“Perpetual problem-solving”: An ethnographic study of clinical reasoning in a therapeutic recreation setting
Hutchinson, Susan L
The purposes of this paper are to review literature on the concept and practice of clinical reasoning and to present evidence of clinical reasoning in a therapeutic recreation (TR) setting. Clinical reasoning is considered both a way of thinking and interacting with clients that facilitates effective client-centered practice. Observational and interview data of two recreation therapists’ work with six people (three men and three women, aged 23 to 67) receiving inpatient services in a rehabilitation hospital in Eastern Canada provides evidence of the therapists’ clinical reasoning practices. This ethnographic evidence supports the way clinical reasoning is conceptualized in allied health professions. The paper ends with a discussion of the implications of clinical reasoning for research and practice in clinical therapeutic recreation settings.
KEY WORDS: Clinical Reasoning, Therapeutic Recreation Practice, Reflective Practice
“We have conceptualized clinical reasoning as a spiralling thinking process; a search for a growing understanding of the clinical situation as the basis for clinical intervention” (Higgs & Jones, 1995, p. xv).
“Beth,” a recreation therapist in a rehabilitation hospital, was working with “Travis,” a young man who had a spinal cord injury, and who now required the use of a wheelchair for mobility in the community. While on an outing with Travis, Beth’s goals had been to assess and, in turn, work on increasing his awareness of community access issues and safe wheelchair handling. In this context, assessment and intervention occurred simultaneously. After the outing Beth described the process by which she engaged in what she named “perpetual problem-solving” to facilitate learning on this outing:
I’m thinking … he [Travis] wants to go to the drug store and there are two doors and one’s at a ninety degree angle and how’s he going to manage? And there’s a little bit of a lip [in the door frame], and people are going to be walking by, and it’s hard to get through [the doorway], so how’s he going to manage it? So you watch and wait to see how he’s going to problem solve, and then have other suggestions ready…. It’s allowing people to be in a situation so they can experiment with some of the skills they’re going to need related to those things they are going to want to do and, in that context, problem solve in a safe environment.
For Beth, the “perpetual problem-solving” that occurs while she is working with clients involves “observation in connection with anticipation … anticipatory skills so that you can see how a situation may possibly develop.” In allied health professions, such as nursing and occupational therapy, clinical reasoning is the term used to describe such processes.
Clinical reasoning is considered both a way of thinking and way of interacting with clients that facilitates effective practice. Some argue that the ability to make sound clinical judgments is the most important factor in effective clinical practice (e.g., Higgs & Jones, 1995; Mattingly & Fleming, 1994). Yet clinical reasoning refers to more than rational or scientific reasoning-the application of theories in search of universal forms of expert practice. Instead, clinical reasoning is concerned with the specific; the particular details of people’s lives, including their illness or disability. These details are central to the ends to which recreation therapy is directed, and to the meanings clients derive from their participation in therapy.
The purpose of this paper is to review literature on clinical reasoning and then to present evidence of the processes by which two recreation therapists in a rehabilitation setting engaged in clinical reasoning, based on an ethnographic study of therapeutic recreation practice in eastern Canada. This evidence supports the way clinical reasoning is conceptualized in allied professions. The paper ends with a discussion of the implications of clinical reasoning for research and practice in clinical therapeutic recreation settings.
Clinical Reasoning
In simple terms, clinical reasoning is the thinking and decision-making processes which are integral to clinical practice. However, clinical reasoning also results from a complex interplay of many factors including “contexual and disciplinary parameters, emotions, knowledge, experience, cognitive skill and personal frames of reference” (Higgs & Jones, 1995, p. xiv). Clinical reasoning is not separate from clinical practice; in fact, thought (clinical reasoning) and action (clinical practice) are interdependent (Mattingly & Fleming, 1994). Moreover clinical reasoning is not just about better meeting the needs of individuals through good clinical practice; rather it refers to the decision-making and actions required of clinicians to effectively work within a particular organizational and health care culture. Higgs and Jones characterized clinical reasoning as “a process of reflective inquiry, in collaboration with the client (if possible), which seeks to promote a deep and contextually relevant understanding of the clinical problem, in order to provide a sound basis for clinical intervention” (p. 6). Writing about occupational therapists’ clinical reasoning, Mattingly and Fleming suggested:
Clinical reasoning is not reducible to a method (or even several methods) of thinking; it is also a way of perceiving…. To talk about how therapists think is necessarily to consider what therapists think about, what they perceive in the way they view their clients, what they focus on as the central problem, what they ignore, how they describe what is physiologically problematic for the client, and even their view of who the client is as a person. (p. 9)
According to proponents of clinical reasoning, such a process requires having more than good technical knowledge or skills. “It involves deliberation about what an appropriate action is in this particular case, with this particular client, at this particular time. This is no technical question” (Mattingly & Fleming, pp. 9-10).
In summary then, clinical reasoning is the process of thinking, reflecting and decision– making, grounded in interactions with clients, that practitioners undertake in their efforts to develop interventions and to provide experiences that will best meet the particular needs of individuals. The next section elaborates the contextual factors that influence, and sometimes constrain, clinical reasoning.
The Multiple Contexts of Clinical Reasoning
As indicated in the introduction, clinical reasoning involves making context-specific judgments about the best course of action for a particular client at that particular time. To this end clinical reasoning requires that practitioners attend to the immediate personal context of the individual, the multiple aspects of his or her clinical problem that can be addressed within a particular clinical setting, as well as their own personal and professional philosophies that frame the way they understand clients’ problems and their role in addressing these problems (Hutchinson & Samdahl, 2000). In addition, clinicians must be cognizant of the institutional discourse and practices that shape (and constrain) practice as well as the broader context of health care delivery within which they are operating (Hutchinson & Samdahl, 2001; Mattingly & Fleming, 1994).
According to Mattingly (1991) one of the primary goals of clinical reasoning is to determine the meaning of disability from the client’s perspective. Five types of knowledge about a client are required to establish a picture of this meaning: (1) knowledge of the client’s motivations, desires, and tolerances; (2) knowledge of the environment and context within which client performance will occur; (3) knowledge of the client’s abilities and deficits; (4) insight into the existing relationship with the client, its tacit rules and boundaries; and (5) a predictive knowledge of client potential in the long term. Mattingly explained:
Knowledge from all these factors becomes a dynamic information flow during the process of assessment and treatment, requiring that the therapist constantly review her/his understanding of how the client views (him) herself, how the client views therapy and the therapist, and what the client thinks should be done. (pp. 92-93)
Clinical reasoning focuses, therefore, on the process of individualizing treatment, by attending to the person’s illness or injury, the person, and the personal and cultural meanings the person attaches to his/her illness experiences and experiences within the health care context.
Therapeutic recreation professionals are similarly “client-centered.” That is, they are aware of and attend to the personal context of individuals, including such factors as their unique cultural, family, work and socioeconomic frames of reference. This context shapes clients’ beliefs, values and expectations, and their perceptions and needs in terms of how therapeutic recreation might help them (if at all). However, in the field of therapeutic recreation little emphasis has been placed on understanding the ways a particular social, cultural, and political context directs, to a large degree, what practitioners do and don’t do with their clients. Yet, according to Chapparo and Ranka (1995), clinical reasoning is based on acknowledging the impact of organizational influences over which therapists may have limited control.
Elements of the external organizational context become important and powerful factors in establishing conditions (e.g., values of the organization) and constraints (e.g., policies, budget cuts) within which decision making occurs…. Many times the theoretical perspective or professional value held by the therapist may fail to account for the institutional conditions and in such situations these internal values and goals can come into direct conflict within organizational directions and limitations. The resulting dilemma for clinical reasoning is one of conflict between what therapists perceive should be done, what the client wants done and what the system will allow. (Chapparo & Ranka, p. 92)
In summary, these multiple individual and organizational factors are constitutive of the thinking, reasoning and judgments that recreation therapists must make in deciding what is “the good” (Mattingly & Fleming, 1994) for individuals and the organization (and the practitioner him or herself). In the next section we move beyond the contextual factors that influence clinical reasoning to examine in greater depth the processes by which clinical reasoning occurs.
Clinical Reasoning as the Process of Reflective Practice
Mattingly and Fleming (1994) described clinical reasoning as “judgment in action” leading to “action based upon judgment” and argued that “the confluence of action and judgment may also be the basis for the therapists’ conviction that evaluation and treatment are reciprocal and continuous, not distinct, processes” (p. 342). The process of clinical reasoning, then, occurs throughout the practitioner’s actions and interactions with clients. Each decision or intervention produces a clearer picture of the clinical problem, which in turn generates further avenues for intervention (or further questions) in the continuous process of assessing, making decisions, implementing strategies and then evaluating their effectiveness. This process is ongoing, action– oriented and largely based on practice-based knowledge and experience.
The concept of clinical reasoning parallels Schon’s (1983; 1987) seminal writings on “reflective practice” that have been elaborated for education and other professions. In fact, Schon’s work is the basis for the way clinical reasoning is conceptualized in occupational therapy settings (Mattingly & Fleming, 1994). Schon (1983) contended that professionals need to be reflective practitioners rather than adopting a positivistic view of professional knowledge-technical rationality-which assumes that professional activity consists of instrumental problem-solving made rigorous by the application of scientific theory and technique.
In their study of occupational therapists’ practice, Mattingly and Fleming (1994) identified the processes by which the therapists they observed engaged in practice. Like Beth, the recreation therapist introduced at the beginning of this paper, they found that the therapists monitored and evaluated their clients’ involvement in the therapy session while they were conducting treatment.
They seemed to be deeply involved in directing the therapy session, while simultaneously making a distant evaluation of it…. They were interacting with patients both to elicit their cooperation and to understand the person’s response to the treatment at both physical and interactive levels. In addition, they were not only observing and analyzing their patients’ behavior, but their own as well. Therapists were thinking of themselves as director, actor, audience, and critic all at once. (p. 131)
The occupational therapists in the Mattingly’s Clinical Reasoning Study would often talk about “making something happen” or “keeping the session on track” as a way to characterize the fluid and, often, improvisational nature of the therapy process. Mattingly and Fleming commented:
It is more than simply knowing the correct procedure and executing it well. There is a quality about the practice in which ‘individualizing’ is not simply making a few adjustments to the usual procedure to suit it to the particular peculiarities of this patient…. Experienced therapists seem to have very vivid images in their mind of who the person is and what the person can be like, given time and therapy. Therapists’ visions of this future person guided their evaluation and the day-to– day, as well as the overall, treatment…. “Pulling it all together” means having a person develop a set of insights and skills that will allow her or him to live the life the therapist thought was possible. (p. 132)
In summary, clinical reasoning is a complex, multi-dimensional and continuous process of thinking that practitioners use while engaged in clinical practice. As noted by others who have studied practitioners in allied health fields, clinical reasoning relies on client-centered modes of assessment and treatment which are often in constant flux as practitioners try to decide, often while engaged in the process of assessment or therapy, what is best for this particular client at this moment in his/her rehabilitation process. In this paper, the work of two recreation therapists in a clinical rehabilitation setting is examined. Ethnographic data that demonstrates the reasoning strategies of the recreation therapists in this study supports the concept of clinical reasoning presented above.
Data Collection and Analytic Methods
An ethnographic study of therapeutic recreation services in Canada provides the data for this paper. Qualitative (or interpretive) methods have been advocated for use in therapeutic recreation settings (Bullock, 1983; Dattilo, McCormick & Scott, 1991; Glancy, 1993; Howe, 1991; McCormick, Scott, & Dattilo, 1991). In this study, an interpretive approach was employed to examine the nature of the experiences associated with recreation therapy and the subjective meanings study participants attached to these experiences.
Miller and Crabtree (1994) argued that the strength of qualitative research in clinical settings is its capacity to make explicit underlying assumptions and beliefs that guide clinical practice, and to answer questions that “concem experience, meaning, patterns, relationships, and values” (p. 343). For Miller and Crabtree, the “real world” of clinical practice involves multiple and sometimes conflicting meanings, intentions, values and knowledge. Their recommendations for conducting qualitative clinical research (e.g., attending to underlying values and assumptions) were adopted for this study. The following profiles the setting where data collection occurred, the study participants, and the data collection and analysis methods used.
Study Site
A rehabilitation hospital in eastern Canada was chosen as the site for this study. The rehabilitation hospital was part of a large health care organization that provided acute, rehabilitation and long-term care services to inpatients and outpatients in the region. Six programs comprised the inpatient rehabilitation services: Stroke, amputee, spinal cord injury, trauma, brain injury, and arthritis. A program referred to the overall provision of rehabilitation services (e.g., nursing care, physiotherapy, speech therapy, etc.) to different patient groups. Although the recreation therapy department was responsible to provide both inpatient and outpatient services, the recreation therapists worked mostly with the interdisciplinary teams providing inpatient services.
The majority of recreation therapy services were provided to inpatients over a relatively short-term (two to three weeks). Patients who remained in the rehabilitation center for longer time periods were not interviewed as they often presented with more complex physical needs. For example, one of the recreation therapists worked extensively with a middle-aged man who had a brain stem stroke that resulted in complete aphasia (unable to speak, although he could understand words). He could not be interviewed and thus was not a suitable candidate for the study. The therapists worked during the daytime weekday hours in order to provide interventions during patients’ regular therapy time. Most often patients received individual treatment, leisure education or community integration interventions but were also encouraged to participate in skill development groups (e.g., a crafts group). Often, participation in group interventions was preempted by more pressing demands on patients’ time for other rehabilitation therapies (this was often the preference of the patient). Volunteer-run participatory programs were offered in the evenings. Interesting, although the department ascribed to the Leisure Ability Model of service, the Clinical Manager was adamant that the department should retain the title of “Recreation Therapy” in order to appear more clinically oriented to allied disciplines. As he said, “If we’re not doing therapy, or if we don’t have a name that implies that we’re doing therapy, whether you do or not, then that’s a problem.”
During data collection it became clear that institutional factors (e.g., policies, procedures, staffing budgets) external to the therapy processes influenced what the recreation therapists did with individuals. For example, due to shorter stays in rehabilitation, the therapists had to make instant decisions, often in the context of the screening/assessment interview, regarding what kinds of information (e.g., about community resources or activity modifications) might be relevant for people to receive before discharge. While this process did not reflect the therapists’ actual beliefs about what patients needed most, it did reflect the institutional constraints they worked within.
Study Participants
Two recreation therapists and six people who were receiving inpatient rehabilitation services (three men and three women, aged 23 to 67) participated in the study. Both therapists had worked in clinical therapeutic recreation settings (long term care and physical medicine) within the organization for approximately ten years and had served on several departmental, organization-wide, provincial and national committees associated with the TR profession. One was a certified therapeutic recreation specialist. Both were trained as recreation therapists, although neither had training in or were familiar with the concept of clinical reasoning prior to the study. For the purposes of preserving anonymity the pseudonyms Beth and Ann are used. Up until the year prior to the study there had been two other therapists assigned to the rehabilitation unit. However, with staff cutbacks across the organization those positions had been eliminated. During the three-months of data collection, additional cutbacks and possible restructuring of the hospital left many employees concerned about their jobs. Trying to juggle large patient caseloads with increasing demands to supervise students, participate in research, and contribute to programmatic, departmental and professional development left both therapists feeling stretched.
Subject selection criteria were established to guide recruitment of patients for the study. While the word “patient” is often considered pejorative because of the lack of power connoted by its meaning, in this study the therapists and other health professionals with whom they interacted regularly referred to people receiving rehabilitation services as patients; this is the term that will be used from this point forth when describing study participants. In order to be considered for participation in the study patients had to be suitable candidates for receiving inpatient recreation therapy services, over 18, and able to speak English and carry on a conversation. In addition, patients had to agree to participate in individual and group recreation therapy interventions. As indicated previously, six inpatients agreed to participate in the study. Each therapist worked with three of the study participants.
Helen, a 63-year-old woman, had a stroke just one year after her husband had died of cancer. Marie, 44, had lived with multiple sclerosis for 6 years although this was the first time she had been hospitalized. Bob was a 52-year-old man whose heart attack was precipitated by extreme weight gain and alcohol abuse. Irene, in her early SOs, was hospitalized for rehabilitation after a hip replacement, although her rehabilitation was made more difficult because she also had multiple sclerosis. Clint, 56 years old, had acquired a spinal cord injury that left him quadriplegic as the result of a roofing accident. Travis, a tall young man, 27, received a spinal cord injury as a result of a truck accident. Table 1 profiles these six individuals.
Data Collection and Analysis
Data collection was directed at describing the forms of discourse and practice associated with TR service delivery. Of particular interest was the talk and actions that occurred within formal and informal team meetings, staff meetings, and department meetings; formal and informal interactions with patients (and, sometimes, family members; e.g., during screening/assessment and discharge); and in individual and group therapy, education, community integration, or activity skill development sessions.
Approximately 25 hours per week was spent in the rehabilitation hospital doing data collection over a three-month period. Four data collection methods were used: (1) semi-structure interviews with six patients, the two recreation therapists, two allied health professionals and the Clinical Manager for Recreation Therapy (these interviews were audiotaped and transcribed verbatim); (2) observation of individual assessments and therapy, group skill development sessions, volunteer-run evening activities, team, departmental and organization-wide meetings; (3) debriefing conversations with the therapists after they had facilitated a group or individual intervention; (4) document collection, including assessment and progress notes, policies and procedures, and information brochures. An interview guide was used to direct formal interviews with patients and the therapists (sample questions are provided in the Appendix). Five of the six patients were formally interviewed twice; once soon after they agreed to participate in the study and again just before discharge or when the study ended (which ever came first). Typically, however, the author had daily contact with each of the six individuals. Interviews occurred in a quiet setting within the rehabilitation center, and lasted approximately one to one and one-half hours. The debriefing conversations with the therapists provided a rich source of data for evidence of the reasoning that guided the therapists’ work. Although the therapists informally initiated these debriefing sessions, as the study preceded these conversations were tape-recorded, transcribed and used in the analysis and interpretation process.
It is important to note that the original purpose of the study was not to examine clinical reasoning processes; rather it was to examine the interactions between therapists and people receiving recreation therapy services for the ways patients internalized-created meaning from-this discourse. What became apparent though in the process of data collection were the complex reasoning processes that necessarily guided the therapists’ work. Along with the observational data, debriefing conversations provided the data to reveal the thinking and decision-making processes that underpinned the recreation therapists’ work with patients in this study.
Data Analysis
Several proponents of qualitative research suggest there is no one “right way” to approach data analysis (cf. Cresswell, 1994; Ely, Vinz, Downing, & Anzul, 1997). Instead, data analysis requires being systematic, rigorous, and creative in managing, reducing and interpreting the data.
Data management occurred in several ways. At the end of each day spent on-site at the rehabilitation hospital, the author would transcribe hand-written field notes onto the computer, adding additional notes reflecting any concerns or insights. All audio-taped debriefing conversations, interviews with the therapists, allied health professionals, and the Clinical Manager were transcribed by the author. A typist was hired to transcribe the interviews with the patients. The author was provided with a disk copy of the transcribed interviews, which were subsequently reviewed for accuracy by the author (e.g., by listening back through the tape while reading through transcript). Files were created for each patient who participated in the study. These files included transcriptions from audio-taped interviews, information from the therapist’s assessment and progress notes, observation field notes related to the therapists work with the patient as well as field notes from observing him or her in other settings (e.g., in room or chatting with other patients). In addition, files that contained field note and interview data related to the rehabilitation context, the Recreation Therapy Department, and the work of the recreation therapists in Rehabilitation were established.
Analysis of the data followed a general protocol for inductively analyzing qualitative data (cf. Coffey & Atkinson, 1996; Cresswell, 1994; Ely, et al. 1997). This process involves reviewing data within and across cases, developing preliminary codes, and then returning to the data for categorizing and conceptualizing themes. Coding and categorizing was a way of assigning meaning to chunks of data, and provided a means of linking ideas (generated by the researcher) to the data itself (Coffey & Atkinson, 1996). “Coding generally is used to break up and segment the data into simpler, general categories and is used to expand and tease out the data, in order to formulate new questions and levels of interpretation” (Coffey & Atkinson, p. 30). As Coffey and Atkinson suggested, “codes, data categories, and concepts are related closely to one another. The important analytic work lies in establishing and thinking about such linkages” (p. 27).
Data analysis proceeded iteratively. The first phase focused on defining the contextual factors that most impacted the therapists’ understanding of their work. Analysis of the contextual data focused on finding evidence of tension in the therapists’ everyday work. After completing a description of the context within which recreation therapy occurred, within and cross-case (between the six cases) analysis was used to seek evidence of patterns in the processes associated with recreation therapy and regarding the nature of the interactions between therapist and patients. Coding (by highlighting, underlining and labeling in the margins) was used to organize and reduce data within cases. The codes and categories were derived in part from the data and in part from the research questions that guided data collection.
After completing coding, preliminary categories were generated into which the coded data could be organized. Categories that had some elements in common were clustered together to create themes. These themes were intended to be discrete; that is, they were inclusive of the categories they encompassed but were conceptually and empirically distinct from each other. The themes all dealt with aspects of the “clinical task,” a term chosen to signify the things that the therapists talked about and did in the context of recreation therapy interventions. The data on clinical reasoning was one category of a theme termed “Framing the Clinical Task,” which referred to the approaches the therapists used that seemed most effective in facilitating engagement in the therapy process.
After data analysis was completed, the therapists and Clinical Manager were provided with a draft copy of the results and analysis representing the therapy context and the themes generated from the cross-case analysis. It is important to note that these themes, including the concept of clinical reasoning, were tentatively “tested out” during the many conversations that occurred between the therapists and the author over the three months of data collection. While the therapists were concerned about how they would be perceived by peers as a result of what was written (and what might eventually be published), they nonetheless expressed that the results and analysis accurately reflected their perceptions of their work.
Results: Reflections on “Perpetual Problem-Solving”
As we saw in the introduction, clinical reasoning, or “perpetual problem-solving” as Beth named it, occurred when a therapist was engaged in the present moment with a client, yet was thinking ahead to what might happen next, and how she could structure the environment or what she would say to respond to these anticipated next steps. Three facets of clinical reasoning were evident in this study. First, it was viewed by the therapists as a process that involved information gathering, observing, assessing, anticipating, decision– making, problem-solving. Second, clinical reasoning primarily occurred in the context of activity engagement, wherein the therapists would embed “therapy” and problem-solving suggestions, discussions, and learning opportunities in context of activity participation. Often this involved creating situations for individual problem-solving. Third, there were a number of contextual factors that affected the processes of reasoning and activity engagement. Each of these facets of clinical reasoning are described in more detail below.
Perpetual Problem-Solving as a Process
In this study, the process of perpetual problem-solving began during the therapist’s first meeting with a new patient to assess his or her needs for recreation therapy. Beth explained, “as I am listening I am trying to assess whether the person has a handle on his or her leisure.” She added:
You can learn a lot about what this [particular issue discussed in assessment meeting] means to that person by the way they answer the questions. And that’s where the process gets going. That’s where you start doing the decision-making as therapists, figuring out which way you’re going to go.
For the therapists in this study, perpetual problem-solving involved ongoing efforts to gather information from and about patients as the basis for directing TR interventions. Often the therapists felt they needed to know something not only about patients’ preferred activities, but their patterns of leisure engagement, and, most importantly, the meanings they derived from this engagement. In fact, when the therapists had not fully understood the meaning of a particular activity for individuals, or were unaware of the broader rehabilitation goals to which patients’ efforts were directed, it was difficult to engage patients in the therapy process. Similarly, when patients and therapists held divergent understandings about what role recreation therapy should assume in relation to patients’ therapy goals, then it was difficult to create a tenable therapeutic relationship. An example follows.
In an initial assessment meeting Ann had noted that Bob, who was hospitalized as a result of severe alcohol abuse and obesity, liked to play pool. Even though Bob was reluctant to pursue the leisure education process she advocated for him, Ann hoped that she could get Bob to agree to work with her if they started by focusing on how he could play pool from a wheelchair. However, for Bob, getting his “legs work’n again” was the most important thing. As a result he was vehement that there was “no way” he was going to play pool from a wheelchair; he vowed he was walking out of the rehabilitation center. As it turned out, Ann had made a suggestion for their future work together that was in opposition to his vision of himself walking. Perhaps if Ann had known this she would have been able to emphasize the functional gains to be made from physical activity such as pool playing as a way to frame his continued participation in TR. Ironically, Bob suggested something similar in an interview. “See all those people with their hands? [referring to patients who were getting hand therapy in OT]. I think if you played a little bit of shuffleboard they’d be using their hands. They’d be exercising their hands. That way you could combine the two, the therapy and the recreation.”
These processes of problem-solving, negotiating and framing interactions and practice seemed recursive and improvisational. That is, often the therapists made instant decisions about what to do as they were interacting with patients, and then would read patients’ reactions to decide whether this approach was working or if it needed to be further modified. Furthermore, assessing, observing, anticipating next steps revolved around elaborating a plan for intervention. This plan would often evolve in the context of activity engagement.
Activity Engagement as a Context for Perpetual Problem-Solving
The therapists in this study often used activity engagement (e.g., community outings, activity groups, individual skill development sessions) as the context for further assessing patients’ needs, personal motivations, and feelings about their illness or injury. More importantly, activity engagement afforded the therapists opportunities to move quickly from assessing needs and abilities to acting on this assessment by initiating involvement in the type of activity that might be instrumental in sustaining patients’ engagement in TR. Beth gave an example of her assessment with Travis. She said that as she was talking with him at the pool table she was thinking ahead to the kind of adaptive aid he could manage, given his level of injury and remaining and potential hand function as a result of that injury.
For example, if you’re speaking with someone and you go in and they say “oh gee I haven’t given a lot of thought to that,” but … they’re operating at a wheelchair level, then you know to say, “well, we’ll start with some skill development.” And then in the context of playing pool or doing some skill development, I’ll start to explore a bit more information. Where you live, what do you do in your community, how you’re going to start doing that problem– solving … Or if people come up and say, “I used to play pool but I can’t do that anymore,” so then I have to do some education; exploring those opportunities that are available.
Similarly, in strategizing how she would approach her work with Irene, a middle-aged woman who was experiencing profound fatigue associated with her multiple sclerosis (MS), Beth explained “I decided to focus on some of the more physical activity type of things . . . then in discussions we’re going to have in the [therapy] sessions I’m hoping that we can generate some discussion about some of the issues that are probably related to anyone having progressive MS.”
Beth explained that in all activity-oriented sessions she constantly attends to what is going to happen next, mentally considering how to address these potential next steps. At the same time Beth wants to model an attitude of casual enjoyment. Beth said she tries to juggle this need to be both present-centered-engaged in the moment-while at the same time anticipating the future, even if the future was the next moment in the therapy session. Beth suggested that these processes of anticipation and reasoning are what guide the therapists’ decision-making regarding the approach they take to their work with patients, the types of questions they ask, or the interventions they recommend. Beth gave the example of how she engaged in this process of problem-solving while working with Clint, who had acquired a spinal cord injury as a result of a roofing accident, as he was trying to return to playing cards:
If it’s identified like “Oh, I can’t do that any more” then you swing into “well there are things. There is equipment available and we can look at that.” Either they’re going to need some assistance or they’re going to at least need some opportunities to see if they can hold the cards or whatever. And it was like with Clint, “do you usually play at home or do you play in the community?” “Oh community? Now, who usually does the transportation? And is that going to be available…. So, how are you going to work around these?”. . . And that’s when we get into that perpetual problem solving.
The therapists often used activity-oriented sessions to simultaneously assess patients’ functional abilities, determine to what extent activity modifications are required, and to assess patients’ abilities to problem-solve how they might be able to modify how they do an activity. Describing her efforts to assist Helen, who had a stroke, to return to plastic canvas stitching, Ann explained she first wanted Helen to get started with the activity on her own as a way to assess “Can she follow a pattern? Can she thread a needle? Can she be independent with all the pieces of it?”
Both therapists would use activity engagement as a way to look for “teachable moments” where they could provide information or suggest activity modifications, but, more importantly, where they could foster problem– solving by the individuals themselves. An example of this occurred during a community integration outing with Clint. The primary purpose of the outing was to assist Clint to become familiar with wheelchair handling in the community. Clint was nervous about driving his new power electric wheelchair along busy streets, but wanted to go to a franchise coffee shop that he had frequented prior to his injury.
When Clint got to the entranceway of the coffee shop there was a five-inch high concrete stoop. Clint wheeled up and faced it, staring incredulously. Beth asked “now what?” It was, as Beth later described, a “teachable moment.” Beth stood silently, waiting for Clint to figure out what to do. He finally said, “I guess I can’t get in with my power chair. It’s too heavy to lift up.” Beth asked, “So what can you do when you want to go out to avoid this situation again?” Beth reported that, when she went back to see Clint the next day, he mentioned that he found out about another coffee shop that was accessible. Beth was pleased that he had “already started to problem-solve and make some inquiries.” Later Beth explained that she had not known whether the coffee shop was accessible or not but had reasoned he was the type of person who could “handle it” if it was not accessible. She had decided to take advantage of the coffee shop not being accessible to talk with him about accessibility issues, even though that was not part of her original plan for this outing. By anticipating next steps in the therapy process and looking for these teachable moments Beth used clinical reasoning to guide practice in the immediate.
In summary, activity engagement served as a context in which the therapists in this study could assess patients’ abilities and attachment to a particular activity and could move quickly from assessment to problem-solving for activity modifications or adaptations. Typically the therapists saw activity engagement as a context for doing other things, such as talking about adjustment issues or time management. More importantly, they would often look for teachable moments, often unplanned, to engage patients in learning or problem-solving themselves.
Contextual Factors Affecting the Perpetual Problem-Solving Process
The therapists who participated in this study both explained how they needed to consider the responses given by patients to their questions or suggestions, at the same time use their own knowledge regarding the functional needs and abilities of patients (based on the type or level of their injury) as the basis for making clinical judgments. As we saw with Ann’s work with Bob, however, this is not always a straightforward task, Often patients were dealing with change and loss, operating in a culture of medicine that emphasized return to physical function, and were uncertain about the form their future leisure engagement will take. For many, as indicated earlier, they hoped that by ameliorating their physical problems, return to preferred leisure activities would follow, Finding a way to negotiate a shared vision for their work together in recreation therapy seemed to be one of the most difficult aspects of the therapy process.
For the therapists in this study this process of problem identification and elaboration of a plan for action was often tentative and continuously evolving. For example, Beth explained that she would often try to address multiple issues, such as determining current functional abilities, current problem-solving abilities, and current patterns of involvement through discussions that occurred in combination with activity engagement. Regarding her work with Irene, for example, Beth stated “I try to get a feel for how she is doing with the MS. She has had it for a while and is dealing with problems of fatigue and energy … I’ll need to look at her problem-solving around that.” The suggestions Beth made, however, for activity modifications or fatigue management were related directly to the way Irene described how she would operate in her everyday life when she returned home. Describing how she intended to proceed with a gardening session with Irene, Beth explained, “I’ll introduce looking at her patterns of involvement … We’ll find out at that point if it’s modifications that we have to look at or adaptations, or just information, or development of a post-discharge plan.” While Beth was aware she might need to immediately decide on a plan to address each of these issues, she was not sure which of them would be most relevant until she had the opportunity to discuss these issues with Irene and observe her abilities, in this particular context, to undertake a gardening task.
Having a stock of possible next steps seemed to be necessary for the therapists to be able to quickly and appropriately respond to the issues or resistance raised by patients. From Beth and Ann’s perspective this required being strongly grounded in discipline specific knowledge about how to make activity modifications and adaptations for differing levels and kinds of injuries or illness.
The overall ethos of rehabilitation was the final factor that shaped and often constrained the clinical judgments of recreation therapists regarding how they work with patients. In this setting, institutional ideologies associated with physical medicine often prevented the recreation therapists from intervening in ways they believed could be of most benefit to individuals. Bob’s case (the man who was hospitalized due to substance abuse and severe obesity) provides an example of how the recreation therapists’ clinical judgments can be undermined by the medical ethos that prevailed in the health care institution in which they worked. There were clear rules (albeit unwritten) regarding the kinds of issues that would be addressed in the context of rehabilitation; alcohol or drug use was not among them. Reflecting on her inability to address Bob’s problems with alcohol abuse Ann lamented, “That’s why he’s here. If you only treat the surface of his rehab, then aren’t you teaching him that skill all over again, not to deal with what the issues are? You’re just covering up the issues.” Bob thought he was changing his life because he stopped drinking and was doing physiotherapy, but Ann believed he needed lifestyle changes associated with leisure values, needs, and awareness. In the end, the institutional values of physical rehabilitation defined a setting where only physical health was addressed, not the psychosocial issues that may have been instrumental in creating the illness or injury. Ann had no sanctioned (institutional) authority to deal with drinking and associated premorbid lifestyle habits.
Summary
This data provides evidence of the processes by which the recreation therapists in this study engaged in clinical reasoning as an integral part of engaging in effective clinical practice. Perpetual problem-solving, as Beth intuitively defined clinical reasoning, aided the therapists in deciding how to best approach their interactions with patients, or to present their interventions (e.g., should they model an attitude of enjoyment or appear more serious?). To the extent that the therapists were able to understand the meanings of activities for patients, their illness/injury experiences, and their rehabilitation goals, the therapists moved closer to understanding the patients’ view of their world (including how they viewed leisure). Perpetual problem-solving consequently helped them to share an understanding with patients of how TR could best serve them in their situation. In instances where the therapists did not fully understand the meaning of leisure engagement for people or their rehabilitation goals then this sometimes led to errors in clinical judgment and, often, an unwillingness on the part of clients to invest time or energy in TR. This was exacerbated by the medical ethos of the rehabilitation hospital, which shaped and constrained at times what the therapists (and patients) could and could not do.
Discussion: Clinical Reasoning in TR
In clinical settings, clinicians frequently face ill-defined problems, goals that are complex and outcomes that are difficult to predict clearly. Professional people dealing with, and immersed in the ‘messiness’ of reality in the clinic, need to develop the ability to cope with the uniqueness, uncertainty and conflict inherent in real problems. (Higgs & Jones, 1995, p. 5)
Practice in therapeutic recreation is often similarly “messy” and contested. Often clients are reluctant to participate in TR; for the most part they don’t understand why they might need recreation therapy. Often they see getting their leg or arm working as their priority, with the often unspoken belief that things will “get back to normal” when they get back home. While therapists are assessing potential clients for TR services or interventions they are often also trying to talk a problem into being; that is, convince people that TR is important (Hutchinson, 2000). This process of assessment, negotiation, and intervention is ongoing; each step of the therapy process requires negotiating agreement, for that moment, that this particular intervention is a necessary part of their rehabilitation. At the same time recreation therapists constantly have to advocate for their discipline within the organization or health care teams. Allied health care professions, who have many concerns of their own, may not fully understand why or how leisure or recreation “fits” within a health care service delivery system. How therapists decide on and take action against the backdrop of these contextual factors is reflected in their ability to engage in clinical reasoning and clinical practice at the same time.
When this study was originally conceptualized no thought had been given to the ways that the therapists would think about, plan for, and negotiate with patients their shared participation in recreation therapy interventions. However, from observing the therapists work, and from their ongoing “debriefing” conversations during the study, their largely intuitive processes of anticipating, problem-solving and framing their work with patients were apparent. These processes were central to their ability to construct interventions that led patients to be willing to engage in the therapy process, even if only for that moment.
These data necessitated a return to the literature for explanation of this phenomenon Beth named perpetual problem solving. Reflecting on her own practice and thought processes Beth spontaneously came up with this word-perpetual-to characterize how she thinks she reasons in the midst of practice. Perpetual problem-solving, as evidenced in this study, was consistent with Schon’s (1983, 1987) writing about reflective practice and the concept of clinical reasoning which has received recent attention in health care and rehabilitation literatures. This literature was extensively reviewed earlier.
The purpose of this final section is to discuss how clinical reasoning can be applied in a more systematic fashion to TR practice. First, we advocate for therapeutic recreation practitioners to increasingly become “reflective practitioners.” This notion is essential to the “servant leadership” ethic that is prevalent in recreation, parks and leisure service management (e.g., DeGraaf, Jordan, & DeGraaf, 1999) and is central to the philosophy of person-centered care that dominates healthcare services. The question then becomes “is it possible to teach (and learn) how to be a reflective practitioner or to engage in clinical reasoning?” Schon and others who study clinical reasoning would say “yes,” although the nature of learning is more experientially than technically oriented.
Based on his study of professional schools of architecture, art, music, business, and clinical psychology Schon (1987) developed the concept of a reflective practicum. Schon recommended that students or new practitioners develop their critical thinking skills by engaging in experiences which are as close to real life practice as possible and by being “coached” through the reflective thinking process by working closely with expert practitioners. Schon suggested that this starts with dialogue between the student and coach (expert practitioner). The coach not only addresses substantive issues but also contextualizes them.
In health professions substantial work has been done to articulate ways for new practitioners or students to develop clinical reasoning skills. For example, Ryan (1995) recommended such strategies as case studies and case stories, students’ journal writing or reading ethnographic accounts of clients’ personal experiences, experiential learning, and systematic questioning (similar to debriefing) to help foster the clinical reasoning skills of occupational therapists. Similarly, Higgs and Jones (1995) suggested that:
We strongly recommend the practice of helping students (and clinicians) to learn about thinking and learning, to learn to value cognition and knowledge as valuable tools to facilitate effective clinical practice and to develop expertise in the use of higher level cognitive skills (including metacognition and critical reflection-in-action)…. Experience alone is rarely a sufficient teacher. It needs to be processed through reflection and critical appraisal, to make sense of this experience and to learn effectively from it. (pp. 18-19) Ryan emphasized that significant efforts must be made to prepare practitioners for their role as facilitators of reflective practice in order to implement reflective learning during fieldwork.
There are now several researchers, theorists and educators who believe that clinical reasoning can be taught or improved by various educational methods. These are beyond the scope of this paper. However, the fact that recreation therapists can (and want to) reflect on and articulate their reasoning processes gives strong encouragement to the possibility that such educational methods could be implemented.
Conclusion
Due to the small number of study participants, and the limited context for data collection (one rehabilitation site in Canada), the results from this study cannot be generalized across other target groups (e.g., people with mental illness) or therapeutic recreation settings. Nonetheless, the findings generated in the study related to clinical reasoning do allow for a degree of “transferability,” as Miles and Huberman (1994) suggested, “on the basis of a match to underlying theory” (p. 29).
Based on the evidence of clinical reasoning provided in this study, and from the literature reviewed, there is need for the development and testing of a model for clinical reasoning in therapeutic recreation. Further practice-based research is needed to determine the conditions under which clinical reasoning can be used to guide practice, and to better understand the processes of thinking, observing, decision– making and problem-solving associated with clinical reasoning. For example, most of the evidence for clinical reasoning in this study came from the therapists’ work with individual clients. It may be that facilitating group interventions requires different kinds of clinical reasoning processes. In addition, while clinical reasoning was evidenced in the work of these clinically-based recreation therapists, it may be that it is a process that underpins expert practice in community TR setting as well. Research is needed to examine the diverse factors and contexts that shape clinical reasoning and practice. Interestingly, the therapists in this study stated that it was not until they were asked to describe their work in debriefing sessions during the research process that they came to reflect on the decision-making and “perpetual problem-solving” that intuitively directed their practice. The data represented here provide important insights into the value recreation therapists (or at least the therapists in this study) attach to the meaning making aspects of their interactions with their patients. These findings underscore the importance of providing opportunities for practitioners to reflect on and talk about their practice, not just their clients.
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Susan Hutchinson is an Assistant Professor in the School of Hotel, Restaurant and Recreation Management at The Pennsylvania State University. Adrienne LeBlanc and Rhonda Booth are Recreation Therapists at the Queen Elizabeth II Health Sciences Centre in Nova Scotia, Canada. Thanks are extended to anonymous reviewers, whose feedback strengthened this manuscript immensely. This research was completed as part of the author’s dissertation research, under the guidance of Dr. Douglas Kleiber at the University of Georgia.
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