Clinical Reasoning in Occupational Therapy

Linda Robertson, Linda Robertson

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118281543
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

Clinical Reasoning in Occupational Therapy is a key text for occupational therapy students and practitioners.

Written by an internationally renowned group of clinicians, educators and academics and with a central case study running throughout, the book covers the theory and practice of the following key topics: Working and Thinking in Different Contexts; Teaching as Reasoning; Ethical Reasoning; Diversity in Reasoning; Working and Thinking within 'Evidence Frameworks'; Experience as a Framework; The Client.

FEATURES

• includes case studies
• problem-solving framework
• questions at the end of each chapter
• commentaries on key topics
• relates theory to practice

1

Problem Solving in Occupational Therapy

Linda Robertson and Siân Griffiths

We don’t talk about problems now, we focus on strengths.

An experienced clinician

Introduction

Since the earliest days of occupational therapy, the focus of the therapeutic process has been to assist individuals with the ‘problems of living’ (Meyer, 1992, p. 4). So it should be no surprise that occupational therapists describe themselves as being problem solvers. What is surprising is the limited amount of research which has looked at problem solving processes used in the profession. Notable exceptions include researchers who have used the hypothetico-deductive reasoning literature in medicine as well as general human problem solving to underpin their work (Roberts, 1996a; Robertson, 1996; Rogers and Holm, 1991). To a lesser degree, others have drawn on this framework to inform their studies of clinical reasoning (Hagedorn, 1996; Mattingly and Fleming, 1994). The majority of researchers have looked at what the therapist is reasoning about in general terms, rather than how the therapist is reasoning in relation to a specific problem identification and solving process. Exceptions to this are recent studies which used repertory grids to elicit information about the occupational therapy process (Kuipers and Grice, 2009a) and multiple case vignettes to stimulate decisions about actions, which were compared to decisions agreed on by experienced therapists (Harries and Gilhooley, 2011; Rassafiani et al., 2008). The problem solving process is not unique to occupational therapists but what they incorporate into the process is.

Problem solving is a cognitive approach to reasoning that is encapsulated within the occupational therapy profession by the use of the ‘OT process’, which is evident in all major occupational therapy text books and considered to be an essential tool in the new graduate’s thinking repertoire. Despite an apparent adherence to using a problem solving process, there is reluctance amongst occupational therapists to describe problem identification as being central to their reasoning. Unlike the medical and nursing literature, within occupational therapy it has become fashionable to avoid identifying a ‘problem’ (as illustrated by the opening quote for this chapter). However, Rogers (1983) has repeatedly asked us to be clear about the occupational therapy diagnosis. There seem to be some valuable gains for our profession in thinking through the concept of problem solving a little more coherently. For example, this framework provides a structured way of thinking through reasoning processes, which can be useful not only in forward planning but also in analysing reasoning to identify errors or gaps. In teaching students, it can be a powerful way of clearly identifying steps in decision making processes and the influences on these. This chapter begins, then, the task of clarifying the relevance of problem solving for occupational therapists’ practice by discussing three strands that contribute to the argument that problem solving is an important way to conceptualise reasoning in occupational therapy practice.

Strand One: the theoretical underpinning of problem solving

Problem solving is based on an information processing theoretical approach. Other authors (Carr and Shotwell, 2008; Fleming, 1994b; Rogers and Holm, 1991) have described this approach in detail and the intention of this section is not to replicate their work but rather to focus on aspects that are specific to occupational therapy reasoning. Problem solving is described as a series of steps including referral, data collection, assessment, problem identification, planning, intervention and evaluation, which is mirrored by the OT process. Additionally, there are considered to be two stages (Robertson, 1996): identifying the problem (also called the occupational therapy diagnosis (Rogers and Holm, 1991)) and providing solutions (or ‘resolutions’ (Fleming, 1994b)). The first stage is regarded as being pivotal to problem solving processes because it provides the direction for ongoing planning and implementation of solutions. However, we argue that in occupational therapy the second stage is also a stage of intense reasoning because the plans that are made may need to be evaluated and revised partially or totally before a satisfactory way of working with the client(s) is found. In this second stage the client’s strengths, referred to in the title of this chapter, are important. This process can perhaps be better understood as a spiral rather than as a linear process, where problems are formulated and then reformulated based on a deeper understanding of the problem being addressed (Higgs and Jones, 2008b).

Stage 1 of problem solving: from referral to problem identification

In cognitive science, the brain is often compared to a computer that has an input device and ways of storing and retrieving information on demand. In reality, the human mind is more complex as information is stored in idiosyncratic ways in schemas which act as mental templates, helping us to organise knowledge and make sense out of our current experiences. Like a magnet, what we already know pulls us towards more information with which we can make a connection. Cues stimulate knowledge from long-term memory, which is then drawn into short-term memory to be considered for its match to the situation being confronted. This matching process triggers hypotheses, which are hunches about what problems might need to be addressed and are regarded as tentative explanations for observations that can be tested by further investigation. Essentially they are assumptions made on the grounds of reasonable evidence. They arise on the basis of relatively few cues (such as a referral) and depend on the cognitive ability of the therapist to relate a new situation to past experience (Kassirer et al., 2010).

The following example of the referral of a nine-year-old boy to a child mental health service illustrates the development of hypotheses. Scott is reported as ‘displaying behavioural and learning problems at both home and school’. The referral is brief but two key cues are evident: behavioural problems and learning problems. The therapist immediately considers several explanations for the behaviour (i.e. hypotheses). Her questions include, ‘Are the identified problems related to vision or hearing deficits?’, ‘Have they arisen because of a head injury?’ and ‘Are they a result of problems with relationships at home or at school?’ Influences on the therapist’s reasoning include experiences of working with children who have sensory and motor control difficulties, experiences of working with parents who are struggling to care for a child and her own personal experiences of being a mother. Thus information stored in her long-term memory provides the platform for what she now notices and wants to check out.

In this situation, an occupational therapy problem has not yet been identified. The therapist has focused on the performance components without reference to a particular occupation. This may be ‘implied’ from the therapist’s point of view, however; until the occupational therapy problem is identified, there is no apparent way to identify a relevant goal. One of the confusing factors in occupational therapy reasoning is that a focus on the performance components can distract the therapist from the problem that is specifically related to the occupational concerns. Ryan (2011) refers to this manner of working as ‘pre-occupational’ because it addresses the skills necessary to carry out an occupation. A key concern for occupational therapists is the clarity with which we identify problems that are our core practice; that is, the occupational diagnosis (Rogers, 2004).

While problem solving may appear to be a structured and theoretical approach to reasoning, responses to the data are not impartial – two therapists may see the same situation differently. The problem that the occupational therapist chooses to address arises from the perceived salience of the cues and this is influenced by characteristics specific to the individual therapist, such as past experience, knowledge, values and methods of processing information. In other words, what we have seen and experienced previously becomes integrated into our schemas and will direct our attention to cues that have personal relevance. Each client encounter gives rise to many cues, but as Taylor (1997) reminds us, their relevance and significance is at the discretion of the practitioner. The lens that we use for viewing a situation is never neutral. This lens influences what we ‘see’ in the first instance or ‘read’ in the case notes, and will also impact on ongoing data collection methods such as an interview with a client. As Hooper (2008) notes, therapists’ reasoning is based on personally held assumptions that can influence cue identification and interpretation. This raises the issue of accuracy in reasoning, which is addressed later.

Stage 2 of problem solving: from goal setting to implementation

While Stage 1 is directed to the main goal (e.g. legible writing) and sets the direction for the ongoing planning and intervention, Stage 2 addresses the means of getting to the goal (e.g. sensory integration techniques) and involves implementing plans. Matching client ability and interest to the demands of a task requires a great deal of technical skill (or ‘know how’). Knowing when plans are not working and then deciding how to modify them is essential. As noted in the introduction, occupational therapists are sometimes accused of jumping into the solution phase without being clear about the problem they are dealing with – perhaps this is because this second phase involves much more than applying a standard solution and occupational therapists recognise that reasoning must deal with multiple interrelated elements. Mattingly (1994a) concurs with this when she says that experienced therapists believed that ‘effective therapy depends as much on the capacity to modify plans and to rethink treatment goals as it does on the capacity to create plans and goals in the first place’ (p. 271). However, the effectiveness of the reasoning is dependent on the clarity with which the first stage is defined.

Complexities of the goals

In reality, some problems are more readily defined than others. In problem solving, Gagné (1985) describes three types of problem that have clear end points or goals. Two are described as relatively simple, having one or two routes to get to a defined goal. The choices for solutions may be equally effective or one may be slightly favoured over another. For example, when a referral states that a heavy, immobile client is very difficult to transfer from bed to chair, there might appear to be little doubt about a hoist being the suitable response, but there could be a dilemma about which hoist is most suitable. Such a decision may also be constrained by the funder, with the standard hoist invariably trialled and a more expensive option only considered if the standard one is deemed unsuitable. Essentially this type of problem solving requires little cognitive effort as the choice is limited.

However, even a problem that has a definite end point can be complex and the means of getting to the end point far from obvious. There may be a range of solutions and not necessarily one correct response. This tests our resourcefulness and Gagné (1985) says that the problem solver can think of options but with little assurance that what is tried will lead them closer to their goal. For instance, a therapist reports the following:

Case 1: Creative problem solving

A boy with spina bifida (who uses a wheelchair) is getting too heavy for his mum to lift him in and out of the corner bathtub in the bathroom. A level access shower cannot be installed because the sewer pipes on the property are too close to the surface. A bathlifter will not work as it wobbles when placed on the curved base of the bathtub, and there is not enough room for his legs to fit. The Ministry of Health has turned down my application to install a large box-type shower with a step (which I know he could manage with a shower bench). A completely new and novel solution was reached but it took several months to come up with the idea and even at the point of manufacture I had no idea whether it would work or not, but it did.

Thus planning can be very time consuming while the options are considered. Solutions offered are tempered by the therapist, who in this instance is quite clear about what would work if only the funding were available. The eventual solution was developed by considering all the facts (including cost) and is a good example of both persistence and creativity. The occupational therapist’s job is to ensure that the intervention works.

The idea that reasoning is ‘complex’ pervades the clinical reasoning literature. However, the complexity of the problem may be in ‘the eye of the beholder’, as suggested by Davis (2009, p. 213), where past experience or being new to the job may make the task seem easy or difficult. Additionally, approaches to solving a particular problem may differ between therapists. For instance, does the choice of the type of hoist depend on the therapist’s perception of what should be provided? Past experience may have influenced the therapist to decide that a basic ‘sling’ hoist is the only one likely to be approved in this situation. On the other hand, a novice who has little experience of this type of situation may ‘go for gold’ and decide on a more expensive hoist or panic at the sight of this large man being transferred by his willing family and recommend that he needs carers to provide a safe transfer.

Factors affecting the intervention

Once the goals have been decided, plans are developed and the task becomes deciding how to implement them. Both the physical and the social environment can impact on how the intervention transpires. Many factors need to be considered in treatment planning, which may result in modification of the task or the environment to ensure that end points are reached. So, for instance, bed heights may not allow for a manual hoist to be positioned accurately. While this is not the primary problem it is certainly a feature that has to be considered when recommending a hoist. Another example might be that the client says very little and allows his family to speak for him; this is not a problem to be overcome, rather a condition that is present. The therapist may have attempted to engage the client, but he may not have been willing to converse or a family member may have taken on the role of spokesperson with or without his approval. The methods of achieving the goals may need to be modified for various reasons such as the family’s preferences or the client’s willingness to be transferred with a piece of equipment.

The therapist will also take into account the social environment and explore the family’s view of the situation. This could result in a different way of managing the problem. For instance, instead of deciding on a hoist, the therapist might assist the family in making better use of manual lifting techniques to ensure that all involved are safe, or provide an extra carer to assist with transferring and so reduce the amount of physical strain for the family members. Perhaps the family is not happy to have the client living at home and would rather he was in a residential ho...