Exam Flashcards
(237 cards)
1
Q
Professional reason (Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019))
A
- can be defined as the process used by practitioners to plan, direct, perform, and reflect on the client care
- involves all the thinking processes of the clinician as she/he moves into, through and out of the therapeutic relationship
- a mode of tacit, highly creative and deeply phenomenological thinking
- aimed at determining focus of care for a given client or group of clients
2
Q
Body of Knowledge on professional reasoning for occupational therapy is still inadequate
(Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019))
A
to date, there has been no full, comprehensive review of the scientific literature that would allow us to determine and summarize existing scientific evidence in the area of professional reasoning in occupational therapy
–first article focuses on the clinical reasoning was published in 1982 and aimed to define this area of study within the field of occupational therapy
-Since 1982, there has been a gradual and steady increase in the number of research articles on professional reasoning, which may indicate a growing interest in this area of knowledge
3
Q
We have to be able to identify three major lines of study
Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019)
A
a) professional reasoning in specific fields of practice
b) Professional reasoning among undergraduates and
c) theoretical aspects of professional reasoning
4
Q
It appears the research on professional reasoning in OT is especially concern with the particularities of reasoning in specific fields
(Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019))
A
- to the detriment of the study of information processing that takes place in practice and that shapes professional reasoning in general
- there is a lack of studies focused on the distinctive and unique modalities of reasoning that occur among occupational therapists
- should also be noted that publications from English-speaking countries predominate, particularly the USA, Britain, Australia, and Canada
5
Q
With regards to the second research question, we have been able to describe how research on professional reasoning in OT has evolved
(Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019))
A
Our findings point to three historical periods with distinct characteristics:
a) exploratory phase (1982-1993)
(b) transition phase (1994-2003) and
(c) consolidation phase (2005-present)
6
Q
Exploratory phase (1982-1993)
Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019)
A
the scope of the research that would be developed in later literature is defined, described, and explored
7
Q
(b) transition phase (1994-2003)
Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019)
A
the number of studies increases considerably, the types of studies carried out diversify and there is a significant increase in empirical studies, which outweigh nonempirical studies during these years (qualitative) qualitative articles
Qualitative articles with a phenomenological approach were still predominant
8
Q
(c) consolidation phase (2005-present)
Professional Reasoning in OT: A scoping review (Marquez - Alvarez et al., 2019)
A
the research trend is clearly reversed, with a quantitative approach predominating and an increase in the number of literature reviews
9
Q
Clinical reasoning was coined in the 1980’s to explain clinical decisions are made
( Ch.1: Professional Reasoning as the Basis of Practice)
A
-basically a blend of technology know how combined with reflection during the process of practice
10
Q
Professional Reasoning (PR):
Ch.1: Professional Reasoning as the Basis of Practice
A
the processes used by practitioners to plan, direct, perform and reflect on client care
- term is most reflective of the reasoning associated with OT practice
- It is inclusive- It also includes non medical enviros (school, community)
- It is about framing, implementing, and assessing therapy services
- What is actually going on with the practitioners as they contemplate and engage in therapy actions
11
Q
The only reason they used clinical reasoning in the title of the book
( Ch.1: Professional Reasoning as the Basis of Practice)
A
is because its a very common search term so -basically clinical and professional reasoning is the same thing
-Pr theories are focused on the practitioner and how that person goes about doing or designing therapy
12
Q
Praxis
Ch.1: Professional Reasoning as the Basis of Practice
A
reasoned actions taken to accomplish a specific task
13
Q
Reflection in action vs Reflection on action
Ch.1: Professional Reasoning as the Basis of Practice
A
-Explain how professionals practice and develop expertise
14
Q
5 succeeding Stages of Expertise (pg 140)
Ch.1: Professional Reasoning as the Basis of Practice
A
- Novice
- Advanced beginner
- Competent
- Proficient
- Expert
15
Q
Dewey’s Linear model of reasoning
Ch.1: Professional Reasoning as the Basis of Practice
A
- Reflecting on ideas
- Formulating hypotheses
- Evaluating hypothesis for truths
- Determining a course of action
- Formulating a verbal statement to represent the hypothesis
16
Q
Clinical reasoning and core dimensions
Ch.1: Professional Reasoning as the Basis of Practice
A
context dependent way of thinking and decision making in professional practice to guide practice actions
Core Dimensions: Strong Knowledge base Reflective inquiry -Metacognition
17
Q
Unsworth’s hierarchical Model of Clinical reasoning
Ch.1: Professional Reasoning as the Basis of Practice
A
-a 3 tier: hierarchy to depict the relationship between different types of clinical reasoning found in research
Tier 1: therapists is in a life environment and has a worldview - this influences all the models of reasoning
Tier 2: Contains the 3 models of reasoning: procedural, interactive,conditional
Tier 3: pragmatic reasoning
-This model is client centred and the therapist considers the client condition and experience
18
Q
Schell’s Ecological Model of Professional Reasoning (pg 16)
Ch.1: Professional Reasoning as the Basis of Practice
A
- Describes PR as a process directly to therapy action which is shaped by factors intrinsic to the therapist and client, as well as extrinsic factors in the practice context
- Echoes the EHP model
- Believes that each practitioner brings a situation knowledge, and skills from life experiences, values, beliefs, etc. - which forms a personal self - a lens the therapist frames the therapy encounter
- On top of the professional self is a layer called the professional self which includes knowledge, skills routines etc.. These two selves work together to respond to issues
- The client also has a personal lens which is topped with a client lens
- Together the client and therapist work altogether to shape the therapy process
19
Q
EMPR (an ecological Model of Professional Reasoning)
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
evolved as a way of understanding professional reasoning as a transaction among the therapist context. EMPR emerged from a series of lit reviews
20
Q
Therapy is a function of interplay among
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
the therapist, client and practice context -taking a what we do WITH clients not what we DO to clients
21
Q
Main assumption:
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
PR is an ecological process that involves multiple therapist, client and context factors
22
Q
The Therapist (pg 30)
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
reasoning is shaped by their professional (what it mean to be an OT) and personal (mind/body characteristics) lens
23
Q
The client
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
they also have a personal lens (mind/body) anda client lens (what it means to be an OT client)
24
Q
Practice Context (pg 34)
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
A
Where the therapist and client engage in therapy activities includes materials available) ex. time, physical resources, social enviro, caseload, payment, discharge options
25
Therapy Process
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
Describes therapy actions (what occurs in the evaluation, intervention, discontinuation and follow up phases) that characterize what occurs i the OT process.
26
Therapy Outcomes
Ch.2: An Ecological Model of Professional Reasoning (EMPR)
Statement or expressions of desired actual outcomes that are a result of the therapist - client transaction in the practice (Goals, QOL, OPP)
27
Definition of information processing:
Chapter 4: information processing theory and professional reasoning p.73-103
refers to organization of our memories and the processes used to learn and to use information in those memories
28
Memories
Chapter 4: information processing theory and professional reasoning p.73-103
are organized into stimulations or scripts a professional use these to decide "what works" and "what doesn't work"
29
Information processing involves:
Chapter 4: information processing theory and professional reasoning p.73-103
two systems working memory and long-term memory which work together to allow us to learn, comprehend and respond to our experiences
- Basically working memory processes information whereas long term memory stores information
- In professional reasoning information in long-term memory is skewed by information and working memory
30
Working memory aka short term memory
Chapter 4: information processing theory and professional reasoning p.73-103
mediates our perceptions of the world with our memory but does not store information this allows us to make sense of the incoming information and reflect on what we experience
31
Long-term memory:
Chapter 4: information processing theory and professional reasoning p.73-103
is the storage system for both declarative knowledge and procedural knowledge. Declarative knowledge is what we know and procedural knowledge is the ability to do something
32
Theories how information is organized in long-term memory:
Perceptual symbol systems (PSS) theory (p82)
Chapter 4: information processing theory and professional reasoning p.73-103
is grounded system theory that assumes cognition to be grounded ins sensory experiences
33
Theories how information is organized in long-term memory:
● The ACT model p.83
Chapter 4: information processing theory and professional reasoning p.73-103
long term memory is comprised of two seperate semantic systems of declarative and procedural knowledge. The theory assumes that we store information using a model (non sensory based) semantic representations that have been stripped of sensory representation. Procedural knowledge and declarative knowledge work together in working memory to allow us to understand and respond to our experiences. As our declarative and procedural knowledge become refined with experiences, we rely increasingly on retrieving well learned knowledge and skills form long -term memory. A novice practitioner will have substantial demands placed on their working memory because knowledge in long term is not optimally organized and can't be fluently accessed and used by working memory
34
Differences in novice and expert cognition
Knowledge organization
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: Poorly integrated. Simulations are simple and less organized
Expert: highly integrated. Simulations are complex and well organized
35
Differences in novice and expert cognition
Strategy use:
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: Working backward from the problem presented with no specific plan for problem solving
Expert: Working forward based on a plan for solving the problem from start to finish
36
Differences in novice and expert cognition
Ability to see patterns
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: does not see patterns in information because the patterns do not exist in long term memory
Expert: Can quickly recognize patterns and information because the patterns match patterns stored in long -term memory
37
Differences in novice and expert cognition
Automaticity
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: low automaticity with the novice having to think through each step and each step being separate from the other
Expert: High automaticity with the expert. quickly and efficiently because the steps have been combined into larger steps
38
Differences in novice and expert cognition
Ability to use cues
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: Poor in determining cues and their importance
Expert: Knows what cues to look for and why they are important
39
Differences in novice and expert cognition
Ability to learn new information:
Chapter 4: information processing theory and professional reasoning p.73-103
Novice: Slower at learning new information related to the topic because the novice lacks the integrated knowledge in which to insert the new information
Expert: Fast learning of topic related information because highly integrated knowledge base exists. the expert plugs into appropriate spots
40
Scientific reasoning
Chapter 6: Aspects of professional reasoning
- Used to understand the condition that is affecting an individual and to decide on interventions that are in the clients best interest
- Parallel scientific inquiry
- Diagnostic reasoning -clinical problem sensing and problem definition (e.g. considering referral info)
- Procedural reasoning - thinking about the disease or disability and deciding which intervention activities (procedures) the might employ to remediate the person's functional performance problems (e.g interview or observation of personal engaged in tasks or standardized measures
- Two body practice: body as a machine (procedural) and the person as a life
41
Narrative reasoning
Chapter 6: Aspects of professional reasoning
- Practitioners find a way to understand the meaning of this experience from the clients perspective
- Help their clients invent new life stories with theirs are so disrupted
42
Pragmatic reasoning
Chapter 6: Aspects of professional reasoning
- OTts both actively consider and are influenced by their practice contexts (e.g resources for interventions, organizational culture, power relationships among team members, reimbursement practices, and practice trends in the profession
- The OTs personal situation also plays a part (clinical competencies, preferences, commitment to the profession and the role demands outside of work)
43
Interactive reasoning
Chapter 6: Aspects of professional reasoning
- Gaining trust of clients and using a number of interpersonal strategies that are designed to facilitate collaboration and client centred care
- Doing with as opposed to doing it
44
Professional reasoning as a conditional process
Chapter 6: Aspects of professional reasoning
Conditional reasoning -therapists attempted to understand their client holistically and imagined their
past, current life experiences and the possible future of the person in the fullness of their life world
-A deep appreciation of both the trajectories of various health or disabling conditions as well as the impact of both personal and contextual variables in the person's life world
45
Reasoning and reflection
Chapter 6: Aspects of professional reasoning
- Reflective practitioner: How experts think critically about their own experience
- Reflect in action-think in the midst of action and adapt to meet the demands of the situation, modify the therapy in order to get the just right fit
- Reflect on action- critical thinking that occurs after the practice has occurred
46
Self-assessment
Chapter 6: Aspects of professional reasoning
- Seek a variety of courses including peers and local experts to support and OTs accurate self-assessment and reflection process
- Evidence based practice model emphasizes the use of outcome data, clinical guidelines, chart review, and other "objective" sources of knowledge
47
Reasoning And Practice improvement
Chapter 6: Aspects of professional reasoning
- Evidence informed professional thinking (EIPT) -use of knowledge gained through both critical reflection and systematic appraisal of experience and of peer reviewed literature, leading to alternative causal models for clinical problems and interventions
- EIPT therapist consistently collect and measure outcomes. The reason about desired outcomes., identify and observe short term response and outcomes, and reason about long term real world outcomes
- Professional competence is developmental, context dependent and provisional on the therapists habits of mind and habits of performance
48
Habits of mind
Chapter 6: Aspects of professional reasoning
recurrently and accurately observing and assessing their own thinking, emotional and thinking processes (consistent with self-reflection process)
49
Intellectual humility
Chapter 6: Aspects of professional reasoning
the willingness to consider that one's beliefs or assumptions might be wrong
50
Expertise in OT (good table 140-141)
Chapter 6: Aspects of professional reasoning
- Development is dynamic and influenced by many factors beyond just the years of experience
- Experts do not outperform novices when confronted with unstructured or "messy" problems
51
Scientific Inquiry
Ch.7 Scientific Reasoning and Evidence in Practice
uses the scientific method to systematically pursue the discovery of knowledge about phenomena that is dependable and defensible and most desired, generalizable
52
Scientific reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
a process of uncovering, appraising, interrogating, interpreting and using knowledge to make decisions in professional practice
53
Deductive reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
- impact certainty to the conclusion
- skilled detectives or therapists have strong talents in: seeing what others don't see, how to tease out more evidence through observing or interviewing, connecting clues, drawing correct inferences from patterns, drawings inferences form limited clues, thinking, counterfactually, systematic exhaustive exploration of alternative explanation, pursuing logical conclusions regardless of cost, and maintaining the courage to question
54
Inductive Reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
- Holds the potential for generating new knowledge
| - Given the empirical evidence available what can we reasonably infer about a pattern or predict about a future event?
55
Probabilistic and Statistical reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
These mathematical approaches to uncertainty do not provide solutions of certainty but rather they allow us to quantify the level of our uncertainty about an indicative conclusion
-Statistical reasoning also allows us to draw inferences about certain characteristics of a population based on the limited information contained in a sample
56
Scientific Challenges: Linear to complex
Ch.7 Scientific Reasoning and Evidence in Practice
- Mid 20th century rise of importance of quantitative scientific research in OT
- The use of research findings for the actual practice of the profession has been accelerated by the movement towards evidence based practice (mid 1990's)
57
Scope of scientific reasoning
what are the embedded occupations of reasoning scientifically in the field of OT?
Ch.7 Scientific Reasoning and Evidence in Practice
1) In the creation and testing of disciplinary knowledge through scientific inquiry (conducting research for evidence supported practice: demonstrating the general efficacy of OT)
2) In the use of principles of logic and scientific reasoning about cases in actual practice
3) In the application of the finding of 1) to the actions in 2) evidence informed practice
58
Evidence informed practice
Ch.7 Scientific Reasoning and Evidence in Practice
- The use of published evidence along with clinical experience the practitioner and expertise of others, the values, goals, preferences and wishes of the client; the available resources of the practice setting
- With these four above therapists blend two more sources of info for decision making: theories as to causality of human occupation and the evaluation data and data from client responses to interventions collected by OT
- Ask clinical questions, trackdown best evidence from the literature. Appraise the evidence, use evidence to formulate practice guidelines, evaluate the impact of new guideline
59
Application of scientific reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
referral, therapeutic relations, FOR, occupational profile, analysis of occupational performance, intervention plan, intervention plan implementation, effective activity sequence, effective pacing, adjusting the plan/responding to feedback, extending therapeutic effects, intervention review, outcomes
--->detailed examples in text of scientific reasoning in these areas
60
errors in Scientific Reasoning
Ch.7 Scientific Reasoning and Evidence in Practice
Lists of errors in scientific reasoning come from three sources: studies of medical diagnosticians (cause of performance deficits could be misidentified) general studies of reasoning errors people make, and empirical study of practice reported by OTs
61
Narrative thinking
Chapter 8, Narrative Reasoning
Subjective, personalised particulars of lived experience, intention and action connecting events across time
- ->Not to be generalized beyond the narrator
- we live a narrative made up of our occupational choices
62
Narrative reasoning
Chapter 8, Narrative Reasoning
mode of thought essential to identity
- Use of narrative reasoning to venture out of one's own perspective and into that of the client, look at the story from their POV they are the main character
- ->Empathize
- ->Helps us to stay client centred
- Go beyond the intellectual reasons and OPIs allow the client to be a real person and remain client centred
- ->be willing to let go of your plan
63
Narrative = story in OT litterature
Chapter 8, Narrative Reasoning
- Occupations reflect personal uniqueness and identity, we identify by what we do and how we narrate our world
- This is dynamic interpretation of identity
- ->includes: experiences, intentions, psychology, group membership, personal history, emotional responses, personality traits, role etc
positive life stories promote self-esteem lesser ones do the opposite
- aspects of personality affect how people tell their stories
- Life stories become our perception of reality
64
Health challenges threaten life story and identity
Chapter 8, Narrative Reasoning
Narrative wrek
- Can reform sel-image by telling new stories, reframing thinking
- Hearing people's stories and how they tell them gives the OT perspective into their identity and what is important to them
- Stories socialize and impart culture, define norms, an how to cope with deviations
- People tend not to include the ordinary in narratives, as OTs we must ask questions to get this
65
The illness Narrative
Chapter 8, Narrative Reasoning
tells the story of life altered by illness
| -What is it like to live with a disease or condition
66
The occupational narrative
Chapter 8, Narrative Reasoning
- Shows the relationship between health and participation
- ->illness, disability, or restriction when present or at risk
- Places occupational performance into context
- Expresses meaning behind occupations and relationships
67
Narrative reasoning
Chapter 8, Narrative Reasoning
Inductive cognitive strategy of telling and interpreting occupational narratives to inform client-centred practice
-Created a collaborative story we can enact in treatment
68
Storytelling:
Chapter 8, Narrative Reasoning
makes meaning by telling and listening to stories bridging the occupational past from the actual world of illness disability or OPPs to the present possibility of occupational wholeness and healing
-->repairs narrative wreck
- We set up therapeutic climate within which the client uses their performance skills, patterns, and client factors to identify embedded stories
- Respect the confidentiality of your client stories
69
Recognize stories by looking for common elements
Chapter 8, Narrative Reasoning
- Acor
- action
- Scene
- Goals
- Instruments
- Trouble
- ->can be acute (heart attack) or chronic (MS)
- ->problems with occupational performance
70
Bread and water can be tea and toast
Chapter 8, Narrative Reasoning
- Elicit stories from clients to get more meaningful informations
- Ask for stories directly using open-ended questions
- Ask about past challenges and the response to them
- Allow stories to emerge during standardized assessments
- ->COPM
71
Listening to Narratives:
Listen for plot details
Chapter 8, Narrative Reasoning
- these details can help or hinder progress
- Directs intervention
Progressive plots
-life doesnt stop with disability I choose life
Stable plots
-life comes to a halt
Regressive plots
-Life is deteriorating
72
Listening to Narratives:
Listen for who has agency and locus of control
Chapter 8, Narrative Reasoning
- Vistimic
| - Agentic
73
Listening to Narratives:
Relating the body to others, control, and desire
Chapter 8, Narrative Reasoning
Restitution narratives
- Illness as transitory
- Often acutely or recently ill
- Cure seeking
- Hope
Chaos
- Nothing will get better
- No one is in cont4rol
- No future
- No hope
- Like "living in hell"
Quest narrative
- Like the hero's journey
- face the suffering head on
- OPPs beyond the chief compliant
74
Listening to Narratives:
Listening for the truth
Chapter 8, Narrative Reasoning
- People live atypical lives
| - ask questions but don't assume they are lying
75
Story distoritions
Chapter 8, Narrative Reasoning
- Feeling can be projected onto the therapists
| - Transference and countertransference
76
Story therapists tell each other
Chapter 8, Narrative Reasoning
- Cultural norms and values
| - Think or major lectures
77
Story making
Chapter 8, Narrative Reasoning
Prospective narrative reasoning that links the present to the future by imagining the effect of illness, disability or occupational performance problems in future contexts
- ->ie. making goals by projecting the needs of a preschooler into what they will need as a kindergartener
- ensure client and therapist are in the same story
- Stories are not told but acted through the intervention process, structured around meaningful daily tasks
- Make interventions fill gaps between where they are and where they want to be
- ->what is most important
- Acting out plot show that it will not be linear process, guide, communicate progress
- Stay motivated when goals need to be changed, advocate fro resources
- Let the temporality alert us to new issues
- ->what will be hard with changing seasons
78
Narrative reasoning is an expert process,
Chapter 8, Narrative Reasoning
as a student knowing there are many perspectives will help us get there
-Use narrative reasoning to edit life and past stories
79
Pragmatic Reasoning
| Chapter 9 Schell and Schell Pragmatic Reasoning
describes the practitioner thinkings that focuses on the everyday realities that affect the delivery of service; therapy happens in the real world
- attend to the contextual factors
- See things as they really are and find ways to deal with them
80
Focusses on the practice context and personal context
Chapter 9 Schell and Schell Pragmatic Reasoning
- address the world in which therapy occurs
- the possibility of treatment within a certain setting
- Important not to get stuck in one way thinking, following one part of policy, or one way of accessing funding, this severely limits therapy
- Be willing to improvise
- You are somewhat limited by your own repertoire of therapy skills. negotiation skills, practice culture, and motivation
81
Therapist intentions are influenced by four factors
Chapter 9 Schell and Schell Pragmatic Reasoning
1. Attitude
- ->I always get good results with this approach
2. Subjective norm
- ->We are expected to do this with all our patients
3. Perceived behavioural control
- ->I am really not sure I can do this correctly
4. Personal norms
- ->Core beliefs and world views
82
Pragmatic reasoning and external context table
Organizational norms and policies
Chapter 9 Schell and Schell Pragmatic Reasoning
- Teamwork
- Perceived organizational expectations
- Power relations
83
Pragmatic reasoning and external context table
Time
Chapter 9 Schell and Schell Pragmatic Reasoning
- Scheduling
| - Treatment duration
84
Pragmatic reasoning and external context table
Physical Resources
Chapter 9 Schell and Schell Pragmatic Reasoning
- Space
| - Supplies and Equipment
85
Pragmatic reasoning and external context table
Caseload
Chapter 9 Schell and Schell Pragmatic Reasoning
- Number of clients
- Kinds of clients
- Prioritization
86
Pragmatic reasoning and external context table
Payment of Services
Chapter 9 Schell and Schell Pragmatic Reasoning
- Insurance or government coverage
| - Client ability to pay
87
Pragmatic reasoning and external context table
Discharge Options
Chapter 9 Schell and Schell Pragmatic Reasoning
- Place
| - Timing
88
Personal Context Factors Requiring Pragmatic Reasoning
Chapter 9 Schell and Schell Pragmatic Reasoning
- Therapist skills
- ->Competence
- ->Experience and confidence
- Personal Characteristics
- ->Bodily Factors (Short people may pick a different transfer method)
- ->sensory preferences
- ->Emotional stability
89
Why do therapy and skills that we are comfortable with
Chapter 9 Schell and Schell Pragmatic Reasoning
When you are a hammer everything looks like a nail
90
Ethics
Ch 10: Ethical Reasoning
in our roles as practitioners, educators, and researchers, we confront an increasing number of ethical challenges in our daily work lives
-Clients and families place their trust in therapists to act in their best interests. This is a moral and ethical imperative as important as specific practice process. Ethical reasoning without action is confined to thinking about intellectualization. True moral character leads to practitioner to go beyond thinking, to take action, and learn from action
91
Philosophical Ethical Theories
Ch 10: Ethical Reasoning
- Focus on Consequences (Utilitarianism): the end justifies the means
- Focus on action (Deontology): the act itself, or the means, is what is important, not the consequence
92
Basic Ethical Principles
Ch 10: Ethical Reasoning
-Shared moral norms that provide a framework for analyzing ethical issues and reflecting on the common morality
93
Basic Ethical Principles:
Beneficence
Ch 10: Ethical Reasoning
actions that benefit others; actively "doing good" and considering potential for harm
94
Basic Ethical Principles:
Nonmaleficence
Ch 10: Ethical Reasoning
Refrain from causing harm; assess risk of benefit and avoid actions that may be harmful
95
Basic Ethical Principles:
Autonomy/Self-determination:
Ch 10: Ethical Reasoning
duty to treat client in according to the client's wishes and values within the bounds of accepted standards related to practice. Distributive, procedural, and compensatory justice and subsets of these principles
96
Basic Ethical Principles:
Veracity
Ch 10: Ethical Reasoning
Accurate and objective communication (written and oral) of information and it's comprehension; applicable not just to patients but also to colleagues, students, researchers and research participants
97
Basic Ethical Principles:
Fidelity
Ch 10: Ethical Reasoning
Duty to keep commitments/promises to patients when they are vulnerable and complying with the code(e.g. competence to provide services); duty to disclose information that is meaningful to make decisions; also includes maintaining respectful collegial, and organizational relationships, adherence to standards of continuing competence and policies/procedures of the profession or organization in which care is delivered
98
Moral Developmental Theories
Ch 10: Ethical Reasoning
The principle claims about moral judgement embodies in the cognitive developmental theories are the moral judgement is developmental, primarily controlled by cognitive processes, and hasa role in decision making in real-life situations
99
Moral Developmental Theories:
Kohlberg's stages Theory
Ch 10: Ethical Reasoning
people use 6 problem solving strategies in developmental sequence, moving from simple to complex in a logical manner
100
Moral Developmental Theories:
Four component Model of Moral Behaviour
Ch 10: Ethical Reasoning
Component 1: Moral sensitivity
- making an interpretation of a particular situation in terms of ethical problem, what actions might be taken, and the effects of these actions
Component 2: Moral judgement
- making a judgement about what course of action is morally right
Component 3: Moral motivation
-Giving priority to moral values; having the motivation to do what is morally right
Component 4: Moral Character
-Having the perservernance, ego strength, and skills to do what is morally right
101
Moral Developmental Theories:
Feminist View of Moral Reasoning:
Ch 10: Ethical Reasoning
women might change the rules to preserve relationships, whereas men tend to abide by the rules over relationships
102
ethical Tensions in OT practice
Ch 10: Ethical Reasoning
- Resources and systematic issues
- Upholding ethical principles and values
- Client safety
- Working with vulnerable clients
- Interpersonal conflicts
- Upholding professional standards
- Practice management
- An article found that ethical behaviour was influenced by organizational factors, therapist-related factors, client's family issues, and social factors
- We should strengthen the role of the OTs as moral agents
103
Six-step process of ethical decision making
Ch 10: Ethical Reasoning
1. Get the story straight - gather relevant information
2. Identify the type of ethical problem
3. Use ethics theories or approaches to analyse the problem
4. Explore the practical alternatives
5. Complete the action
6. Evaluate the process outcome
104
Ethical Reasoning in Practice
Ch 10: Ethical Reasoning
- Ethics deals with making morally good choices while the law deals with the regulation and enforcement of justice, right and wrong
- They can overlap
- ->eg. there is both a legal and ethical mandate to avoid treating patients who do not require it. From a legal perspective, documenting and billing for services that do not meet medicare regulations can be considered fraud.From an ethical perspective, this practice contradicts our ethical and professional standards
105
Flemming (1991) said OTs attend to the patient at three levels
Ch. 11 - Interactive Reasoning
- The physical ailment
- The patient as a person
- The person as a social being in the context of family, environment and culture
OTs uses these tracks and switch between them rapidly
106
Interactive reasoning has two important aspects
Ch. 11 - Interactive Reasoning
understanding clients as people who experience illness and disability (rather than impaired bodies) and developing partnerships (therapeutic relationships) with them. These two aspects are intertwined and mutually influencing, in that an understanding of the person develops through the process of relationship building and a deeper mutual understanding tighten relationship bonds
107
Central to therapeutic relationships is the therapeutic use of self.
Ch. 11 - Interactive Reasoning
The concept of emotional intelligence (EI) is useful for exploring the notion of using oneself therapeutically.
Therapeutic use of self is an acknowledgment of the influential place of the OT in the therapeutic endeavor
108
Managing Self-relationships
Emotional Intelligence
Ch. 11 - Interactive Reasoning
Self-awareness
-the ability to recognize and understand your moods, emotions, and drives, as well as their effect o others. Hallmarks: Self-confidence, realistic self-assessment, and self deprecating sense of humor
Self-regulation
- the ability to control or redirect disruptive impulses and moods, the propensity to suspend judgement, to think before acting. Hallmarks: trustworthiness and integrity, comfort with ambiguity, and openness to change
Motivation
-A passion to work that goes beyond money and status, a propensity to pursue goals with energy and persistence
Empathy:
-The ability to understand the emotional makeup of other people, the skill for treating people according to their emotional reactions
Social Skills
Proficiency in managing relationships and building networks,an ability to find common ground and build rapport
109
Considerations for Tailoring Interaction to individuals and groups
Ch. 11 - Interactive Reasoning
Positioning
- Facial expression and gestures
- Voices
- Conversing about other topics
- Seeking point of commonality
- Use of humor
- Meaningful moments of connection
110
Developing and maintaining therapeutic relationships
Ch. 11 - Interactive Reasoning
involves a trusting connection and rapport established between the therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect"
- Tickle-Degnan (2002) identified three periods: building rapport, developing working alliances and maintaining relationships
- Working alliance is formed as individuals collaborate with one another to develop common goals and as they develop a sense of shared responsibility for working on tasks that are involved in achieving these goals
111
The importance and use of Interactive Reasoning in Practice
Ch. 11 - Interactive Reasoning
- Understanding clients as people within specific life contexts
- ->skills interactive reasoning is critical for gathering comprehensive info
- Engaging the client and significant people
- ->Supporting client's self-determination so they can wholly commit to therapy from an affective, behavioural and cognitive perspective
- Creating a shared vision of hope
- ->ongoing as things are constantly changing
112
Reflective practice
Kinsella, A. (2001). Reflections on reflective practice.Canadian Journal of Occupational Therapy 68, 19
a dialogue of thinking and doing through which I become more skillful, develop greater sense of self-awareness and impact my performance -it is an opportunity to learn
113
6 considerations for OTs to think and begin to develop reflective practice
Kinsella, A. (2001). Reflections on reflective practice.Canadian Journal of Occupational Therapy 68, 19
1. learning from our experience: our experiences are resources for genuine learning for future practice
2. Ways of knowing: we come to know through experiences, practical knowledge, social, political, economic and self knowledge
3) Contexts of practice: we must recognize and reflect on contextual factors and how it relates to our practice and our clients life
4) Exploring Assumptions: we must understand and reflect on our own assumptions so that we do not bring them into the workplace and they negatively impact a client as they can influence our behavior without us realizing it
5) Theories of Practices: self-reflecting on our personal theories allows us to identify where we contradict ourselves in what we believe vs. what we say/do
6) Praxis: we need to develop praxis - a balance of reflection and action so that we can grow as OTs
114
Ten actions of reflexive practitioner
Kinsella, A. (2001). Reflections on reflective practice.Canadian Journal of Occupational Therapy 68, 19
1. Practice experience
2. meaning of your practice experience
3. recognize other ways of knowing as important for good practice
4. Self-knowledge as well as traditional scientific knowledge
5. Clients context
6. Ideologies that inform the system you work in
7. Assumptions you bring
8. Articulate your espoused theory of practice
9. Frequently compare your espoused theory with your theory in use
10 develop praxis
115
The mcmaster lens is a way for OTs to bring Theory into practice
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
It consists of 9 lens for the OT to view the client through
| -Each lens is adjustable/moveable depending on the client:
116
1. Occupation
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus. OT Now, 16-19
what occupations does the client engage i/what are currently difficult for them to perform?
117
2. Spirituality
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus. OT Now, 16-19
What is the meaningful/importance/value of these occupations to the client/ Consider cultural context and groups the client belongs to (values, ethnicity, religious affiliations, employment etc. )
118
3. Development:
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
From a lifespan perspective what stage of development is the client? Consider age and cog status
119
4. PEO
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
What is the underlying PEO factors that influence the client's ability to perform these occupations? Consider how each occupation is performed in the clients enviro when they are explaining their OPIs
120
5. Theoretical Approach
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
What theories or models will you use to guide your approach
121
6. Assessment
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
What is the overall Ax plan?
122
7. Fine Tuning
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
Were the theories useful in explaining the OPIs? If yes develop and intervention plan ... if not consider another theory approach and conduct further assessments
123
8. Treatment
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
What is the overall intervention plan? Consider the OT role
124
9. Outcomes
Jung, B., Salvatori, P., Missiuna, C., Wilkins, S., Stewart, D., & Law, M. (2008). The McMaster Lens for occupational therapists: Bringing theory and practice into focus.OT Now, 16-19
How will you determine if the intervention/treatment is successful? will you measure change?
125
Professional reasoning requires
Therapists Assumptions as a Dimension of Professional Reasoning
Practitioners to assemble and reflect on multiple levels of knowledge and experience in order to guide client care
-The therapists personal legends: tier knowledge, experience, personality, values, beliefs and assumptions
126
What are assumptions
Therapists Assumptions as a Dimension of Professional Reasoning
-They continuously influence our actions and emotions in ways big and small
Anything we take for granted as the basis for argument or action in relation to professional reasoning assumptions can be thought of as an underground component of reasoning that helps to orchestrate above ground actions in practice
127
Basic assumptions
Therapists Assumptions as a Dimension of Professional Reasoning
define for us what to pay attention to, what things mean, how to react emotionally to what is going on and what actions to take in various kind of situations
128
Flower Model
Therapists Assumptions as a Dimension of Professional Reasoning
end of roots Sociocultural Context : family roles, education and experience, gender roles, culture
Worldview: (still root)
baseis for faith
life, dealth, natur e of humans
Intervention ( flower above ground)
-Treatment
treatment rationale
129
These assumptions taken together establish a personal lens or world view through which we filter perceive, understand and interact with events in the external world like OT practice
Therapists Assumptions as a Dimension of Professional Reasoning
- Therapists not only reason from their internal assumptions outward to actions but also take in new experiences of life dilemmas that often alter makeup of their deeply rooted assumptions
- Life dilemmas are often born from conflicts between inner assumptions and outer experiences
130
Two way process
Therapists Assumptions as a Dimension of Professional Reasoning
Assumptions influence how we see and what we do while at the same time we see and what we do affects our assumptions
131
Influence of therapists assumptions about the human on professional reasoning
Therapists Assumptions as a Dimension of Professional Reasoning
- Assumptions and explicit beliefs related to the question "what is the nature of humans " can shape how therapists interact with clients and approach clinical problems
- Therapists assumptions about essence within human nature and experience helped explain why did what they did with clients
- Therapists had optimistic views of human potential and described their practice as means for tapping their potential
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Assumptions about the Human Body
Therapists Assumptions as a Dimension of Professional Reasoning
- Occupational therapists because of their relationship with biomedicine view the body "as a machine" but because of their profession roots phenomenology also views the body "as a lived body"\-Assumptions about the body as a machine often lead therapists to identify dysfunction and design diagnosis specific interventions
- Assumption about the body as a lived experience sometimes lead to therapist to view engagement in daily life tasks as experiences whereby patient learn to reconstruct the self and rembody the world
133
Assumptions about what knowledge is core to OT practice
Therapists Assumptions as a Dimension of Professional Reasoning
-There is a medical/scientific view and an occupational view
-what therapists adopt as core knowledge influences professional reasoning and clinical actions
-Different models of practice may rest upon and demand different assumptions about core knowledge and the alignment to a therapist's personal knowledge
beliefs may make one model more attractive than others
134
Assumptions about how knowledge is obtained and generated
Therapists Assumptions as a Dimension of Professional Reasoning
- Researchers in education suggest that adults progress through stages of assumptions about knowledge and how it is acquired
- Engaging in challenging learning experiences can call into questions existing assumptions about knowledge and how it is acquired
- Students obtain knowledge b having to assemble it in response to particular situation and context of a larger knowledge community such as profession of OT
- Examples of different OT knowledge pg 61
- Expert professional reasoning makes demands o therapists to assemble knowledge about a client, a diagnosis, occupational needs, practice models, available and absent evidence, a practice setting and their own experience and viewpoints into a particular construction of what the intervention will be in this case
- The practice of more complex professional reasoning rests on and calls for the development of particular assumptions about knowledge
135
Influences of assumptions about the future on professional reasoning
Therapists Assumptions as a Dimension of Professional Reasoning
- OTs working with adults with CVA assumptions about the future of the client were expressed as expectations about what would occur in the near future as a result of rehab
- Assumed the clients immediate and short term future would entail Neuromotor change in the UE and return of function
- As a result of this assumption therapists selected treatment approaches they believe were associated with neuromotor recovery and often persisted with those approaches even after a client recovery seemed to plateau
- Assumption about the course of the clients near future served not only to guide therapeutic approaches but also as criteria by which therapists judged the success of their therapy
- In addition to assumptions about the clients future OT practice can be intimately tied to therapists assumptions about their own future or personal process of becoming
136
How do assumptions shape professional reasoning
Therapists Assumptions as a Dimension of Professional Reasoning
Through the reinforcement of culture, experience and language one's to "gel" ino habits of expectations
- In turn habits of expectation act to selectively determine the coope of our attention by filtering information and guiding perceptions toward what to notice, what to ignore, what is relevant and what is irrelevant
- Assumptions play an influential role in action by a) filtering and directing attention, b) guiding and constricting choices and c) interpreting the meaning of an act or experience
- Overtime these become habitual ways of seeing and thinking
- As perceptual filter assumptions form the screen through which therapists view and interpret therapeutic experiences
137
What if our assumptions limit how we practice?
Therapists Assumptions as a Dimension of Professional Reasoning
- The cognitive rational approach asks us to reflect on the content of our actions along with the process and premises within our action
- ->Content- thinking about what happened
- ->Process- thinking about how we were perceiving, thinking, judging, feeling and acting within what happened
- ->Premise- thinking about why we repeatedly perceive, think, feel or act as we did in what happened
- The more imaginative approach to reflection draws attention to the images that emerge in the mind's eye or the metaphors that come to time when we work with clients and think about our practice
138
Challenges faced by newly graduated OTs in the literature include:
Professional identity, mismatches between organizational expectations and OT values and beliefs, using research, evidence lack of practical experience, perceived lack of intervention skills, reduced role clarity, unmet support needs, and higher rates of job stress and being more susceptible to burnout
139
Various strategies have been propose to overcome these difficulties including
-advocating for supervision, support and education to facilitate clinical reasoning, professional identity and active approach to learning and reflective practice, preceptorship for graduate OTs and support from colleagues and peers
140
This study aimed to explore the experiences of new graduates at a major Australian metropolitan hospital occupational therapy department, the support provided to them and their perceptions of this support (12 months graduate programme)
Research Question
What were the graduates' experiences of their first year of practice
what support was provided to graduates and what were their perceptions of this?
141
In the first year of practice, topics included:
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
feeling overwhelmed and having mixed emotions, being responsible (and not being a student), feeling supported, finding that everything takes longer and starting to feel confident
- ->some reported feeling excited
- ->a lot felt supported by the OT department and their inter-professional teams
142
Interviews indicated that graduate received substantial formal and informal support and valued it highly. Participants discussed:
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
Valuing their general medicine caseload, being supported by their inter-professional teams and participating in interprofessional education sessions, receiving profession-specific guidance from their clinical senior, participating with their OT team leader in formal supervision tailored to their needs, being guided by questioning and reflection, contributing to peer support and experiencing a supportive culture (sharing experiences)
143
-This graduate programme used the three actions identified by Moors and Fitzgerald (2016)
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
as facilitating graduates' transition to practice
- supervision,
- support
- education
-Formal supervision provided a regular avenue for promoting clinical reasoning and professional skills
144
Through being responsible for their own caseload on a daily basis
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
The graduates developed their practice knowledge and skill and professional identities as OTs
145
In order to increase interest in and enjoyment of work and enhance a sense of competence,
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
supervision should be included authentic praise, positive messages, provision of optimal challenges and informational rewards
146
While novices use context-free and rule-based learning , advanced beginners start to make comparisons with previous experiences.
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
Therefore, progressing to the advanced beginner phase requires regular substantial experience in a particular context
147
Key points for OT:
Turpin et al (2020) (Week 3-5) Experiences of and support for the transition to practice of newly graduated occupational therapists undertaking a hospital graduate Program
- The transition to practice for new OT grads can be overwhelming
- Engagement in a professional community of practice is important for development of skill, competence, confidence and professional identity
- New grads value and benefit from tailored supervision, "talking through" and guided questioning with and from experienced OTs
- Remaining in the same caseload for longer enables new grad to develop the level of experience required to sue the reasoning strategies of advanced beginners
148
The context based teaching model for professional reasoning
Ch.21 Teaching for professional reasoning in higher education
-Continuous circle with no beginning, end or particular sequence
-Moves along various instructional locations on the circle as needed until higher levels of learning and increased independence are achieved
-Direct instruction that results in co constructed and interpreted knowledge
-Systematic reflection -->learner and teacher get a sense of how valuable this learning exploration might be
-
149
The context based teaching model for professional reasoning
Important themes to guide the model:
Ch.21 Teaching for professional reasoning in higher education
promotion of
a) higher order cognition and critical thinking
b) systematic reflection
c) constructivist instruction
d) learning transfer
e) authentic contexts and
f) cognitive apprenticeship teaching
150
Higher order cognition and critical thinking
Critical thinking definition
Ch.21 Teaching for professional reasoning in higher education
calling into question the assumption underlying our customary, habitable ways of thinking and acting and then being ready to think and act differently on the basis of critical questioning
151
-Learning critical thinking skills can be disconcerted for learner in two ways:
Ch.21 Teaching for professional reasoning in higher education
1) learning to question personal assumptions can lead to scary dissonant worldview that is in conflict with firmly held beliefs
2) learning there are no definite answers to ill-structured problems often encountered in clinical settings
-Trust between learner and teacher is so important
152
Systematic Reflection
-Model of professional thinking is comprised of stages:
Ch.21 Teaching for professional reasoning in higher education
a) what -->dissonance that results from a therapeutic interaction
b) so what-->critical analysis of event
(3 stages: critical analysis of event, seeking and reviewing knowledge and formulating new ideas and sharing them
c) now what --> decision about how to incorporate new thinking into practice
153
Dialectical constructivism instruction
Ch.21 Teaching for professional reasoning in higher education
an educational philosophy where teacher and learners act as co-learners and interpreters of knowledge
154
Learning transfer
Ch.21 Teaching for professional reasoning in higher education
Transfer is the degree to which behaviour will be repeated in a new situation
- Near transfer- repeated in a similar situation
- Far transfer- different context
- Very little evidence individuals routinely transfer even in similar settings
- Instructional opportunities called affordances help students make connections between and among skills and ideas across different social and physical contexts and settings
155
Real Context is critical to learning
Ch.21 Teaching for professional reasoning in higher education
- In real contexts teachers can create and then use authentic affordances to support possible learning transfer
- To the extent possible teachers should default to realistic settings for better learning, teaching and a higher probability of learning transfer
156
Cognitive Apprenticeship
Ch.21 Teaching for professional reasoning in higher education
```
master of a skill teaches to an apprentice
4 boxes:
content
Sequencing
Methods
Sociology
```
157
Shared experiences in authentic contexts
Ch.21 Teaching for professional reasoning in higher education
- Authentic and real contexts are critical to teaching adults and instruction in professional education
- Cognition is not just a psychological phenomenon but rather is stretched across mind, body, activity and setting
- It is the meaningfulness that a learner attaches to the content that makes possible multiple uses of information
158
What the teacher does to foster shared experiences
Ch.21 Teaching for professional reasoning in higher education
- Carl rogers three qualities of facilitators:
a) genuineness,
b) sense of caring,
c) empathetic understanding and ability to listen
Instructional sequence:
-What to teach, to whom and when
Basics first curriculum:
-basics taught first them build on it
```
Global before local:
-before starting class present big overview or big picture of context
```
Increasing capacities:
-introduction of central concept that the learning will encounter
Increasing diversity:
-use of a skill in a variety of conditions (students need to apply the right technique at the right time)
159
Co-construction of knowledge
Ch.21 Teaching for professional reasoning in higher education
- Dialectical constructivism→ best suited to cognitive apprenticeship approach, allows for setting levels of instructional content appropriate to higher order thinking and use of concordant teaching methods
- Individual learns within a community of practice to organize and construct knowledge while gaining competence and membership
- Learned content is interpreted in light of cultural beliefs, tools and artifacts of the community
160
What the teacher does to encourage co-construction
Ch.21 Teaching for professional reasoning in higher education
- Direct instruction is best given in the format of a two way discussion not a lecture
- Instructional content organized in four levels:
a) domain knowledge (basic facts),
b) heuristic strategies (tricks of the trade- experts),
c) control strategies (monitor progress and mastery)
d) learning strategies (metacognitive strategies to learn how to learn)
- Professional education focused on b, c and d
- Levels of content can be matched with cognitive apprenticeship teaching methods
- Instructional methods:
a) modelling
b) coaching
c) scaffolding and fading
d) articulation
e) reflection and exploration
161
Articulation of Knowledge
Ch.21 Teaching for professional reasoning in higher education
- When articulation is combined with reflection in authentic context, powerful learning and meaning making opportunities are generated
- Articulation of what interpreted knowledge should be shared in social settings
- Learners gradually become more in control of their knowledge and begin the movement from novice towards expert
- Reflection skills promote critical thinking and student construction of knowledge
- Articulation skills give students the ability to communicate knowledge with others (best if done using a variety of media)
- These methods give students the opportunity to express what they are learning as it relates to their own learning experience and to self-evaluate their process
162
What the teacher does to encourage articulation and set the stage for reflection
Ch.21 Teaching for professional reasoning in higher education
- Assist students to decide and format and audience for sharing their constructed knowledge
- -> e.g. time to process knowledge soon after they have it then re-experience the experience with similar clients so they get an opportunity to exercise their new learning and cement their thinking
163
Systematic reflection for meaning, reasoning and practice
Ch.21 Teaching for professional reasoning in higher education
- Reflection is the glue that holds critical thinking and use of quality evidence as key elements of professional reasoning
- To begging the facilitation of reflection once new information has been constructed, interpreted and articulated it needs to be critically unpacked and examined for meaning, quality of reasoning, and utility to professional practice
- Enables new learners to make connections with other information, validate the quality of their professional reasoning and to place a level of importance on new information as it might relate to practice
- Ask students to examine what, how and why
164
What the teacher does to facilitate systematic reflection
Ch.21 Teaching for professional reasoning in higher education
- Frequent and deep reflection
| - -> mini reflections in the moment activities, professional reasoning courses, weekly seminars
165
Fieldwork is an essential component of learning
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- fieldwork=practice-based learning
- Good for developing and refining professional reasoning
- Fieldwork gives the opportunity to embody knowledge:
166
Types and sources of knowledge in fieldwork
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
Propositional Knowledge
- Declarative knowledge
- ->Can be stated ie the knee is a hinge joint
- Facts are combined into theories
- Cognitive knowing
Non-propositional knowledge
- Procedural knowledge
- Practical experience
- Associated with skill i.e. how to make a splint
- Knowledge of the professional craft, personal knowledge, emotional intelligence
- ->Associated with ecological model on professional reasoning
- Non-cognitive knowing
167
Academy Learning
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Schooling
| - Courses
168
EBP Literature
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Research
- Clinical experience
- Patients
- Clients
- Caregivers
- Local practice context
169
Clinical reasoning demands more than knowing
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
Action can gather information, or be a decision
- Intervention that isn’t effective
- Must involve this in thinking
Action is visible, meaning behind it is not
Practice articulation of reasoning
Students are responsible for the actions they take
-Learn what it means to be an OT
Learning with others from other disciplines helps to identify your own
170
The centrality of context
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Clients live in unique situations
- Therapy exists in a specific context
- This shapes what is done, how, and by whom
- Shaped by culture and worldviews
- Professional enculturation is a goal of OT education
- Reflect on the culture, are things transferable, be aware
- Get info to help imagine a clients home
- Consider all life circumstances of the client
- Compare your fieldwork sites and their cultures and contexts
171
4 layers of context:
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- The professional relationship developed between the professional and the person ie. client
- the organization
- legislation the government policy
- Social structures and culture and development of a person professional relationship might attract conscious attention
Surrounding layers represent invisible forces shaping practice
172
Field work supervision models:
Apprentice/traditional model
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Preceptor as expert
- Student mirrors preceptor
- one-on -one supervision
- Working within an established role
- Preceptor models and facilitates learning
- ->Learning objectives
- ->Specific skills practice
- Focuses on clinical experience
- ->Mentoring and decision making practice are key
- -> Graded out over time
- Limits student initiative, problems solving, and independence
- ->Must be mitigated
173
Field work supervision models:
Collaborative Model
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Multiple students one preceptor
- Social constructivist learning, co-construction of knowledge
- Can be used in sites without established OT
- Open dialogue is key
- Encouraged to seek own learning
- Must be prepared in advance at site by clinical coordinator
- ->assigns diverse caseloads
- Students appraise one another
- Reduced modeling from preceptor
- Help students process experiences
- Students should be prepared and ask questions
- Can be 1 student several preceptors or one preceptor several students
- Used in role emerging placements
- Down sides
- ->Less individual feedback
- ->Less independence with caseload
174
Benefits to collaborative model
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
1. manage time/self-directed and independent
2. communication skills
3. Expand learning beyond client contact
4. Seek Resources
5. responsibility
6. EBP
7. developing and implementing innovative interventions
8. new ideas
9. self-confidence
10. prepares students for role emerging
175
Fieldwork Educator's perspective on Learning Professional Reasoning During Fieldwork
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Students need to be aware of an articulate reasoning both own and preceptors
- ->think out loud
- There isn't a ‘right’ answer
- Students mirror without knowing why
- Its okay for things to go wrong
- Don't be afraid to ask questions
- Document your practice in writing
- Commit reasoning to paper
- Sort out the ‘messiness’
176
The model of context specific professional reasoning (MCPR)
Chapter 22 Learning Professional Reasoning in Practice Through Fieldwork
- Helps to organize thinking
- Accounts for context
-foreground of the model are the person's in the encounter
perspectives that are both personal and shaped by his or her role
two other components:
process of reasoning through action (action, observation, and interpretation) which forms a feedback loop in which outcomes of reasoning through action can build knowledge for both professional and the community of practice.
- four nested layers of context conceptualized as surrounding and forming a background to an encounter
- provides a framework for systematically considering the influence of the layers of context.
177
Difference between managing and leading
Chapter 23 Professional Reasoning in Occupational therapy Management
- Maintaining stability vs. fostering change
- Managers maintain stability day-to-day, focus on rationality and control
- Leaders focus on developing new approaches to common issues
- Managers solve problems of all sorts
- ->Occupational therapists using clinical reasoning are like OT managers who use the same strategies to give evidence based management.
178
Management functions
Chapter 23 Professional Reasoning in Occupational therapy Management
Planning
- Deciding by setting performance objectives, expectations of performance and outcomes
- Short term or operational planning
- Strategic planning involves envisioning the future
- Includes financial
Organizing
- Designing workable units or teams
- Determine authority and communication
- Assign people with the right skills to the right teams
Staffing
- Right person is completing the right task
- Recruiting
- ->hiring , salary, benefits
- Orienting new employees
- Provide training and assess competency
- Progressive discipline
- Separation
- Termination
Controlling
- Establish performance standards, evaluate and correct performance
- 3 phases
- ->Establish standards
- ->Measure performance
- ->Correct deviations
- Can focus on a process or outcomes
Directing
- Provide guidance and leadership
- Keep work goal oriented
- Motivate staff to understand common goal/ organization mission
179
Professional reasoning and decision making
Chapter 23 Professional Reasoning in Occupational therapy Management
- some decisions are simple others are more complex
- ->worst kind of decision is to delay a difficult decision until later or pass it to someone else
- make quick decisions that benefit employees and organization
- use same types of reasoning as clinical to solve these problems
180
There is a table that I think is pretty important has examples of the different reasonings and examples of applications to common managerial problems
pg 466
Chapter 23 Professional Reasoning in Occupational therapy Management
example interactive:
| managing difficult interpersonal relationships between staff members or between staff member and customers
181
Daily Dilemmas in the life of a manager
Chapter 23 Professional Reasoning in Occupational therapy Management
- Right thing to do or path is not always clear
- Resources are limited
- Many stakeholders with differing needs
- Balance prioritizing productivity, ethics, quality care etc
- Personnel with a large variety of backgrounds may work with you
- ->HCPS
- ->HR
- ->Other staff
- ->Varying approaches
- We want high quality, cost effective, evidence based, client centred
- ->Many clinical questions do not have research based answers
- ->Questions regarding scope of practice
- ->Essence of OT intervention may be questioned
- Can’t rely on own values or beliefs
182
Using multiple forms of reasoning in management
Chapter 23 Professional Reasoning in Occupational therapy Management
We shift between these often
IE. A DAY
-Lead a team in planning a new clinical program
-Steps to take
-Who is involved
- Pragmatic reasoning (Based on prior experiences of what is needed)
-Procedural (Using best practices)
-IP meeting (Performance meeting)
--> Making recommendations for patient equipment needs
--> Complex discharge issues
--> Deciding between strategies
--> Anticipate conflict or resistance to change
-----> Use scientific reasoning and data from other facilities
-----> Interactive reasoning to discuss reactions of those affected by changes
-Meeting discussing ethics of treating lower priority patients or those with little benefit from services
-->Ethical reasoning
-Narrative reasoning to talk to a therapist taking offense to unsolicited feedback from IP team
-Conditional reasoning to consider recommendations for an OT in a new leadership role
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From a novice to expert manager using professional reasoning
Chapter 23 Professional Reasoning in Occupational therapy Management
-OT managers begin as novices
-Dreyfus model of acquisition
-Acquire more advanced skills as we progress through the stages:
Novice
-learners focus on learning the rules of a particular skill
Advanced beginner
-Learners focus on applying the rules of a skill in specific situations that increasingly depend on the particular context of the situation
Competency
-Learners see actions in terms of long-range goals or plans and are consciously aware of their skills
Proficiency
Learners perceive situations as "wholes" rather than "aspects" and their performance is guided by intuitive behaviour
Expert
-Learners integrate mastered skills with their own personal styles
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5 stages of conflict process:
Chapter 23 Professional Reasoning in Occupational therapy Management
Latent stage:
-Participants are not yet aware of conflict but antecedent conditions may be present that contribute to conflict development
Perceived stage:
Participants become aware that a conflict exists and begin to name the problem but may not agree on the cause and nature of the conflict
Felt stage:
-Participants feel stress and anxiety that may contribute to conflict escalation
Manifest stage:
-conflict is open and can be observed in the actions of the participants
Aftermath: outcome of conflict, resolution or dissolution, and creation of new antecedent conditions that will affect the participants in the future
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- 38% of papers in medicine used the term clinical reasoning, 27% in nursing, 235 in dentistry, 835 in physical therapy, and 81% in occupational therapy
- In the entire corpus of 625 papers, coders identified a total of 110 different terms used in reference to clinical reasoning. A total of six overarching categories of terminology were identified:
Young et al (2020) (week 6) - Mapping clinical reasoning literature across the health professions: a scoping review
Reasoning skills
- referred to the abilities needed in order to reason clinically
- -> terms such as clinical skills, cognitive skills
- Reasoning performance
- referred to aspirational goals for clinical reasoning to be attained
- -> terms such as competency, acumen, or expertise
Reasoning process
- focused on the ‘how" of clinical reasoning
- -> proposing component processes or means by which the reasoning process unfolds (e.g. analytic reasoning, intuition, heuristics)
Outcome of reasoning
- focused on the ‘what’ results from a reasoning process
- ->(e.g. a diagnosis, a management plan), the quality of that outcome (e.g. accuracy, quality), and the errors or failures in reasoning (e.g. bias, error)
Contextual reasoning
-included notions of ‘where’ the reasoning process is occurring ‘outside’ of the individual clinicians’ cognition, or factors that could influence that reasoning --> including notions such as participatory approaches or shared decision making, or situational awareness which includes notions of influences on cognition that are more situationally or contextually derived
purpose/goal of reasoning
-focused on the ‘why’ of clinical reasoning for patient management, to determine a treatment, or to propose a diagnosis
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There is a multitude of terms being used to refer to clinical reasoning
-However, based on their differential representation across paper type, health profession, and the inclusion of an assessment, these terms do not appear to be used synonymously
Young et al (2020) (week 6) - Mapping clinical reasoning literature across the health professions: a scoping review
- This result suggests that clinical reasoning may be an overarching concept, rather than a singularly definable entity in itself.
- Rather, the concept of clinical reasoning appears to manifest, be operationalized, or crystalized differently depending on the context - whether ross individual health professions, different publication types, or assessment focus
-These different dominant conceptualizations of clinical reasoning across the Health Professions will - and likely already do - inform the complex context of both Interprofessional Education (IPE) and Interprofessional Collaborative Practice. IPE competencies currently do not explicitly focus on clinical reasoning, yet clinical reasoning has been identified as important across Health Professions and thus may be reasonable, or even essential, for IPE to address.
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the nature of a therapist expertise
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- Expertise has been defined as the ability to show exceptional and appropriate/adaptive performance or behaviour in response to a situation that contains a degree of unpredictability or uncertainty
- The defining attributes of expertise across professional fields include personal qualities and characteristics (i.e. attitudes, values and traits), skills and abilities (e.g. technical, interpersonal, self-regulation, cognitive and metacognitive skills) and self-, content and procedural knowledge
- Experts possess a broad and deep knowledge base, enabling them to distinguish the most critical and relevant information and to engage in effective action (superior procedural knowledge)
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Learning needs of novice and expert therapists
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- Novices are not always able to pick up on cues about the more crucial aspects of a situation, which may be communicated subtly or non-verbally by clients
- This uncertainty in knowing what to attend to and do is associated with their learning preferences. Typically, novices are more interested in acquiring concrete skills and techniques and they value rules, direction and explicit instruction
- ->They prefer structured learning opportunities, structured forms of self-assessment and structured resources, including supports that guide them through the process of reflection
-experts are typically more interested in observing how other therapists engage clients and in understanding the meaning of experiences for clients. Experts learn experientially, through engagement (deliberate practice), feedback and reflection
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a model of the development of professional expertise
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
a circle on the left optimal conditions (boxes over lap):
availability of growth-enhancing environment
-Aspects of person
-->person Qualities and characteristics
-->skills and abilities
Motivation to seek experience (transition to next step)
-Engaging in deliberate practice
-Feedback
- Processing of experience (reflection)
- ->enhance knowledge (arrow back to engagement in deliberate practice
- ->Enhanced content
- Enhanced procedural knowledge
- ->Enhanced client outcomes
- ->elevated professional Reputation
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more about the model of the development of professional expertise
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- the development of expertise is seen as requiring certain capacities and motivation on the part of the individual (developmental perspective)
- The model in Fig. 1 draws attention to (i) the availability of a growth-enhancing work environment, (ii) personal qualities and characteristics, and skills and abilities, and (iii) the processing of various aspects of experience (involving reflection on the self, on feedback and on practice) (Jensen et al. 1999). The presence of these factors leads to increased self-, content and procedural knowledge and superior outcomes as perceived by others, namely enhanced client outcomes and elevated professional reputation
- A fundamental premise, from a developmental perspective, is that all individuals are capable of growth towards competence and expertise.
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A framework of strategies to foster the development of expertise
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- A premise of the framework is therefore that there are basic strategies by which therapists develop their knowledge and skills.
- The strategy framework (Fig. 2) consists of 21 strategies gleaned from the literature, organized into three basic types: personal experience, supports and resources, and workplace opportunities
- three strategy groups reflect the major ways by which competence is considered to develop.
- Each of the 21 strategies addresses one or more types of learning. Experiential learning involves learning from the consequences of one’s behaviour. Instructional learning involves the sharing of information and reflection on this information. Observational learning involves modelling the behaviour of others
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A framework of strategies to foster the development of expertise
describe figure 2
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
Columns:
Route to expertise:
- Personal Experiences (personal level strategies)
- Support and resources (Person-Environment "Fit" strategies)
- ->(one-on-pne coaching and mentoring across all columns)
- Workplace Opportunities (environmental strategies) Caseload Experiences
- ->Structured Formal Opportunities
- ->Formal Apprenticeship Models (in this section cognitive, apprenticeship, critical companionship Guided participation in communities practice)
Experiential Learning
Instructional Learning
Observation Learning
whole thing is group under optimal development
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Personal Experience To develop skills and knowledge - person level strategies
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- The majority of the personal strategies discussed in the literature are based on principles of experiential learning.
- engaging in experiential learning is considered to be a defining characteristic of individuals who are or will become ‘experts’
- Deliberate practice refers to extensive, sustained and focused practice in authentic, real-life clinical activity (direct experience)
- Feedback is considered to be important in developing the metacognitive skills involved in expertise
- In contrast to novices, experts may be more comfortable asking for feedback on how a therapy session has gone. They also appear to value client feedback more strongly than feedback from peers.
- The knowledge and awareness that arise through reflection are considered to be necessary ingredients for the development of clinical expertise
- reflection is considered to be the best method for the professional growth of novices
- Reflection is facilitated by self-feedback strategies such as guided self-reflection, journal writing, and other informal techniques in which thoughts, goals and intentions are put in writing.
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Supports and resources: person-environment fit strategies
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- it is important for organizations to provide supports and resources to encourage therapists’ ongoing development of skills and knowledge. This strategy group consists of three informal, individualized instructional opportunities for practitioners to gain practice-relevant knowledge and develop skills that are core aspects of expertise.
- Therapists need tools to assess their progress on the path from novice to competent practitioner to expert. Unfortunately, there are few psychometrically sound assessment tools targeting attributes of therapist expertise
- Therapists can benefit greatly from session-specific tools designed to gather information about client changes occurring in the period between sessions and client experiences of the interaction, including their sense of working in partnership and engagement in the intervention process
- Frameworks make the expertise trajectory clear by showing what the end goal of ‘expertise’ looks like and how to get there
- Non-prescriptive frameworks/models of how therapists approach practice serve to encourage reflection and the integration of knowledge with action.
- Mentorship
- ->Good mentors provide learners with an appropriate level of challenge and support, taking them to the next step of their development in a comfortable, paced manner
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Workplace opportunities: environmental strategies
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
- Case-load experiences include opportunities to work with clients with complex service needs; to work with the same population for extended periods
- Although in-depth experience in a particular programme is beneficial, therapists also appreciate opportunities for lateral moves in an organization, which allow them to extend their knowledge and skills.
- When formal opportunities for interaction occur within climates of trust and respect, this promotes heedful relating among staff members, enabling them to acquire and use new skills, and experience a sense of thriving in the workplace
- mentorship programmes should provide structure and guidelines, but allow individuals to select their own mentor – someone they respect who has skills they want to learn.
- To be effective, feedback has to be immediate, which is antithetical to performance appraisal systems in which feedback is given on an annual basis.
- A number of workplace strategies provide opportunities for self-development and learning in the context of interaction among therapists. These include opportunities for one-on-one discussion; regularly scheduled team meetings in which peers discuss clinical cases, issues and dilemmas, or aspects of practice and project work of all kinds. These opportunities provide content to be learned, allow therapists to use their knowledge and creativity, and enable them to see how others think.
- Group instruction- This commonly used strategy includes problem- or scenario-based instruction, case study methods, discussion of critical incidents, and cognitive coaching. Cognitive coaching refers to a structured instructional programme teaching conceptual skills such as problem solving and reflection
- Since practical knowledge is highly dependent on the situation or setting, apprenticeship models of learning are considered to have high potential utility
- Guided participation in communities of practice allows apprentices to learn implicit cultural and social roles, and gain tacit knowledge
- Apprenticeship models therefore provide linked experiences and involve multiple processes, thereby supporting knowledge, skill development and socialization in a multi-faceted, concerted way. The main disadvantages of these models are their cost (in terms of therapist and coordinator/trainer time) and their suitability for larger organizations.
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Summary for A framework of personal and environmental learning based strategies to foster therapist expertise
Week 6 King et al. A framework of personal and environmental learning based strategies to foster therapist expertise
-According to the framework, the development of knowledge and skill is facilitated by learning processes arising from three distinct groups of strategies: direct experience, the provision of supports and resources, and the availability of opportunities. The framework provides a ‘whole picture’ starting point from which strategies can be selected for implementation or research.
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context
CH. 12: Context and Reasoning
-Means so much surely than events located in place and time. Context also consist of unconscious assumptions we absorb growing up tenaciously held convictions we gain as by if osmosis of worldview that unobtrusively shapes our sense of reality
is an interaction among our internal professional worldwide (know and tacit) and our larger cultural beliefs, values and practice
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Professional reasoning
CH. 12: Context and Reasoning
- is an interaction among our internal professional worldview (known and tacit) and our larger cultural beliefs, values and practices
- it is a dynamic interaction among each practitioner and the properties of a particular practice situation
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Role of context in daily life
CH. 12: Context and Reasoning
- Communities of practice hs become a popular term to connote the overlay of context and practice
- Three essentials:
- ->Domain
- identity shared by a collective of individual with common interests; variable level of competence that differentiates individuals from other members of the community
- Community
- collective of members who engage in joint activities and share knowledge inherent to its purposes; they learn and reason together
- Practice
- practitioners who have a shared repertoire of reasoning and actions based on common culture, tools, stories and ways to fix common problems
-COP describes collectives of individuals have agreed to function, it does not give satisfactory insight into the interactive nature of context for each individual
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Bronfenbrenner's Bioecological Model
CH. 12: Context and Reasoning
- His work was grounded in the assumption that the ecology of environment is central to the interaction of a developing person and an ever changing environment in which they live or grow
- Microsystem- persons relationship within immediate institutions such as family, a faith group, school or community centre
- Mesosystem- interactions of institutions in the mesosystem, family interactions are included but with maturity or extends beyond family. a mesosystem is a system of microsystems. (e.g.)
- ->The mesosystem is where a person's individual microsystems do not function independently, but are interconnected and assert influence upon one another
● Exosystem- settings where individuals are influenced by larger external settings without direct contact such neighborhood, government rules and policies or insurance systems
--> It incorporates other formal and informal social structures, which do not themselves contain the child, but indirectly influence them as they affect one of the microsystems.
● Macrosystem- social expectations, cultural traditions, religion or other forms of ideology (e.g. technology and social media)
--> how cultural elements affect a child's development, such as socioeconomic status, wealth, poverty, and ethnicity.
● Chronosystems- life events that are so strong they shape culture and our lives (e.g. COVID-19, 9-11)
-->This system consists of all of the environmental changes that occur over the lifetime which influence development, including major life transitions, and historical events.
● Bronenbrenner illustrates human development within levels of context over a lifetime
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Situation Cognition- Jean Lave
CH. 12: Context and Reasoning
-Cognition is a complex social phenomenon that is constituted by a balance of social systems and the experience of an individual
-“Cognition is a nexus of relations between the mind at work and the world in which it works”
-Lave’s view of context is based on the interface of two elements of context that she calls arenas and settings
-->Arenas:
physical space and a complex interaction of economics, politics and socially organized ideas, these interactions are external to the individual who has little or no control over this overarching milieu
-->Setting
-the space created by the activity of an individual as he or she experiences these arena (e.g. for a mother of a young child the setting for the store includes going to the baby section to buy diapers)
-It is interaction between arenas and settings that forms activity and purpose
-Actions are generated within the arena and are also generated by how the arena is experienced
-Context is critical because it gives insight into relationships among the actors the artifacts needed to complete the task and the social structure of this encounter
-Participants engage with the arena and improvise according to their interpretation of the many elements of the arena
-Social structures, history of the institution and issues of race, gender or economic status can influence the person within the arena
-Lave takes an anthropological view of how context influences participation
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Context in professional reasoning
CH. 12: Context and Reasoning
-Researchers who study professional reasoning routinely surface the role that the practice context plays in the reasoning process
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Mindlines
CH. 12: Context and Reasoning
- The intent of the researchers of two primary care general practices in england (nurses, physicians, phlebotomist and office staff) was to understand how these individuals as well as their groups went about making their decisions
- “Clinicians rarely accessed, appraised and used explicit evidence directly from research or other formal sources.. Instead the relied on that we have called “mindlines”
- -> collectively reinforced, internalized, tacit guidelines”
- This knowledge was often built early on in their training and acquired more tacit knowledge by their colleagues through things such as meetings
- The result was day to day practice based on socially constituted knowledge
- Practice knowledge and practical knowledge played a significant role
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acute care
practice setting is fast paced, dynamic, and stressful environment for healthcare professionals
- takes place within medical model as it is heavily dependent on devices and equipment
- ->patients are often critically ill or have complex and challenging medical conditions
- It is the first stop in continuum of care
- ->resulting in short hospital stays and OT's need to rapidly assess their patients
- in AC OT's use the medical diagnosis as a starting point but also considers the phenomenological meaning of the illness described as "two body practice" aka looking at the clients age/gender/medical hx & their understanding of condition and expectations
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Main types of CR in AC: procedural, interactive, pragmatic, and ethical
Chapter 13: Acute Care
Procedural:
- focus on assessing occupational performance deficits, identify the problem area
- draw on your experiences with similar conditions, knowledge of medical conditions, symptoms
Interactive:
- focus on understanding the patient as a person, develop rapport, and create collaborative problem solving
- Listen to the stories a patient tells
Pragmatic:
-Provide an effective service while in an enviro that imposes limitations
-Work out what is achievable within an organizational system largely directed by hospital policies, limited patient/provider time and short hospital stays
-AC care focuses on quick discharge
-Patient sessions are usually not scheduled like in other settings
-->client may be with another HCP, be at an appt/procedure
● Ethical:
-->Most times OT's feel their recommendations are comprised of the third payer reimbursement policies
--> known as constrained practice when a therapist using their professional judgement to make a less effective recommendation because of third party reimbursement policies
-Forming an occupational diagnosis is helpful to assist reasoning when medical diagnoses dominate team thinking in AC
-The pressure for fast decisions may impact client centredness in acute settings
-In AC OT's have limited time to consider the latest research evidence
--> consult with other therapists about what "works"
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3 Aims for OT's in Acute Care
| Chapter 13: Acute Care
1) Enable occupational engagement by focusing on doing
- ->need to understand how medical conditions affect everyday occupations.
- ->Mostly procedural reasoning
2) Complete tasks related to safety and independence
- provision of equipment, education, and referrals to facilitate a safe discharge.
- ->Procedural, and pragmatic reasoning mostly
3) Empower and motivate clients to do the things they value to build their confidence
- ->this involves interactive reasoning
Challenges:
- working in AC includes the managerial context and the complex needs of patients that have to be addressed in a short time frame
- Working within AC comes with certain practice contexts
- -> certain rules, expectations, and priorities that dictate what actions are allowable
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Neonatal Intensive Care:
Case Study
Chapter 14 – Neonatal intensive care p.285
- need to balance a fine interplay of medical knowledge and psychosocial support of their parents.
- Therapist must hold their assumptions about the backgrounds of families who enter the NICU and make space to truly appreciate parent perceptions values and aspirations and becoming a parent to preterm infant.
-Factors that contribute to that reasoning include characteristics of the:
infant,
parents,
and in the NICU environment.
-It's important for therapists to reflect on how their professional reasoning is shaped by their own personal and professional perspectives, and how this affects practice.
-important to consider their influence that the individual therapist lens, parents’ lens, and the environment factors have unprofessional reasoning
- Understanding parents’ perceptions of their experience in the NICU and their developing parent identity and the self-efficacy are key professional reasoning factors.
- Participation in meaningful co-occupations can become a symbol that the parents and their infant are moving towards a more “normal” family life.
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OT role in NICU
Chapter 14 – Neonatal intensive care p.285
- Validate parents concerns and feelings about NICU
- Share strategies how they can feel close and connected to baby:
- ->recognizing facial expressions, activity in arms/legs, how to use their hands to provide containment holding to support baby when their receiving care, learning about baby’s cues.
- Building competence and confidence around parent-infant co-occupations.
Think about ecological model, example in the text
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Schell's Ecological Model
| Chapter 15: Home Modifications
in the practice context
situation shaped by the client and professional "lens" within the practice context
```
Professional:
Personal lens
-Beliefs
-Values
-Intelligence
-Embodied sense and abilities
also life-experience and situation
Professional Lens
-Practice theories
-Knowledge
-Experience
-Professional skills
```
```
Client
Personal lens (same concepts as client)
-Beliefs
-Values
-Intelligence
-Embodied sense and abilities
also life-experience and situation
Client len
-Understanding of health condition
-Theories about how the condition affecting performance
-Experience as a patient or a client
-Expectations about occupational therapy
```
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Types of reasoning and home safety assessment
Chapter 15: Home Modifications
Scientific reasoning
- Focus on impact of diagnosis on typical functional use of home
- consider typical prognoses and clinical course of the diagnoses in forecasting future needs
- Observe abilities and deficits in different areas of the home
- Draw on comprehensive knowledge about impairments
Narrative Reasoning
- consider occupational narrative of the home and homeowners
- Explore experience of disability
- Consider daily roles and routes
- Provide opportunities to discuss wants, needs and expectations
Pragmatic Reasoning
- Consider costs of interventions
- Consider size and structure of different spaces and home
- Consider client(s) anthropometrics
- Consider contextual factors
Ethical reasoning
- Consider alternative options for each recommendation
- Consider consequences of recommending or not recommending interventions
- Consider financial and safety risks
- Collaborate with client(s) on decisions
Interactive reasoning
-Using multiple forms of reasoning in complex interactions and decisions
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School based practice
Emphasis on:
Chapter 16 School Based Practice
- Services in natural contexts
- Services based on what students need to participate in their school context
- Collaborative planning with all stakeholders
- Monitoring, services linked to performance
- Evaluation in context
- Include direct, team, and systems supports
- Make decisions based on data, modify intervention if its not increasing performance
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What influences reasoning of the school based practitioner
Chapter 16 School Based Practice
In the centre
- Your practice in the schools/agencies
- ->you bring personal and professional characteristics)
Client Perspective
- Student
- Team
- System
Research
```
State Government
-(legislature, Governor, State Department of Education)
Court Decisions
-National
-Local
```
Professional Affiliations
- Code of ethics
- Licensure
- Practice framework
Fads and trends
- Classes
- Workload
```
Federal Government (congres, President, Department of education)
-School District/Agency
```
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- Used to use pull-out bottom up methods, now we seek top down in context methods
- Uses the ecological model of professional reasoning (chapter 5)
- Consider a holistic perspective taking into consideration complexities
- When looking at a referral consider:
Chapter 16 School Based Practice
- Resources in the literature
- Best practices
- Practice process framework
- Policies and procedures
- Consider the team and all stakeholders
- Timelines for entry into programs
- Consider what you will assess to save time and tolerance
- Your reports contribution to the IEP
- Consider the opinions and beliefs of relevant stakeholders.
- Don't be afraid to do things differently
- Clarify your reasoning for choices
- Make sure recommendations are realistic for staff and family
- Collect data for progress reports
- Use all kinds of clinical reasoning throughout the process
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OTs in Palliative and End-of-Life Care have a dual approach to their role:
Chapter 17 – Palliative and End-of-Life Care p.337
- finding a balance between occupational goals that focus on living
- while also assisting clients to prepare for death.
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To focus on living:
Chapter 17 – Palliative and End-of-Life Care p.337
OTs should encourage their clients to prioritize engagement in meaningful activities, while assisting them to adapt to their changing occupational performance status.
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Preparing for death:
Chapter 17 – Palliative and End-of-Life Care p.337
-OTs can enable people to make practical preparations, and encourage activities that help to facilitate closure.
When Celine was on hospice floor/palliative we mainly focused on making sure the client was safe and comfortable. Provided the opportunity to engage in therapy (light exercises, getting out of bed into chair, etc). And also did some home visits to make sure the client would be able to safely remain home in their last days; recommended appropriate services and equipment they would need.
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Again, a chapter that focuses on a case study and how to apply the Ecological model:
Chapter 17 – Palliative and End-of-Life Care p.337
Personal self:
ie the therapists and their personal experiences in/out this setting.
Professional self:
- the therapists professional experience in/out of this setting.
- Amount of years of experience,
- what drives the professional (ie practice theories, client centered practice, etc.).
- Discussing with other professionals in this area, researching literature
The context:
-working with clients in their homes
The client:
-meeting the client, getting background information, their OPIs, goals, their environment (social, physical etc), etc.
OT intervention:
-using occupations as means or ends, checking in with family, really focusing on clients wishes and goals, education on signs and symptoms, what to expect.
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Learning activity: some questions to guide your thinking
| Chapter 17 – Palliative and End-of-Life Care p.337
- What are the likely occupational needs the client will need as the disease progresses
- What are the key professional, personal, and contextual factors that influence your reasoning
- How will you enable the client and their family to continue to focus on life despite their terminal diagnosis?
- How will you assist the client and family in preparing for their death?
- What are your feelings about the clients decision about their end of life care?
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Screening and assessing older drivers
Chapter 18 – Screening and assessing older drivers p. 351
Narrative reasoning
assess the parts of personal life story finding out what driving as a lifelong occupation means to them
- Effects of aging
- ->(ie reduced physical, sensory and cognitive capacity)
- ->may have an effect an individuals safety and participation in driving.
- ->Driving cessation has been linked to negative health and lifestyle outcomes, like a reduction in social and recreational outings, and premature entry into LTC facilities.
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Types of reasoning used:
Procedural
Chapter 18 – Screening and assessing older drivers p. 351
- reasoning associated with evaluation, intervention, and thinking about how the client is performing
- pulling the client over and giving them feedback and a give them a second chance to change their performance
- Want to see client in traffic more than once (do not want to base it off one event)
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Types of reasoning used:
Interactive reasoning
Chapter 18 – Screening and assessing older drivers p. 351
-reasoning that guides interactions with the client, understanding the client as a person, understanding the clients problems from the clients POV, individualizing therapy, building a shared language, and monitoring progress
- self restricting himself to drive only in the day
- vision was being monitored regularly
- Cognition main concern -->had difficulty with diagrams and questions
he appeared confused and needed clarification on instructions he didn't really understand the questions.. I noted my considerations for the on road to be cognition and decision making and reaction time if we needed to do an emergency brake that he had both hearing and vision deficits and monitoring his awareness for other road users….
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Conditional reasoning
Chapter 18 – Screening and assessing older drivers p. 351
reasoning about the whole of the client's condition in relation to temporal, personal, cultural, and social contexts
- client was independent before stroke
- client really wanted to go to church so its coming up with ways to make that happen, weighing the options
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Generalization reasoning
Chapter 18 – Screening and assessing older drivers p. 351
reasoning used within procedural interactive conditional and pragmatic reasoning to draw on past experience and knowledge to assist in making sense of the client's current circumstances
-basically everyone gets a road test unless they do not pass visual requirements for driving
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Pragmatic reasoning
Chapter 18 – Screening and assessing older drivers p. 351
- reasoning related to the therapist practice context demands such as resources and reimbursement and may include elements of personal context such as the therapist's own negotiation skills and ability to read the practice culture
- So, I think about who the client has for support but I'm also making sure I protect myself. So, I guess I'm thinking about the practical issues of how feedback is given and where and what the client's possible responses might be.
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Non-driver trained occupational therapists reasoning and older adults
May be the first health care professional to notice difficulties with a person driving. Roles in this area include:
Chapter 18 – Screening and assessing older drivers p. 351
- Screening clients who identify themselves as drivers to determine if the client meets the national medical standards imposed for driving
- identification of clients who may require further specialist assessment for driving
- referral of clients to a driver trained occupational therapist when indicated or to local services for assistance with alternative forms of transport
- education of clients about time to return to driving after a short-term medical event and about the alternative forms of transport and other options for community mobility
- counseling clients related to driving cessation and long-term alternatives to driving
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Case Study
Chapter 18 – Screening and assessing older drivers p. 351
Using conditional reasoning:
as the therapist thinks about their client over the years and how her health is changing
Using narrative reasoning:
- as they therapists share stories about past experience with clients and how these played out
-drawing on personal and professional ethics debating what is the right thing
- using interactive reasoning:
- to build a trusting relationship over the years and understanding decline as a person
-using procedural reasoning;
as the therapist thinks about the client's medical health and if this is being managed by a doctor
interactive and conditional reasoning:
-when thinking about the client’s husband and how they might involve him in their concerns
- using pragmatic reasoning:
- directly related to their practice context and thought about the constraints of their service and resources
using procedural reasoning
-to determine of course of action but heavily relying on interactive reasoning as she broached this topic of driving and gauged if the client is open to discuss her driving status and what options there might be ahead of her.
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Driver-trained occupational therapists’ (CDRSs) reasoning and older drivers
Chapter 18 – Screening and assessing older drivers p. 351
Expert status is not distinguished by years of experience but rather by the attributes knowledge personal qualities and characteristics skills and abilities reputation and ability to produce superior outcomes.
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Off-road assessment
Chapter 18 – Screening and assessing older drivers p. 351
to consider the client's:
- current patterns of driving
- their need for driving
- informally assess their physical sensory and cognitive perceptual skills for the driving task.
This assessment uses:
procedural reasoning and also interactive reasoning
-->as the therapist needs to develop a relationship and establish a good rapport with the client.
-->They must get to know the person and understand their motives and need for driving and how they won't respond best to instruction and possible feedback.
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On-road assessment:
Chapter 18 – Screening and assessing older drivers p. 351
- this assessment is completed in a dual controlled test vehicle under the guidance of a driver instructor.
- Following the assessment and depending on the country and licensing jurisdiction a number of recommendations may be made by the occupational therapists including:
- ->to cancel the driver's license
- ->to suspend the driver's license
- ->to award a conditional license such as to drive only in a local area or during daylight hours
- ->to award a full license to the driver.
During the drive the therapist is using all forms of professional reasoning such as:
- procedural reasoning:
- ->as the test unfolds
- Interactive reasoning:
- -> as the therapist observes the client respond to both the driving instructor's instructions and the changing Rd environment
- conditional reasoning:
- as the therapist considers how the client's driving is conditional upon skill behavior an environment and also whether the client may have the capacity to respond to rehabilitation in the future
- generalization reasoning:
- as the therapist considers how other clients with similar problems have progressed in the past
- pragmatic reasoning:
- as the therapist weighs the traffic the weather and how long the assessment has taken
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3. driver rehabilitation:
Chapter 18 – Screening and assessing older drivers p. 351
- this might be recommended when there is enough evidence to suggest that a client has the potential to pass an on road assessment and continue to drive safely if provided with the appropriate intervention
- Literature has shown that there is a significant variability between studies with regards to frequency duration and total number of interventions sessions recommended this systematic review suggests that no formulas exist to determine optimal driver rehabilitation programs.
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Making optimal licensing recommendations for older drivers:
Chapter 18 – Screening and assessing older drivers p. 351
```
-not to be based on age, but rather
driving instructor interventions,
driver behaviour,
cognitive and perceptual skills
and vehicle handling skills were the 4 most important information used by CDRSs when making licensing recommendations.
```
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Role of OT in mental health
The goals of occupational therapy are twofold:
- one to promote mental health and well-being in all persons with and without disabilities
- two to restore maintain and improve function and quality of life for people at risk for or affected by mental illness.
- support health and participation and life through engagement and occupation.
- use engagement in activity to promote mental health and well-being and maximal functioning.
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Group vs. individual intervention
Group intervention:
- has evolved to be the preferred model of practice in mental health settings.
- Groups can be beneficial in terms of having people with a common experience and in providing peer support.
- Groups are the preferred method of intervention in community-based practice.
- Group interventions also provide significant challenges in planning and implementing groups that meet the goals for all clients within those groups.
-A study found that the occupational therapists working in a community based mental health day treatment program exhibited simultaneous use of both procedural and interactive reasoning.
Aspects of procedural reasoning:
is when the therapist focused on assessing the client's mental status as well as evaluating the functional goals of the group and individuals within the group.
Interactive reasoning is used by:
-observing behaviors and providing appropriate cues as well as humor to create a safe caring environment for all the clients. Another study found that the environment had a great influence on the clinical reasoning process.
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Clinical and professional reasoning in community-based practice/mental health settings
-In community based practice settings there are many constraints to clinical reasoning including high caseloads time and resource constraints and ill structured nature of this practice environment. (pragmatic)
Therapists use theoretical approaches from OT as well as other disciplines like psychology sociology anthropology and neuropsychology to guide the process of clinical reasoning during evaluation and intervention.
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Conditional reasoning/ narrative
implementing groups in the therapist thinks about what the client's lives were like outside of the day treatment program and this also served narrative reasoning when the therapist brought her clients into a community setting for real life interaction.
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Using pragmatic reasoning
when thinking about timing of their groups and keeping groups going while attending to the needs of multiple participants.
Using theory such as the MOHO theory can inform the process of reasoning and psychiatric OT
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Clinical and professional reasoning case study application
Using diagnostic reasoning:
-to determine that a client might have a severe and persistent mental illness and might not be stable on medication as well as like burns on his fingers might be evidence of recently smoking drugs
using scientific reasoning:
- based on a sensory processing model by telling another client to take a walk somewhere quieter and moving people away from Jorge’s table.
- The therapist wanted to remove as many distractions as possible to help calm Jorge and Angel during group activities that may have been overstimulating
Pragmatic reasoning:
- can be seen where the therapist had the woman with decreased mobility and processing issues near the exit and placing the two students close to them to provide physical assistance when necessary
- contextual and pragmatic factors came into account when the therapists encouraged Lucian (a student) to move from the front room near Jorge, knowing he is a combat veteran, previous experience in a MH setting and had de-escalation training.
- Another pragmatic and contextual factor was to keep Cliff away from Jorge so Jorge wouldn't have a visual of cliff's offensive tattoo that would have angered him.
Conditional reasoning was used
-when envisioning possible future scenarios based on previous interactions with the clients so telling the client to take a walk in the hallway to avoid an accident/group to go off.
