The narrative nature of clinical reasoning

Hope as experienced by people with acquired brain injury in a rehabilitation-or recovery process: a qualitative systematic review and thematic synthesis

Background

There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad population of people with acquired brain injury (ABI). Furthermore a majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI.

Methods

A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adults with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology.

Results

Through a thematic synthesis eleven subthemes were identified relating to experiences of hope. These were grouped into four analytical themes: (1) hope a two folded phenomenon; (2) time and temporality; (3) progress, goals and visibility and (4) the alliance; a balancing act requiring good communication skills.

Conclusion

This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

Healthcare Education: Can Literary Narratives Address Occupational Therapy's 'Incongruence' in Values?

Occupational therapy may be facing an incongruence in values. A growing body of literature, based on occupational therapy documentation and the perspectives of clients, suggests the profession is more focused on productivity and institutional demands than the individualized needs of clients. A proposed solution in occupational therapy education is the critical reading of literary narratives with qualities of complex characters, sensory evoking language, and the subjective truths of the individual experience. This is proposed because empathy has been shown to improve client outcomes and the reading of literary narratives has been shown to improve levels of empathy. Instruction through literary narratives, versus medicalized case studies or videos, may help occupational therapists practice with consilience, regain what is threatened, and provide more impactful and empathic-centered care.

Thinking in Stories: Narrative Reasoning of an Occupational Therapist Supporting People with Profound Intellectual Disabilities' Engagement in Occupation

This article illustrates narrative reasoning using the findings from research into an occupational therapy intervention promoting changes in the ways a staff team facilitated meaningful engagement in occupation. Qualitative critical ethnographic case study research explored a single case over one year of an occupational therapist working with five people with profound intellectual disabilities and their support network. Data were collected using participant observation, interviews and document analysis. Illustrated by an ethnodramatic vignette, the findings demonstrate how the occupational therapist reasoned narratively by eliciting, telling and creating stories and how this supported individualization of her intervention to the specific context. Creation of a prospective story that the support network were invited to share, guided and propelled the intervention toward its hoped-for ending. Narrative reasoning was particularly apparent in opportunities to reflect aloud, supporting occupational therapists' need of opportunities for reflection through story-sharing and story-making. Case study and ethnographic research methodologies may be useful in further clinical reasoning research to better understand narrative reasoning.

Optimizing Occupations, Habits, and Routines for Health and Well-Being With Lifestyle Redesign®: A Synthesis and Scoping Review

IMPORTANCE

Lifestyle Redesign® originated as a preventive occupational therapy intervention for healthy older adults, and it was found to be both effective and cost effective in the Well Elderly Studies initiated in the 1990s. Building on that empirical foundation, the scope of Lifestyle Redesign has been greatly expanded as a general intervention framework addressing prevention and chronic condition management in a wide range of populations, settings, and conditions. Yet until now, its full scope, defining characteristics, and supporting evidence have not been clearly and succinctly described, limiting its potential reach and impact.

OBJECTIVE

To outline the definition and key characteristics of Lifestyle Redesign, provide a scoping review of its evidence base and future directions for research, describe its current applications, and make recommendations for its use in clinical practice.

EVIDENCE REVIEW

We searched PubMed and CINAHL, tables of contents of 10 occupational therapy journals, and citations in two seminal Lifestyle Redesign publications to identify articles published in 1997-2020 that described quantitative outcomes (for n ≥ 20) of interventions meeting the defining characteristics of Lifestyle Redesign.

FINDINGS

Our scoping review yielded 12 publications providing supportive evidence for Lifestyle Redesign's positive impact on a range of health and well-being outcomes among both well populations and those with chronic conditions.

CONCLUSIONS AND RELEVANCE

Lifestyle Redesign has the potential to meet a growing need in clinical and community settings for health care services that address prevention, health promotion, and chronic disease management. What This Article Adds: Current evidence supports the use of Lifestyle Redesign to improve health and well-being for a range of client populations. This review outlines its defining characteristics and current applications to improve its implementation in clinical practice and expand related research efforts.

Why treatment is not an option: Treatment naïve individuals, suffering from alcohol use disorders’ narratives about alcohol use and treatment seeking

Aims: To investigate the narratives of in- and outpatients at mental health and somatic hospitals, who suffer from alcohol use disorders (AUD) but have never sought AUD treatment. More specifically, to understand how the individuals view their alcohol use and explore their reasons for not seeking treatment. Methods: Individuals suffering from AUD were recruited at somatic and mental health hospitals. The study was qualitative, based on semi-structured individual interviews. A narrative analysis was performed. A total of six patients participated: three recruited at a mental health hospital, three from a somatic hospital. Results: The individuals described how heavy alcohol use had always characterised their lives; it was part of their surroundings and it added to their quality of life. Two narrative forms within the individuals’ stories were identified, in which treatment was considered either as a positive option for others but not relevant for themselves, or as representing a threat to the individuals’ autonomy. The participants expressed that they did not believe treatment was relevant for them, and if necessary, they preferred to deal with their heavy drinking themselves. Conclusions: Our findings indicate that a broad focus is needed if relatively more individuals suffering from AUD should seek treatment, since they – in spite of clearly suffering from AUD – nevertheless see themselves as heavy drinkers and have not even thought of seeking treatment. Thus, it is not (only) a question about the attractiveness of the treatment offer or due to lack of knowledge about treatment options that patients suffering from AUD do not seek treatment.

Exploring clinical reasoning in Austrian mental health physiotherapy: the physiotherapist´s perspective

INTRODUCTION

In mental health physiotherapy, there is a lack of research investigating the assumptions and clinical reasoning strategies of the professionals. A critical view on what is taken for granted within physiotherapy promotes professional development.

PURPOSE

The purpose of this study was to explore and describe the essence of clinical reasoning of Austrian mental health physiotherapists, and to illuminate the meaning of their experiences.

METHOD

Ten semi-structured individual interviews were conducted with Austrian mental health physiotherapists. The transcripts were analyzed using a phenomenological hermeneutical method.

RESULTS

The informants' clinical reasoning emerged as a process of three perspectives: 1) a relational and interactional perspective; 2) a perspective of wholeness; and 3) a perspective of symptoms. The results were then further interpreted using the theories of intercorporeality and bodily resonance.

CONCLUSION

To bring the different clinical reasoning perspectives together to one clinical reasoning process, a discourse of reconciliation is suggested as a favorable strategy, which may be useful both in clinical practice and education.

Understanding clinical reasoning: A phenomenographic study with entry-level physiotherapy students

INTRODUCTION

Entry-level students' conceptualizations of clinical reasoning can provide a starting point for program planning related to clinical reasoning development with a focus on patient-centered care.

OBJECTIVE

The aim of the study is to explore how physiotherapy students understand clinical reasoning midway through their education. Nine physiotherapy students were interviewed at the end of their third semester.

METHODS

Semi-structured individual interviews were conducted, recorded and transcribed verbatim. A phenomenographic approach to qualitative data analysis, seeking to explore variations in students' conceptions was applied.

RESULTS

The students' ways of understanding clinical reasoning could be described as: 1) the cognitive process of the physiotherapist; and 2) the relational process of the collaborative partnership between the physiotherapist and the patient. A contrastive analysis shows how the cognitive and relational perspectives are developed through the relationships among three dimensions of clinical reasoning: 1) problem-solving; 2) context of working; and 3) own learning.

CONCLUSION

By identifying the critical variation in students' conceptions of clinical reasoning, focus can be placed on pedagogical arrangements to facilitate students' progression toward a person-centered approach.

Vocational rehabilitation for young stroke survivors in Gauteng public healthcare: Occupational therapists' perceptions1

BACKGROUND

The prevalence of working-aged stroke survivors is increasing yearly. Stroke is an expensive disease, causing financial burden to the government, the family and caregivers of the patient, thus making it imperative for working-aged stroke survivors to work to remain financially independent. Survivors' need to work necessitates occupational therapists to shift their focus from basic activities of daily living, to rehabilitating work.

OBJECTIVES

This study aimed to determine the perceptions of occupational therapists working with younger stroke survivors in public hospitals and clinics in Gauteng South Africa, about rehabilitating working-aged stroke survivors' work ability.

METHODS

Ethical clearance was obtained. A qualitative research design was used to obtain narrative, descriptive data from six focus groups. Therapists from public healthcare settings, who had more than six months' experience and had worked in neurological rehabilitation within the six months preceding the focus group, were invited to participate. Focus groups were audio recorded and transcribed. Inductive content analysis was used to identify themes and categories.

RESULTS

Few participants are involved in rehabilitating younger stroke survivors' work ability or facilitating return to work (RTW). The study identified perceived barriers and enablers to rendering OT services that meet working-aged stroke survivors' needs.

CONCLUSIONS

Despite enabling employment equity laws in South Africa, OTs working in the public sector appear to experience a sense of futility when trying to rehabilitate young stoke survivors to RTW. Fragmentation of the public sector and limited resources impede successful RTW for working-aged stroke survivors. Survivors' employment status and motivation to RTW facilitated rehabilitating work ability.

The puzzle of therapeutic emplotment: creating a shared clinical plot through interprofessional interaction in biopsychosocial pain rehabilitation

Interprofessional collaboration is increasingly encouraged and studied. However, there remains a need to broaden the understanding of professionals' contributions through their day-to-day interactions to minimize the impact of professional boundaries that evoke gaps in patient care. Drawing upon narrative theory emphasizing therapeutic emplotment, this ethnographic study explores how professionals contribute to interprofessional collaboration through social interactions during teamwork. Data collection was undertaken in a biopsychosocial pain rehabilitation ward in a hospital in Norway in 2016, and included participant observation of the ward-based work of two teams, and interviews with professionals from six professions (12) and patients (7). Formal and informal interprofessional interactions and patient encounters were observed. The study found that through interactions, the professionals' shared their understandings across all professions about the successfulness of their own work and of what outsider professionals were doing incorrectly when addressing patients from a biomedical approach. Imbued in these interactions were the pieces of an implicit shared clinical plot for their patients' journeys through rehabilitation and life afterwards. We argue that creating the shared clinical plot enhances conciliation across professions and interpersonal motivation to carry out the work. A struggle between perspectives in interprofessional collaboration should not be prematurely interpreted as an obstruction to collaboration, since the struggle can imbue essential narrative work. This extends the theoretical study of therapeutic emplotment as a central motivational process in interprofessional collaboration in teams.

The Limits of Knowing Other Minds

New care workers in Britain typically struggle to understand, on their initial encounters, people who communicate atypically due to their intellectual disabilities. But they are required to provide care that is attuned to these individuals’ desires and intentions. Why, then, does a care organization called L’Arche UK make it harder for carers to learn what is going on inside these people’s minds? I argue that doing so does not prevent the acquisition of essential knowledge, but rather trains new carers to relate to those with intellectual disabilities as opaque. This creates a more involved relationship that opens up the possibility of forms of status and intimacy otherwise closed to such people—thereby raising questions about the supposedly fundamental role that transparency and knowledge play in knowing others.

The Limits of Knowing Other Minds

New care workers in Britain typically struggle to understand, on their initial encounters, people who communicate atypically due to their intellectual disabilities. But they are required to provide care that is attuned to these individuals’ desires and intentions. Why, then, does a care organization called L'Arche UK make it harder for carers to learn what is going on inside these people's minds? I argue that doing so does not prevent the acquisition of essential knowledge, but rather trains new carers to relate to those with intellectual disabilities as opaque. This creates a more involved relationship that opens up the possibility of forms of status and intimacy otherwise closed to such people—thereby raising questions about the supposedly fundamental role that transparency and knowledge play in knowing others.

'Not at the diagnosis point': Dealing with contradiction in autism assessment teams

Social science literature has documented how the concept of diagnosis can be seen as an interactive process, imbued with uncertainty and contradiction, which undermines a straightforward notion of diagnosis as a way to identify underlying biological problems that cause disease. We contribute to this body of work by examining the process of resolving contradiction in autism diagnosis for adults and adolescents. Autism is a useful case study as diagnosis can be a complex and protracted process due to the heterogeneity of symptoms and the necessity to interpret behaviours that may be ambiguous. We audio-recorded and transcribed 18 specialist clinical assessment meetings in four teams in England, covering 88 cases in two adult, one child and one adolescent (14+) setting. We undertook a qualitative analysis of discursive processes and narrative case-building structure utilised by clinicians to counteract contradiction.We identified a three-part interactional pattern which allows clinicians to forward evidence for and against a diagnosis, facilitates their collaborative decision-making process and enables them to build a plausible narrative which accounts for the diagnostic decision. Pragmatism was found to operate as a strategy to help assign diagnosis within a condition which, diagnostically, is permeated by uncertainty and contradiction. Resolution of contradiction from different aspects of the assessment serves to create a narratively-coherent, intelligible clinical entity that is autism.

Doing Occupational Justice: A Central Dimension of Everyday Occupational Therapy Practice

BACKGROUND.

The Canadian Association of Occupational Therapists (CAOT) and the American Occupational Therapy Association (AOTA) state that occupational justice is part of the domain of occupational therapy and that occupational justice is "an aspect of contexts and environments and an outcome of intervention" (AOTA, 2014, p. S9).

KEY ISSUES.

Despite the increasing focus on justice in the occupational therapy and the occupational science literature, many practitioners in traditional settings do not see its relevance to their everyday practice (Galvin, Wilding, & Whiteford, 2011) or have difficulty envisioning how to enact a justice-informed practice.

PURPOSE.

This paper demonstrates how occupational justice is germane to all settings of occupational therapy, and how it can be enacted at micro, meso, and macro levels of occupational therapy practice.

IMPLICATIONS.

We argue that occupational therapy is a justice-oriented profession at its core and will discuss how occupational justice can be enacted at all levels of practice.

Capabilities, Opportunities, Resources and Environments (CORE): Using the CORE approach for inclusive, occupation-centred practice

BACKGROUND/AIM

Occupational participation is often claimed as a human right and determinant of health by occupational science and therapy scholars. Yet, maintaining occupation at the centre of practice is a challenge. The Capabilities, Opportunities, Resources and Environments (CORE) approach provides a mechanism for occupational therapists to address this challenge by viewing their practice through an inclusive lens, and enacting inclusive, occupation-centred occupational therapy. This paper presents applications of the CORE approach via three case narratives. The aim is to increase occupational therapists' understanding of how to apply the CORE approach and to facilitate research-to-practice knowledge translation.

METHODS

The CORE approach is introduced and applied through three case narratives, each highlighting one of the CORE elements within the context of the broader approach.

FINDINGS

The narratives contain critical reflective case narratives on the application of the CORE approach in the context of three different practice settings in Australia based on the authors' experiences. Practice settings include working within the National Disability Insurance Scheme, in a secure forensic mental health facility, and in rural community health. The forensic health case narrative documents findings from the authors' research which applied the CORE approach as an analytical tool, providing an additional layer of analysis of the identified themes from the original study.

CONCLUSION

This paper provides occupational therapists with a practical understanding of how to apply the CORE approach through diverse case narrative examples. The practical "how to" questions that guided the development of the case narratives can be used by occupational therapists and occupational therapy students in individual or group critical reflection to support development and application of socially inclusive and occupation-centred praxis. If occupational therapists are to claim expertise in enabling occupation and social inclusion, then using the CORE approach is vital to designing and implementing inclusive, occupation-centred interventions.

Evaluating a telehealth intervention for urinalysis monitoring in children with neurogenic bladder

Telehealth as a community-monitoring project within children's urology care is an innovative development. There is limited evidence of the inclusion of staff and parents in the early-stage development and later adoption of telehealth initiatives within routine urological nursing care or families' management of their child's bladder. The aim was to explore the experiences of key stakeholders (parents, clinicians, and technical experts) of the proof of concept telehealth intervention in terms of remote community-based urinalysis monitoring by parents of their child's urine. A concurrent mixed-methods research design used soft systems methodology tools to inform data collection and analysis following interviews, observation, and e-surveys with stakeholders. Findings showed that the parents adopted aspects of the telehealth intervention (urinalysis) but were less engaged with the voiding diary and weighing. The parents gained confidence in decision-making and identified that the intervention reduced delays in their child receiving appropriate treatment, decreased the time burden, and improved engagement with general practitioners. Managing the additional workload was a challenge for the clinical team. Parental empowerment and self-efficacy were clear outcomes from the intervention. Parents exercised their confidence and control and were selective about which aspects of the intervention they perceived as having credibility and which they valued.

Razonamiento clínico en terapia ocupacional. Una revisión narrativa

 Introducción. El razonamiento clínico ordena el procesamiento de la información obtenida durante la evaluación, facilitando tomar decisiones para implementar planes de tratamiento. Esta área es cada vez más relevante para la formación de estudiantes y profesionales de terapia ocupacional. Objetivo. Analizar la literatura sobre razonamiento clínico en terapia ocupacional publicada entre 2009 y 2018. Materiales y métodos. Se realizó una revisión de la literatura en bases de datos, repositorios institucionales, monografías y literatura gris de alcance. Se establecieron criterios de selección para la obtención de documentos que luego se analizaron estableciendo un conjunto de variables que permitieron el análisis de la literatura. Resultados. La literatura sobre razonamiento clínico en el período estudiado fue de 99 publicaciones, más de la mitad que en los 33 años anteriores. El razonamiento clínico en el ámbito docente es el de mayor impacto (41.4%); 52.5% son publicaciones que mejoran la práctica con sus aportes al reforzar el desarrollo de destrezas profesionales y la calidad de las intervenciones. Conclusión. El aumento de la investigación sobre razonamiento clínico en terapia ocupacional dota a esta área de conocimiento y rigor, mejorando así la eficacia de los terapeutas ocupacionales.

Narrative Reasoning in Practice A Case Study in Podiatry

BACKGROUND

Clinical reasoning and decision making within health care are as important as ever in a world where evidence-based health care and patient outcomes are highly valued. It is increasingly recognized that decisions are not made in isolation, and are influenced by many factors, both intrinsic and extrinsic. Expert and novice practitioners share reasoning techniques, and there are many interpretations of reasoning paradigms within the field of health care.

METHODS

A reflective diary was kept for 3 months linking personal reflections on a particular clinical decision with theoretical learning on clinical reasoning. Several decision-making paradigms were looked at in relation to the decision, with a deeper focus on narrative reasoning. Narrative reasoning resonated particularly with the author's previous experience studying literature.

RESULTS

The clinical decision was usefully analyzed using a narrative reasoning strategy. The decision made by the author was perhaps contrary to the evidence, and yet had a positive outcome. The positive outcome of the decision was looked at within the context of evidence-based practice and ethical practice.

CONCLUSIONS

Narrative reasoning comes from within the interpretive research model and puts the patient's experience at the heart of decision making. Narrative reasoning can be a valuable way of combining diagnostic, management, and ethical aspects of care. Further research-particularly in podiatry, where research is lacking-could identify helpful reasoning strategies for care of patients with long-term chronic conditions or complex conditions.

The virtual patient as a learning tool: a mixed quantitative qualitative study

BACKGROUND

The use of simulation in medical education has been widely accepted. There are different types of medical simulators that vary in both accuracy to emulate the real world (fidelity) and cost of development or acquisition. There is significant evidence that supports the use of high-fidelity simulators (i.e. mannequins or dummies) to prepare students for clinical environments, less attention has been given to low-fidelity simulators. This article aims to present evidence regarding the effectiveness of a low-fidelity simulator: Virtual Patient (VP), which develops several interactive computer-based clinical scenarios, seeking to promote an alternative learning environment and the development of necessary medical skills such as clinical reasoning in students of medicine.

METHODS

A quasi-experimental study was designed to investigate the results on the development of history taking and clinical reasoning skills in a group of undergraduate medical students, in a course devised under the concepts of constructivism in education, which used the Virtual Patient as the fundamental teaching tool. Results were measured through a mixed, quantitative and qualitative study, triangulating the results of the students' skills evaluation when facing a clinical case represented by an actor patient before and after the course. Additionally, the description of the students' and tool's performance was measured by way of a qualitative study.

RESULTS

The comparison of the students' skills on the evaluation matrix before-and-after the course evidenced a statistically significant advance (p < 0.01) in all aspects (interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case). Students described the VP as an easy-to-use and motivating tool for learning without stress, especially at the beginning of their career. VP allowed them to create logical and structured processes, to be wrong without consequences, and to review and reassess information available. From the professor perspective, it allowed a better follow-up of the students' learning process and favored reflections on the teaching-learning process.

CONCLUSIONS

VP proved to be a valuable and useful tool for the development of clinical reasoning and history taking skills in medical students, as part of a constructivist learning course.

Use of Biography in the Development of Applicable Knowledge

A narrative understanding of clients is needed to supplement traditionally developed research for making clinical judgments about which approaches should be used in working with older adults. Narrative biographical knowledge of clients integrates the historical events and happenings of their lives with the social and cultural contexts through which they attribute meaning to their distresses and symptoms. Applications based on narrative knowledge differ from those based on the conventional model. The conventional model draws on general knowledge of what interventions are likely to be effective in treating particular diagnoses. Narrative understanding is concerned in knowing the configuration of past events and present tasks that compose individual lives. Expert practitioners make use of a narrative understanding of their clients in judging their intervention activities. Development of a narrative understanding of present clients can be assisted by consulting narratives of clients with whom a practitioner has previously worked. Narratives are remembered as stories, retaining the patterns and details of the individual clients’ lives. Through experience, practitioners develop a collection of remembered narratives of the clients they have assisted. A practitioner's experiential collection of narratively known clients can be supplemented with narrative biographies and case studies of clients treated by other practitioners. When working with a new client, practitioners can draw on these narratively retained past understandings by comparing the similarities and differences of their present client to a remembered past client. The process of comparison with past narratively understood clients helps the practitioner compose a new narrative that expressly captures the individual life of the present client. This narrative understanding of the client provides an integrated view of the influence of general social and biological contexts with the unique values, aims, and history of the client.

The Dr Elizabeth Casson Memorial Lecture 2018: Occupational stories from a global city

The Dr Elizabeth Casson Memorial Lecture 2018, given on June 12th 2018 at the 42nd Annual Conference and Exhibition of the Royal College of Occupational Therapists, held at the Belfast Waterfront, Belfast, UK.

This lecture aims to set out the potential for the global occupational therapy profession to exchange knowledge for social transformation practice. It identifies the profession’s concern with narratives as a vehicle for a socially critical approach to occupation, which can be used to negotiate intervention and action. Drawing on examples from literature, history and service users, the paper suggests that narrative provides a means for relating the value of occupation beyond professional boundaries to capture popular imagination and demand for the profession. Examples are given of the critical discussion of the everyday impact of health inequity, and in addressing diversity both in the profession and engaging service users.

My lecture concludes that occupational therapy is a global network with the population of a city, and thus represents a community that can be a vibrant voice for social transformation through occupation through a reciprocal exchange of narrative. This is a collective and dialogical process which can draw on the experiences of both southern and northern hemispheres.

Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement

Staff members' engagement with patients is a critical element of inpatient psychiatric care, essential to safety, the hospitalization experience and the development of a culture of care. Currently broad concerns exist around the amount of time inpatient psychiatric nurses expend in patient engagement and the quality of these interactions. In this paper we present a model of engagement that clarifies necessary skills to support the engagement process. The model is based on Peplau's theory of interpersonal relations, patients' ideas on healing elements of psychiatric hospitalization and research on inpatient therapeutic relationships. We are currently using this model for a web-based teaching/learning course to cultivate interpersonal engagement, and to explicate how through operationalizing their inpatient role, nurses support patients in the development of their mental health and well-being.

Clinical Reasoning: Survey of Teaching Methods, Integration, and Assessment in Entry-Level Physical Therapist Academic Education

BACKGROUND

Although clinical reasoning abilities are important learning outcomes of physical therapist entry-level education, best practice standards have not been established to guide clinical reasoning curricular design and learning assessment.

OBJECTIVE

This research explored how clinical reasoning is currently defined, taught, and assessed in physical therapist entry-level education programs.

DESIGN

A descriptive, cross-sectional survey was administered to physical therapist program representatives.

METHODS

An electronic 24-question survey was distributed to the directors of 207 programs accredited by the Commission on Accreditation in Physical Therapy Education. Descriptive statistical analysis and qualitative content analysis were performed. Post hoc demographic and wave analyses revealed no evidence of nonresponse bias.

RESULTS

A response rate of 46.4% (n=96) was achieved. All respondents reported that their programs incorporated clinical reasoning into their curricula. Only 25% of respondents reported a common definition of clinical reasoning in their programs. Most respondents (90.6%) reported that clinical reasoning was explicit in their curricula, and 94.8% indicated that multiple methods of curricular integration were used. Instructor-designed materials were most commonly used to teach clinical reasoning (83.3%). Assessment of clinical reasoning included practical examinations (99%), clinical coursework (94.8%), written examinations (87.5%), and written assignments (83.3%). Curricular integration of clinical reasoning-related self-reflection skills was reported by 91%.

LIMITATIONS

A large number of incomplete surveys affected the response rate, and the program directors to whom the survey was sent may not have consulted the faculty members who were most knowledgeable about clinical reasoning in their curricula. The survey construction limited some responses and application of the results.

CONCLUSIONS

Although clinical reasoning was explicitly integrated into program curricula, it was not consistently defined, taught, or assessed within or between the programs surveyed-resulting in significant variability in clinical reasoning education. These findings support the need for the development of best educational practices for clinical reasoning curricula and learning assessment.

Frida Kahlo: Portrait of Chronic Pain

The Mexican artist Frida Kahlo (1907-1954) is one of the most celebrated artists of the 20th century. Although famous for her colorful self-portraits and associations with celebrities Diego Rivera and Leon Trotsky, less known is the fact that she had lifelong chronic pain. Frida Kahlo developed poliomyelitis at age 6 years, was in a horrific trolley car accident in her teens, and would eventually endure numerous failed spinal surgeries and, ultimately, limb amputation. She endured several physical, emotional, and psychological traumas in her lifetime, yet through her art, she was able to transcend a life of pain and disability. Of her work, her self-portraits are conspicuous in their capacity to convey her life experience, much of which was imbued with chronic pain. Signs and symptoms of chronic neuropathic pain and central sensitization of nociceptive pathways are evident when analyzing her paintings and medical history. This article uses a narrative approach to describe how events in the life of this artist contributed to her chronic pain. The purpose of this article is to discuss Frida Kahlo's medical history and her art from a modern pain sciences perspective, and perhaps to increase our understanding of the pain experience from the patient's perspective.

Clinical Reasoning during Community Health Home Visits: Expert and Novice Differences

Very little is known about the differences between novice and expert clinical reasoning in community health practice. This article presents the findings of a study of the clinical reasoning of five expert and five novice community health occupational therapists (CHOTs) during the conducting of home visits. A head-mounted video camera was used to record the visits, followed by the participants reporting their clinical reasoning verbally using a video-assisted debriefing method. The transcripts from these verbal reports were analysed quantitatively and qualitatively.

The quantitative results demonstrated many differences between experts and novices in terms of the amounts and types of clinical reasoning used. For example, the novices used more procedural reasoning whereas the experts used more conditional reasoning and mixes of different reasoning types. The qualitative results demonstrated that the experts used a free-flowing conversational approach when reasoning during home visits whereas the novices depended on external structures such as assessment forms to guide the process. Given their experience and familiarity with the process, the experts were confident and clear in their reasoning whereas the novices were more awkward and self-conscious. The experts handled sensitive issues whereas the novices seemed to avoid them.

The study findings may provide insights for student and novice therapists concerning expert CHOTs' practice and promote reflection in general on the attainment of expertise in clinical practice.

Clinical Reasoning, Part 1: The Nature of Problem Solving, a Literature Review

The information-processing literature has been reviewed to identify the component parts of problem solving. The difference between the problem representation and the subsequent solving process is highlighted, as is the role of memory within problem solving. The techniques for searching data and novice/expert differences are outlined. Finally, a model of problem solving in occupational therapy is proposed. The implications of this model for student education will be discussed in part 2 of this article.

Quality of Life for People with Motor Neurone Disease: A Consideration for Occupational Therapists

Motor neurone disease (MND) is a rapidly progressive neurological disease of unknown cause, which results in relentless loss of function and, conversely, high levels of disability. There has been a significant increase in quality of life (QoL) literature in recent years and the philosophy of the occupational therapy process may be considered consistent with the QoL construct. However, little is documented in occupational therapy literature that promotes consideration of the QoL construct in practice. This may be explained by the profession's adherence to the medical model of health care intervention.

Expectations and desires continually shift for people with MND and individual-perceived QoL is determined by a continuous process of adjustment to increasing disability. In order to promote wellbeing, occupational therapists must identify what people with MND consider important in their lives.

The Model of Human Occupation: An Overview of Current Concepts

The model of human occupation has evolved since it was first published. A number of important changes and refinements have been made. These changes reflect research findings, new interdisciplinary theory and insights encountered in practice. This article provides an overview of the current theoretical arguments. These concepts attempt to offer a way of understanding how human occupation is motivated, organised, performed and influenced by the environment. This is followed by a discussion of how occupational therapists can use this framework in their clinical practice.

Interdisciplinary Collaborative Goal Planning in a Post-Acute Neurological Setting: A Qualitative Study

The aim of this qualitative study was to explore the use of interdisciplinary collaborative goal planning from the perspective of patients, their relatives and professional staff. Eighteen patients and their relatives who had been involved in collaborative goal planning were interviewed individually after the patient was discharged from the ward of a neurological rehabilitation hospital. The members of the interdisciplinary team responsible for implementing the goal planning process were also interviewed.

The findings showed that the majority of the patients and their relatives valued highly the opportunity to become actively involved in their care and discussed the impact of this on motivation, perceptions of control and freedom in decision making. The professional staff also identified benefits, which included giving clarification and direction to treatment and further opportunities for patient-centred practice. Challenges emerged as well, including the question of how to implement collaborative goal planning with people with severe language or cognitive impairment, those with poor insight or those in low awareness states. Further consideration of the issues raised is recommended as a means to promote patient-centred care.

Studying Clinical Reasoning, Part 1: Have We Been Taking the Wrong ‘Track’?

This is the first of two papers that examine clinical reasoning research in occupational therapy. It discusses the reasoning studies of the 1980s and 1990s, focusing on ethnographic and process-tracing approaches. From this critique, a need for an approach that acknowledges the experienced thinker's intuitive reasoning is identified. The second paper will present such an approach, based on social judgement theory, and demonstrate the first application of such a method in the field of occupational therapy.

Using the Occupational Performance History Interview (OPHI): Therapists' Reflections

Clinical interviews provide occupational therapists with sensitive and versatile sources of information; however, reliable means to collect and interpret this information are necessary for effective clinical decision making. The Occupational Performance History Interview (OPHI) is a semi-structured interview, designed to address the need for a reliable and clinically useful interview tool in occupational therapy. This article describes a qualitative research study, in which four experienced therapists reflected on their use of the OPHI to interview people referred to a psychiatric day hospital service.

The therapists' reflections, based on listening to audiotapes of these interviews, focused on the interview procedure and on themselves as interviewers. They illustrate how the conduct and interpretation of interviews may be guided by interactive reasoning and professional values. The development of a conversational interviewing style, whilst using this semi-structured interview tool, is also described. To develop reliable interview tools that are also consistent with the particular values and perspective of occupational therapy, consideration might usefully be given to using evaluation criteria applied to qualitative research, as well as conventional scientific criteria of reliability and validity.

Expert Clinicians' and Students' Views on Clinical Reasoning in Occupational Therapy

In this study, an examination was made of the clinical reasoning processes used by expert occupational therapists and post-clinical fourth-year occupational therapy students. Using nominal group technique, the factors involved in clinical reasoning were derived and their relative importance determined.

The most highly valued skill for the experts was good communication, while the most highly valued skill for the students was a knowledge of and understanding of disability. The experts considered a wider range of factors when making clinical decisions than did the students, and rated their level of clinical reasoning at a higher level than did the students. For the experts, the factors identified as important in clinical reasoning were concerned more with gaining an understanding of the patients both by using general principles of diagnosis and illness and by gaining an understanding of the illness as it affected the individual patient. Meanwhile, for the students, greater emphasis was placed upon the influence of pragmatic factors on treatment, such as resources, time constraints and other environmental factors.

Occupational Therapy in Community Mental Health, Part 1: Intervention Choice

Arguments about the blurring of roles between the members of multidisciplinary community mental health teams and the generic style of intervention within them are well rehearsed. However, an empirical description of the daily work practice of occupational therapists in this field has not yet been attempted. This article presents a study examining the choices made by 12 therapists in the south east of England when working with their clients. Part 1 reports quantifiable findings on intervention media chosen over a 4-week period, drawn from diary data.

The results revealed diverse patterns of intervention choices. However, an emphasis on anxiety management chosen 295 times (16% of intervention selections), supportive counselling chosen 348 times (18% of selections) and problem-solving discussion with clients about aspects of their daily lives chosen 255 times (13% of selections) emerged. Follow-up interviews explored each participant's rationale for the patterns of practice highlighted by the diaries, which will be illustrated and discussed in part 2.

Approaches to Reasoning in Occupational Therapy: A Critical Exploration

This article approaches reasoning from a cognitive science paradigm. It is proposed that problem solving follows a basic process common to all human beings faced with a problem. However, there are variations in the process that are caused by the nature of the problem and the expertise of the problem solver. These variations in problem-solving methods should not be confused with the content of the reasoning which may be influenced by the domain in which the problem is framed and the individual characteristics of the problem solver. Clinical reasoning in nursing and medicine has been well researched and provides a benchmark for approaching reasoning in occupational therapy. This article outlines approaches to reasoning, emphasising the information-processing approach and its relevance to occupational therapy. It concludes with a critique of the modes of reasoning proposed by Mattingly and Fleming.

Spinal Cord Injury; Quality of Life; Occupational Therapy: Is There a Connection?

Although occupational therapists frequently state that one of their primary goals is that of enhancing quality of life, this does not appear to be supported by either their outcome measures or their literature. Studies have shown that satisfaction with quality of life following a spinal cord injury is not predicted by either degree of impairment or disability. Handicap is negatively correlated with quality of life and this may require interventions that are focused towards the environment rather than the individual. Occupational therapists may need to adopt a more client-centred approach to practice, in which assessment, Intervention and outcome measures are sensitive to the subjective views of the individual, thus enabling therapists to understand more of what quality of life means to each client.

Clinical Reasoning in Community Occupational Therapy

A qualitative research study was undertaken in order to ascertain the scope and nature of clinical reasoning in community occupational therapy. Thirty occupational therapists based in social work departments in Scotland participated in this study, which required them to describe the content and meaning of their thinking during routine interventions with clients and carers living in their own homes.

The findings indicated that the participants adopted patterns of reasoning that consisted of three elements: reflection, decision making and reasoning. Reflection-in-action was commonplace during the home visits, while decision making was found to be concerned more with interactive than with technical or procedural issues. Reasoning was relativistic or pragmatic in response to contextual influences. In addition, it was found that the respondents tended to use coded meaning when explaining their thinking, which may in part account for the difficulties in articulating the reasoning that underpins clinical action. These issues are discussed in the context of current research on thinking.

True to Our Philosophy? Sexual Orientation and Occupation

Occupational science and occupational therapy suggest that people engage in occupations that are meaningful and relevant to them on personal and cultural levels. Sexual orientation is one theme of meaning in a person's life which influences his or her choice of occupations and the meaning and relevance those occupations hold. Sexual orientation, as it is conceptualised here, encompasses far more than a person's choice of sexual partner and is, therefore, an important area for an occupational therapist to consider. It is, however, an often neglected area in both curricula and the literature.

This paper presents the results of a qualitative study which investigated the perspectives of basic grade occupational therapists regarding working with clients of gay, lesbian or bisexual sexual orientation. Six basic grade occupational therapists were interviewed using a semi-structured format and four themes emerged. The findings included that the basic grade occupational therapists interviewed did not consider occupation in its complexity and so did not appreciate how sexual orientation might be expressed in a person's occupations. The interviews also indicated that the subject of sexuality is still taboo in occupational therapy.

Applying Phenomenology in Research: Problems, Principles and Practice

Interest in phenomenological research has been growing steadily over the last decade as researchers have sought to capture the richness of individual experience. However, the sheer complexity of ideas embedded within phenomenology is challenging. Confusions abound as to what phenomenology means, let alone how to apply it as a research method. Misconceptions and contradictions are apparent in the literature.

This paper starts with a broad review of some current phenomenological literature relevant to occupational therapy. The key principles of the phenomenological approach are then clarified, followed by an exploration of how these might be applied practically in research.

Clinical Reasoning through Story Telling: Examining a Student's Case Story on a Fieldwork Placement

This article considers narrative (story telling) as the way In which human experience Is made meaningful. Narrative reasoning has been Identified as a means of enabling occupational therapists to explain their practice. A review of the literature Includes the concepts of the professional artist, narrative reasoning, expert and novice practitioners, and experiential learning and reflection.

A single case study looked at the use of narrative reasoning by a second year occupational therapy student (novice) on a fieldwork placement and an experienced therapist (expert) who was supervising her. During the routine fieldwork visit of the academic staff member to the student, both novice and expert were asked to tell their story about one particular client with whom they were working. The findings highlighted the fact that the expert and the novice told different narrative stories but that, by asking probing and reflective questions, the student's story could be enhanced to Include more narrative. This study has Implications for the education of students in both university and the fieldwork setting.

Use of the Model of Human Occupation: A Survey of Therapists in Psychiatric Practice

This study sought to examine how occupational therapists (OTs) who utilize the Model of Human Occupation as their primary practice model applied concepts of this model to describe the occupational functioning of their clients. A telephone survey method was created to elicit quantitative and qualitative data. The findings suggest that therapists value the holistic approach of this model and often incorporate parts of other practice models into it, although sometimes they ignore conceptual differences between the models. Therapists questioned found major concepts of the model useful for conceptualizing their clients' occupational functioning, but found the further subdivision of major concepts into several variables to be less useful. These preliminary findings and how they relate to the model as a practice theory are examined, and the parts of the theory that may bear refinement or change are discussed.

Institutional Ethnography: A Method for Showing How the Context Shapes Practice

The article illustrates the sociological theory and method of institutional ethnography by describing a study of occupational therapy's mental health practice. Over almost 6 months, the author collected data through observation, interviews, and review of documents. Data describe the practice of occupational therapy in seven adult mental health day programs with at least one site in each of the four provinces of Atlantic Canada. The question asked was, What are the possibilities and constraints for occupational therapists to enable the empowerment of adults who attend mental health day programs? Although developed as a feminist methodology for displaying the social organization of patriarchy, institutional ethnography is used in this study to show how the organizational context invisibly shapes occupational therapy practice. Through this method, occupational therapy ideas about occupation can be seen to be organizationally subordinated. Occupational therapists' work in enabling empowerment through occupations such as “chores” is relegated to the background to make practice fit prevailing medical and psychologic ideas about health.