Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: https://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 (2016) Occupational science: An important contributor to occupational therapists’ clinical reasoning, Scandinavian Journal of Occupational Therapy, 23:3, 240-243, DOI: 10.3109/11038128.2015.1083054 To link to this article: https://doi.org/10.3109/11038128.2015.1083054

Published online: 22 Sep 2015.

Submit your article to this journal

Article views: 4137

View related articles

View Crossmark data

Citing articles: 2 View citing articles

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iocc20 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY, 2016 VOL. 23, NO. 3, 240–243 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, and 4Department of Social Medicine and Rehabilitation, Faculty of Health Sciences, University of Aarhus, Denmark

Introduction based on biomedical, social, and humanistic knowledge and the profession’s practice is supported by research The influence of occupational science is evident in the based on both qualitative studies and quantitative studies. theoretical and research-based knowledge base within Some occupational therapist researchers argue that occupational therapy. Moreover, studies show that knowledge derived from qualitative research is crucial in contributions from occupational science are also a client-centred practice (7–10). The demand for know- reflected in clinical reasoning – a key occupational ledge developed by means of qualitative methods opposes therapy competence – as well as in values and practice. relying solely on the notion of high evidence according to Clinical reasoning is regarded as a core element of health the evidence hierarchies and gives rise to discussions of professional practice and provides a link between how to evaluate evidence (11–13). Consequently, whether research and practice. Therefore, it is important that evidence-based practice represents adequate respect for occupational therapists endeavour constantly to develop patients’ preferences and rights is under discussion. their knowledge of occupational science literature and clinical reasoning competence. Occupational science Likewise, there is a debated argument about the extent provides targeted and up-to-date research findings that to which practice-based experience is considered on an contribute to the development of occupational therapists’ equal footing with research-based evidence. Some OTs are reasoning in education and practice. demanding a higher level of recognition and integration Occupational therapy is founded on both scientific and of practice-based knowledge (14,15). The purpose of this professional knowledge – the latter acquired through contribution is to debate ways in which occupational practice, – and is based on biomedical, social, and science could contribute even further to occupational humanistic theory (1–3). Growing demands are placed therapists’ clinical reasoning and inform the occupational on health professionals to develop and demonstrate therapy curriculum. professional quality. There is a steadily growing engage- First, we discuss the role of occupational science, and ment by occupational therapists (OTs) in international then its impact on clinical reasoning. Next, we discuss discussions regarding how to implement evidence-based the interrelationship between occupational science and occupational therapy. It is becoming increasingly urgent theory and finally we discuss the connection to the for OTs to develop evidence-based practice that will occupational therapy curriculum. embrace all aspects of their practice. The biomedical approach, which relies principally on scientific research Occupational science as an important ranked in evidence hierarchies (4,5), is still the tendency knowledge source for occupational therapy in evidence-based practice, despite the emphasis placed on the value of clinical expertise and patients’ preferences In occupational therapy, health and well-being are by, for example, Sackett (6). The biomedical approach considered to be strongly influenced by choice, control, represents significant challenges for OTs in practice, in and the ability to engage in everyday life occupations. education, and in research. Occupational therapy’s foun- Occupational science was established by OTs and dation of professional knowledge is considered to be 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] ß 2015 Taylor & Francis SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 241 occupational being, including the need for, and capacity Clinical reasoning underlies occupational to engage in and orchestrate, daily occupations in the therapy practice environment over the lifespan (16). Hence, occupational Clinical reasoning has been defined as a context- science makes a connection between engagement in dependent way of thinking and decision-making in occupation and human development, well-being, and professional practice to guide practice utilising core health (17). Therefore, occupational science is a particu- dimensions of practice knowledge, reflexivity, reasoning, larly important knowledge source in occupational prac- and metacognition (26). In occupational therapy clinical tice, education, and research. reasoning is an essential skill and central to the quality of Research discussions strengthen OTs’ critical reflec- practice, as it enables OTs to make the best professional tions regarding their profession and give access to updated decisions in relation to individual patients. Moreover, the research results and theory that inform their practice. In recent decades, discussions within occupational science OT’s personality and life story come into play, along with have focused increasingly on the impact of cultural and practical experience, theoretical and research-based social factors. In 2000, Hocking called attention to the fact knowledge, and the patient’s needs, preferences, and that the concept of ‘occupation’ was characterised as quite situation (15). Besides, professional dialogues behind the individualistic and largely health-focused (18). The same development of evidence-based practice could be issue is discussed by Dickie et al. (19), who state that enriched by including the practice knowledge and clinical occupational science would benefit from even further experience that are developed in clinical contexts (28). investigation into, and interpretation of, how occupations In a 2012 Danish study of OTs’ clinical reasoning that are integrated with social relationships, cultural contexts, focused on the implementation of evidence-based prac- and community actions. Leclair later points out that tice, Kristensen, Borg & Hounsgaard found interactions occupations can be shared among individuals, groups, and between OTs’ clinical reasoning and the scientific know- communities (20). Rudman and Dennhardt (21) discuss ledge that is developed in occupational therapy and yet another issue related to the concept of occupation. occupational science. OTs in both hospital and commu- They argue that occupation, as defined within contem- nity settings reflected on their reasoning-based profes- porary occupational therapy models, is a basic need of all sional values that were consistent with the profession’s people, regardless of culture. Rudman and Dennhardt core values, as set out in the conceptual models and claim that, even though culture is increasingly recognised frameworks published by Gary Kielhofner and Canadian as having a profound influence on occupation, there has occupational therapists (15). Across rehabilitation con- been little critical reflection on the cultural underpinnings texts, it was found that OTs considered it important to of central occupational concepts. Hammell (22) also ensure that patients and their relatives had the oppor- argues that scientific and professional integrity requires a tunity to take an active part in their own rehabilitation, sceptical approach and a sound evidence base. Both and that a shared understanding and sense of the patient’s Hammell (22) and Hocking (23) draw attention to the fact future was established. OTs recognised that patients that most influential occupational therapy theories have attributed specific significance to occupations that were been developed in urban areas of the English-speaking meaningful to them, and that this was closely linked to the nations of the Western world; from a global perspective, individual’s situation, contexts, and cultural background this reflects only minority viewpoints. In line with this, (15). These findings call for further theories and evidence Pollard et al. advocate that occupational science should be within the occupational therapy community that offer the theoretical basis of evidence of practice changes, from insight into the perspectives of ill and disabled people and, their critical standpoint and focus on social changes and moreover, are informed by a wide range of cultural, social, occupational justice (24). These discussions reflect the and geographical contexts. need for further research into, for example, the diversity of occupational engagements, and this would inform OTs’ The dynamic relationship between occupational practice and education. While OTs in Scandinavia have science and occupational therapy theory welcomed development and discussions around occupa- tional science (25), the science is yet to be implemented or In its development of knowledge related to the complex- integrated to any great extent in practice, education, or ities of human activity, occupational therapy research is Nordic research. Occupational therapy interventions guided by three main assumptions: people as active could benefit greatly from the knowledge and evidence entities, the relationship between activity and health, and generated within the occupational science community – if the importance of context (2). First, people are regarded as our aim is to provide up-to-date, client-centred occupa- active beings with abilities and the need to participate in tions-based therapy. activities and to express themselves through the things 242 H. K. KRISTENSEN & K. S. PETERSEN they do. Second, the relationship between activity and how to think like an OT and how to make clinical health is of paramount importance, because human decisions in practice. Based on the statement that activities either sustain or undermine health and well- ‘clinical reasoning is recognized as the core of occupa- being, and, conversely, one’s health condition either tional therapy practice’ (26), and client-centred practice allows or prevents participation in activities. The links is best embodied by occupation-focused interventions in between health and occupation are central in a number of the natural environment of everyday living (27), occupational science studies; among others the works of Mattingly and Fleming developed a terminology made Professor Ann Wilcock are valuable in informing and up of both terms used informally by OTs and terms developing occupational therapy theory and conceptual borrowed from other disciplines. This terminology models. The third assumption deals with the importance quickly became familiar in occupational therapy com- of the environment or the context in which people find munities (29) and has provided inspiration to OTs in the themselves. Elizabeth Yerxa contributed to the recogni- development of occupational therapy curricula and in tion of the role of the environment in connection with the their research. Moreover, ethical reasoning is closely establishment of research in occupational science. She linked to client-centredness and is informed by the stated that therapists should recognise that a host of concept of occupational justice developed by Ann factors, such as other people, the weather, cultural and Wilcock and Elizabeth Townsend, both of whom have religious beliefs, economics, space and resources, and the contributed to its the development and exploration (30). natural environment among many other factors inform Moreover, Gail E. Whiteford has thrown light on how we act (16). occupational deprivation as a condition in which This notion that occupations are performed in a people are constrained in, or excluded from, engagement particular historical and cultural context is key to the in meaningful and purposeful occupations due to social, holistic approach in occupational therapy practice and political, or economic factors beyond their control (31). education. The influence of occupational science is not Both concepts have informed client-centred occupational only clearly reflected in the profession’s theoretical and therapy as clients’ roles, interests, environments, and research-based knowledge, but also in OTs’ professional culture are central in order to enable participation in core competencies and values, and in their practice. everyday lives. Occupational therapy reference frameworks consist of More research on the meanings of occupations is sets of interrelated theories and concepts that determine important for occupational therapy as a health care how specific, occupation-based challenges are explained profession. In this development occupational science and approached (18). OTs use multiple frames of may include explorations of the relationship between reference in their practice. The choice of frame of occupation and development, how occupation changes reference is influenced by the local culture, the over the lifespan, how people organise and engage in individuals to whom the therapy is directed, and the their daily occupations, and the personal and socio- individual OT’s experience and values. The OT will cultural meanings of occupation (32,33). Occupational plan and perform any intervention based on a selected science could more specifically contribute to the devel- frame of reference. In this way, the choice of reference opment of occupational therapy paradigms by generat- has an impact on the way the OT performs clinical ing knowledge and evidence of the interplay between the reasoning, and the steps involved in the reasoning individual, groups, communities, and social, political, process. As stated by Gupta & Taff, services that are and cultural contexts. As a consequence, occupational impairment-focused and provided in unfamiliar settings are not appropriate to client-centred practice. Rather, science research should play a more central role in client-centred practice is best embodied by occupation- occupational therapy education programmes at all levels, focused interventions in the natural environment of from bachelor to PhD level. everyday living (2). This would suggest that the occupational therapy profession is dependent on know- Declaration of interest ledge generated from occupational science if its core The authors report no conflict of interest. The authors alone elements are not to be in jeopardy. are responsible for the content and writing of the paper.

Clinical reasoning and occupational science References inform the occupational therapy curriculum 1. Mattingly C, Fleming M. Clinical reasoning. Forms of As a key element clinical reasoning has implications for Inquiry in a Therapeutic Practice. F. A. Davis Company, occupational therapy education, as it helps students learn 1994 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 243

2. Kielhofner G. Conceptual Foundations of Occupational 18. Hocking C. Occupational science: A stock take of Therapy. 4th edition, Philadelphia: FA Davis Company; accumulated insights. J Occup Sci 2000;7:58–67. 2009 19. Dickie V, Cutchin MP, Humphry R. Occupation as 3. Townsend EA, Polatajko HJ. Enabling Occupation II. transactional experience: A critique of individualism in Advancing an Occupational Therapy Vision for Health, occupational science. J Occup Sci 2006;13:83–93. Well-being, & Justice through Occupation. CAOT 20. Leclair LL. Re-examining concepts of occupation and Publications ACE. 2007 occupation-based models: Occupational therapy and 4. Upshur REG, Van Den Kerkhof EG, Goel V. Meaning and community development. Can J Occup Ther 2010;77: measurement: An inclusive model of evidence in health 15–21. care. J Eval Clin Pract 2001;7:91–6. 21. Rudman DL, Dennhardt S. Shaping knowledge regarding 5. Rycroft-Malone J, Seers K, Titchen A, Harvey G, occupation: Examining the cultural underpinnings of the Kitson A, McCormack B. What counts as evidence in evolving concept of occupational identity. Aust Occup evidence-based practice?. J Adv Nurs 2004;47:81–90. Ther J 2008;55:153–162. 6. Sackett DL, Rosenberg WMC, Gray JAM, Haynes R, 22. Hammell KW. Sacred texts: A sceptical exploration of the Richardson WS. (2000) Evidence based medicine: How to assumptions underpinning theories of occupation. Can J practice and teach EBM. Churchill Livingstone. Occup Ther; 2009;76:6–13. 7. Egan M, Dubouloz CJ, von Zweck C, Vallerand J. The 23. Hocking C. Occupations through the looking client-centred evidence-based practice of occupational glass: Reflecting occupational science ontological assump- therapy. Canadian Journal of Occupational Therapy tions. In: Whiteford GE, Hocking C, eds. Occupational 1998;65:136–43. Science. Society, Inclusion, Participation Wiley-Blackwell. 8. Hammell KW. Using qualitative research to inform the 2012;54–66. client-centred evidence-based practice of occupational 24. Pollard N, Sakellariou D, Lawson-Porter A. Will occupa- therapy. British Journal of Occupational Therapy, tional science facilitate or divide the practice of occupa- 2001;64:228–34. tional therapy?. Int J Ther Rehabil 2010;17:40–47. 9. Rappolt S. The role of professional expertise in evidence- 25. Bendixen HJ, Nielsen LM. Aktivitetsvidenskab. In: Brandt, based occupational therapy. The American Journal of Å, Madsen AJ, Peoples H, eds. Basisbog i ergoterapi. 3. Occupational Therapy 2003;57;589–93. udgave. København:Munksgaard; 2013;411–26. 10. Reagon, C, Bellin, W, Boniface, G. Reconfiguring evi- 26. Chapparo C, Ranka J. Clinical reasoning in occupational dence-based practice for occupational therapists. therapy. In: Higgs J, Jones MA, Loftus S, Christensen N, International Journal of Therapy and Rehabilitation eds. Clinical reasoning in the health professions. Third 2008;15:428–36. Edition, Butterworth Heinemann Elsevier. 2008. 11. Hayes RL. Evidence-based occupational therapy needs 27. Gupta J, Taff SD. The illusion of client-centred practice. strategically-targeted quality research now. Australian Scand J Occup Ther 2015;12:1–8. (Epub ahead of print). Occupational Therapy Journal 2000;47:186–90. 28. Kielhofner G. Scholarship and practice: Bridging the 12. Tickle-Degnen L, Bedell Client-centred practice, thera- divide. Am J Occup Ther 2005;59:231–239. peutic relationship, and the use of research evidence. 29. Mattingly C, Fleming M, Gilette N. Narrative explorations American Journal of Occupational Therapy 2002;56: in the tacit dimension: Bringing language to clinical 470–4. 13. Tuntland H. Hvordan bli en kunnskapsbasert practice. Nordiske Udkast 1997;1:65–77. yrkesutøver. Ergoterapeuten 2008;1–6. 30. Townsend E, Wilcock A. Occupational justice. In: 14. Cusick A, McCluskey A. Becoming an evidence-based Christiansen C, Townsend E, eds. Introduction to occu- practitioner through professional development. Aust pation: The art and science of living. Upper Saddle River, Occup Ther J 2000;47:159–70. NJ: Prentice Hall; 2004. 15. Kristensen HK, Borg T, Hounsgaard L. Aspects affecting 31. Whiteford G. Knowledge, power, evidence: A critical occupational therapists’ reasoning when implementing analysis of key issues in evidence based practice’’. I: research-based evidence in stroke rehabilitation. Scand J Whiteford G, Wright-St Clair V, eds. Occupation & Occup Ther 2012;19:118–31. Practice in Context. Sydney: Elsevier Churchill 16. Yerxa EJ, Clark F, Frank G, Jackson J. An introduction to Livingstone; 2004;34–50. occupational science, a foundation for occupational 32. Pierce D. Promise. J Occup Sci 2012;19:298–311. therapy in the 21st century. Occup Ther Health Care 33. Ikiugu MN, Pollard N. Meaningful Living across the 1990;6:1–17. Lifespan: Occupation-based intervention strategies for 17. Jonsson H. A New Direction in the Conceptualization and occupational therapists and scientists. Critical Studies in Categorization of Occupation. Journal of Occupational Occupational Therapy & Occupational Science. Whiting Science 2008;15:3–8. & Birk Ltd. 2015.