; that is, the content of our reasoning.

Linda Robertson

Robertson_fpref.indd xivRobertson_fpref.indd xiv 1/28/2012 9:36:39 AM1/28/2012 9:36:39 AM