Capacidad secuestradora de radicales (ensayo del DPPH)

There has been an increasing number of studies regarding the concept of occupational therapists’ professional reasoning skills which describe the thinking processes of planning, implementing and reflecting on practice which ‘tend to remain unseen and are rarely articulated’ (Turner and Alsop 2015, p741). A recent systematic review of literature on professional reasoning in occupational therapy states that occupational therapists have a ‘strong, often tacit, yet consistent approach to the delivery of services which is guided by a shared philosophy,

enabled by supporting theories, and put into practice every day through the way we think’ (Unsworth and Baker 2016, p5). Hitch et al (2014) stated that occupational therapists need to have a wider view of how theory and evidence integrate into practice and that sources of evidence should include other aspects of practice such as ethical behaviour and professional judgement. Samuelsson and Wressle (2015) acknowledged that evidence for occupational therapy practice includes research findings but can also include ‘clients’ self-reports and subjective outcome

measures, which corresponds with occupational therapists’ conception of clinical reasoning as a complex process that takes multiple factors into account’

(Samuelsson and Wressle 2015, p175).

Boyt Schell and Schell (2008) built on Schön’s (1991) concept of professional artistry in reflective practice to consider the development of professional reasoning in occupational therapy. They suggested that professional reasoning is a high level

54 of skill that is developed from experience and critical reflection. The skills required include an understanding of the client, person-centred values, skills learnt from experiences in practice and being able to use creative imaginative approaches to address unique problems. They suggest that ‘both the practice context in which care occurs and the therapist’s own skills set are factors that therapists reason about when deciding on what care to actually provide’ (Boyt Schell and Schell 2008, pxv). Although some guidance on how to practice is available they argued that

occupational therapists need to make multiple decisions based on the individual encounter with the person they are working with. They base their understanding on the work by Schön (1991), which he referred to as reflection-in action, in that professionals usually need to act immediately without time for extensive reflection. Boyt Schell and Schell (2008) suggest that occupational therapists’ practice decisions can be guided by scientific or technical information ‘but much of practice requires a multitude of nuanced decisions and actions’ (Boyt Schell and Schell 2008 p6) rather than specific guidance or processes. Professional reasoning is used to decide what and how it can be applied to practice.

Dreyfus (2004) described a five stage model of adult skills acquisition that

progresses from novice, advanced beginner, competent, proficient to expert. The novice stage relies on rules, that can be followed exactly, but experts have built up experience which results in their ability to make an ‘immediate intuitive situational response’ (Dreyfus 2004, p180). Therefore, occupational therapy ‘experts are more intuitive and take reflexive actions based on past practice and greater understanding of the situation’ (Boyt Schell and Schell 2008, p10). This model implies that the linear application of a piece of evidence or a standardised assessment to practice without adapting it or questioning the findings is the level of a novice. Reasoning about how the assessment findings or evidence contributed, or not, to the unique practice situation by considering the subtleties of the nuanced responses is the higher level thinking processes of the expert. As has been discussed in Section 2.4 many of the studies on why occupational therapists do not use evidence based practice tended to be dismissive of more experienced staff or people who rely on colleagues and peers for knowledge. It could be argued that some of these experienced occupational therapists are carrying out intuitive, expert practice but may not be able to articulate this in a way that can be understood in the narrow parameters of traditional evidence based practice. As professional reasoning uses intuitive processes ‘much of the current research is inadequate to completely comprehend the complexities of reasoning that occur in the real-life context of

55 professional practice’ (Boyt Schell and Schell 2008, p6). Boyt Schell and Schell (2008) identified different aspects of professional reasoning from their own and other studies (see Table 2.2) to support occupational therapists in identifying and

articulating their reasoning processes in practice. They suggested that occupational therapists may use any of the following eight aspects of reasoning: scientific,

diagnostic, procedural, narrative, pragmatic, ethical, interactive and conditional; or a combination of them.

Table 2.2: Different aspects of reasoning in occupational therapy

summarised from Boyt Schell and Schell 2008, p7

Aspect of reasoning Description and focus

Scientific reasoning Applied logical and scientific methods. Theory based decision making. Evidence.

Diagnostic reasoning Cause and nature of conditions.

Procedural reasoning Intervention routines for identified conditions- science based or local habits/culture

Narrative reasoning Make sense of occupational performance on daily lives in specific circumstance.

Pragmatic reasoning Practical reasoning- therapy needs vs realities and resources available.

Ethical reasoning Analysing an ethical dilemma, systematic approach to moral conflict

Interactive reasoning Collaborative problem solving with client

Conditional reasoning Blending of all for purposes of flexibility, responding to changing conditions, predicting client future.

Boyt Schell and Schell (2008) stated that the occupational therapy profession ‘now feels very comfortable in viewing professional reasoning and reflection as a means of excavating, examining and passing on theories in use’ (Boyt Schell and Schell 2008, p414). They proposed that research to understand professional reasoning requires longitudinal studies to consider changes over time and to link what therapists were thinking with their actions.

Morley (2007) explored the experiences of recently qualified occupational therapists and how they needed critical appraisal from more experienced colleagues and facilitated reflective practice to develop professional reasoning skills, ‘personal autonomy and professional development’ (Morley 2007, p332). A study by Dougherty et al (2016) explored the perspectives of six occupational therapists working with children based in schools. The findings were that evidence is defined

56 differently from the perspective of research and of practice. The occupational

therapists’ perceptions were that there are two major categories of evidence:

 Internalised, in which external evidence is synthesised using a personal knowledge base built up from professional experience and expertise;

 Evidence gathered for the specific intervention which includes multiple observations, verbal and written reports from the client and all involved. Professional reasoning was reported to occur in practice and was perceived to be unique to each therapist who had developed this knowledge over time. The

occupational therapists were continually gathering and synthesising information and testing the effectiveness of their interventions with clients throughout their practice. They concluded that ‘the emphasis on research influencing practice has created a de facto dearth of evidence-based practice knowledge about the use of therapists’ expertise and about how the nature of evidence in practice might inform research’ (Dougherty et al 2016, p288). They recommended that further investigation of evidence building in practice is required to ‘reconceptualise practice base evidence recognising client, therapist and research evidence as equally important’ (Dougherty et al 2016, p294).

Practice based evidence can be understood as a combination of external evidence, professional reasoning and reflection in action. However, it has been acknowledged that there are challenges in finding evidence for client centred, intuitive reflective occupational therapy practice.

2.6 Summary

This chapter has reviewed the literature related to the practice of occupational therapy with adults with learning disabilities in a community setting. Four of the key areas for research recommended by the COT review (Lillywhite and Haines 2010) were explored in this chapter and identified as having significant gaps in the literature. The four areas (Table 2.1) were: the need to gather evidence of occupational therapy practice from the perspective of adults with learning disabilities, carers and other key stakeholders; the effectiveness of occupational therapy interventions; assessments that are appropriate for adults with learning disabilities; and the impact of service expectations on the quality of occupational therapy interventions. These areas were all related to the thematic concern, identified by the local occupational therapists at the start of this research study,

57 which was introduced in Chapter one (Section 1.7). The thematic concern which underpinned this study was the quest of the local occupational therapists to seek and generate evidence on which to evaluate and improve their local practice with adults with learning disabilities.

The research question for this study arose from the thematic concern and was as follows:

what is the evidence that the local community occupational therapy service for adults with learning disabilities is:

(i) meeting the needs of adults with learning disabilities; (ii) achieving the service objectives of the employer; and

(iii) meeting the expectations of the professional body (the College of

Occupational Therapists) for evidence-based practice in line with the core principles for occupational therapists working with people with learning disabilities (COT 2003 and 2013a).

The expectation from the professional body appeared to be that occupational therapists should be basing their practice on ‘evidence’ that had been obtained through research that was traditionally seen as separate from actual practice to demonstrate rigour and justify their actions. However, the limited literature regarding the practice of occupational therapy with people with learning disabilities living in the community often had a narrow focus that did not reflect holistic occupational therapy practice. Occupational therapy practice based knowledge is developed from

professional experience, reasoning and reflection. However, as much of real life occupational therapy practice uses hidden or intuitive processes it is difficult for these to be shared and presented within current research studies and this is seen as a challenge but a gap in the literature.

Several gaps were identified in the literature on occupational therapy with adults who have learning disabilities which the research study aimed to address:

 Obtaining the perceptions of adults with learning disabilities, who have experienced occupational therapy was identified as a gap in the literature. Only one study (Melton 1998) used qualitative methods to explore the views of people with learning disabilities in relation to the relevance of occupational therapy to their lives (Section 2.4.1).

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 Historically, people with learning disabilities were regarded as lacking the ability to participate in research and were often excluded. More recent occupational therapy studies have highlighted the importance of involving people with learning disabilities in research and have valued their

contribution. However, none of the studies asked people with learning disabilities specifically about their experience of occupational therapy (Sections 2.4.1 and 2.4.2).

 The perceptions of the carers of people with learning disabilities and other stakeholders of occupational therapy practice are also important but their views continue to be missing from most studies (Section 2.4.1).

 Many of the studies focused on a narrow aspect of practice which did not reflect the wider holistic nature of occupational therapy or the conceptual model of practice used (Sections 2.3 and 2.4.2).

 Practice that is relevant to people with learning disabilities can be difficult to measure effectively, or ethically, within the rigour of scientific enquiry. Further exploration is needed on methods of gathering evidence of the effectiveness of occupational therapy which encompass the person-centred, holistic and individual nature of intervention (Section 2.4.2).

 There were limited studies on occupational therapy assessment tools that can be used with adults with learning disabilities (Section 2.4.3).

 There were no studies identified on how the need to meet service

expectations, such as meeting waiting list targets, impacted on the quality of occupational therapy services for adults with learning disabilities (Section 2.4.4).

 There is a limited body of evidence on occupational therapy practice based knowledge and how this develops for all client groups and more specifically when working with adults with learning disabilities. Occupational therapy practice knowledge needs to include professional reasoning, multiple perspectives, evidence from experience as well as traditional evidence (Section 2.5).

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 Boyt Schell and Schell (2008) proposed that research to understand professional reasoning requires longitudinal studies to consider changes over time and to link what therapists were thinking with their actions. The views of the occupational therapists and their reflections on their practice provide an essential insight into how and why a service for people with learning disabilities develops (Section 2.5.1).

The overall purpose of this study was to evaluate the current occupational therapy practice conducted by a local community health team working with adults with learning disabilities and to further develop and improve practice based on the evidence generated. The action research objectives (Section 1.6) aimed to address the gaps identified in the literature review.

Action research was selected as the methodology for this study as it offered the flexibility required to evaluate practice from multiple perspectives. It also allowed for the demands, expectations and policies of the service (employer) to be taken into account. The details of the methodology are discussed in Chapter three.

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Chapter three: Methodology of the inquiry

3.1 Introduction

The initial driver for this research study, described in Chapter one, was that the local occupational therapists were confident in their practice but were aware of the limited published evidence and standardised assessments available to justify their work. Schön (1991)described this experience in his examination of how a range of professionals in various fields continued to ‘feel profoundly uneasy because they cannot say what they know how to do, cannot justify its quality or rigor’ (Schön 1991, p69). He rejected the positivist approach and model of technical rationality as this could not explain all of real world practice and instead proposed that professionals have tacit knowledge and patterns of actions that they have developed from their experiences. This professional knowing is reflection-in- action defined as when professional problem solving is linked with reflective inquiry. Schön (1991) proposed that professional practice is more than just applying theories and research findings and so his epistemology of practice involved reflective practitioners using their professional artistry as well as their technical knowledge. Reflection on this knowing in action can help to reveal how the practitioners apply their knowledge to make these reasoned actions. Based on Schön (1991)’s epistemology of reflective practice, it would be expected that occupational therapists make decisions and actions in their practice that are often unplanned, even when they are following research based theories or techniques. The methodology for this research study, therefore, needs to be flexible to allow the local occupational therapists to explore and develop their practice-based knowledge and artistry within the spontaneity and uncertainty of the local service context.

Action Research was selected as the methodology for this research study. It has been used in a variety of ways but usually incorporates a review of a situation to identify a concern; an attempt to change this by using a participatory and

consensual approach to finding solutions, monitoring the action and gathering data to describe what has been learnt from the change process; and generating

knowledge (Winter and Munn-Giddings 2001, McNiff and Whitehead 2011, Bellman 2003). Stringer (2007) described action research as ‘a systematic approach to investigation that enables people to find effective solutions to problems they confront in their everyday lives’ (Stringer 2007, p1). Action researchers acknowledge that real

61 life is complicated and the expertise in solving problems is not found in centralised policies but in the action of those involved such as professionals, clients and families.

The methodology needed to be consistent with the occupational therapy core values and beliefs so that the outcomes would be more likely to be congruent with the professional experiences of the local occupational therapists. It was also important to choose a methodology that could be easily understood and perceived as relevant by the occupational therapists so that they would be motivated to participate in the inquiry and develop their practice. Occupational therapists’ explicit critical value base is that people are healthy if they can do the things they need and want to do effectively and are satisfied with the balance of their occupations. Occupational therapists, therefore, work collaboratively with others to seek new improved ways of doing things. Action research, with its emphasis on starting at the problem within its context and working together to seek solutions was compatible with the views and understanding of the local occupational therapists as it had a similar approach to the occupational therapy intervention and process model (OTIPM) that they had

adopted in their practice. (see Figure 2.1). The methodology needed to involve the local occupational therapists in a process of change and innovation within their work with adults with learning disabilities and sought to understand how they interact and respond to events. Action research could fulfil this as it ‘is closely linked to practice and … can be undertaken by practitioners’ (Winter and Munn-Giddings 2001, p3).

Hart and Bond (1995) were among the first researchers to use action research in health and social care settings in the United Kingdom. They set out seven criteria of action research:

 Educative base

 Deals with individuals as members of social groups

 Problem-focused

 Involves a change intervention

 Aims at improvement and involvement

 Cyclical process which links research, action and evaluation

 Founded on a research relationship; involving participants in the change process.

62 Bellman (2003), like Hart and Bond, suggested that the action research process is educative, but also empowering for the practitioners. It is carried out with people not on people and so is interested in all participants’ interpretations of events. It seeks reality but recognises that phenomena can be represented from different

perspectives. As action research values multiple accounts, large quantities of data can be collected through both quantitative and qualitative methods. Quantitative research can be problematic as it can fail to take into account social concepts and contexts and, as has been explored in Chapter two, there are limitations in being able to measure the holistic and individualised nature of occupational therapy practice in this way. However, qualitative research can be perceived as lacking generalisability and validity due to the small samples used. Williamson (2012a) argues that action research may have features of qualitative and quantitative

traditions but is different from other research paradigms as the researcher’s aim is to collaborate with the participants in order to change an aspect of their situation. It is ‘a process by which change is achieved and new knowledge about a situation is generated’ (Williamson 2012a, p7). This matches the intention of this study in that the researcher planned to work with the local occupational therapists as an equal partner to improve the local practice. As action research is collaborative, only the approach can be planned in advance, methods and strategies have to be developed in the field of practice. Identifying the problem, planning and evaluating are

interlinked in a dynamic way and so findings are fed back to participants throughout the process to inform the decision making process for the next stage.