Linda Robertson

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.

Clinical Reasoning, Part 2: Novice/Expert Differences

In part 1, a model of problem solving in occupational therapy was presented; the problem-representation component of this has now been developed to depict the differences between student and clinician in problem representation. This new model illustrates that both students and clinicians have access to the same information but that this is more clearly defined and organised in the clinician. The abstract, unlinked data of the student are ultimately transformed by concrete experience to a rich supply of schemata, which then become the basis for further development of problem representations in a particular area of practice. Clinicians frequently weave a human perspective into their understanding of the client whereas students, although able to note the clients concerns, are more likely to treat this information as another piece of data than to integrate it into treatment planning. A number of educational strategies are discussed.

Hard Complexities – Soft Complexities: An Exploration of Philosophical Positions Related to Evidence in Occupational Therapy

The practice of occupational therapy rests upon the ontological assumption that there is a relationship between engagement in occupation and health. Different traditions of knowing about and investigating this relationship are evident within the literature. The professional link with biomedicine has led to an adherence to positivistic methodologies but, as the profession has begun to generate discipline-specific knowledge, inquiry approaches consistent with interpretative and critical theory have become evident. This paper explores the nature of inquiry underpinning current practice. It suggests that contemporary developments have been a reaction to a climate of uncertainty, generated by rapid political, fiscal, technological and ideological change in the delivery of health and social care in the last four decades. From these rapid changes, different views of ‘best practice’ have developed: evidence-based, reflective and reflexive practice, each with its own source of knowledge and method of inquiry. It is postulated that each of these views has implications for education, practice and research.

Evaluation of a peer-led falls prevention program for older adults.

OBJECTIVE To evaluate measures of strength and balance and falls incidence in participants attending fall prevention exercise classes taught by volunteer peer leaders, paid professional (Age Concern Otago group), or a comparison class (comparison group). DESIGN Quasi-experimental evaluation with 12-month follow-up. SETTING Community. PARTICIPANTS Older adults with increased fall risk (N=118; mean age, 75.5 y; age range, 65-94 y), with 23% drop out at 12 months. INTERVENTION Peer-led group (n=52) and Age Concern Otago (n=41) weekly 1-hour strength and balance classes adapted from a home-based nurse/physical therapist-administered program and comparison group (n=25) 1-hour weekly seated exercise classes. MAIN OUTCOME MEASURES Timed Up and Go test, 30-second chair stand, functional reach, step touch, Single Leg Stand, and balance confidence at baseline, 10 weeks, and 6 and 12 months. Falls diaries collected monthly for 12 months. Continued exercise participation questionnaire at 6 and 12 months. RESULTS At baseline, the peer-led group achieved normative standards on most tests and performed significantly better than the Age Concern Otago and comparison groups (overall P<.05). The Age Concern Otago group reached normative standards on most tests at 10 weeks. Functional improvements were similar in the peer-led group and Age Concern Otago groups from 10 weeks to 12 months, and all functional measures were significantly greater than in the comparison group (overall P<.02). Poisson regression showed a tendency for a 27% decrease in falls for the peer-led group compared with the comparison group (incidence rate ratio [IRR], .73; 95% confidence interval, .48-1.1; P=.07). Continued participation in strength and balance classes at 12 months was greater in the peer-led group and Age Concern Otago groups compared with the comparison group. CONCLUSIONS This peer-led model maintained measures of strength and balance and was superior to seated exercise. People in the Age Concern Otago group chose to continue these classes over other activities, whereas the comparison group had discontinued exercise classes by 12 months. Peer-led classes may decrease the fall incidence, although larger studies are needed to confirm this finding.

The Conceptualisation of Residential Home Environments: Implications for Occupational Therapy

This paper examines the views of staff about the environments of two residential homes: one representative of a homely environment and the other more reminiscent of a hotel. A qualitative study using in-depth semi-structured interviews was conducted with a purposive sample of 21 staff. Emerging themes in the data from the first facility related to kinship, recognition of history, individuality and meaningful relationships in the homely environment. This contrasted with a more conscious awareness of the tone of the second facility, the need for correct behaviours and a bureaucratic organisation in the hotel-like home. The findings showed that the meanings attached to a residential home and its press for occupational behaviours are shaped by cultural, social and historical experiences. Such meanings are strongly influenced by management, with staff and residents adjusting to expectations as indicated by the social and physical environment. There is very little in the literature that reflects how one should conceptualise a residential home, yet it is the very nature of this perception that is crucial to the development of an atmosphere that indicates expectations for actions – for both staff and residents.

What Actually Informs Practice: Occupational Therapists' Views of Evidence

Introduction: This research aims to explore what New Zealand occupational therapists consider ‘evidence’ to be and how the search for evidence is accomplished in their practice. Method: Semi-structured interviews were conducted with 14 therapists who had shown variations in comfort levels with locating and implementing evidence. Findings: Four themes emerged from the data: (1) finding evidence to support practice: informal quick methods were favoured; (2) the nature of available evidence: evidence was considered to be of limited value in practice as the context of the research was often very different to the context of local practice; (3) the organisational influences: the culture of the work environment played a key role in the dissemination of knowledge and (4) the importance of evidence: the need to use evidence to support practice was appreciated by most therapists. In general, using reliable resources was regarded as key to evidence-based practice with availability of resources, therefore, deemed essential. Conclusion: Therapists value trustworthy research information that is pre-digested and can be readily used in practice. Where there is limited research evidence, the focus should be on the generation and dissemination of information from critical reflections on practice.

Promoting staff development in occupational therapy: a reflective group approach

Staff development is a vital aspect of professional practice. It enables occupational therapists to observe latest practice and upgrade standards appropriately. Staff development opportunities often ensure that practitioners have access to theoretical knowledge as the basis for improving practice. This approach may be ineffective or minimally effective if it provides only theoretical professional knowledge and is not integrated into everyday practice. A more productive staff development procedure involves an exploration of practical knowledge. This is not theoretical knowledge about practice, but the kind embedded in practice. Such practical theories gained through reflective processes may be discussed informally during workplace interactions but rarely are opportunities available for therapists to articulate these in a systematic way. Given the above, this paper reports on the procedures of a staff development research project which engaged a sample of practising occupational therapists from the Dunedin community in a process of reflective group practice. The project focused on two main questions: what are the issues that influence practice? And are the uses of reflective peer groups an effective staff development strategy? Two themes emerged from the investigation, the first being that practice is fraught with uncertainties and the second that the aims of occupational therapists are not necessarily supported by other health team members. These two themes highlight the notion that occupational therapists cannot rely on theoretical knowledge alone prior to graduation and that practical knowledge plays a substantial part in their learning. The use of reflective groups was endorsed by all participants as a viable method of staff development. The reported effectiveness was in facilitating change at various levels: simple raising of awareness; encounters with ideas of others different from ones own; stated intention to change practice in light of new insights; and reports of actual changes because of group insights.

Quality in residential care: exploring residents’, family members’, managers’ and staff perspectives

Purpose The purpose of this paper is to explore the indicators of quality in care for people working and living in aged residential care (ARC) settings. Design/methodology/approach This research was conducted using an ethnographic design in two distinct ARC facilities in a New Zealand city, a large facility with residential, dementia and hospital level care, and a small family owned facility providing residential care only. In total, 50 hours of observational data were collected, and semi-structured interviews were conducted with 21 people, including managers, careworkers, nurses, family members and residents. These data were thematically analysed using the constant comparative method. Findings The main indicators of quality for staff, family and residents included: a home-like, friendly and safe environment; good medical and personal care; respect for the residents; and good staff. Participants also acknowledged the need for adjustments by residents to living in aged care; and the challenges of caring for increasingly frail residents. Originality/value Findings support the growing recognition of a need for resident-centred approaches to ARC that are reflected in government policy and regulatory apparatus. Managers in ARC facilities must balance adherence with health and safety standards, and providing an environment where their residents can enjoy a meaningful life that has purpose and value.

New graduates’ experience of evidence-based practice: An action research study:

Introduction The aim of this project was to explore how occupational therapy graduates in New Zealand engaged with evidence-based practice. Method The study adopted an action research approach. Five new graduates were recruited and worked with the researcher to identify practical problems related to using evidence-based practice and to propose solutions. Surveys, email and discussion groups were used to collect data over three action research cycles. Findings The main findings from this study were that new graduates are more likely to use research evidence when prompted to do this by their supervisor (or another external source) and that senior occupational therapists are identified as essential to both demonstrate and motivate evidence-based behaviours. New graduates used evidence to justify their practice to others, increase self-confidence and to inform themselves. The evidence used was commonly based on the expertise of senior therapists. Conclusion For new graduates the tasks of searching and evaluating evidence are secondary to developing and clarifying their clinical knowledge and skills. The expectations of the workplace and the partnership between new graduate and experienced clinician are highly influential in establishing regular habits related to evidence-based practice.

Adding self-management of chronic conditions to fall prevention: A feasibility study.

Assess feasibility and impact of adding a long‐term condition self‐management program (Living a Healthy Life, LHL) into Steady as You Go (SAYGO) fall prevention exercise classes.