Ikiugu's eclectic method of combining theoretical conceptual practice models in occupational therapy

Background/aim: Occupational therapists are often reluctant to use single theoretical conceptual practice models to guide practice because they recognise the limitation of individual models in addressing clients’ occupational performance issues. However, there is a dearth of eclectic methods of guiding theoretical model combination in the profession. The effectiveness of one such newly developed method in guiding combination of models by students working on a case study was investigated. Methods: This was a mixed methods study with experimental and phenomenological designs in which forty‐three occupational therapy students participated. Results: There was increased confidence in ability to apply theory in a case study for all research participants. The improvement was significantly higher for participants in the experimental group, who had been introduced to the eclectic method. Participants in the experimental group were more capable of combining models systematically in a case study compared with those in the control group. Conclusions: Adopting Ikiugu’s eclectic method of combining theoretical conceptual practice models may help students learn how to combine them systematically and increase their likelihood of using theory effectively to guide clinical practice in their future as occupational therapists.     

Clinical reasoning and the occupational therapy curriculum

Several reasoning styles are used by occupational therapists when they evaluate clients' problems. This study investigated the influence of the occupational therapy curriculum in Hong Kong on therapists' clinical reasoning styles. Two groups of therapists with different clinical experience were recruited. Through interviews with the therapists after identifying clients' problems using the Canadian Occupational Performance Measure, their clinical reasoning styles were explored. The local occupational therapy curriculum was analysed to isolate the components that influence clinical reasoning. Results showed that more experienced therapists use conditional reasoning that considers clients' needs in their future lives whereas junior therapists use procedural reasoning that focuses on clients' disabilities. The analysis of the occupational therapy curriculum indicated that it prepared the students with an equal emphasis on theoretical and clinical subjects and fieldwork practice. The present curriculum was useful in providing educational preparation for novice therapists. However, the period of fieldwork practice can be lengthened to allow adequate maturation of clinical reasoning skills. Problem‐based learning can be incorporated to facilitate students' problem‐solving and self‐directed learning skills. Copyright © 2000 Whurr Publishers Ltd.     

Becoming “At Home” in Home Modifications: Professional Reasoning Across the Expertise Continuum

ABSTRACT

Professional reasoning used by occupational therapists in home modifications as they develop from novice to expert was explored in this grounded theory study. Eight occupational therapists participated in multiple interviews and member checks about home modifications training and practice. Formal academic and experiential learning provided the foundation for reasoning systems and habits of practice. As therapists gained expertise, they were able to shift their primary focus from systematic reasoning steps to focus on the comprehensive, client-centered, and contextual picture. Creative educational strategies support confidence in engaging in home modifications practice.     

Clinical Reasoning and Reflective Practice: Implications of Fieldwork Activities

Objectives. Theories and research suggest that learning clinical reasoning skills requires students to be reflective in their practice. To explain this proposition, five research questions were developed to examine the effect of: (a) the fieldwork experience on clinical reasoning skills, (b) degree of participation in different clinical reasoning activities on clinical reasoning skills, and (c) the total number of clinical reasoning activities in which students participated related to clinical reasoning.

Method. Data (n = 70) were collected using a researcher-developed case analysis test, the Adaptive Style Inventory, and a questionnaire. Paired t tests, ANCOVA, and multiple regressions were used to analyze the data from the research questions.

Results. Fieldwork does improve clinical reasoning skills (large effect size). Participation in activities thought to develop clinical reasoning skills was mixed.

Conclusion. The results support the improvement of fieldwork as a mode of developing clinical reasoning skills in occupational therapy students.     

Expanding client-centred thinking to include social determinants: a practical scenario based on the occupation of breastfeeding

Abstract

Background: Client-centred thinking in occupational therapy underemphasizes the influence of social determinants and societal-level factors on occupation across the life course. When client-centred thinking focuses solely on the local or immediate contexts of individuals, therapists may not fully recognize or understand how social determinants can create barriers to occupational participation and performance. Aim/Objectives: This article critically examines gaps in traditional thinking concerning client-centredness and demonstrates how the complex interplay between social determinants and societal-level factors may lead to occupational injustices. Material and methods: A practical example from a recent study on breastfeeding and accompanying scenario is used to examine limitations in current client-centred reasoning. The Life Course Health Development framework, a theoretical framework examining contexts of health disparities, is applied to illustrate the opportunity to expand thinking about client-centredness. Results: The Life Course Health Development framework may be a useful addition to client-centred thinking about social determinants of occupation. Conclusion and significance: Expanding client-centred thinking to include awareness, understanding, and respect for social determinants of occupation may enhance therapist–client interactions and outcomes of the occupational therapy process, and address gaps in current thinking that may contribute to occupational injustices.     

Instructing Occupational Therapy Students in Use of Theory to Guide Practice

ABSTRACT. We investigated the effectiveness of instructing students in occupational therapy practice models to facilitate their competence in applying theory in clinical practice. Course evaluation data were gathered and analyzed retrospectively. We found that perceived understanding of theory and its application improved significantly after instruction. The students’ perceived competence in theory use predicted their level of confidence in their assessment and intervention skills. We concluded that emphasis on instruction of students in the use of occupational therapy practice models could be a viable method of improving practice through consistent use of theoretical guidelines in clinical reasoning.     

Re-imagining occupational therapy clients as communities: Presenting the community-centred practice framework

Background: Occupational therapists’ are increasingly working with communities and providing services at the community level. There is, however, a lack of conceptual frameworks to guide this work.

Aim: The aim of this article is to present a new conceptual framework for community-centered practice in occupational therapy.

Material and Method: The conceptual framework was developed from qualitative multi-case research on exemplars of community participation. The first was, a network of Canadian food security programs, and the second, a rural Australian community banking initiative. Key themes were identified from across the case studies, and cross-case findings interpreted using occupational therapy and occupational science knowledge, and relevant social theory. The outcome is a four-stage, occupation-focused, community-centered practice framework.

Findings: The Community-Centred Practice Framework can be used by occupational therapists to understand and apply a community-centered practice approach. The four stages are: (1) Community Identity, (2) Community Occupations, (3) Community Resources and Barriers, and (4) Participation Enablement.

Conclusions: Further research is needed to trial and critically evaluate the framework, to assess its usefulness as a robust, occupation-focused, frame of reference to guide community-centered practice in occupational therapy.

Significance: The proposed framework should assist occupational therapists to conceptualize community-centered practice, and to utilize and apply theory.     

A tool to enhance occupational therapy reasoning from ICF perspective: The Hasselt Occupational Performance Profile (H-OPP)

Background: In order to enhance occupational therapy reasoning in clinical practice, different elements such as client-centred approach, evidence-based care and interdisciplinary work should be taken into account, but is a challenge.

Aim: To describe the development of the digital Hasselt Occupational Performance Profile (H-OPP^©) that enhances occupational therapy reasoning from ICF perspective.

Method: A participative qualitative design was used to create the H-OPP^© in an iterative way in which occupational therapy lectures, ICF experts, students and occupational therapists in the field were involved.

Results: After linking occupational therapy terminology to the ICF, different stages of the H-OPP were identified and elaborated with main features: generating an occupational performance profile based on inventarization of problems and possibilities, formulating an occupational performance diagnosis and enabling to create an intervention plan. In all stages, both the perspectives of the client and the occupational therapist were taken into account. To increase practical use, the tool was further elaborated and digitalized.

Conclusion: The H-OPP^© is a digital coach that guides and facilitates professional reasoning in (novice) occupational therapists. It augments involvement of the client system. Furthermore, it enhances interdisciplinary communication and evidence-based care.     

Analyzing and Critiquing Occupational Therapy Practice Models Using Mosey's Extrapolation Method

ABSTRACT

Over time, there has been a persistent gap between theory and practice in occupational therapy. In this paper, it is suggested that this gap could be decreased by enhancing therapists' knowledge and understanding of the nature of theory. Mosey's (1996a) 9-step extrapolation method of developing theoretical conceptual practice models is proposed as one way of improving clinicians' understanding of the structure of theoretical conceptual practice models and knowing how to analyze and critique them to determine their usefulness in specific clinical contexts. This understanding will hopefully translate into increased utilization of theoretical conceptual practice models to guide every day practice.     

Exploring Arising Moments and Mindfulness in Occupational Therapists Working in Diverse Clinical Practice Areas

ABSTRACT

An online survey was conducted with 72 Canadian occupational therapists to (1) explore if and how occupational therapists were aware of “arising moments” in clinical practice, which are moments that give rise to emotions, sensations, and thoughts, and (2) to examine therapists’ responses to questions related to mindfulness. Participants described arising moments through an open-ended survey question. Framework analysis was used to develop key themes and subthemes. A modified Philadelphia Mindfulness Awareness (PHLMS) subscale with two additional survey questions “understanding of living in the moment and being present, and awareness of mindfulness” (sum = PAM) were used as indicators of mindfulness. There were significant differences in the means of PHLMS mindfulness among therapists working in diverse practice areas (F = 3.63, p = .009). Posthoc analysis revealed that therapists working in mental health had higher mean PHLMS-mindfulness scores than in all other groups. There were no significant differences in PAM mindfulness among the practice areas (ANOVA, F = 2.15, p = .08). However, posthoc tests showed that the participants in the mental health practice area had a significant difference with one group, general physical health. Findings have implications for practice in occupational therapy and education about mindfulness in occupational therapy.     

The structure of novice and expert occupational therapists' clinical reasoning before and after exposure to a domain-specific protocol

Background/aim:  The research aimed to determine the influence of a protocol designed for use in the domain of upper limb hypertonia due to brain injury on novice and expert occupational therapy clinical reasoning.
Method:  Individual, structured repertory grid interviews were completed with 13 novice and eight expert occupational therapists prior to, and following, exposure to a domain-specific clinical reasoning protocol. Data were subjected to quantitative analyses (Principal Components Analysis, Generalised Procrustes Analysis).
Results:  Novice participants demonstrated statistically significant change in the structure of their clinical reasoning following exposure to the protocol ( P  < 0.004). Prior to exposure, novices relied on therapy tasks, the problem-solving process, environmental factors and standard practice to structure their reasoning. Following exposure, novices' clinical reasoning changed to more closely reflect experts' reasoning. Thus, a 'structured approach' and (theoretical) practice perspectives became evident. Prior to exposure to the protocol, experts structured reasoning in terms of (personal and theoretical) practice perspectives, therapy tasks and the scope of such tasks (either 'general' or 'specific'). Following exposure, therapist/client collaboration and upper-limb-related constructs emerged as being used to structure experts' reasoning, although these changes were not statistically significant.
Conclusion:  A protocol designed for guiding clinical reasoning in the context of upper limb hypertonia was perceived to be conceptually useful by novice and expert occupational therapists.     

A Call to Wellness – Whitiwhitia i te ora: Exploring Māori and Occupational Therapy Perspectives on Health

The World Health Organization records that indigenous peoples throughout the world experience poor health. The concept of health was explored from a Māori world view and compared with occupational therapy perspectives. The aim was to understand and value indigenous knowledge and promote culturally safe responsive practice. Māori methodologies were employed to protect the Māori knowledge shared in the study. This involved applying seven principles, including respect for people, be cautious, and look, listen, and speak. Perspectives on health and wellbeing were collected in 2008–2009 from indigenous occupational therapists, other occupational therapists and indigenous health practitioners using interviews and a questionnaire. The findings are presented as a conceptual framework, depicting a whare, a Māori meeting house to show relationships between culture and health. Key concepts held by occupational therapists and Māori were spirituality, holistic views, client responsive practice, and environmental contexts. Areas of difference were the focus on occupations, the interdependence of indigenous relationships, and the place of the extended family in supporting wellness. A strength was the respect for Māori methodologies and limitations were the number of participants (N = 23) and the small proportion of Māori therapists in Aotearoa/New Zealand. Recommendations: Attention to culture is vital for appropriate, safe, and responsive practice. The conceptual framework provides a tool to inform, guide, and evaluate practice understandings. It acknowledges the importance of the individual within their extended family, their natural environment, and the historical, social, and political realities of living as Māori. Further research should explore the use of the framework and interaction between occupational therapy practice and specific indigenous cultures. Copyright © 2014 John Wiley & Sons, Ltd.     

Occupational therapy assessments used in acute physical care settings

Abstract

Objective: The aim of this study was to identify the assessments used by occupational therapists in acute care practice, their purpose, and the role of home visits and standardized tests. Methods: A cross-sectional survey containing closed and open questions was sent to therapists working in physical acute care settings using convenience sampling. This article reports on the responses of 70 New Zealand occupational therapists (response rate = 74%). Results: The study found that informal assessments (i.e. interviews and observations) were commonly used to evaluate daily living skills and to provide information about the home environment, cognition, transferring, leisure, and upper limb function. When situations were particularly complex, cognitive assessments and home visits were used judiciously to further investigate assumptions related to safety in discharge procedures. Standardized assessments were not widely used but were typically considered when cognitive ability needed to be confirmed. Conclusions: Occupational therapists' expertise lies in interviewing clients and in skilled observations of function. Standardized ADL assessments could complement occupational therapy practice but further research is needed to determine their value. In the final analysis, assessments should ensure that that both safety and client/carer concerns are at the centre of decision-making.     

Occupational therapists’ reflection on practice within psychiatric care: A Delphi study

Aim: The aim of this study was to describe the reflections on practice in a group of Swedish occupational therapists in psychiatric care in order to illuminate the present practice and ideas about the future using a Delphi survey of three rounds. Material and method: The sample consisted of 14 occupational therapists in psychiatric care. The answers from the first and second rounds illustrate the wide variation in their practice. The third round points out consensus and disagreements in the domains: professional role, theories in practice, domain of concern, occupational therapy assessment, goal setting/treatment, outcome/evaluation and thoughts about the future. A consensus was reached in all domains, but not regarding competence to treat functional reduction and symptoms, or on the importance of theories for documentation, the choice of a theoretical foundation, and the importance of an evidence-based treatment model, although the theories were seen as supporting practice. Disagreements were found as to the effectiveness of repeated assessments as a means of evaluation. The future for OTs within psychiatric care was looked upon as positive. Discussion: The results developed from providing a relatively unclear and shallow perspective on OT practice to indicating a depth that shows what occupational therapy within psychiatry can be. During the process it became more and more clear how OTs think and act.     

Client-centred practice in occupational therapy: Critical reflections

Abstract

Aims: The occupational therapy profession has long proclaimed its commitment to a client-centred philosophy of practice and the assumption that occupational therapists consistently practice in a client-centred manner has become central to the profession's self-image and public rhetoric. However, client-centred practice has been subjected to little critical reflection within the occupational therapy profession. The aim of this paper is to foster critical reflection concerning the authenticity and veracity of the profession's commitment to client-centred practices. Major findings: Client-centred practice is defined without evident reference to clients' perspectives. Few occupational therapy researchers have sought clients' perceptions of the client-centred nature of their occupational therapy services. Occupational therapy research is neither consistently undertaken in a collaborative manner, nor are the profession's theories developed through explicit reference to a diversity of clients' perspectives. Professional practices and service evaluations do not consistently seek clients' viewpoints. Client-centred rhetoric is politically expedient and may be a professionalizing strategy employed to increase status and entrench power. Practice conclusion: Although exemplary client-centred occupational therapy practices exist, evidence suggests that the profession does not adhere consistently to its espoused client-centred principle in all its practices. The client-centred practice of occupational therapy should be subjected to assiduous critical reflection.     

Client-centred occupational therapy: the importance of critical perspectives

Abstract

Background: The occupational therapy profession has proclaimed itself to be client-centred for over 30 years, but until recently this assertion remained largely unchallenged. Critical thinkers, who have begun to explore client-centred practice in occupational therapy, highlight the necessity for further critical reflection. Aims. This paper aims to define what constitutes “critical” thinking; and to persuade occupational therapists of the importance of employing critical perspectives towards the profession’s assumptions and assertions regarding occupational therapy’s “client-centred” practices. Major findings. Critical thinking is not solely a process of carefully and thoughtfully weighing various arguments or evidence, but of additionally appraising the ideological and structural contexts in which these positions or evidence have arisen. Critical perspectives towards occupational therapy’s client-centred practices identify the ways in which power is exercised by the profession, and culturally specific and disabling ideologies are perpetuated. Practice conclusion. Critical thinking enables occupational therapists to reflect on their own inequitable access to privilege and power, and reduces the potential for the profession to re-inscribe dominant ideologies that devalue disabled people and justify their inequitable opportunities. Because critical thinking demands a readiness to restructure one’s thinking, and decreases the risk of acting on faulty assumptions, it is an essential component of client-centred practice.     

Community occupational therapists' clinical reasoning: identifying tacit knowledge

Background: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community‐dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions. Aim: To synthesise current knowledge about community occupational therapists’ clinical reasoning. Method: A scoping study of the literature on community occupational therapists’ clinical reasoning was undertaken. Results: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists’ clinical reasoning, were reviewed. Community occupational therapists’ clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists’ clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear. Conclusion: Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.     

The self-reported use of research in clinical practice: A survey of occupational therapists in Sweden

Background: Today, healthcare providers and occupational therapists are increasingly required to rely on evidence-based practices. In both outpatient and inpatient settings, the use of research-based practices can be identified using the Research Utilization Measure questionnaire. Aim: This study explores how occupational therapists in Sweden perceive research utilization. Method: The Research Utilization Measure was sent to 807 randomly selected occupational therapists in Sweden, and the response rate was 59% (n = 472). Results: The majority of respondents (56%, n = 256) reported use of research-based knowledge in their practice “very or rather often”, although 49% (n = 225) of the therapists noted that they “very seldom or never” discussed research findings with their managers. Differences in answers for most items were related to degree of education and length of experience. Occupational therapists with higher education levels more often reported use of research in their clinical practice and therapists with greater experience less often reported use of research in their clinical practice. Conclusion: Education seems to influence the degree to which occupational therapists rely on research to inform their practices. A future challenge for managers and occupational therapists is to create strategic discussions on how to implement treatment that is based on current research.