1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 1 Professional Reasoning as the Basis of Practice Barbara A. Boyt Schell John W. Schell

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Professional Reasoning Research Rogers & Masagatani (1982): Research how clinical decisions were made –Therapists often could not explain what they had done (or why) Rogers’ Eleanor Clark Slagle Lecture at AOTA (1983) –Aware of emerging research in cognitive science & medicine

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Professional Reasoning Research (Con’t) AJOT Special Issue on Clinical Reasoning (1991) –Enlarges research focus in OT field Based on Schön (The Reflective Practitioner, 1983) –Commonalities in practice among professions –AOTF & AOTA funded the Clinical Reasoning Study (Mattingly & Fleming, 1994) Mattingly & Fleming (1994) publish –Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins History of Professional Reasoning Research (Con’t) More than 50 books & articles published in recent years The current text –Unit I – Describes the nature of clinical and professional reasoning –Unit II – Summarizes clinical & professional reasoning in OT –Unit III – Identifies implications for OT education for: curriculum planning, classroom teaching, fieldwork education, & professional development –Unit IV – Summarizes the state of literature, identifies future directions for research

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thinking About Thinking “There is a high hard ground where practitioners can make…use of…theory & technique, & there is the swampy lowland where…confusing “messes” [are] incapable of technical solution. The…problems of the high hard ground…are…relatively unimportant…while in the swamp are…problems of greatest human concern” (Schön, 1983, p. 42)

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Definitions of Clinical & Professional Reasoning (C&PR) “The process used by practitioners to plan, direct, perform & reflect on client care” (Schell, 2003, p. 131) Professional reasoning is added because: –It broadens the discussion to: Nonmedical environments such as schools & community settings Reasoning done by supervisors, fieldwork educators, & OT managers

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thinking in Context The thinking that guides practice is: –The interplay among the person, the context, & specific therapy tasks Theories about C&PR are focused on therapists & how they provide therapy

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thinking in Context (Con’t) Some practice decisions are easy: –Scientific or technical information is applied Most decisions require nuanced decisions & actions C&PR research attempts to: –Identify the “high hard ground” of therapist thinking –Surface the “swampy lowland” where most live Current research does not reach the complexities of C&PR in real life

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thinking in Context (Con’t) This book seeks to promote C&PR research using: –“Hard” & –“Soft ground” methodologies

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Views of Clinical & Professional Reasoning C&PR topical areas are: –Scientific reasoning –Diagnostic reasoning –Procedural reasoning –Narrative reasoning –Pragmatic reasoning –Ethical reasoning –Interactive reasoning –Conditional reasoning Many different perspectives exists on the nature & process of C&PR (Rogers, 1983; Mattingly & Fleming, 1994; Schell & Cervero, 1993; Rogers & Holms, 1991)

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Scientific Reasoning Description & FocusClues for Recognizing in Therapist Discussions Reasoning involving the use of applied logical & scientific methods, such as hypothesis testing, pattern recognition, theory-based decision making, & statistical evidence Impersonal; focused on the diagnosis, condition, guiding theory, or evidence from research or what “typically” happens with clients like the one being considered

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnostic Reasoning Description & FocusClues for Recognizing in Therapist Discussions Investigative reasoning & analysis of cause or nature of conditions requiring occupational therapy intervention; can be considered one component of scientific reasoning Uses both personal & impersonal information; therapists attempt to explain why client is experiencing problems using a blend of science-based & client-based information

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Procedural Reasoning Description & FocusClues for Recognizing in Therapist Discussions Reasoning in which therapist considers & uses intervention routines for identified conditions; may be science based or may reflect the habits & culture of the intervention setting Characterized by therapist using therapy regimes or routines thought to be effective with problems identified & that are typically used with clients in that setting; tends to be more impersonal & diagnostically driven

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Narrative Reasoning Description & FocusClues for Recognizing in Therapist Discussions Reasoning process used to make sense of people’s particular circumstances; prospectively imagine the effect of illness, disability, or occupational performance problems on their daily lives; & create a collaborative story that is enacted with clients & families through intervention Personal; focused on the client, including past, present, & anticipated future; involves an appreciation of client culture as the basis for understanding client narrative; relates to the “so what” of the condition for the person’s life

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Pragmatic Reasoning Description & FocusClues for Recognizing in Therapist Discussions Practical reasoning that is used to fit therapy possibilities into the current realities of service delivery, such as scheduling options, payment for services, equipment availability, therapists’ skills, management directives, & the personal situation of the therapist Generally not focused on client or client’s condition, but rather on all the physical & social “stuff” that surrounds the therapy encounter, as well as the therapist’s internal sense of what he or she is capable of & has the time & energy to complete

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Ethical Reasoning Description & FocusClues for Recognizing in Therapist Discussions Reasoning directed to analyzing an ethical dilemma, generating alternative solutions, & determining actions to be taken Systematic approach to moral conflict; tension is often evident as therapist attempts to determine what is the “right” thing to do, particularly when faced with dilemmas in therapy, competing principles, risks, & benefits

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Interactive Reasoning Description & FocusClues for Recognizing in Therapist Discussions Thinking directed toward building positive interpersonal relationships with clients, permitting collaborative problem identification & problem solving Therapist is concerned with what client likes or doesn’t like; use of praise, empathetic comments, & nonverbal behaviors to encourage & support client’s cooperation

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Conditional Reasoning Description & FocusClues for Recognizing in Therapist Discussions A blending of all forms of reasoning for the purposes of flexibly responding to changing conditions or predicting possible client futures Typically found with more experienced therapists who can “see” multiple futures, based on therapists’ past experiences & current information

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Putting Reasoning in a Larger Context Brief overview of selected C&PR contributors –Purpose is to highlight key researchers & concepts shaping current C&PR thinking

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Selected Contributors Aristotle Darwin Gestalt & Bruner Paget Vygotsky Lave & Wenger

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributor: Aristotle Artisans’ work involved thinking & reasoned action –Actions taken within artisan’s “praxis” –Praxis is reasoned actions taken to accomplish a specific task

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributor: Darwin Theory of evolution –Humans as “biologically continuous” with animal kingdom –Human progression as basis of learning & thinking –Strong influence on development of behaviorism & developmental psychology

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributors: Gestalt & Brunner Classical theories of psychology emerged –Gestalt theories focused on patterns & structured experiences –Brunner introduced schemes to illustrate cognitive structures

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributor: Piaget Assumed learning as an artifact of biologic functioning –Research focused on “mental or cognitive structures” as the way children organize their minds –Stages of human development

25. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributor: Vygotsky Examined the use of knowledge within social structures –Human development as social interaction –Zones of proximal development (ZPD)

26. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Contributors: Lave & Wenger Emphasis on context & social engagement –Situated cognition –Communities of practice

27. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Reasoning in a Social World 20th-century researchers: Social relationships form basis of human thinking & reasoning –Ricœur influenced Heidegger, Gadamer, Merleau-Ponty, Sartre, & Schütz Examined conscious existential experience for understanding actions of individuals –Schütz emphasized “lived experiences” through “flowing consciousness” as they passed from experience into memory

28. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Reasoning in a Social World: Schön Reflective practice & organizational “systems of learning” –An avid jazz musician Jazz improvisation perhaps led to ideas about “thinking in the moment” Origins of “reflection in action” & “reflection on action”

29. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Reasoning in a Social World: Dreyfus & Dreyfus (Athanasiou) Mind over Machine (1986) –Influenced researchers in many professions How experts shape novices who become experts Five stages of expertise: –Novice –Advanced beginner –Competent –Proficient –Expert

30. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Reasoning in a Social World Many writers have influenced present-day thinking –Dewey, Lewin, Rogers, & Kolb have significantly contributed –“Thinking about thinking” has been handed down by several generations of researchers & practitioners