Clinical reasoning and the occupational therapy curriculum

Headnote

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

Key words: conditional reasoning and long-term disabilities, problem-based learning, putting theory into practice.

Introduction

Mattingly and Fleming (1994) identified several forms of clinical reasoning used by occupational therapists: procedural, interactive and conditional reasoning. Procedural reasoning focuses on the process used to maximize clients' functioning. Interactive reasoning emphasizes occupational therapists' understanding of clients' feelings about themselves and about the intervention they receive. Conditional reasoning involves the understanding of clients' disabilities in specific life contexts. Therapists using conditional reasoning need to integrate clients' deficits in each performance component, each occupational performance area and each environment with their needs (Canadian Association of Occupational Therapists, 1991). Conditional reasoning is appropriate for working with clients suffering from complex longterm disabilities such as stroke. Therapists using conditional reasoning are able to translate clients' deficits into possible adaptations that will facilitate their life roles in each environment within the Canadian Model of Occupational Performance (Canadian Association of Occupational Therapists, 1991; Mattingly and Fleming, 1994). The results of Mattingly and Fleming's study of clinical reasoning (1994) showed that therapists, especially those in their early years of practice, tend to use procedural reasoning when working with their clients. Junior therapists tended to focus on deficits and disabilities instead of integrating clients' disabilities with their needs in each area and environment.

The type of clinical reasoning style used by therapists could be influenced by several factors: 1) the theoretical framework used; 2) the application of theory; and 3) the level of experience. The first two factors are related to the design of the occupational therapy curriculum, and the last relies on therapists' accumulation of clinical experiences.

In the occupational therapy curriculum, students often express difficulties in integrating the knowledge acquired in different clinical and theory courses, such as pathology and occupational therapy theory, which compromise their ability to use conditional reasoning. Problems with integration lead to difficulties in making decisions about clients' problems in occupational performance when they graduate and become therapists. A study involving students attending an accredited occupational therapy undergraduate programme in the USA showed that conditional reasoning concepts are not well integrated into the adult physical dysfunction course (Neistadt and Atkins, 1996).

This study investigated the use of clinical reasoning by occupational therapists with different types of clinical experience who had graduated from the same educational programme. The content of the occupational therapy undergraduate curriculum was also analysed so as to gain better understanding of the choice of the therapists' clinical reasoning style, particularly the novice practitioners. The results obtained could shed light on the design of the occupational therapy curriculum that would enhance students' integration of knowledge and use of appropriate clinical reasoning during their practice.

Method

The study consisted of two parts. In part one, the use of clinical reasoning by occupational therapists with different lengths of clinical experience was investigated. In part two, the undergraduate curriculum was analysed for theoretical concepts and those components that facilitate development of clinical reasoning skills.

Occupational therapists' clinical reasoning

Participants

A total of 12 occupational therapists with different lengths of clinical experience with inpatient rehabilitation services were recruited from five local rehabilitation hospitals. Six comprised the 'senior' group of three men and three women, with a mean age of 30.7 years (SD=1.0). Six comprised the 'junior' group, who were all women, with a mean age of 24.0 years (SD=0.9). All therapists were working in stroke rehabilitation programmes. The mean years of clinical experience for the 'senior' and 'junior' groups were 8.1 and 1.7 years respectively.

Procedure

The participating therapists were asked to complete Step I of the Canadian Occupational Performance Measure (COPM) (Law et al., 1994) to identify the problems in occupational performance of each of five clients under their case management. All the clients had had a stroke and none had been previously assessed with the COPM by their therapists. The whole procedure was conducted 5-10 days after the therapists received the referral for the particular clients, to ensure the therapists' equal understanding of their clients' problems and background. The standardized procedure of the COPM was followed in obtaining responses from the therapists on the problems that their clients might experience. After completing the COPM for one client, an in-depth interview was conducted with the therapist to obtain an explanation of the responses made on the COPM. The interview was carried out five times with participating therapists, once for each of their clients. A set of prompting questions was used to guide the process. The interview aimed to show the therapists' different ways of perceiving clients' problems, to identify the type of clinical reasoning used.

The sample prompting questions were:

How did you identify this clients problems?

When you said problems were important or unimportant for the client, what was on your mind?

When you came up with these problems for the client, what were you thinking of?

Let's recall what you have on the list. Can you think of what was on your mind?

The whole process was also audiotaped for analysis.

Instrumentation

Part I of the COPM was used to enable therapists to list the perceived problems of their clients.

Canadian Occupational Performance Measure

The Canadian Occupational Performance Measure (COPM) is `designed for use by occupational therapists to detect change in a client's self-perception of occupational performance over time' (Law et al., 1994: 1). The COPM is administered in a five-step process, which includes problem definition, problem weighting, scoring, reassessment and follow-up. In the first step that was adopted in this study, problem identification, the COPM `identifies problem areas in occupational performance' of the client (Law et al., 1994: 1). Because the study was not to compare problems of performance over time, scoring, reassessment and follow-up were not necessary.

A test-retest reliability study performed on a group of 27 clients of senior occupational therapists, where the clients had a variety of impairments, indicates that the instrument has good reliability for performance (intra-class correlation coefficients ICC=0.63) (Law et al., 1994). A validation study on clients of two diagnostic groups, orthopaedic and stroke (Chan, 1995; Chan and Lee, 1997), showed evidence of the content-related validity of the COPM, encompassing all three areas of occupational performance when clients are identifying their problems in occupational performance. It also showed evidence that clients' responses to problem identification on the COPM reflect their existing life roles and role expectations.

Protocol analysis

In reviewing the clinical reasoning styles used by the therapists, protocol analysis was adopted during the interview process.

Protocol analysis is based on the theoretical framework of human information-processing theory (Ericsson and Simon, 1980). The theory postulates a transformation process through which the sequence of internal states or thinking processes of an individual is transformed successively to form information structures. These information structures are available in the short-term memory and can be retrieved through verbalizations. Hence, the verbal protocols of individuals can reflect the ongoing cognitive processes in a clinical setting (Chan, 1995).

In this study, protocol analysis was used to elicit the clinical reasoning styles that occupational therapists used in perceiving clients' problems in occupational performance during the assessment by the COPM.

Data analysis

The qualitative data on protocol analysis of clients and therapists were transcribed from the audiotapes by the researcher. To ensure the accuracy of the transcription, a second reviewer was recruited to cross-check the transcripts by replaying the audiotapes. Thematic content analysis was used (Leininger, 1985). The theme for the content analysis of the data was developed from the three types of clinical reasoning methods used by the occupational therapists. Guidelines on classifying occupational therapists into the three types of clinical reasoning styles are:

1. Therapists who use procedural reasoning:

think at the disease or disabilities level, focusing on the problems of the physical body;

decide on particular procedures or treatment activities to maximize clients' functioning;

concentrate on dealing with clients' performance problems.

2. Therapists who use interactive reasoning:

intend to understand and interact with clients and see them as people and do not view them at the level of their disability;

interact with their clients to understand their needs;

are interested in knowing how their clients feel about the treatment.

3. Therapists who use conditional reasoning:

attempt to understand the whole person in the context of the life world, given the influence the disability may have on the client's future;

try to integrate procedural and interactive reasoning and place concerns in broader social and temporal contexts;

imagine how the condition of clients can change and become a revised condition;

consider clients' participation.

To confirm the interrater reliability on the content analysis, two occupational therapists with more than two years of experience in the field of physical rehabilitation were recruited and each completed the content analyses on the protocols of all 12 therapists. Per cent agreement was used to compare the coding of the two raters and the researcher by dividing the number of agreements by the total possible number of agreements (Portney and Watkins, 1993).

Occupational therapy undergraduate course content

Since their undergraduate education should affect therapists' use of clinical reasoning, especially for junior therapists, the undergraduate curriculum in occupational therapy offered in Hong Kong in 1995-97 was analysed to identify the major components that offered the transfer of theory into practice.

The analysis was based on the classification used by the curriculum. Subjects were classified into background-related knowledge (such as anatomy and neurological conditions), theory subjects (such as theories of occupational therapy), clinical subjects (such as occupational therapy applied to neurological conditions) and fieldwork practice. The credit points of the four categories were isolated to reflect the opportunities for integration of knowledge in the whole curriculum. Although the course had been upgraded to an honours degree course in 1998, the 1995-97 curriculum was used for the purpose of analysis as the junior therapists recruited in the clinical reasoning part of this study had completed their education during that period. In order to confirm the results of the analysis, a second reviewer was recruited to cross-check the results. The credit points of the subjects in the identified major components, and their respective weights in the course, were reported and compared.

Results

Clinical reasoning of occupational therapists

From the analysis of 60 clients' protocols from 12 occupational therapists, it was revealed that therapists applied procedural reasoning to analyse the problems of 18 clients (30%), interactive reasoning to 17 clients (28.3%) and conditional reasoning to 25 clients (41.7%). A therapist who used procedural reasoning gave the following explanation: `She does not have good bilateral hand use and her trunk control is just fair. So, she has problems in all activities such as dressing, toilet use, bathing, cooking, shopping.'

The typical explanation provided by a therapist using conditional reasoning was as follows: `She doesn't have good standing balance. She has her maid to help in the household chores. So, independence in self-care activities is the treatment priority.'

About 74% of the senior therapist group used conditional reasoning, compared with only 10% in the junior group. Sixty per cent of the therapists in the junior group used procedural reasoning, compared with none of the senior group.

Reliability of content analysis of therapists' clinical reasoning

The percentage of agreement on the classification of the therapists into three types of clinical reasoning by the researcher and the two raters ranged from 0.82 to 0.87, indicating good interrater reliability on the content analysis.

Content of occupational therapy undergraduate courses

From the analysis of the 1995-97 occupational therapy undergraduate curriculum, four major components were identified: `background-related knowledge', `occupational therapy theory subjects', `occupational therapy clinical subjects' and `fieldwork practice'. The elective subjects and those that were related to the use of languages were classified as 'others'. Percentages were used to determine the respective weights of the credit points of the four major components.

Subjects in background-related knowledge included anatomy, physiology, psychology, medical conditions, management and research, which accounted for 38.8% of the course. The proportion of the occupational therapy theory subjects such as occupational therapy theory and process, the clinical subjects such as occupational therapy for physical dysfunction, and fieldwork practice were: 18.6% in the theory subjects, 14.0% in the clinical subjects, and 18.6% in fieldwork practice.

Discussion

Conditional reasoning was mostly used by the senior therapists (73.3% of therapists in the senior group versus 10.0% in the junior group), whereas procedural reasoning was used only by the therapists in the junior group (60.0% of therapists in the junior group versus 0% in the senior group). This finding is similar to the results of other studies on clinical reasoning (Mattingly and Fleming, 1994; Alnervik and Sviden, 1996). Therapists in their early years of practice tend to use procedural reasoning. It is not until they have more adequate clinical experience that they shift to using conditional reasoning. When using conditional reasoning, therapists spent more effort integrating clients' deficits into their life roles. This approach coincides with the theoretical framework and practices of the Model of Occupational Performance (Canadian Association of Occupational Therapists, 1991). In contrast, this study shows that therapists who used procedural reasoning focused on clients' functional problems and level of independence, and seemed to put less emphasis on clients' life roles and environment. As a result, they used a disease-oriented model as their theoretical frame of reference and adhered to standardized clinical protocols.

Analysis of the curriculum indicated that, in the three-year undergraduate course, the occupational therapy students were first equipped with background knowledge of human anatomy, psychology and pathology, together with occupational therapy theories, before taking up the clinical subjects such as occupational therapy for physical dysfunction. The clinical subjects were divided by clinical conditions such as physical and psychiatric dysfunction and based on the lifespan approach with paediatric and geriatric conditions. The blocks of fieldwork practice were integrated into the curriculum. The length of the blocks progressed from two weeks to nine weeks, with a heavier load towards the final year. The curriculum design of the local university was found to be similar to those of universities overseas. For example, one university in the USA puts more emphasis on background-related knowledge, whereas for occupational therapy theory subjects, clinical subjects and fieldwork practice, the proportions are similar (Table 1).

In developing clinical reasoning, it is crucial for students to master the knowledge base and establish their competence in integrating their knowledge into practice. In the curriculum, the components of the clinical subjects and the fieldwork practice were important in this process. The clinical subjects provide the opportunity for students to apply what they had learnt in terms of theories, clinical and technical knowledge and professional practices to actual case management. The limitation of these clinical subjects is that the students learn the knowledge on paper and by case discussion. They do not have direct contact with the clients for intervention implementation and interactive evaluation of its outcome. Because of the lack of feedback mechanism, students tend to develop the procedural reasoning style rather than the interactive or conditional reasoning styles, which demand an input from and interaction with the clients.

TABLE 1:

The fieldwork practicums therefore are regarded as the major channel through which occupational therapy students integrate knowledge into practice. A well-designed fieldwork practice better prepares novice therapists to choose the appropriate clinical reasoning styles to match with clients' needs. The clinical placements offered by the local curriculum are relatively short, the longest being only nine weeks. The longer placements give students ample time to grasp the basic clinical routine required by the setting before developing the appropriate clinical reasoning skills. Very often, the placement ends when students start to grasp simple reasoning skills. By comparison, other curricula in the USA offer longer clinical placements such as 12 weeks towards the end of the programme. However, a short placement usually does not allow the development of clinical reasoning skills to be accomplished at the desirable level of competence.

The development of clinical reasoning follows a continuum from novice to expert with the accumulation of the clinical experience (Benner, 1984; Slater and Cohn, 1991; Dutton, 1995; Neistadt, 1996). According to Dutton (1995), a novice therapist is less flexible in applying the rules and principles learnt in school without considering the circumstances of the particular case when compared with the expert counterpart. Expert therapists seem to be able to organize their approach more from clients' cues than from preconceived plans of treatment. They are able to recognize clients' problems and potential by relating past and present experiences to set realistic goals with their clients. It is a normal development process for newly graduated therapists to practice to move from being novice to experts and to develop competence in using appropriate clinical reasoning styles with different clients. However, other studies showed that this process could be facilitated when novice therapists went through a curriculum that prepared them with the awareness of the types of reasoning and their practices (Benner, 1984; Neistadt, 1996).

The two strategies in curriculum design can be adopted. These are the use of problem-based learning and the lengthening of the fieldwork practice. These help to better choose the type of clinical reasoning to match the clinical disease. Because the medical system is adopting a client-centred approach, the provision of healthcare services should be geared towards clients' individual needs that result from their disease (Blank et al., 1995; Coles, 1995; Duffy and Lemineus, 1995; Luban-Plozza, 1995). The occupational therapy curriculum is also changing its structure to cope with today's need for client-centred practice-ready graduates. Therefore, practice-related and contextual problembased learning is an approach that appeals to today's occupational therapy education (Vroman and MacRae, 1999). These lifelong and self-directed learning skills enable students to attain a high level of clinical competence years after their graduation (Chan et al., 1999). With a higher level of clinical competence, therapists make the transition from novice to expert more smoothly and thus are more ready to use more desirable clinical reasoning. Examples of occupational therapy educational programmes that are based on problem-based learning are those at McMaster University in Canada, and Shenandoah University and the University of New Mexico in the USA (Watson and West, 1996; Royeen and Salvatori, 1997). However, as pointed out by Vroman and MacRae (1999), the definition of problem-based learning varies from programme to programme. No matter what the definition is, the primary outcome is that students learn to synthesize knowledge for practice in the occupational worlds of their clients, influenced by the level of impairment and handicap (Vroman and MacRae, 1999). This helps students to choose the appropriate clinical reasoning that matches well with clients' needs.

The revised curriculum offered in the Hong Kong Polytechnic University since 1998 incorporates the concept of problem-based learning and lengthens the period of fieldwork practice to help students to refine their clinical reasoning skills and to develop lifelong learning skills in helping clients to resume productive lives. The use of problem-based learning helps students to direct their interests and skills to solving the problems of a particular client or type of client. With the lengthened fieldwork practice, students' skills in applying knowledge to practice can be refined.

Conclusion

In occupational therapy, clients' life contexts and the disease process are important considerations. The use of appropriate clinical reasoning is essential for clients with different disabilities and stages of disease. The current occupational therapy education, which builds the application to case management on basic knowledge in pathology and occupational therapy theory, aims to develop competent, practice-ready therapists. However, new graduates or students may find it difficult to transfer this knowledge into practice. They may not be able to select appropriate clinical reasoning for different clients and thus the service they provide to clients is not person-specific.

To help new graduates and students to focus on the specific problems that are related to clients' problems and to use an appropriate clinical reasoning style, it is suggested that students' fieldwork practice be long enough to allow them sufficient time to practise and refine their clinical reasoning skills. It is further suggested that practice-related contextual problem-based learning be incorporated into the occupational therapy curriculum. Problem-based teaming helps students to develop lifelong learning skills in integrating pathology and occupational therapy theory, and to focus on clients' specific needs in their life contexts resulting from the effect of the disease. Although the use of more desirable clinical reasoning is largely affected by therapists' clinical experience, it is postulated that problem-based learning reinforced by fieldwork practice promotes therapists' transition from being novices to experts, and hence improves the competence of less experienced students and clinicians at using the appropriate clinical reasoning style.

References

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