The nature of professional practice

Occupational therapy is an important profession to society. Therefore, we commence our investigation of occupational therapy practice by considering the nature of professional practice more generally, beginning with the question: what does it mean to be a professional? According to Coles (2002), “society asks certain of its members to be professionals – to undertake certain tasks and perform certain roles that others cannot or will not do” (p. 3). This definition associates professionalism with social roles. Blair (1998) defined social role as guiding “the behaviour expected of an individual because of the social status occupied. For example, the behaviour expected of a health professional is specific expertise and proven ability to alter the illness or problem experienced by an individual” (p. 45). The social status that Blair mentions refers to both rights and obligations that are afforded on the basis of professional status.

Professionals like occupational therapists have a particular place in the social hierarchy, in that they are expected to perform tasks that others are not expected to perform and they have certain rights and obligations that others don’t have. These rights include higher levels of financial remuneration and greater autonomy, for which society expects a higher level of expertise (obligations). This expertise relates to both skills and knowledge, in that particular professions often claim particular skills as exclusive to that profession and each profession has to demonstrate a particular and extensive knowledge base that others in society would not normally be expected to possess.

Professions also are afforded a level of autonomy, in that professions are not expected to detail everything they do and the reasoning behind those actions. This is partly because their reasoning is expected to be based on their extensive and particular knowledge base. It follows, then, that only others who have that same knowledge base can fully understand what is required of and appropriate to that particular profession. Therefore, professions are expected to engage in self-regulation (Coles, 2002).

Fish and Coles (1998) summed up well the status of professions in our society in the following statement:

Professionals are expected to be trustworthy, and in their turn they expect to receive the public’s trust in them. In return professionals were prepared to undertake a lengthy period of education, which for many was particularly protracted in order for them to gain higher professional qualifications. They were prepared to commit considerable amounts of time and effort to their work. They did not watch the clock, or do it for the money. They did more than was asked of them. They went further than their contracts of employment. All because they felt it was right to do so. They were professionals. They stood somewhat apart from the rest of society. They took on a professional role. And in recompense for their personal commitment, society gave them professional status, a greater than average income. For this society expected high ethical standards of course, and the maintenance of confidentiality. The tacit agreement was this: society would trust professionals if they could be trusted. (p. 4)

One way that professions demonstrate their trustworthiness is through the development of codes of ethics. These are statements of the types of behaviours that can be expected of members of that particular profession. Often professionals have access to privileged and sensitive information and they need to be able to assure society that they will deal with this information properly. In the context of the helping professions, this sensitive information usually relates to those receiving services, that is, clients. For example, clients often have to disclose very personal information about themselves to professionals and might have to participate in activities (such as having a person they don’t know very well toilet or shower them) which require a higher level of physical contact than they would have with many people they know very well. Therefore, the codes of ethics of the helping professions detail the nature of the relationships in which professionals will and will not engage, how the rights of those people receiving services will be upheld and protected, and how information relating to those people will be handled. Consequently, codes of ethics usually contain statements about respecting clients and their privacy, maintaining relationships that have appropriate boundaries and that acknowledge the power imbalance inherent in professional relationships, and providing competent and effective services.

The purpose of codes of ethics is associated with the autonomy afforded and self-regulation expected of professions. While codes of ethics are necessary for outlining the behaviours that society should be able to expect from professionals, they only provide the foundation for self-regulation. The reputation of a profession is dependent on the degree to which the behaviours outlined in these codes are adhered to by individual professionals and the support for professional standards that is provided by regulatory bodies.

Another distinguishing feature of professional practice is the expectation that professionals are able use judgement to determine the best course of action in any given situation. As professionals are asked to deal with complex situations and problems, professionals are expected to use their judgement to discern when to apply which procedures (and when to refrain from applying those procedures). Often, the ability to use a high level of judgement is the criterion used to distinguish between professionals and technicians, where technicians might have a high level of technical expertise but not the knowledge base required to make such judgements. For professional practice, it is not enough to have only the technical skills required to carry out a particular range of procedures, although these skills are necessary. Professionals are expected to use their extensive knowledge and apply this knowledge in different settings to address problems that present in a particular situation.

The primary purpose of this expert judgement is to make decisions about a course of action. Society expects professionals to be able to make decisions about action. Carr (1995) emphasized that professional action is not ‘right’ in an absolute sense (of there being a right thing to do) but that it is right when it is “reasoned action that can be defended discursively in argument and justified as morally appropriate to the particular circumstances in which it was taken” (p. 71, italics in original). Higgs et al. (2001) referred to professional practice as requiring “thoughtful action” (p. 5) in which professionals need to be able to take action to relieve or improve problems that clients encounter. Thus, the purpose of using professional judgement is to determine action that is reasoned and thoughtful.

Professionals are expected to use their profession’s knowledge base as a foundation for their judgements. Having a unique knowledge base is central to the notion of profession. As Higgs et al. (2001) described:

A ‘profession’ is an occupational group that is able to claim a body of knowledge distinctive to itself, whose members are able to practice competently, autonomously and with accountability, and whose members contribute to the development of the profession’s knowledge base. In the emergence of the health occupations as professions, propositional knowledge, derived from research and scholarship, was sought to provide the foundation of the professions’ knowledge base and their theory for practice, and to establish the professions’ status and credibility. (p. 4)

Traditionally, the ability to make professional judgements about appropriate action has been conceptualized as a process of applying theory, given that professionals are expected to possess extensive theoretical knowledge. However, this assumption has been questioned. Mattingly and Fleming (1994) stated of occupational therapists:

While [they] sometimes speak of clinical reasoning as the application of theory to practice, this is a deceptive statement. A grounding in theory is essential for expert practice but does not guarantee such practice. One cannot do without such grounding, but it, alone, will not yield good clinical interventions, because theoretical reasoning differs from practical reasoning. (p. 9)

If, as Mattingly and Fleming (1994) argued, theory is essential for professional practice but insufficient to guarantee expert practice, then professionals might need a range of different types of knowledge and skills to support their practice. As professionals need to both make judgements and engage in reasoned action, they need information that supports them to gain an expert understanding of the overall situation as well as information that provides the basis for judgements about action.

In Chapter 1, we discussed three different types of knowledge that professionals use, which could be categorized as either propositional or non-propositional knowledge. All three types of knowledge are necessary for expert and well-reasoned professional practice. By understanding the general principles conveyed through propositional knowledge, professionals can generate an understanding of the specific situation from a broader perspective of how things are structured and operate (e.g. using knowledge bases such as anatomy, physiology, psychology, sociology), knowledge of the general effectiveness of particular interventions (using ‘evidence’ generated from systematic research such as randomized controlled trials) and the perspective generated by theories that underpin the particular profession to which the professional belongs. However, they also need non-propositional knowledge. Context-specific professional craft knowledge underpins their ability to judge what action is required in the specific situation and to know how to carry out that action. Personal knowledge is used for the interpersonal aspects of professional action, as the ability to listen to, communicate with and develop a professional relationship with clients is well recognized as an essential component of professional practice (Price, 2009).

In summary, to be a professional means to fulfil a social role. This comes with social expectations as well as social privileges. The expectations include ethically sound behaviour and the ability to make well-reasoned and thoughtful judgements about action. These expert judgements are expected to be based on a unique and extensive base of propositional knowledge. Increasingly, it is recognized that well-reasoned judgements also rely on non-propositional knowledge such as professional craft knowledge and personal knowledge.

Communities of practice

While professional practice is situated within the context of a society that expects its professionals to be able to provide services that are not expected of others, it also exists within the historical and social context of a particular profession. Carr (1995) made the point that to practise as a professional:

is always to act within a tradition, and it is only by submitting to its authority that practitioners can begin to acquire the practical knowledge and standards of excellence by means of which their own practical competence can be judged. (pp. 68–69)

Professionals are expected to develop expertise in a particular type of practice, but how does this occur? A traditional approach to this question is to focus on the knowledge and skills that characterize the practice of a particular profession. From this perspective, teaching student and novice professionals the knowledge and skills of the profession is the logical approach to the development of expertise. The structure of many professional courses requires students to demonstrate their acquisition of the knowledge base that underpins practice as well as those skills deemed necessary for that particular kind of practice. In addition, practice educators recognize the importance of practical experience in developing expertise (Evenson, 2009). Consequently, bodies such as the World Federation of Occupational Therapists outline what they conceive as minimum standards for professional education that include a minimum number of hours of practice-based learning (Hocking & Ness, 2002). Professional expertise is based on practical experience as well as the acquisition of knowledge and skills.

Sociocultural approaches to learning provide a useful way of explaining the development of professional expertise. These approaches “explain learning and the development of expertise in terms of an individual’s enculturation into the cultural practices or activities of their society and, more particularly, into the subcultures or communities of that society” (Walker, 2001, p. 24). Lave and Wenger (1991) used the term ‘communities of practice’ (p. 29) to refer to the communities to which individuals belong and within which they engage in situated or context-specific learning. Individual professionals develop expertise by participating in the cultural practices of the community of practice (in this case the profession, but they could also refer to multidisciplinary teams that the occupational therapist works in). Cultural practices include actions that are routine within a particular group. Often the practices are so accepted and routine that they might not be noticed by the group itself. As such, these practices are often described as tacit or embedded in practice, because they are probably not usually put into words or commented on.

From this perspective, professional learning is not simply the acquisition of skills but involves a transformation in the way that an individual participates in their community of practice. This process of transformation is a mutual one. As Walker (2001) explained, “As individuals are enculturated into the practices of their society and communities, they are transformed by the experience, and simultaneously may transform the community’s practices” (p. 24). Participating in cultural practices contributes to a transformation in the professional’s identity and action. The transformation of practices that results from such participation also contributes to the growth and development of the profession. In many ways, the models reviewed in this book could be seen as cultural artefacts (Iwama, 2007, p. 185) and reviewing how they have changed over time demonstrates one type of transformation that has occurred in the profession of occupational therapy. As Walker noted, cultural practices are interconnected but “have their own histories and trajectories and are part of, and linked to, other practices” (p. 24).

Professional relationships appear to be important for learning cultural practices. Parboosingh (2002) proposed that the interactions and relationships that professionals have with each other are important to the learning that occurs through participation in communities of practice. He stated, “the experiences of practitioners suggest that interacting with peers and mentors in the workplace provides the best environment for learning that enhances professional practice and professional judgment” (p. 230). In occupational therapy, Unsworth (2001) also proposed that “novice therapists could benefit from spending more time reflecting on the therapy process, and discussing their therapy with expert colleagues” (p. 163). Coles (2002, p. 7) explained that such learning also changes practice by leading to the “critical reconstruction of practice”, that is, developing and enriching practice traditions, rather than just reproducing current practice.

In summary, practice expertise or practical wisdom is built through participation in communities of practice and enhances professional practice and professional judgement. Professional expertise requires extensive and relevant propositional knowledge bases and the ability to exercise professional judgements in order to make decisions about the best course of action in a particular situation. Practical wisdom is highly context-specific. Professionals have to combine and evaluate different types of knowledge in order to make practice decisions. A variety of terms are used to refer to the processes they use to do this. These terms include professional reasoning, clinical reasoning, professional or clinical judgement, and professional or clinical decision-making. Now we turn to an exploration of professional reasoning in occupational therapy.

Occupational therapy professional reasoning

Coles (2002) defined professional practice as “the exercise of discretion, on behalf of another, in a situation of uncertainty” (p. 4). This definition points to the requirement for professionals to make judgements that will affect their clients and that such judgements are often made in conditions of uncertainty. The uncertainty of the situations in which professional practice takes place (Coles, 2002; Hunink et al., 2001) and the need for professional judgements are well recognized (Higgs & Jones, 2008).

As professionals, occupational therapists need to be able to make well-reasoned decisions about their professional action. In this section of the chapter, we discuss professional reasoning from a historical perspective, explore the nature of occupational therapy practice as requiring art, science and action, and propose a model for conceptualizing context-specific reasoning in occupational therapy.

Historical view of professional reasoning in occupational therapy

In occupational therapy, research into the process of thinking and making judgements in practice has generally adopted the term clinical reasoning. This term was used in medicine and the early conceptualizations of occupational therapy reasoning were largely influenced by that research. The initial clinical reasoning research in occupational therapy was conducted by Joan Rogers and her colleagues in the early 1980s (Rogers, 1983; Rogers & Masagatani, 1982). At that time, clinical reasoning was generally understood from the perspective of artificial intelligence, with its focus on acquiring and managing information. Therefore, clinical reasoning was described as a process involving the acquisition and interpretation of cues (information) and the generation and testing of hypotheses (about what the cues might mean and their implications for professional action). This way of thinking often was called logico-deductive reasoning, because the emphasis was on a logical process of systematically collecting, combining and interpreting information in the light of established theories (i.e. deducing meaning).

Research funded by the AOTA and conducted by Cheryl Mattingly and Maureen Hayes Fleming in the late 1980s has dominated subsequent thinking about clinical reasoning in occupational therapy. Mattingly and Fleming (1994) presented their observations of clinical practice in a large rehabilitation facility in the United States of America. They argued that reasoning could be categorized into four different types: procedural, interactive, conditional and narrative. This work was influential, not only through the results of their methodologically rigorous research, but through introduction of the idea that occupational therapists might have multiple ways of reasoning. Prior to their work, clinical reasoning in occupational therapy had been conceptualized (in the same way as medicine) only as a hypothetico-deductive process. In contrast, Mattingly and Fleming stated that, in occupational therapy, “different modes of thinking are employed for different purposes and in response to particular features of the clinical problem complex” (p. 17).

Using the term the three track mind, Mattingly and Fleming (1994; also see Fleming, 1991) observed that occupational therapists switched between the first three of the four types so rapidly that they appeared to be using them simultaneously. First they used procedural reasoning, which relates to situations in which therapists focused on defining problems and considering intervention possibilities. They thought about the procedures they might use to remediate the person’s problems with functional performance. Second, an interactive mode of reasoning was used when the therapist wanted to “interact with and better understand the person” (p. 17). This understanding appeared to be particularly important when the therapist wanted to tailor their intervention for the particular client. The third type of reasoning that formed part of the three track mind was conditional reasoning, which is “a complex form of social reasoning, [that] is used to help the patient in the difficult process of reconstructing a life that is now permanently changed by injury or disease” (p. 17). It is interesting to read their comments about this type of reasoning because it alludes to the problems of trying to put language to practice when much of it is embedded within practice and not generally put into words. They wrote, “The concept of conditional reasoning is perhaps the most elusive notion in our proposed theory of multiple modes of thinking. Yet we are firmly, if intuitively, convinced that there is a third form of reasoning that many experienced therapists used. This reasoning style moves beyond specific concerns about the person and the physical problems and places them in broader social and temporal contexts.” (p. 18.) In addition to the three modes of reasoning that contributed to the three track mind, the final form of reasoning these authors proposed was a narrative mode of reasoning in which occupational therapists swapped stories and engaged others in discussing puzzling situations. They suggested that this storytelling also served as a way to enlarge each other’s “fund of practical knowledge” vicariously (p. 18).

In 1993, Schell and Cervero published an “integrative review” of the clinical reasoning literature at the time. As a number of terms had been used to discuss different aspects of clinical reasoning that could be categorized as predominantly hypothetico-deductive, such as diagnostic reasoning (Rogers, 1983) and procedural reasoning (Mattingly, 1991; Mattingly & Fleming, 1994), Schell and Cervero grouped these together and labelled the category “scientific reasoning”. This term was adopted by other authors and used frequently in subsequent publications relating to clinical reasoning in occupational therapy. Possibly taking Mattingly’s and Fleming’s lead of proposing that occupational therapists use multiple modes of reasoning, Schell and Cervero proposed an additional category of reasoning, which they called “pragmatic reasoning”. Pragmatic reasoning referred to those times when occupational therapists thought about what actually could be done, given the practice resources available in the situation, the broader organizational and political context and the wishes of the client. They also made reference to ethical reasoning, where occupational therapists attended to what should be done (Rogers, 1983).

These earlier studies were followed by a continued interest in clinical reasoning over the following years, with a number of journals publishing special editions on clinical reasoning in the mid 1990s. More recently, Unsworth (2005) undertook research to test the presence of the various types of reasoning that had been described. She concluded that occupational therapists do appear to use procedural, interactive, conditional and pragmatic reasoning (proposing that this last one was more related to the influence of the practice environment than to the therapist’s personal philosophy − both of which had been proposed by Schell & Cervero earlier) and that occupational therapists also seemed to use a process of linking the current situation to broader principles. She called this process “generalization reasoning” and proposed that it was a subcategory of each of the other types of reasoning. Examples of generalization reasoning included making generalizations about people with a particular medical diagnosis and general principles relating to the provision of services (both in that organization or service context and relating more specifically to occupational therapy interventions).

Only gold members can continue reading. Log In or Register to continue