Occupational therapy diagnostic reasoning: a component of clinical reasoning

Investigating the effect strength of positive risk-taking barriers on discharge decisions in occupational therapy intermediate care: A factorial survey

Introduction:

Positive risk-taking in occupational therapy intermediate care is a requirement, yet little is known about how positive risk-taking barriers influence discharge decisions at different experience levels.

Method:

A factorial survey was used to investigate positive risk-taking barriers (Limited Capacity, Risk Averse Family, Blame Culture and No Support). Participants self-categorised their experience level into Novice or Semi-expert or Expert before analysing four vignettes relating to recommending a home discharge for an older adult. Data were analysed using Multiple Regression and One-Way Analysis of Variance.

Results:

Seventy-four participants responded to two hundred eighty-one vignettes. The barriers that reduced the likelihood to recommend a home discharge for an older adult were ‘No Support’, Novices (β = −0.315, p = 0.002), Semi-experts (β = −0.313, p = 0.001) Experts (β = −0.254, p = 0.009); ‘Limited Capacity’, Novices (β = −0.305, p < 0.003), Semi-experts (β = −0.254, p = 0.006) Experts (β = −0.376, p = 0.001) and ‘Blame Culture’ Semi-experts (β = −0.240, p = 0.010). Novices were found to be less likely to recommend a home discharge by comparison.

Conclusion:

The ‘Limited Capacity’, ‘No Support’ and ‘Blame Culture’ barriers had the strongest effect and Novices were less likely to recommend a home discharge overall. These findings could inform future research and pre-registration Occupational Therapy education.

Developing of Multidimensional Perspectives Checklist of Professionalism for Undergraduate Occupational Therapy Students in Assistive Technology Service: Delphi Study

Professionalism is a critical attribute that occupational therapy students must establish throughout education, especially in the context of assistive technology (AT). This study aimed to construct a multidimensional perspectives checklist (MPC) from the stakeholders to reflect professionalism development in the AT service courses. Fifteen experts in AT clinical practice and educators (N = 15) consented to and completed three rounds of the Delphi survey. Data were qualitatively analyzed to form a preliminary checklist in the first round. In rounds two and three, participants rated their level of agreement with the MPC items. A descriptive analysis of consensus was performed. Thirty items were classified into five subscales (teachers, therapists, patients, peers, learners) and fit into a framework with three dimensions and seven categories. After the Delphi survey, the MPC achieved high consensus, convergence, and stability. Two additional categories of professionalism emerged in the study, namely aesthetic and personal characteristics and reflection. The MPC developed in this study reflects the perspectives of various stakeholders in occupational therapy practice, providing helpful information for students to prepare themselves. Therefore, the MPC could contribute to expanding and developing the scope of professionalism in occupational therapy, especially in AT service.

From Clinical Practice to the Classroom. Advantages and Disadvantages of Video and Paper Cases on the Motivation and Clinical Reasoning of Occupational Therapy Students

Case-based learning enables the application of theory to practice using real-life patient cases. The present study aims to compare the effect between video cases and paper cases on motivation for learning and knowledge acquisition to perform a clinical reasoning case exercise by occupational therapy students. A mixed-methods design was used with 120 students randomized into two groups. All students conducted a clinical reasoning case exercise on the same case, although in different presentation formats: paper case and video case. The quantitative measures of this study were the scores of motivation for learning from the Instructional Material Motivation Survey and the grades of a clinical reasoning case exercise. The qualitative part was based on the positive and negative aspects perceived by the participants. The results showed that the motivation for learning was significantly higher for the video case compared to the paper case, although there were no differences in the grades of the clinical reasoning case exercise between the two groups. The video cases were perceived as more relevant to professional practice and more informative in terms of non-verbal communication and context. In light of the results, teachers could use these two formats of presentation of cases with different objectives.

Vocational rehabilitation for young stroke survivors in Gauteng public healthcare: Occupational therapists' perceptions1

BACKGROUND

The prevalence of working-aged stroke survivors is increasing yearly. Stroke is an expensive disease, causing financial burden to the government, the family and caregivers of the patient, thus making it imperative for working-aged stroke survivors to work to remain financially independent. Survivors' need to work necessitates occupational therapists to shift their focus from basic activities of daily living, to rehabilitating work.

OBJECTIVES

This study aimed to determine the perceptions of occupational therapists working with younger stroke survivors in public hospitals and clinics in Gauteng South Africa, about rehabilitating working-aged stroke survivors' work ability.

METHODS

Ethical clearance was obtained. A qualitative research design was used to obtain narrative, descriptive data from six focus groups. Therapists from public healthcare settings, who had more than six months' experience and had worked in neurological rehabilitation within the six months preceding the focus group, were invited to participate. Focus groups were audio recorded and transcribed. Inductive content analysis was used to identify themes and categories.

RESULTS

Few participants are involved in rehabilitating younger stroke survivors' work ability or facilitating return to work (RTW). The study identified perceived barriers and enablers to rendering OT services that meet working-aged stroke survivors' needs.

CONCLUSIONS

Despite enabling employment equity laws in South Africa, OTs working in the public sector appear to experience a sense of futility when trying to rehabilitate young stoke survivors to RTW. Fragmentation of the public sector and limited resources impede successful RTW for working-aged stroke survivors. Survivors' employment status and motivation to RTW facilitated rehabilitating work ability.

Learning and Development of Diagnostic Reasoning in Occupational Therapy Undergraduate Students

Background/Aim

One way to facilitate occupational therapy undergraduate students transferring their academic skills of data gathering and analysis to professional settings is to ensure they can competently use diagnostic reasoning. Nevertheless, there are several obvious gaps in empirical evidence related to the learning and development of this style of reasoning in occupational therapy undergraduates. The most important are related to promoting higher-order thinking and the use of information to solve problems in the context of professional practice. This study analyses undergraduates' diagnostic reasoning and its changes during their education.

Materials and Methods

This multicentre study was conducted with a descriptive observational design. The study took place at the University of Coruña (Spain), University of Castilla-La Mancha (Spain), and University of el Valle (Colombia). The sample was n = 247. For data collection, a clinical case was specifically designed. IBM SPSS Statistics (v19) and EPIDAT 3.1 were used for the data analysis.

Results

Participants identified and categorized occupational performance problems. However, they had difficulties when identifying and categorizing the occupational performance components (specifically, the symptoms and signs of the disease presented in the study case). They presented limitations to analyse and synthesize the information collected to develop an explanation of the occupational problems and their causes.

Conclusions

Undergraduate students' ability to analyse and synthesize information during data collection is poorly organized, so it makes the problem formulation difficult. This study contributes to the knowledge of undergraduates' diagnostic reasoning features, specifically the undergraduate students' capacities and limits to process information during the occupational assessment.

Razonamiento clínico en terapia ocupacional. Una revisión narrativa

 Introducción. El razonamiento clínico ordena el procesamiento de la información obtenida durante la evaluación, facilitando tomar decisiones para implementar planes de tratamiento. Esta área es cada vez más relevante para la formación de estudiantes y profesionales de terapia ocupacional. Objetivo. Analizar la literatura sobre razonamiento clínico en terapia ocupacional publicada entre 2009 y 2018. Materiales y métodos. Se realizó una revisión de la literatura en bases de datos, repositorios institucionales, monografías y literatura gris de alcance. Se establecieron criterios de selección para la obtención de documentos que luego se analizaron estableciendo un conjunto de variables que permitieron el análisis de la literatura. Resultados. La literatura sobre razonamiento clínico en el período estudiado fue de 99 publicaciones, más de la mitad que en los 33 años anteriores. El razonamiento clínico en el ámbito docente es el de mayor impacto (41.4%); 52.5% son publicaciones que mejoran la práctica con sus aportes al reforzar el desarrollo de destrezas profesionales y la calidad de las intervenciones. Conclusión. El aumento de la investigación sobre razonamiento clínico en terapia ocupacional dota a esta área de conocimiento y rigor, mejorando así la eficacia de los terapeutas ocupacionales.

Narrative Reasoning in Practice A Case Study in Podiatry

BACKGROUND

Clinical reasoning and decision making within health care are as important as ever in a world where evidence-based health care and patient outcomes are highly valued. It is increasingly recognized that decisions are not made in isolation, and are influenced by many factors, both intrinsic and extrinsic. Expert and novice practitioners share reasoning techniques, and there are many interpretations of reasoning paradigms within the field of health care.

METHODS

A reflective diary was kept for 3 months linking personal reflections on a particular clinical decision with theoretical learning on clinical reasoning. Several decision-making paradigms were looked at in relation to the decision, with a deeper focus on narrative reasoning. Narrative reasoning resonated particularly with the author's previous experience studying literature.

RESULTS

The clinical decision was usefully analyzed using a narrative reasoning strategy. The decision made by the author was perhaps contrary to the evidence, and yet had a positive outcome. The positive outcome of the decision was looked at within the context of evidence-based practice and ethical practice.

CONCLUSIONS

Narrative reasoning comes from within the interpretive research model and puts the patient's experience at the heart of decision making. Narrative reasoning can be a valuable way of combining diagnostic, management, and ethical aspects of care. Further research-particularly in podiatry, where research is lacking-could identify helpful reasoning strategies for care of patients with long-term chronic conditions or complex conditions.

Clinical Reasoning, Part 1: The Nature of Problem Solving, a Literature Review

The information-processing literature has been reviewed to identify the component parts of problem solving. The difference between the problem representation and the subsequent solving process is highlighted, as is the role of memory within problem solving. The techniques for searching data and novice/expert differences are outlined. Finally, a model of problem solving in occupational therapy is proposed. The implications of this model for student education will be discussed in part 2 of this article.

Assessment of Bathing in Occupational Therapy

Personal cleanliness is important for all of us. The ability to bath independently is considered important by occupational therapists and their clients. This paper describes the assessment methods used by occupational therapists working with adults with physical disabilities. In addition, it explores the factors that were considered important during the assessment and solution phases of bathing intervention.

A survey questionnaire was sent to 108 occupational therapists working in health and social services within Greater London. The findings highlighted that the methods of assessment used most frequently by practitioners were observation in the home or in a simulated environment and face-to-face interviews. During assessment, the components ranked as most important for consideration were ‘mobility’, ‘client priorities’, ‘safety factors’ and ‘medical diagnosis’. During the solution phase similar factors were found, with the additional item of the availability of bathing equipment.

The findings of this study raise questions related to bathing issues and indicate a need for further study. Of particular interest are the questions of client priorities within the process and the high number of practitioners not including water in the assessment of this potentially dangerous activity.

A Description of a Functional Screening Assessment Developed for the Acute Physical Setting

This article provides a description of the development, process and introduction of the Structured Anchored Approach to Functional Assessment (SAAFA).1 The approach was designed to include a person-centred and time-efficient occupational therapy functional screening assessment that would meet the needs of patients and be appropriate for use in an acute physical inpatient setting. SAAFA assessments were developed to incorporate the strengths of both quantitative and qualitative occupational therapy assessments and research methods. Taken in the round, SAAFA assessments follow a process that corresponds with the four processes of qualitative research: data gathering, analysis, interpretation and reflexivity (Miller and Crabtree 2003).

The SAAFA is a dynamic approach that continues to evolve in response to developments in theory and practice. Information from occupational therapists' reports of their day-to-day practice indicate that SAAFA assessments reflect the complexity of individual patients' functioning and lead to the development of recommendations based on pragmatic consideration of a wide range of contextual influences. Research on the SAAFA commenced in 2002.

Occupational Therapy in Community Mental Health, Part 1: Intervention Choice

Arguments about the blurring of roles between the members of multidisciplinary community mental health teams and the generic style of intervention within them are well rehearsed. However, an empirical description of the daily work practice of occupational therapists in this field has not yet been attempted. This article presents a study examining the choices made by 12 therapists in the south east of England when working with their clients. Part 1 reports quantifiable findings on intervention media chosen over a 4-week period, drawn from diary data.

The results revealed diverse patterns of intervention choices. However, an emphasis on anxiety management chosen 295 times (16% of intervention selections), supportive counselling chosen 348 times (18% of selections) and problem-solving discussion with clients about aspects of their daily lives chosen 255 times (13% of selections) emerged. Follow-up interviews explored each participant's rationale for the patterns of practice highlighted by the diaries, which will be illustrated and discussed in part 2.

Approaches to Reasoning in Occupational Therapy: A Critical Exploration

This article approaches reasoning from a cognitive science paradigm. It is proposed that problem solving follows a basic process common to all human beings faced with a problem. However, there are variations in the process that are caused by the nature of the problem and the expertise of the problem solver. These variations in problem-solving methods should not be confused with the content of the reasoning which may be influenced by the domain in which the problem is framed and the individual characteristics of the problem solver. Clinical reasoning in nursing and medicine has been well researched and provides a benchmark for approaching reasoning in occupational therapy. This article outlines approaches to reasoning, emphasising the information-processing approach and its relevance to occupational therapy. It concludes with a critique of the modes of reasoning proposed by Mattingly and Fleming.

Is Assessment of Function the Core of Occupational Therapy?

The focus of this article is to discuss whether or not assessment of function is the core of occupational therapy. This is primarily undertaken through examining the analysis and debate surrounding the literature related to this area. Evidence suggests that the concept of function is interpreted in diverse ways and the need for commonly accepted definitions is highlighted. The nature of assessment in relation to core skills is examined, together with the potential for assessment of function to assist in defining occupational therapy. It is concluded that assessment of function cannot be isolated as the singular core of occupational therapy.

Clinical Reasoning in Community Occupational Therapy

A qualitative research study was undertaken in order to ascertain the scope and nature of clinical reasoning in community occupational therapy. Thirty occupational therapists based in social work departments in Scotland participated in this study, which required them to describe the content and meaning of their thinking during routine interventions with clients and carers living in their own homes.

The findings indicated that the participants adopted patterns of reasoning that consisted of three elements: reflection, decision making and reasoning. Reflection-in-action was commonplace during the home visits, while decision making was found to be concerned more with interactive than with technical or procedural issues. Reasoning was relativistic or pragmatic in response to contextual influences. In addition, it was found that the respondents tended to use coded meaning when explaining their thinking, which may in part account for the difficulties in articulating the reasoning that underpins clinical action. These issues are discussed in the context of current research on thinking.

Clinical Reasoning in Occupational Therapy: Idiosyncrasies in Content and Process

This article describes part of a research project that aims to examine the content and process of occupational therapists' reasoning. Thirty-eight experienced occupational therapists participated. This qualitative study gathered written text from the therapists, representing their thinking when presented with facsimiles of practice situations. Analysis of both the content of the reasoning and the component processes of the reasoning took place. The processes observed were similar to those observed in studies of medical problem solving. Some therapists demonstrated a rapid formulation of the problem, indicating the use of pattern recognition. There was also an element of hypothetico-deductive reasoning, as has been observed in medicine and physiotherapy. This article explores these findings, relating them to the research of other theorists in the field of reasoning and concluding with a discussion of some apparent idiosyncrasies in the participants' reasoning.

Managing Upper Limb Hypertonicity: Factors Influencing Therapists' Decisions

This study employed social judgement theory to identify and determine the relative importance of factors influencing occupational therapists' subjective decision making when managing children and adolescents with cerebral palsy and upper limb hypertonicity. An extensive literature review was conducted to identify potential factors that might be used. Two clinical experts were then asked to review and refine these factors. Finally, 12 experienced occupational therapists who had worked with people with cerebral palsy for at least 5 years were asked to add or exclude factors and then to rank them. Thirty-seven factors that might influence therapists' decision making were identified and ranked.

The reason for referral and family's goals were ranked as the first and second most important factors respectively. Agreement among therapists was significant, but low (Kendall's W = 0.38; p<0.0001). When participants were divided into two groups, those who were very experienced (mean = 13 years, SD = 6.95) and those with less experience (mean = 5.6 years, SD = 0.55), the ranking of the factors did not differ significantly. These findings are discussed with respect to research in clinical decision making, the training of occupational therapists and the education of students.

The Role of Computer Simulation in the Development of Clinical Reasoning Skills

A multidisciplinary project is under way to develop a computer model which will simulate the hip fracture care process in both a large teaching hospital and a district general hospital (Currie et al 1998). This paper describes the occupational therapy contribution to the project.

The complex process of care will be simulated by integrating each clinical group's patient intervention (strategy) at each point of the patient's journey. As part of this research, the literature was referred to for evidence to support current occupational therapy and to form a structure for simulation. The occupational therapy strategy is represented as a flow chart which leads the patient from admission to the acute orthopaedic ward, through to assessment, rehabilitation and, finally, discharge. The literature suggested that the way in which each occupational therapist individualised this strategy (based on Hagedorn's [1997] model) was influenced by his or her own clinical reasoning, which might in turn affect outcome.

The notion that mental modelling (clinical reasoning) might be simulated has led to the suggestion that computer simulation could be used as a learning tool to develop clinical reasoning skills in the novice, with the aim of improving patient care.

Clinical Decision Making in Familiar Cases: A Model of the Process and Implications for Practice

This qualitative study describes the clinical reasoning and decision-making processes used by experienced occupational therapists in physical practice when deciding on the first intervention in a familiar type of case. The main finding was that therapists use schematic processing to speed the identification of problems and to indicate potential solutions and actions. Such processing is rapid and automated. Theory appears to become embedded in practice to the point where the therapist is no longer conscious of using it.

A model of the mental problem space generated by therapists during decision making is proposed and the implications for practice are discussed. This model may help to explain some of the differences observed in the reasoning of novice and experienced practitioners. The sample is too small to permit generalisation, but the findings are compatible with theories of cognition and problem solving and also with the results of studies into medical decision making.

Learning in Context: Perceived Benefits of Fieldwork Education within Community Mental Health Settings

The emphasis on community-based services for people with psychiatric disorders requires a concerted response from occupational therapists, if we are to assist people to live meaningful lives in their own communities. This article draws on the fieldwork experiences of 16 Australian and American occupational therapy students, to reflect on fieldwork education and how it may be preparing students to meet the demands of proactive practice in psychiatry. Attention is drawn to the Importance of fieldwork education in community contexts for occupational therapy students, if these future therapists are to be adequately prepared for the demands of community mental health practice.

Use of the Model of Human Occupation: A Survey of Therapists in Psychiatric Practice

This study sought to examine how occupational therapists (OTs) who utilize the Model of Human Occupation as their primary practice model applied concepts of this model to describe the occupational functioning of their clients. A telephone survey method was created to elicit quantitative and qualitative data. The findings suggest that therapists value the holistic approach of this model and often incorporate parts of other practice models into it, although sometimes they ignore conceptual differences between the models. Therapists questioned found major concepts of the model useful for conceptualizing their clients' occupational functioning, but found the further subdivision of major concepts into several variables to be less useful. These preliminary findings and how they relate to the model as a practice theory are examined, and the parts of the theory that may bear refinement or change are discussed.

Inter-Rater and Intra-Rater Reliability of the Occupational Therapy Diagnosis

A registration form based on the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) was developed and its reliability as a registration of occupational therapy (OT) diagnosis was assessed. Fifty patients from a psychiatric hospital and 57 patients from a rehabilitation center participated in this study. Reliability was determined using two measures: the percentage of agreement and Cohen's kappa. Findings of this study indicate that the reliability of the assessments of functional deficits of the patients by occupational therapists is satisfactory to very good. In the rehabilitation center all items, and in the psychiatric hospital 88% of the items, had a kappa value higher than .45. This implies that the registration form can be used in survey research.

Screening for sensory impairment in older adults: Training and practice of occupational therapists in Quebec

BACKGROUND

The goal of occupational therapy education is to train generalists who can refine their knowledge after graduation according to the requirements of the professional environment. However, it is currently unclear to what extent sensory screening should be included in the educational curricula.

PURPOSE

The purpose of this study was to examine the sensory screening education for and practice by occupational therapists working with older adults.

METHOD

A cross-sectional survey was used to collect data from members of the Quebec Order of Occupational Therapists. Descriptive statistics were used in the analysis.

FINDINGS

Data from 102 respondents indicated that training on sensory impairment-related topics was minimal and in stark contrast to the proportion who reported serving clients with a visual (92%), hearing (84%), or combined impairment (53%).

IMPLICATIONS

Occupational therapy considers numerous aspects of physical, cognitive, and emotional well-being. The question remains as to what extent vision and hearing health should take their place among these priorities.

Influence of societal and practice contexts on health professionals' clinical reasoning: a scoping study protocol

INTRODUCTION

In a context of constrained resources, the efficacy of interventions is a pivotal aim of healthcare systems worldwide. Efficacy of healthcare interventions is highly compromised if clinical reasoning (CR), the process that practitioners use to plan, direct, perform and reflect on client care, is not optimal. The CR process of health professionals is influenced by the institutional dimension (ie, legal, regulatory, administrative and organisational aspects) of their societal and practice contexts. Although several studies have been conducted with respect to the institutional dimension influencing health professionals' CR, no clear integration of their results is yet available. The aim of this study is to synthesise and disseminate current knowledge on the influence of the institutional dimension of contexts on health professionals' CR.

METHODS AND ANALYSIS

A scoping study of the scientific literature from January 1980 to March 2013 will be undertaken to summarise and disseminate research findings about the influence of the institutional dimension on CR. Numerous databases (n=18) from three relevant fields (healthcare, health law and politics and management) will be searched. Extended search strategies will include the manual search of bibliographies, health-related websites, public registries and journals of interest. Data will be collected and analysed using a thematic chart and content analysis. A systematic multidisciplinary team approach will allow optimal identification of relevant studies, as well as effective and valid content analysis and dissemination of the results.

DISCUSSION

This scoping study will provide a rigorous, accurate and up-to-date synthesis of existing knowledge regarding: (1) those aspects of the institutional dimension of health professionals' societal and practice contexts that impact their CR and (2) how these aspects influence health professionals' CR. Through the synergy of a multidisciplinary research team from a wide range of expertise, clinical pertinence and an exhaustive dissemination of results to knowledge-users will be ensured.

Identification of occupational therapy clinical expertise: decision-making characteristics

BACKGROUND

Experts are usually determined on the basis of length of experience, reputation, peer acknowledgement, and certification. While these characteristics are important they may, however, not be sufficient for this purpose. Another method for determining clinical expertise is to look at how individuals make decisions in their area of expertise. This study aims to identify clinician expertise on the basis of participants' decision performance and examines this in relation to their length of experience and type of decision-making.

METHODS

The Cochran-Weiss-Shanteau (CWS) is a statistical method that can be used to examine individuals' expertise on the basis of how they discriminate between hypothetical cases and consistency in their decision-making. Participants comprised 18 occupational therapists, each with more than 5 years of experience working with children with cerebral palsy. They were required to make treatment judgements for 110 cases (20 of which were repeated) of children with cerebral palsy. The CWS was calculated for each participant.

RESULTS AND CONCLUSIONS

Two groups of participants were identified on the basis of their CWS index--one with both high consistency in decision-making and the ability to discriminate between cases, the other with low consistency and poor discrimination. These two groups did not differ significantly on the basis of length of experience or work setting but did differ on the basis of intervention chosen and their type of decision-making. The CWS method seems to offer promise as a means of determining clinical expertise on the basis of clinical decision-making. Its application to the investigation of clinical reasoning and education is discussed.

Community occupational therapists' clinical reasoning: identifying tacit knowledge

BACKGROUND

  Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community-dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions.

AIM

  To synthesise current knowledge about community occupational therapists' clinical reasoning.

METHOD

  A scoping study of the literature on community occupational therapists' clinical reasoning was undertaken.

RESULTS

  Fifteen textbooks and 25 articles, including six focussing on community occupational therapists' clinical reasoning, were reviewed. Community occupational therapists' clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists' clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear.

CONCLUSION

  Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.

Occupational therapists’ decision-making in the management of clients with upper limb hypertonicity

This study applied social judgement theory to the exploration of factors influencing occupational therapists' decision-making when they manage upper limb hypertonicity in clients with cerebral palsy. To achieve this goal, both objective and stated policies were investigated. This quantitative study drew information from a literature review and a survey with experienced occupational therapists to identify 12 factors that could influence decision-making. Based on these 12 factors 110 case vignettes of individuals with cerebral palsy and upper limb hypertonicity were generated. Intervention decisions were elicited from 18 experienced occupational therapists for each of the 110 case vignettes. Therapists were also asked to rank the factors in order of perceived importance. Occupational therapists generally used severity of spasticity, wrist and finger posture, and client and family background information to guide their clinical intervention choices. However, therapists demonstrated poor insight into the nature of their decision-making processes. This was highlighted in the disparity between their stated and objective policies. These findings have implications for both the professional development of therapists and the training of students.

Diagnostic practise in nursing: A critical review of the literature

The purpose of this article is to critically review and synthesize the literature related to the general concepts and the process of diagnosing the client's condition, and the possible variables which influence diagnostic practise in nursing. It is suggested that statistical theories are capable of capturing the diagnostic process and offer an effective means to predict diagnostic decisions. Studies underpinned by information-processing theory argue that diagnosing a patient's condition follows a hypothetico-deductive model that consists of specific stages. Those who hold a phenomenological perspective remark that there is yet another form of diagnostic practise: intuitive reasoning, which plays an important role in diagnosing the patient's clinical condition. Other related studies suggest that diagnostic practise is contingent on some personal, psychosocial, and structural variables. Regrettably, these studies offer no conclusive explanation to delineate diagnostic practise in nursing. Based on the literature reviewed, a conceptual framework is suggested to help articulate the underlying structures and processes of diagnostic practise in nursing.

Working collaboratively in health care contexts: the influence of bioscientific knowledge on patient outcomes

This paper explores work-based learning and collaborative working in health care by drawing on the findings of a completed study about the influence of nursing knowledge on patient outcomes. A qualitative research approach was used to explore the experiences of nurses in critical care settings. Interviews and analysis produced a descriptive and interpretive account of everyday working and learning for these specialist nurses. Findings showed that nursing knowledge influenced patient outcomes in a number of ways. Nurses draw on bio-scientific knowledge and experience in order to achieve patient outcomes. Moreover, they collaborated with other health professionals in everyday working and learning. The study findings are explored with reference to the literature about situated knowledge, clinical problem solving and work-based learning. The significance of the findings is that the kind of 'collaborative competence' identified here contributes to the achievement of the aims of the NHS plan and ' Working Together, Learning Together' [Department of Health, 2001. Working Together, Learning Together. Department of Health, London]. Despite the centrality of team working and the trend for more work-based learning in NHS contexts, there is a limited evidence base to date about the influence of team working or work-based learning on patient outcomes. The analysis and discussion in this paper adds to this body of knowledge.

Clinical reasoning, looking back

Expert clinical reasoning is a vital skill for occupational therapists, particularly in today's rapidly changing health care environment. Clinical reasoning may be the strongest building block of the profession as it diversifies and grows to meet the challenges of the new millennium. Therefore, it is a critical time to continue the research to understand, further develop, and expand occupational therapy's knowledge of clinical reasoning. This article describes the development of the occupational therapy clinical reasoning process and compares it to that of medicine and nursing.

Feasibility and acceptability of the COOP/WONCA charts for identification of functional limitations in rural patients of the People's Republic of China

The aim of this study was to test whether the COOP/WONCA Charts could help doctors in three specialty outpatient clinics of Hebei Provincial Hospital, China to identify functional limitations in rural patients and promote more patient-centred care. In this descriptive, cross-sectional study, a sample of 113 rural patients from Hebei Province attending outpatient Neurology, Orthopaedic and Cancer clinics completed the COOP/WONCA Charts. The 80 rural patients who indicated significant functional difficulty and 11 doctors then responded to questionnaires to determine perceived usefulness and satisfaction with use of the COOP/WONCA Charts. Respondents remained blind to the other's responses. A focus group interview was conducted to expand overall views on perceived advantages and disadvantages of the charts. Of the 113 patients completing the COOP/WONCA Charts, 71% (n = 80) were considered to report significant difficulty on at least one chart. Fifty-six per cent of patients rated themselves as having significant functional problems in physical fitness and 65% for daily activities. In contrast, a response indicating 'no or little limitation or effect' was given regarding patients' feelings and/or participation in social activities by 75% of patients in all three clinics. There was no statistically significant difference in the proportion of patients with functional impairment between the three clinics when analysed using a Chi-square test. Over 90% of doctors and patients perceived the COOP/WONCA Charts as helpful with 'increased communication' as an outstanding benefit. This study has shown the COOP/WONCA Charts to be feasible and useful tools: to help identify functional limitations in Chinese outpatients; to trigger a more functionally focused patient-centred model of practice; and to encourage appropriate referrals to existing rehabilitation efforts in large Chinese hospitals.

Clinical Reasoning of a Novice versus an Experienced Occupational Therapist: A Qualitative Study

The clinical reasoning process is an important aspect of occupational therapy practice. The purpose of this critical, focused ethnography was to compare the clinical reasoning process of an experienced and novice therapist. Individual semi-structured interviews were conducted with an experienced and a novice therapist after each had reviewed a sample case study to help elicit the clinical reasoning process. Observations in the clinical setting were conducted. Themes which emerged include definitions of clinical reasoning, sources used when reasoning, factors influencing clinical reasoning, ability to prioritize, patient viewed as an individual, patients' role in treatment, and clinical reasoning as an evolving process. Similarities and differences between the therapists are noted and discussed. Implications for practice, education, and future research are identified.

Process over person?: occupational therapy students' fieldwork experiences of people in psychiatric settings

This paper explores influences of psychiatric service system processes on occupational therapy students' understanding of people with psychiatric disorders. The fieldwork experiences of 16 occupational therapy undergraduates in clinical settings were studied via in-depth interviews and participant observation. An important part of the students' understanding of people with psychiatric disorders arose from the manner in which the psychiatric service system and occupational therapists have structured their dealings with people as patients or clients. Students were influenced by system practices such as the classification of people as acute/chronic, and a heavy emphasis on quantitative performance indicators of services rendered; along with an occupational therapy process that may be excessively problem-oriented, at the expense of attending to other significant personal and environmental factors within patients'/clients' lives. Such circumstances are likely to undermine students' appreciation of the humanity and individuality of people using the psychiatric service system.

Application of the ICIDH in survey research on rehabilitation: the emergence of the functional diagnosis

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) has been hypothesized to be an excellent conceptual framework for the functional diagnosis, i.e. the evaluation of health problems by rehabilitation specialists. The ICIDH-based functional diagnosis was assessed in a series of survey studies on physical therapy, exercise therapy, occupational therapy, podiatry, and speech therapy. The results show that the functional diagnosis tends to be reliable; that treatment goals, derived from the diagnosis, offer a sensible characterization of care given by rehabilitation specialists; and that treatment goals validity predict the selection of interventions by rehabilitation specialists. It is concluded that the application of the ICIDH in research on the functional diagnosis is highly appropriate. In future studies the concept of the functional diagnosis and the diagnostic procedures should be further developed.

Impairments and disabilities in hand therapy: the necessity of a uniform terminology for communication and research purposes

Uniformity in the use of professional language is very important in the field of medicine. Impairments and disabilities are terms that are often used interchangeably. To health professionals analyzing a patient's health problem, formulating treatment goals, or writing questionnaires and protocols, the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) offers a conceptual framework that has a great potential to remedy improper use of terms and that can enhance communication. The purpose of this article is twofold: (1) to familiarize the hand therapist with the ICIDH and (2) to present some proposals for a revision of the ICIDH that will make the classification structurally more practical and thereby will facilitate its use.