image: St Pancreas Station statueOne of our recent posts has been discussing the issue of what undergraduates need to know. I did consider leaving this thought as a comment on this post - but decided to create a new post instead and would be keen to know your thoughts.
I really like what Creek(2009) has to say in her letter "Achieving a higher level of expertise". In this letter she discusses the nature of expertise in practice and states that within education, students are "taught that using a model for practice represents the highest level of skill" of the OT - a point she refutes by using Benner and Tanner's (1987) work on how expert nurses work and her own description of expert practice "the context of the intervention modifies the occupational therapy process and the therapists thinking, negotiation and action" (Creek 2003 p17).
The point she is making in this letter is that undergraduates are taught how to be competant and not proficient or expert in occupational therapy- therefore undergraduates need to understand that their approach to models of practice tends to be limited to an acceptable yet limited standardised and routine approach. Only with practice and experience can this be moved forward. Therefore those practitioners that are flexible, responsive and 'eclectic' with their use of models and interventions could be said to be practicing at a proficient and/or expert level.
References:
Benner P, Tanner C (1987) Clinical Judgement: how expert nurses use intuition AmJ Nursing Jan 23-31
Creek J (2003) Occupational Therapy defined as a complex intervention London:COT
Creek J (2009) Letters to the Editor: Achieving a higher level of expertise BJOT 72(2) 90
8 comments:
Just as a PS - I've just had a thought to add to the post - how do practitioners get to be proficient/expert - does it happen on the job with supervision etc or should there be more formal training programmes moving this forward?
I think you sum up my thoughts well already Sarah. I would add that in addition to the range and flexibility of theories of practice which differ on the continuum from novice to expert there is also the factor of "levels of consciousness" (for want of a better phrase). I have observed that students often feel the need to externalize and scaffold their practice through theory in an overt way (perhaps because they feel the need to do this because they believe that showing a knowledge of OT theory is important for assessment). Those practitioners towards the expert end of the scale often struggle more to explain clearly the theorectical knowledge because it is so closely intertwined with the often below conscious process of reasoning and theorizing "in action".
I hope that makes some sense, trying to post in a few spare moments while eating lunch before an assessment!
Also interesting that Jennifer's letter was related to an article about a service designing itself around a single model. I wholeheartedly agree with her in that focusing a service on one single model and be limiting. This desire to force a service around a one theorectical model may be a response to this OT "urban myth" that models equate to competence in some way. Models should support and inform practice and give practitioners language to help them to articulate what they do rather than prescribe an approach.
Expert practitioners I think are expert 'pattern matchers' (also refer to Linda J Robertson's articles in BJOT I think in the mid 1990's) published on problem solving. The quickly recognise the cues, and have a range of hypothesis generated, which they then go on to 'test'. Robertson statesthat the most difficult part is problem identification - and I think expert practitioners are expert at this - and I think the truly expert clinicians actually can tell you their reasoning - exactly!
Expert practitioners think evolve through range of ways - and the underpinning or key attribute or quality is the ability to reflect, and to revisit their reasoning. I know some very experienced OT's (who I'd call experts) who have got there by lots of experience, questionning of themselves, and always seeing 'answers' to the questions they raise for themselves. I've also seen expert practitioners come that way through a mixture of formal learning and informal learning. But common to them all has been this questionning attitude, a desire to always offer quality occupational therapy, and so a zest for learning (in what ever way best suits them).
I documented my own clinical reasoning process at http://abctherapeutics.blogspot.com/2006/11/clinical-problem-solving-in.html in a blog post around two years ago. My own process sounds a little like Merrolee's description of hypothesis testing.
Interestingly, I found myself using this same process just yesterday in trying to help a staff member understand the nature of a problem. I guess I haven't changed!
Ok..... I was one of the OT's trained in the UK just before models were "invented". I think I learned that OT was about enabling people to engage in meaningful and purposeful activity on the basis that their health and wellbeing would improve but putting that into practice initially was difficult and seemed open to massive interpretation.
I remember being introduced to CMOP and COPM early in my career and thinking thank goodness! A framework that affords some consistency and a bit of theoretical underpinning. It did assist me in my practice, I became quicker, more focused and hopefully more effective. Then CMOP wasn't enough. I needed more theory and turned to MOHO which I believe has enabled me to more effectively understand people as occupational beings in their wider environment. Kawa offers a different perspective again.
As educators we are training our students to become competent practitioners. I believe that models are an essential part of this process. Once a student reaches a level of being able to critically appraise a range of models they have the tools for using them judiciously in practice. Slavishly following a model is limiting, but so is rejecting them altogether. It's all about balance.
I couldn't respond to this briefly enough - so I posted in the OT only section of my blog to give me room to rant! I don't know if I can do the HTML thing on here, but it's here: http://healthskills.wordpress.com/2009/03/15/clinical-reasoning-and-science-in-occupational-therapy/
It's password protected, so if you haven't had the p/w before, you'll need to email me for it.
cheers
Bronnie
My thoughts - The usefulness of a model is in its attempt to capture the complexity of occupation and occupational lives. Models help to signpost the practitioner to the various things that need considering. The commonly used models also provide a shared language and range of concepts.So they have a usefulness. But it seems to me that an independent, critical thinking OT may practice from the basis of their own personally constructed model, which may shift and change according to context, and evolve over time. The true 'expert' must be able to think outside boxes, in order to meet the challenges of new and unanticipated problem-solving..
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