What are theory and practice and why do they matter?

In occupational therapy, theory has been defined as a set of connected ideas or concepts that can be used to guide or form the basis for action (Crepeau et al., 2009; Melton et al., 2009). If a given theory is good, it can be used to explain phenomena as well as predict the likely outcomes of changes to those phenomena. Because they are made explicit, theories can be scrutinized and tested (Melton et al., 2009).

Theories form part of a profession’s body of knowledge. Higgs et al. (2001) explained that, without a theoretical base, practice would be akin to guesswork. While experienced occupational therapists often have difficulty explaining the theoretical bases for their practice, the fact that they make well-reasoned and effective decisions after gaining very little information (Mattingly & Fleming, 1994) suggests that they are not engaged in ‘guesswork’ but are combining the information obtained with their body of knowledge. As Melton et al. (2009) explained, disciplines develop “a specialized knowledge base, important concepts, models and theories to help busy practitioners make rapid but well-informed decisions about their practice” (p. 12). In occupational therapy, Crepeau et al. (2009) stated that its theoretical knowledge base “concerns occupation, how occupation influences health and well-being, and how occupation can be used therapeutically to enable people to engage in those occupations they value most” (p. 429).

Melton et al. (2009) proposed that providing a “framework of conceptual ideas” serves purposes such as the following:

Practice is more than theory

While theory appears to be essential for practice, it is rarely considered to be sufficient for practice. The practice of occupational therapy refers to what occupational therapists do in their professional roles. It is a process that requires decision-making about action and can be thought of as reasoned action (Carr, 1995). Sometimes practice is conceptualized as the application of theory, but Mattingly and Fleming (1994) proposed that practice is much more than this because it requires a different type of reasoning.

Both theory and practice are important for the work of professionals. However, they are not the same. Higgs et al. (2001) distinguished between knowing that and knowing how. Theory can be thought of as knowing that. By making explicit what a particular profession knows about, theory is essential to both the organization and sharing of the profession’s knowledge base in its area of concern. On the other hand, practice is more aligned with knowing how. It requires both skills, in particular aspects of the profession’s work and the ability to choose action (or non-action) wisely.

Different types of knowledge

In discussing the difference between theory and practice, some authors (e.g. Higgs et al. 2001; Mattingly & Fleming, 1994) refer back to the ancient philosophies of Plato and Aristotle. While both philosophers agreed that there are different types of knowledge, Plato argued for the superiority of the type of knowledge associated with mathematics. This kind of knowledge was called episteme and gives rise to the term epistemology. This type of knowledge is: (a) propositional, that is, it comprises a set of assertions or propositions that can be explained, studied and transmitted in words and often includes assertions of truth; (b) generalized, aiming to state universal principles; and (c) purely intellectual (rather than emotional). It is generally associated with a scientific way of thinking and is the type of knowledge that the word theory usually conjures.

The type of knowledge that is often associated with practice is phronesis or practical wisdom. As Kessels and Korthagen (1996) explained, “this is an essentially different type of knowledge, not concerned with scientific theories, but with the understanding of specific concrete cases and complex or ambiguous situations” (p. 19). This type of knowledge is situated in and relevant to particular times and places. As Aristotle stated, while phronesis can involve general principles, “It must take into account particular facts as well, since it is concerned with practical activities, which always deal with particular things” (Aristotle, 1975, p. 1141). Practice requires more than just knowing information and is often distinguished by the need to act in a particular situation (even if it is only to make decisions, a form of action). Understanding a situation is dependent on experience, which allows the practitioner to see patterns and similarities (upon which to base practice ‘rules’) in a series of particular instances. As Kessels and Korthagen explained, “particulars only become familiar with experience, with a long process of perceiving, assessing situations, judging, choosing courses of action, and being confronted with their consequences” (p. 20).

Often, theories are conceptualized as being ‘applied’ to practice, the implication being that theory somehow precedes (and is possibly superior to) practice. Certainly, most occupational therapy courses in Western countries are structured with theoretical concepts taught first and more extensive professional practice experiences occurring later. An extensive knowledge of theory – generally conceptualized as generalized, propositional knowledge – is consistent with society’s expectation of professionals as ‘experts’. Mattingly and Fleming (1994) explained that, in the health professions, the reasoning required has generally been conceptualized as “applied natural science” in which “reasoning is presumed to involve recognizing particular instances of behaviour in terms of general laws that regulate the relationship between cause and a resultant state of affairs” and that “practice is considered the application of empirically tested abstract knowledge (theories) and generalizable factual knowledge” (p. 317).

Higgs et al. (2001) identified three forms of knowledge that professionals use. The first of these, propositional knowledge, is the type of knowledge that is most associated with professions and aligns most closely with the concept of episteme. It is also known as theory or scientific knowledge. As Higgs et al. explained:

The second type of knowledge identified was professional craft knowledge. This type of knowledge is based on experience in practice and relates to knowing how to do something. It includes the skills required to practice; knowing from experience about particular client groups, the types of problems that they might face and the kinds of interventions that are often useful to them; and knowledge about the particular client with whom the professional is working at the time. As Higgs et al. stated, “Professional craft knowledge can be expressed in propositional statements, but here no attempt is made to generalize beyond the individual’s or a group of colleagues’ own practice” (p. 5). Thus, professional craft knowledge is often highly context-specific, rather than generalized (or necessarily generalizable) like propositional knowledge. As a practical form of knowledge, it aligns most closely with phronesis.

The third type of knowledge is personal knowledge. This includes the professional’s knowledge of him- or herself as a person and in relation to others. It is built up over the course of a person’s life and can relate to the social mores that the individual professional has experienced (and internalized or rejected), his or her world view, and any knowledge of him- or herself as a person that may have been developed through reflection and experience.

While theoretical knowledge can be conceptualized as propositional knowledge, the other two types of knowledge are primarily examples of ‘non-propositional’ knowledge (Higgs et al., 2001, p. 5). The distinction between propositional and non-propositional knowledge relates, respectively, to the difference between knowing that and knowing how (Polanyi, 1958; Ryle, 1949) mentioned earlier. It also aligns with the distinction Mattingly and Fleming (1994) made between theoretical and practical reasoning. In contrast to propositional knowledge, which exists in the public sphere through wide dissemination, non-propositional knowledge is often “tacit and embedded” (Higgs et al., p. 5), that is, not necessarily put into words or easy to explain but embedded in the action of practice.

Aligning with the concept of propositional and non-propositional knowledge being important aspects of practice, Crepeau et al. (2009) distinguished between formal and personal theories. Formal theories are those that are “publicly articulated, published and validated to varying degrees by scientific study” (p. 429). Personal theories are those beliefs held by individuals. They are formed through the individual’s experiences and perspectives formed from observations and exposure to ideas and beliefs. They are not made widely available and, therefore, are less likely to have been publicly scrutinized and debated.

Implications of different types of knowledge

The distinction between personal and formal theories is important to consider in relation to the current emphasis in health on evidence-based practice (EBP). The desire to provide quality and cost-effective services that have a positive impact of outcomes for clients and patients is widely shared by a range of stakeholder groups including clients, health professionals, managers of services and funding bodies (Turpin & Higgs, 2010). However, there is a lack of consensus as to how to achieve these outcomes. In its approach to achieving these outcomes, the EBP movement generally values formal theories over personal theories. It promotes the use of knowledge that has been generated and tested using rigorous research methods such as randomized controlled trials and their systematic reviews. The emphasis on research findings that are generalizable to situations other than those in which the results were generated aims to overcome the limitations in reasoning that have been noted in professionals. As Duncan (2006) explained, “it is known that professionals’ individual perspectives are highly vulnerable to a range of biases and heuristics when making clinical judgements” (p. 60).

A problem facing practitioners is that, if they only rely on their own experiences of phenomena in the local context, they are likely to make their decisions based on a reasonably narrow range of choices. These are often influenced by factors other than effectiveness of interventions (the focus of EBP). An example includes the difference between a practitioner’s extensive knowledge of the services they can provide and their relative lack of knowledge of the interventions that another professional or service could provide (and the research outlining the effectiveness or otherwise of these interventions).

On the other hand, the advantage of personal theories is that they are based on experience within the particular practice context and knowledge of, and the capacity to respond to, individual variations in client preferences and needs. Sackett (2000) defined evidence-based medicine (upon which EBP in occupational therapy is based) as “the integration of best research evidence with clinical expertise and patient values” (p. 1). This definition suggests that both formal and personal theories may be constitutive of EBP.

There is much discussion about theory and practice in professional disciplines. In these discussions, frequent reference is made to a ‘gap’ between theory and practice. Examples from a range of disciplines include education (Kessels & Korthagen, 1996), nursing (Rolfe, 1998), physiotherapy (Rothstein, 2004), and occupational therapy (Melton et al., 2009). The concept of the theory–practice gap provides a way of articulating the problem inherent within professional practice of having to integrate different types of knowledge from different sources when making decisions about professional action. While definitions of evidence-based practice, such as the one by Sackett (2000) quoted before, refer to the integration of different types of information, little has been done to investigate the process of integration.

Valuing, and therefore having to combine, different types of knowledge in practice is particularly powerful within occupational therapy. The equal valuing of both propositional and non-propositional knowledge has been expressed in occupational therapy through concepts such as art and science and the ‘two-body practice’ (Mattingly & Fleming, 1994). In addition, through its focus on occupation as both a means to facilitate occupational performance and participation and an end in itself, the practice of occupational therapy requires both theory about occupation and practical guidance on how to use occupation to achieve these aims (theory and practice or episteme and phronesis).