Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=iocc20
Download by: [University of Lethbridge] Date: 28 September 2015, At: 22:35
Scandinavian Journal of Occupational Therapy
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
Occupational science: An important contributor to occupational therapists’ clinical reasoning
Hanne Kaae Kristensen & Kirsten Schultz Petersen
To cite this article: Hanne Kaae Kristensen & Kirsten Schultz Petersen (2015): Occupational science: An important contributor to occupational therapists’ clinical reasoning, Scandinavian Journal of Occupational Therapy, DOI: 10.3109/11038128.2015.1083054
To link to this article: http://dx.doi.org/10.3109/11038128.2015.1083054 Published online: 22 Sep 2015.
Submit your article to this journal
Article views: 11
View related articles
View Crossmark data
2015; EARLY ONLINE: 1–4
http://dx.doi.org/10.3109/11038128.2015.1083054
SHORT COMMUNICATION
Occupational science: An important contributor to occupational therapists’
clinical reasoning
Hanne Kaae Kristensen1,2& Kirsten Schultz Petersen3,4
1Health Sciences Research Centre, University College Lillebaelt, Denmark,2Institute of Clinical Research, University of Southern Denmark, Denmark,3CFK – Public Health and Quality Improvement, Central Denmark Region, and4Department of Social Medicine and
Rehabilitation, Faculty of Health Sciences, University of Aarhus, Denmark
Introduction
The influence of occupational science is evident in the theoretical and research-based knowledge base within occupational therapy. Moreover, studies show that contributions from occupational science are also reflected in clinical reasoning – a key occupational therapy competence – as well as in values and practice.
Clinical reasoning is regarded as a core element of health professional practice and provides a link between research and practice. Therefore, it is important that occupational therapists endeavour constantly to develop their knowledge of occupational science literature and clinical reasoning competence. Occupational science provides targeted and up-to-date research findings that contribute to the development of occupational therapists’
reasoning in education and practice.
Occupational therapy is founded on both scientific and professional knowledge – the latter acquired through practice, – and is based on biomedical, social, and humanistic theory (1–3). Growing demands are placed on health professionals to develop and demonstrate professional quality. There is a steadily growing engage- ment by occupational therapists (OTs) in international discussions regarding how to implement evidence-based occupational therapy. It is becoming increasingly urgent for OTs to develop evidence-based practice that will embrace all aspects of their practice. The biomedical approach, which relies principally on scientific research ranked in evidence hierarchies (4,5), is still the tendency in evidence-based practice, despite the emphasis placed on the value of clinical expertise and patients’ preferences by, for example, Sackett (6). The biomedical approach represents significant challenges for OTs in practice, in education, and in research. Occupational therapy’s foun- dation of professional knowledge is considered to be
based on biomedical, social, and humanistic knowledge and the profession’s practice is supported by research based on both qualitative studies and quantitative studies.
Some occupational therapist researchers argue that knowledge derived from qualitative research is crucial in a client-centred practice (7–10). The demand for know- ledge developed by means of qualitative methods opposes relying solely on the notion of high evidence according to the evidence hierarchies and gives rise to discussions of how to evaluate evidence (11–13). Consequently, whether evidence-based practice represents adequate respect for patients’ preferences and rights is under discussion.
Likewise, there is a debated argument about the extent to which practice-based experience is considered on an equal footing with research-based evidence. Some OTs are demanding a higher level of recognition and integration of practice-based knowledge (14,15). The purpose of this contribution is to debate ways in which occupational science could contribute even further to occupational therapists’ clinical reasoning and inform the occupational therapy curriculum.
First, we discuss the role of occupational science, and then its impact on clinical reasoning. Next, we discuss the interrelationship between occupational science and theory and finally we discuss the connection to the occupational therapy curriculum.
Occupational science as an important knowledge source for occupational therapy In occupational therapy, health and well-being are considered to be strongly influenced by choice, control, and the ability to engage in everyday life occupations.
Occupational science was established by OTs and conceived as a basic science of the human as an
Correspondence: Dr Hanne Kaae Kristensen, Health Sciences Research Centre, University College Lillebaelt, Denmark. [email protected] ß2015 Taylor & Francis
Downloaded by [University of Lethbridge] at 22:35 28 September 2015
occupational being, including the need for, and capacity to engage in and orchestrate, daily occupations in the environment over the lifespan (16). Hence, occupational science makes a connection between engagement in occupation and human development, well-being, and health (17). Therefore, occupational science is a particu- larly important knowledge source in occupational prac- tice, education, and research.
Research discussions strengthen OTs’ critical reflec- tions regarding their profession and give access to updated research results and theory that inform their practice. In recent decades, discussions within occupational science have focused increasingly on the impact of cultural and social factors. In 2000, Hocking called attention to the fact that the concept of ‘occupation’ was characterised as quite individualistic and largely health-focused (18). The same issue is discussed by Dickie et al. (19), who state that occupational science would benefit from even further investigation into, and interpretation of, how occupations are integrated with social relationships, cultural contexts, and community actions. Leclair later points out that occupations can be shared among individuals, groups, and communities (20). Rudman and Dennhardt (21) discuss yet another issue related to the concept of occupation.
They argue that occupation, as defined within contem- porary occupational therapy models, is a basic need of all people, regardless of culture. Rudman and Dennhardt claim that, even though culture is increasingly recognised as having a profound influence on occupation, there has been little critical reflection on the cultural underpinnings of central occupational concepts. Hammell (22) also argues that scientific and professional integrity requires a sceptical approach and a sound evidence base. Both Hammell (22) and Hocking (23) draw attention to the fact that most influential occupational therapy theories have been developed in urban areas of the English-speaking nations of the Western world; from a global perspective, this reflects only minority viewpoints. In line with this, Pollardet al. advocate that occupational science should be the theoretical basis of evidence of practice changes, from their critical standpoint and focus on social changes and occupational justice (24). These discussions reflect the need for further research into, for example, the diversity of occupational engagements, and this would inform OTs’
practice and education. While OTs in Scandinavia have welcomed development and discussions around occupa- tional science (25), the science is yet to be implemented or integrated to any great extent in practice, education, or Nordic research. Occupational therapy interventions could benefit greatly from the knowledge and evidence generated within the occupational science community – if our aim is to provide up-to-date, client-centred occupa- tions-based therapy.
Clinical reasoning underlies occupational therapy practice
Clinical reasoning has been defined as a context- dependent way of thinking and decision-making in professional practice to guide practice utilising core dimensions of practice knowledge, reflexivity, reasoning, and metacognition (26). In occupational therapy clinical reasoning is an essential skill and central to the quality of practice, as it enables OTs to make the best professional decisions in relation to individual patients. Moreover, the OT’s personality and life story come into play, along with practical experience, theoretical and research-based knowledge, and the patient’s needs, preferences, and situation (15). Besides, professional dialogues behind the development of evidence-based practice could be enriched by including the practice knowledge and clinical experience that are developed in clinical contexts (28).
In a 2012 Danish study of OTs’ clinical reasoning that focused on the implementation of evidence-based prac- tice, Kristensen, Borg & Hounsgaard found interactions between OTs’ clinical reasoning and the scientific know- ledge that is developed in occupational therapy and occupational science. OTs in both hospital and commu- nity settings reflected on their reasoning-based profes- sional values that were consistent with the profession’s core values, as set out in the conceptual models and frameworks published by Gary Kielhofner and Canadian occupational therapists (15). Across rehabilitation con- texts, it was found that OTs considered it important to ensure that patients and their relatives had the oppor- tunity to take an active part in their own rehabilitation, and that a shared understanding and sense of the patient’s future was established. OTs recognised that patients attributed specific significance to occupations that were meaningful to them, and that this was closely linked to the individual’s situation, contexts, and cultural background (15). These findings call for further theories and evidence within the occupational therapy community that offer insight into the perspectives of ill and disabled people and, moreover, are informed by a wide range of cultural, social, and geographical contexts.
The dynamic relationship between occupational science and occupational therapy theory
In its development of knowledge related to the complex- ities of human activity, occupational therapy research is guided by three main assumptions: people as active entities, the relationship between activity and health, and the importance of context (2). First, people are regarded as active beings with abilities and the need to participate in activities and to express themselves through the things
2 H. K. KRISTENSEN & K. S. PETERSEN
Downloaded by [University of Lethbridge] at 22:35 28 September 2015
they do. Second, the relationship between activity and health is of paramount importance, because human activities either sustain or undermine health and well- being, and, conversely, one’s health condition either allows or prevents participation in activities. The links between health and occupation are central in a number of occupational science studies; among others the works of Professor Ann Wilcock are valuable in informing and developing occupational therapy theory and conceptual models. The third assumption deals with the importance of the environment or the context in which people find themselves. Elizabeth Yerxa contributed to the recogni- tion of the role of the environment in connection with the establishment of research in occupational science. She stated that therapists should recognise that a host of factors, such as other people, the weather, cultural and religious beliefs, economics, space and resources, and the natural environment among many other factors inform how we act (16).
This notion that occupations are performed in a particular historical and cultural context is key to the holistic approach in occupational therapy practice and education. The influence of occupational science is not only clearly reflected in the profession’s theoretical and research-based knowledge, but also in OTs’ professional core competencies and values, and in their practice.
Occupational therapy reference frameworks consist of sets of interrelated theories and concepts that determine how specific, occupation-based challenges are explained and approached (18). OTs use multiple frames of reference in their practice. The choice of frame of reference is influenced by the local culture, the individuals to whom the therapy is directed, and the individual OT’s experience and values. The OT will plan and perform any intervention based on a selected frame of reference. In this way, the choice of reference has an impact on the way the OT performs clinical reasoning, and the steps involved in the reasoning process. As stated by Gupta & Taff, services that are impairment-focused and provided in unfamiliar settings are not appropriate to client-centred practice. Rather, client-centred practice is best embodied by occupation- focused interventions in the natural environment of everyday living (2). This would suggest that the occupational therapy profession is dependent on know- ledge generated from occupational science if its core elements are not to be in jeopardy.
Clinical reasoning and occupational science inform the occupational therapy curriculum As a key element clinical reasoning has implications for occupational therapy education, as it helps students learn
how to think like an OT and how to make clinical decisions in practice. Based on the statement that
‘clinical reasoning is recognized as the core of occupa- tional therapy practice’ (26), and client-centred practice is best embodied by occupation-focused interventions in the natural environment of everyday living (27), Mattingly and Fleming developed a terminology made up of both terms used informally by OTs and terms borrowed from other disciplines. This terminology quickly became familiar in occupational therapy com- munities (29) and has provided inspiration to OTs in the development of occupational therapy curricula and in their research. Moreover, ethical reasoning is closely linked to client-centredness and is informed by the concept of occupational justice developed by Ann Wilcock and Elizabeth Townsend, both of whom have contributed to its the development and exploration (30).
Moreover, Gail E. Whiteford has thrown light on occupational deprivation as a condition in which people are constrained in, or excluded from, engagement in meaningful and purposeful occupations due to social, political, or economic factors beyond their control (31).
Both concepts have informed client-centred occupational therapy as clients’ roles, interests, environments, and culture are central in order to enable participation in everyday lives.
More research on the meanings of occupations is important for occupational therapy as a health care profession. In this development occupational science may include explorations of the relationship between occupation and development, how occupation changes over the lifespan, how people organise and engage in their daily occupations, and the personal and socio- cultural meanings of occupation (32,33). Occupational science could more specifically contribute to the devel- opment of occupational therapy paradigms by generat- ing knowledge and evidence of the interplay between the individual, groups, communities, and social, political, and cultural contexts. As a consequence, occupational science research should play a more central role in occupational therapy education programmes at all levels, from bachelor to PhD level.
Declaration of interest
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References
1. Mattingly C, Fleming M. Clinical reasoning. Forms of Inquiry in a Therapeutic Practice. F. A. Davis Company, 1994
Downloaded by [University of Lethbridge] at 22:35 28 September 2015
2. Kielhofner G. Conceptual Foundations of Occupational Therapy. 4th edition, Philadelphia: FA Davis Company;
2009
3. Townsend EA, Polatajko HJ. Enabling Occupation II.
Advancing an Occupational Therapy Vision for Health, Well-being, & Justice through Occupation. CAOT Publications ACE. 2007
4. Upshur REG, Van Den Kerkhof EG, Goel V. Meaning and measurement: An inclusive model of evidence in health care. J Eval Clin Pract 2001;7:91–6.
5. Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence-based practice?. J Adv Nurs 2004;47:81–90.
6. Sackett DL, Rosenberg WMC, Gray JAM, Haynes R, Richardson WS. (2000) Evidence based medicine: How to practice and teach EBM. Churchill Livingstone.
7. Egan M, Dubouloz CJ, von Zweck C, Vallerand J. The client-centred evidence-based practice of occupational therapy. Canadian Journal of Occupational Therapy 1998;65:136–43.
8. Hammell KW. Using qualitative research to inform the client-centred evidence-based practice of occupational therapy. British Journal of Occupational Therapy, 2001;64:228–34.
9. Rappolt S. The role of professional expertise in evidence- based occupational therapy. The American Journal of Occupational Therapy 2003;57;589–93.
10. Reagon, C, Bellin, W, Boniface, G. Reconfiguring evi- dence-based practice for occupational therapists.
International Journal of Therapy and Rehabilitation 2008;15:428–36.
11. Hayes RL. Evidence-based occupational therapy needs strategically-targeted quality research now. Australian Occupational Therapy Journal 2000;47:186–90.
12. Tickle-Degnen L, Bedell Client-centred practice, thera- peutic relationship, and the use of research evidence.
American Journal of Occupational Therapy 2002;56:
470–4.
13. Tuntland H. Hvordan bli en kunnskapsbasert yrkesutøver. Ergoterapeuten 2008;1–6.
14. Cusick A, McCluskey A. Becoming an evidence-based practitioner through professional development. Aust Occup Ther J 2000;47:159–70.
15. Kristensen HK, Borg T, Hounsgaard L. Aspects affecting occupational therapists’ reasoning when implementing research-based evidence in stroke rehabilitation. Scand J Occup Ther 2012;19:118–31.
16. Yerxa EJ, Clark F, Frank G, Jackson J. An introduction to occupational science, a foundation for occupational therapy in the 21st century. Occup Ther Health Care 1990;6:1–17.
17. Jonsson H. A New Direction in the Conceptualization and Categorization of Occupation. Journal of Occupational Science 2008;15:3–8.
18. Hocking C. Occupational science: A stock take of accumulated insights. J Occup Sci 2000;7:58–67.
19. Dickie V, Cutchin MP, Humphry R. Occupation as transactional experience: A critique of individualism in occupational science. J Occup Sci 2006;13:83–93.
20. Leclair LL. Re-examining concepts of occupation and occupation-based models: Occupational therapy and community development. Can J Occup Ther 2010;77:
15–21.
21. Rudman DL, Dennhardt S. Shaping knowledge regarding occupation: Examining the cultural underpinnings of the evolving concept of occupational identity. Aust Occup Ther J 2008;55:153–162.
22. Hammell KW. Sacred texts: A sceptical exploration of the assumptions underpinning theories of occupation. Can J Occup Ther; 2009;76:6–13.
23. Hocking C. Occupations through the looking glass: Reflecting occupational science ontological assump- tions. In: Whiteford GE, Hocking C, eds. Occupational Science. Society, Inclusion, Participation Wiley-Blackwell.
2012;54–66.
24. Pollard N, Sakellariou D, Lawson-Porter A. Will occupa- tional science facilitate or divide the practice of occupa- tional therapy?. Int J Ther Rehabil 2010;17:40–47.
25. Bendixen HJ, Nielsen LM. Aktivitetsvidenskab. In: Brandt, Å, Madsen AJ, Peoples H, eds. Basisbog i ergoterapi. 3.
udgave. København:Munksgaard; 2013;411–26.
26. Chapparo C, Ranka J. Clinical reasoning in occupational therapy. In: Higgs J, Jones MA, Loftus S, Christensen N, eds. Clinical reasoning in the health professions. Third Edition, Butterworth Heinemann Elsevier. 2008.
27. Gupta J, Taff SD. The illusion of client-centred practice.
Scand J Occup Ther 2015;12:1–8. (Epub ahead of print).
28. Kielhofner G. Scholarship and practice: Bridging the divide. Am J Occup Ther 2005;59:231–239.
29. Mattingly C, Fleming M, Gilette N. Narrative explorations in the tacit dimension: Bringing language to clinical practice. Nordiske Udkast 1997;1:65–77.
30. Townsend E, Wilcock A. Occupational justice. In:
Christiansen C, Townsend E, eds. Introduction to occu- pation: The art and science of living. Upper Saddle River, NJ: Prentice Hall; 2004.
31. Whiteford G. Knowledge, power, evidence: A critical analysis of key issues in evidence based practice’’. I:
Whiteford G, Wright-St Clair V, eds. Occupation &
Practice in Context. Sydney: Elsevier Churchill Livingstone; 2004;34–50.
32. Pierce D. Promise. J Occup Sci 2012;19:298–311.
33. Ikiugu MN, Pollard N. Meaningful Living across the Lifespan: Occupation-based intervention strategies for occupational therapists and scientists. Critical Studies in Occupational Therapy & Occupational Science. Whiting
& Birk Ltd. 2015.
4 H. K. KRISTENSEN & K. S. PETERSEN
Downloaded by [University of Lethbridge] at 22:35 28 September 2015
