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THERAPY THIRD EDITION JOHN W. SCHELL, PhD Professor Emeritus Mary Frances Early College of Education University of Georgia Athens, Georgia Schell Consulting Athens, Georgia


School of Occupational Therapy Ivester College of Health Sciences

Brenau University Gainesville, Georgia Schell Consulting Athens, Georgia

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Names: Schell, Barbara A. Boyt, editor. | Schell, John W. (John William), 1947- editor. Title: Clinical and professional reasoning in occupational therapy / [edited by] Barbara A. Boyt Schell, John Schell. Description: Third edition. | Philadelphia: Wolters Kluwer, [2023] | Includes bibliographical references and index. | Summary: “Clinical and Professional Reasoning in Occupational Therapy, by Barb and John Schell, was a groundbreaking text when it first published - addressing the clinical reasoning process occupational therapists use when evaluating and treating patients. New texts have since published that address clinical reasoning from a practical perspective - ie, ‘how-to’ books for new OTs entering clinical practice - but the Schell text remains unique in analyzing the clinical reasoning process from a theoretical”— Provided by publisher. Identifiers: LCCN 2023024647 | ISBN 9781975196851 (paperback) Subjects: MESH: Occupational Therapy—methods | Clinical Reasoning | BISAC: MEDICAL / Occupational & Industrial Medicine Classification: LCC RM735 | NLM WB 555 | DDC 615.8/515—dc23/eng/20230706 LC record available at

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Dedicated to Scholars of Professional Reasoning While we wrote, collaborated, and edited this edition, we became great grandparents. This was a joyous generational event that reminded us that time is passing. In this new edition, we are particularly mindful of the new generations of scholars who joined our many long-time colleagues as we co created this new edition. We dedicate this edition to our newer colleagues who accept the challenge of exploring and improving professional reasoning research that will result in exciting new insights, theories and practices. We’ll be the harmony you hear when you sing your new songs.

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“We are in need of inquiry into the epistemology of practice. What is the kind of knowing in which competent practitioners engage?” —Schön (1983, p. vii) In the 1980s, scholars became interested in the epistemology of practice—the way professionals think in action. Donald Schön’s 1983 influential work, explicated in The Reflective Practitioners: How Professionals Think in Action , focused on the competence valued in a range of professional practices. He observed that practice was messy and uncertain and that straightforward standard theories were insuffi cient to address the complexities and demands of practice. Drawing on the work of philosopher Polanyi (1996/2009, p. 4), Schön argued that competent practitioners’ reasoning is complex and tacit, that is, “we can know more than we can tell.” Given that practitioners often know more than they can say, to understand the reasoning processes of professionals, Schön observed practitioners from various disciplines in action as they developed creative responses to address the puzzles of practice. In the same year that Schön published his work, a prominent occupational therapy (OT) scholar, Joan Rogers, used her 1983 Eleanor Clarke Slagle address to the American Occupational Therapy Association audience to propose the first comprehensive exploration of how OT practitioners reason in the situation of prac tice. She challenged practitioners to explain the tacit reasoning behind their ac tions to improve their ability to explain their reasoning, which would also help educate future practitioners. Rogers’ Slagle lecture and Schön’s work became the catalyst for a collaboration among the American Occupational Therapy Association and the American Occupational Therapy Foundation to investigate the “clinical knowledge and expertise within the profession” (Mattingly & Fleming, 1994, p. ix). This investigation, now known as the “Clinical Reasoning Study,” transformed OT practitioners’ understanding of our clinical and professional reasoning. The proj ect was led by Cheryl Mattingly, an anthropologist and, at the time, a graduate student of Schön’s. Together with OT educators and practitioners, Mattingly used action-oriented and narrative approaches to engage OT practitioners in a process of studying their own practice in action. I had the honor of collaborating with Dr Mattingly and other scholars in this research project to closely examine what OT practitioners think about as they are engaged in their work. Serving as the guest editor for a 1991 special issue of the American Journal of Occupational Therapy that

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disseminated the initial key theoretical findings from this important research, I was encouraged that we had begun to answer Schön’s question about what competent OT practitioners know and do. Collectively, the articles introduced language to describe the reasoning practitioners utilize to enact the philosophical core values of our profession, “often invisible to the uniformed observer” (Cohn, 1991, p. 969). Each article highlighted and encouraged the value of reflecting on and evaluating the reasoning processes of everyday practice. Years later, based on accumulating evidence and new theoretical frameworks on clinical and professional reasoning, I urged OT practitioners to demonstrate our “competence with confidence.” When we give voice to our reasoning, we can con fidently communicate the power of occupation to support people to engage in the occupations that give their lives meaning. We now have rigorous scientific evidence to support our competence and, based on that evidence, we are well prepared and positioned to embrace the power of meaningful occupation as a strength, as an asset to our profession (Cohn, 2019 Slagle lecture). Thanks to Schell and Schell’s third edition of Clinical and Professional Reason ing in Occupational Therapy , we have an updated text that consolidates contempo rary theories and research seeking to answer Schön’s question regarding the kind of knowing and action in which competent practitioners engage. This compendium provides a coherent conceptual resource for all OT practitioners, worldwide, to explain, examine, reflect on, teach, and further research the complexity of our ex traordinary practice in which we enable others do the ordinary that they cannot do without OT intervention. Schell’s Ecological Model of Professional Reasoning (EMPR) builds on earlier conceptualizations of reasoning by highlighting the trans actional role of context, the personal and professional lenses of both the therapist and clients. This edition has something for everyone—it is applicable for an inter national audience of OT students, faculty, fieldwork supervisors, and managers, as well as others from related disciplines who are interested in clinical and profes sional reasoning. This is an essential book for OT students. Throughout the book, each of the 30 chapters provides a foundation for students to understand the reasoning pro cess of OT practitioners and gain metacognitive skills to develop, articulate, and evaluate their professional reasoning. This is also an essential book for all educa tors of future OT practitioners. The entire book reinforces Schön’s proposition that standard theories applied to straightforward situations are insufficient to prepare practitioners for the complexities of practice. The chapters highlight the complexity of our reasoning processes that enable educators to teach others a “process” for striving to understand what really matters to those who seek intervention designed with an OT practitioner. The vivid examples of the thought and action described in case situations throughout the text enable readers to reflect on and examine the reasoning nuances specific to each contextual setting. As our world changes and our practice evolves to address the complex nature of human occupation, our reasoning processes will continue to evolve. The scholars who have contributed to this edition provide comprehensive insight into current state of clinical and professional reasoning. This book provides essential answers to the question of how OT professionals think in action. The evidence provided in these chapters continues to name what we do, to frame what we do, and provides a foundation to enable OT practitioners to confidently assert the power of occupation to be a meaningful agent of change.

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Cohn, E. S. (1991). Clinical reasoning: Explicating complexity. American Journal of Occupational Ther apy, 45 (11), 969–971. Cohn, E. S. (2019). 2019 Eleanor Clarke Slagle Lecture—Asserting our competence and affirm ing the value of occupation with confidence. American Journal of Occupational Therapy, 73 (6), 7306150010p1–7306150010p10. Mattingly C., Fleming M. H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice . Phila delphia: F. A. Davis Company. Polanyi, M. (1996/2009). The tacit dimension . University of Chicago Press (Original work published 1996). Schön, D. A. (1983). The reflective practitioner: How professional think in action. Basic Books.

Ellen S. Cohn, ScD, OT, FAOTA Clinical Professor Emeritus Department of Occupational Therapy Boston University Boston, Massachusetts

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Photo by Helen Kabat. Used with permission Barbara Schell.

BARBARA AND JOHN SCHELL We believe it is helpful to understand a bit about the people behind books such as this one. Here are brief narratives of our experiences for you to gain a glimpse of our personal and professional selves.


Barbara first began to explicitly explore clinical reasoning when she was an occu pational therapy manager at Harmarville Rehabilitation Center in Pittsburgh, PA. In that capacity, she had oversight of a large department, including over 30 oc cupational therapy personnel, along with other related professionals and support staff. When she first came to Harmarville, there was a great deal of work aimed at focusing departmental efforts and developing systems to support staff in the deliv ery of services (Schell & Braveman, 2005). This was during the 1980s, when there was an extreme shortage of personnel and significant turbulence in healthcare as funding mechanisms began to shift from retrospective to prospective systems. During this same period, Joan Rogers made clinical reasoning the subject of her Eleanor Clark Slagle Lecture (1984) and, in the latter part of the decade, the American Occupational Therapy Foundation (AOTF) and the American Occupa tional Therapy Association (AOTA) funded the research project, which came to be known as the Clinical Reasoning Study (Mattingly & Fleming, 1994). In order to progress the department’s practices and to support her leadership of this process, Barbara wrote a grant to bring in Wendy Wood (fresh from her master’s coursework at the University of Southern California) as a consultant to assist the department

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About the Authors


to move from what today would be called a medically based approach to a more occupation-based approach. It was Wendy who first suggested to Barbara that what she was focusing on was clinical reasoning. From this early beginning, Bar bara went on to become what she called a “clinical reasoning groupie,” closely fol lowing the unfolding research of the Clinical Reasoning Study. After leaving Harmarville, Barbara pursued her doctoral work in Adult Educa tion at the University of Georgia, where she was fortunate to have Dr Ron Cervero as her advisor. Ron, who is internationally known for his scholarship on continu ing professional education, pushed Barbara to articulate her concerns with the limitations of clinical reasoning as it had been described to date. That effort ulti mately resulted in her introduction of the concept of pragmatic reasoning to the field (Schell & Cervero, 1993). After completing her doctoral work, Barbara became involved in academia, founding the occupational therapy program at Brenau University in Gainesville, Georgia. This effort required her to move from thinking about how to develop prac titioners in the field to how to give them the best start possible. During the 20 plus years that Barbara worked at Brenau, she continued to review and synthesize the literature in numerous publications, develop undergraduate and graduate courses related to professional reasoning, and provide continuing education and consulta tion to managers and educators on how to support effective clinical reasoning in practice. From this work, she conceptualized the Ecological Model of Professional Reasoning. She also initiated the Clinical and Professional Reasoning Scholars net work, which is an international group of 60 plus occupational therapy colleagues. In 2016, Barbara retired from full-time academics at Brenau as a Professor Emer ita. Since her retirement, Barbara has continued to support scholars from a variety of countries who are interested in clinical and professional reasoning. Her pro fessional contributions in this area are primarily through keynote presentations, workshops, academic consultations, and by serving as a reviewer or external mem ber on a number of doctoral dissertation and capstone projects. She also remains an active writer and editor, retiring as the lead editor for Willard and Spackman’s Occupational Therapy after the 13th edition. SHAPING PRACTICE: JOHN’S PURSUIT OF LEARNING AND TEACHING Just as Barbara has a long history of assisting practitioners as an occupational therapy manager and educator, John has an even longer one researching the na ture of social learning that can serve as a foundation for effective contextual teach ing. After graduating with a degree in Social Studies from Central Missouri State University, John spent early years in Kansas City, Missouri, as a local manager of federally funded employment and training programs. These experiments of the 1960s, 1970s, and 1980s in social engineering aspired to promote a strong Ameri can workforce among the economically disadvantaged through vocational training and education. During this period, he earned a master’s degree at the University of Utah, David Eccles School of Business. In 1978, John became State Coordinator for School to Work Transition in the State of Missouri. Subsequently, he became State Supervisor in the Missouri Department of Elementary and Secondary Education for federally funded adult vocational education in a wide area of the state. Eventually, John’s path led to the University of Missouri-Columbia, where he earned his PhD. After graduating, he started a successful educational consulting firm that contin ues today as Schell Consulting. Later, he became an administrator at the Allegany

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About the Authors


County Community College in Pittsburgh, Pennsylvania. In the academic part of his role, John joined the faculty at the University of Pittsburgh, School of Education, and then became a member of the College of Education faculty at the University of Georgia in 1990. John conducted many research projects in the area of contextual learning and teaching. He was instrumental in obtaining a U.S. Office of Educa tion grant to explore contextual learning and teaching as a foundation for teacher education in collaboration with five other major U.S. research universities. John supervised more than 25 successful doctoral dissertations and countless master’s and specialist program completers. His graduates continue to make contributions around the world. In 2012 John became emeritus, but continues to teach graduate classes part-time and collaborates with Barbara in teaching a variety of Profes sional Reasoning and Teaching workshops and providing academic consultation. COMBINING FORCES When we first met (in our early 30s), we used to humorously tell people that be tween us we covered health, education, and welfare (after the now defunct U.S. federal agency of the same name). For the first 15 years of our marriage, we both pursued relatively separate career paths, although there was always plenty to talk about between educational and rehabilitation management. However, as Barbara moved from practice management into academics, it became obvious that we were grappling with many of the same concepts and reading some of the same pro fessional literature. Now, for almost three decades, we have enjoyed collaborative projects and consultations. MORE THAN WORK Now after more than 40 years, we still work together. Mostly, we enjoy time with our family of two grown children and their families, including our six grown grandchil dren and our new great grandson. We also share a love of art (watercolors for Barb, photography for John), music, nature, and golf. We share our lives with our dog, Brandy, who takes her responsibilities seriously to remind us of when it is time to leave the computer, take a walk, provide her dinner, and go for a ride.


Mattingly, C., & Fleming, M. (1994). Clinical reasoning: Forms of inquiry in a clinical practice . Philadel phia: F.A. Davis. Schell, B. A. B. & Braveman, B. H .(2005). Turning theory into practice: Management strategies. In B.H. Braveman (Ed.) Leading and managing occupational therapy services: An evidence-based approach, 1e . Philadelphia: F.A. Davis. Schell, B. A., & Cervero, R. M. (1993). Clinical reasoning in occupational therapy: An integrative re view. The American Journal of Occupational Therapy, 47 (17), 605-610. ajot.47.7.605

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This book is an outgrowth of reflection, scholarship, and love. And we might add, persistence, as we are now in the third edition. Our missions have been to help practicing therapists advance their professional reasoning; managers and supervi sors to effectively support their staff members in professional reasoning; teachers become more effective; and assist students appreciate the importance and com plexity of professional reasoning in occupational therapy practice. We have done this work because we believe that the world will be a better and more democratic place if people reach their full potential. Even more importantly, we affirm that reasoning, learning, reflection, and teaching are all acts of love. BOOK THEMES The third edition continues many valued traditions and assumptions about pro fessional reasoning in occupational therapy. As we celebrate our past accom plishments, we look forward as well. Understanding effective reasoning requires a mindful examination of what is involved in the process of reasoning. To that end, we have examined materials from a broad array of research and practice scholars. We continue to invite experts to contribute chapters, while we author chapters within our own areas of expertise. To enrich our planning for this edition, we initiated the Professional Reasoning Colloquium in 2021 for researchers and invited scholars from around the world to discuss emerging knowledge about occupational therapy professional reasoning. We are thankful to Texas Woman’s University School of Oc cupational Therapy and Wolters Kluwer in joining us to sponsor this 2-day online conference and to the over 60 presenters from eight different countries around the world. As a result of input from scholars who attended the Symposium and the new research we found as we prepared for this book, we identified several new themes that we integrated into this new edition. These are: • Professional reasoning across cultures. We adopted the stance of cultural humility by recognizing that much of the scholarship on occupational therapy professional reasoning is based on Western-centric points of view. We are ex cited to find emerging scholarship in Asian and South American countries and have included authors and scholarship from all over the world.

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• New and emerging research. We incorporated new research in professional reasoning, acknowledging and also challenging past understandings in light of current scholarship. • Emphasizing reflection . We encouraged contributors to illustrate relation ships among reasoning, reflection, and reflective practices; reinforce linkages among reasoning, context, learning, and teaching; and make connections with how research-based and practice-based evidence can prompt reflection and practice improvement. • Assessment of professional reasoning. An area of interest among current scholars is the assessment of clinical and professional reasoning. We encour aged contributors to include information on assessment when appropriate for their contributions. • Interprofessional reasoning . We acknowledged increased emphasis on inter professional teamwork, and thus added a new chapter on this, and encouraged contributors to share examples of reasoning in collaborative contexts as well as demonstrate cooperative practices across disciplines. Learning activities designed to promote effective reasoning are provided at the ends of chapters, and additional learning activities are provided online with pur chase of Lippincott Connect. Later chapters also recommend strategies for teaching and researching reasoning in academic and practice settings. TERMINOLOGY The term professional reasoning continues in the title of this book as well as the term clinical reasoning . Although recent literature reviews still find the term clinical reasoning used most across health professions, occupational therapy scholars as well as those writing policy documents are increasingly following our suggestion to use the term professional reasoning . Colleagues who practice in educational and community settings find the word clinical to be one that presumes a medically based orientation and is therefore inappropriate to their contexts. Additionally, there is a significant amount of reasoning related to therapy practice, program ming, etc., which is done by supervisors, managers, and others. It seems appropri ate to acknowledge that this reasoning, although not directed to a specific patient or client, also has aspects similar to clinical reasoning. ORGANIZATION The content of this edition of Clinical and Professional Reasoning in Occupational Therapy consists of summaries of different perspectives and presents new research about reasoning in professional contexts. The field of professional reasoning con tinues to advance, and this new edition illustrates the growth. All chapters have been either updated or completely rewritten. A third of the chapters have new au thors and coauthors, reflecting a new and more international generation of contrib utors. Six new chapters were added to expand the scope of the book. Yet we retain the ethics that made earlier editions successful. Many textbooks provide suggestions about what therapists should think about and how they should conduct therapy. In contrast, contributors from the first edition and all subsequent editions were asked to build their discussions using solid and applied research. We have focused research on what therapists actually think about and, subsequently,

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act on during therapy. In many cases, research findings from within occupational therapy were combined with salient scholarship from a variety of other disciplines, such as psychology, anthropology, philosophy, nursing, medicine, and physical therapy. Although the units and chapters are related, each can also stand alone, thus allowing the text to be used either in a specific class or across different courses, depending on the curriculum design. Those outside of the academic sphere can se lect materials most relevant to their needs. Clinical and Professional Reasoning in Occupational Therapy is organized into four units. Unit I, Nature of Professional Reasoning , focuses on clinical and pro fessional reasoning as processes grounded in human experience. The introductory chapter provides an overview of the definitions of clinical and professional reason ing. Chapter 2 describes human neurocognitive research, explaining cognitive pro cesses and related neurology that underpin professional reasoning. This chapter has new authors who have completely rewritten the chapter. Chapter 3 discusses how humans are all influenced by their cultures and experiences, such that they gain a worldview that influences their thinking. Each therapist’s worldview shapes the assumptions that become an inherent part of that person’s professional reason ing. Several new authors joined in the development of a new iteration of this chapter, bringing a variety of international perspectives, some of which challenge taken-for granted assumptions in professional reasoning theory and research. Chapter 4 dis cusses the notion of reasoning as an “embodied” process: one in which the artificial convention of separating mind and body is reconceptualized into a holistic knowing evident through our practice actions. Chapter 5 presents an ecological model of professional reasoning that serves to guide readers about how the many aspects of professional reasoning are related. By the end of this unit, readers will appreciate the commonalities of humans as they reason, as well as the individual variances that form the ground on which each therapist reasons in practice. Unit II, Aspects of Professional Reasoning , provides in-depth explorations of the different facets of therapists’ reasoning. Chapter 6 introduces readers to var ied forms and aspects of professional reasoning and explains how these forms intertwine during practice actions. These aspects of reasoning may not represent different kinds of reasoning from the perspective of cognitive psychology, but they do highlight how therapists shift their attention to different aspects of the ther apy process, and in doing so change the rhetoric and ways of framing problems in practice. Chapter 7 provides an extensive examination of scientific reasoning, the kind of thinking that attempts to be objective and that seeks theory, evidence, and the use of logic to understand therapy issues. This chapter has new authors and was completely rewritten. Chapter 8 describes narrative reasoning, an aspect of reasoning in which the therapist’s attention moves from the objective science to clients’ subjective experiences. By attending to the client’s life stories, therapists’ reason about the meaning of health experiences to their clients and choose therapy actions informed by this knowledge. Chapter 9 goes beyond the therapist–client relationships to pragmatic reasoning, in which therapists attend to the practical is sues in delivering care. These include the practice context in which care occurs and the therapist’s own personal skills and differences, all of which become factors in determining what a given therapist believes to be possible or practical when deliv ering services. In Chapter 10, a former contributor steps into the lead author role, examining therapists’ moral sense and ethical frameworks which guide therapists when they must choose the right action from among competing options. The unit concludes with Chapter 11, which emphasizes interactive reasoning, the consider ations associated with therapy as a process of communication with the client.

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Unit III, Professional Reasoning in Context , focuses on providing examples of specific professional reasoning as it occurs in a variety of practice contexts. The unit starts with Chapter 12, which provides a deeper investigation of the nature of context and how it affects professional reasoning. Chapter 13 is a new chapter focused on interprofessional reasoning and thus brings attention to reasoning with teams. The first two chapters in this unit thus provided immersion into aspects of the practice context that are important and often unique within a given setting. Subsequent chapters each provide background information about important con siderations in that area of practice, along with case studies in which real-life exam ples of reasoning in specific cases are shared. Returning authors updated chapters related to their context. There are new authors for some chapters and three new chapters focusing on systems-level professional reasoning. The context-specific chapters are: Clinical Reasoning in Acute Care (Chapter 14, new author); Neonatal Intensive Care (Chapter 15); Home Modifications (Chapter 16); School-Based Practice (Chap ter 17); Public Education Systems and Populations (Chapter 18, new chapter), Palliative and End-of-Life Care (Chapter 19); Screening and Assessing Older Driv ers (Chapter 20); Mental Health (Chapter 21); Community and Population Health Practice: Health Literacy (Chapter 22, new chapter and author); and Supervision and the Development of Professional Reasoning (Chapter 23, new chapter and new authors). Unit IV, Promoting Effective Professional Reasoning , has been expanded from the previous edition to include chapters on professional reasoning development and reflection in addition to prior topics related to learning, teaching, thinking, and scholarship. The unit starts with a new chapter, Chapter 24, Development of Professional Reasoning, which includes new content on expertise. This is followed by the next new chapter in this unit, Chapter 25, Improving Practice Through Re flective Strategies. The remaining chapters from the previous edition return, all up dated to reflect current research and practice. These include Epistemology: Knowing How You Know (Chapter 26); Learning and Teaching for Reasoning (Chapter 27); Learning Professional Reasoning in Practice Through Fieldwork (Chapter 28); and Professional Reasoning in Occupational Therapy Management (Chapter 29). As be fore, Research and Scholarship in Clinical and Professional Reasoning (Chapter 30) concludes the book. For those wishing to access some of the previous case studies of curricular approaches to supporting reasoning in entry-level prac titioners, the chapters from the first edition related to using communities of practice and evidence-based practice remain available online with purchase of Lippincott Connect. Features Many features are provided to enhance the understanding and application of the content. Objectives serve to orient the reader, as well as assist faculty in focusing learners on core content in the chapter. The Chapter Outline at the beginning of each chapter helps readers find material quickly and serves as study resources and summaries of important constructs. Key Terms are printed in bold and defined in the chapter. The Thinking About Thinking quotes (typically from outside of occupational therapy) have been selected to prompt readers to think about meta cognitive issues from different perspectives. In Unit III, Consider This highlights quotes or comments that characterize professional reasoning in a specific context relevant to the chapter focus. The Learning Activities at the end of each chapter have been designed to provide learners with ways to reflect on their experiences

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and gain deeper learning. Each activity includes its purpose, how it connects to major constructs about reasoning, and directions. Where appropriate, content for handout materials is provided. Additional learning activities are available with pur chase of Lippincott Connect for most chapters. A Glossary of key terms is included at the end of the book as well. SUMMARY As in the past, this text is a gift to all of you who are seeking to become outstanding occupational therapy practitioners and to those educators, supervisors, managers, and administrators who support this important work. It reflects our best efforts to share enduring understandings about professional reasoning and to shine a light on new scholarship. We encourage you to take this opportunity to appreciate this work and we challenge you to advance it.

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Jennifer Allison, OTD, OTR/L, BCMH, CCAP Associate Professor School of Occupational Therapy

Brent Braveman, PhD, OTR, FAOTA Director Department of Rehabilitation Services MD Anderson Cancer Center Houston, Texas

Brenau University Gainesville, Georgia

Suzanne Perea Burns, PhD Associate Professor Department of Pediatrics University of New Mexico Albuquerque, New Mexico

Antoine Bailliard, PhD, OTR/L Associate Professor Occupational Therapy Doctorate Division Duke University School of Medicine Durham, North Carolina Anne Baker, ClinDoc, BOT (Hons), GCTE Lecturer in Occupational Therapy Institute of Health and Wellbeing Federation University Churchill, Victoria, Australia Mary Frances Baxter, PhD, OT, FAOTA Professor and Associate Director at Houston Center Dr. Sophie Lin Rydin School of Occupational Therapy Texas Woman’s University Houston, Texas Angela Benfield, PhD, OTR/L Assistant Professor Department of Occupational Therapy UT Health San Antonio San Antonio, Texas

Rosalind Bye, PhD, MAppSc (OT), BAppSc (OT) Director of Academic Program Department of Occupational Therapy School of Science and Health Western Sydney University Sydney, New South Wales, Australia Ellen S. Cohn, ScD, OT, FAOTA Clinical Professor Emeritus Department of Occupational Therapy Boston University Boston, Massachusetts Jodie A. Copley, PhD, BOccThy (Hons) Associate Professor School of Health and Rehabilitation Sciences The University of Queensland Brisbane, Queensland, Australia

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Susan Coppola, OTD, OT/L, FAOTA Professor Division of Occupational Science and Occupational Therapy University of North Carolina at Chapel Hill Chapel Hill, North Carolina Jenene Woods Craig, PhD, MBA, OTR/L, CNT Program Director PhD Program—Infant and Early Childhood Development School of Psychology Fielding Graduate University Santa Barbara, California Karina Dancza, PhD, MA (SEN), PGCLT (HE), GCert Health Sciences, BAppSc (OT) Associate Professor Department of Health and Social Sciences Singapore Institute of Technology Singapore, Singapore Regina F. Doherty, OTD, OTR/L, FAOTA, FNAP Professor and Chair Department of Occupational Therapy School of Health and Rehabilitation Sciences MGH Institute of Health Professions Boston, Massachusetts

Soren Grieve, PT, DPT Assistant Professor & Chair Health Sciences and Kinesiology & Human Performance Departments Briar Cliff University Sioux City, Iowa Toby B. Hamilton, PhD, MPH, BS, AS Professor Emeritus Department of Rehabilitation Sciences College of Allied Health University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Kathrine Hammill, PhD, BApScHons (OT) Allied Health Manager Department of Health and Disability 3Bridges Community Limited Penshurst, New South Wales, Australia Debra J. Hanson, PhD Professor Department of Occupational Therapy University of Mary Fargo, North Dakota Barbara Hooper, PhD, MS, BS Division Chief and Program Director Division of Occupational Therapy Duke University Durham, North Carolina Elizabeth Anne Kinsella, PhD, MAdED, BSc (OT) Professor and Director Institute of Health Sciences Education McGill University Montreal, Quebec, Canada

Lisette Farias, PhD, MScOT, OT Reg Assistant Professor

Department of Neurobiology Care Sciences and Society Karolinska Institutet Solna, Sweden

Deanna Gibbs, PhD, MOT, BAppSc (OT), GC Res Meth Director of Clinical Research for Neonates and Children (N+AHP) Department of Corporate Nursing

Jessica Kitchens, OTD Occupational Therapist Independent Practitioner Columbus, Georgia

Barts Health NHS Trust London, United Kingdom

Cortni Krusemark, OTD, OTR/L Program Director and Associate Professor Department of Occupational Therapy Briar Cliff University Sioux City, Iowa

Kay Graham, PhD, MOT, BA Associate Professor School of Occupational Therapy

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Brenau University Gainesville, Georgia



Patricia Laverdure, OTD, OTR, BCP, FAOTA Assistant Professor, Program Director Department of Occupational Therapy School of Rehabilitation Sciences Old Dominion University Norfolk, Virginia John Lien Margetis, OTD, OTR/L Associate Professor of Clinical Occupational Therapy Chan Division of Occupational Science and Occupational Therapy University of Southern California Los Angeles, California Rochelle J. Mendonca, PhD, OTR/L Assistant Professor Department of Rehabilitation and Regenerative Medicine/Occupational Therapy

Yvonne Swinth, PhD, OTR/L, FAOTA Professor and Program Director School of Occupational Therapy University of Puget Sound Tacoma, Washington

Stephanie Tempest, PhD, MSc, BSc (Hons) Occupational Therapist and Independent Consultant Stephanie Tempest Consultancy Ltd London, United Kingdom Orley A. Templeton, MSOT, OTD Assistant Professor Department of Occupational Therapy Misericordia University Dallas, Pennsylvania Merrill J. Turpin, PhD, BOccThy, GradDipCounsel Senior Lecturer Department of Occupational Therapy School of Health and Rehabilitation Sciences The University of Queensland St. Lucia, Queensland, Australia Carolyn A. Unsworth, PhD, BAppSci (OccTher), GCTE, OTR, MRCOT, FOTARA Discipline Lead Occupational Therapy Institute of Health and Wellbeing Federation University Churchill, Victoria, Australia Anita Volkert, MPhil, PGDip, PGCLT (HE), BAppSc (OT) Lecturer in Occupational Therapy and AHP Practice Placements Lead Department of Occupational Therapy, Human Nutrition and Dietetics School of Health and Social Care, School of Health and Life Sciences Glasgow Caledonian University Glasgow, United Kingdom

Columbia University New York, New York

Noralyn Davel Pickens, PhD, OT Associate Dean and Professor

College of Health Sciences Texas Woman’s University Denton, Texas

Barbara A. Boyt Schell, PhD, OT, FAOTA Professor Emerita School of Occupational Therapy Ivester College of Health Sciences

Brenau University Gainesville, Georgia Schell Consulting Athens, Georgia

John W. Schell, PhD Professor Emeritus Mary Frances Early College of Education University of Georgia Athens, Georgia Schell Consulting Athens, Georgia Mary P. Shotwell, PhD, OT/L, FAOTA Professor of Health Sciences Department of Occupational Therapy Rocky Mountain University of Health Professions Provo, Utah

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Professional Reasoning as the Basis of Practice, 3 Barbara A. Boyt Schell and John W. Schell


Cognition in Professional Practice, 23 Orley A. Templeton and Mary Frances Baxter


Culture, Assumptions, and Reasoning, 45 Lisette Farias, Susan Coppola, and Barbara Hooper


Embodied Reasoning in Professional Practice, 73 Elizabeth Anne Kinsella and Antoine Bailliard An Ecological Model of Professional Reasoning, 97 Barbara A. Boyt Schell




Aspects of Professional Reasoning, 127 Barbara A. Boyt Schell


Scientific Reasoning and Evidence in Practice, 143 Angela Benfield and Jessica Kitchens


Narrative Reasoning, 175 Toby B. Hamilton Pragmatic Reasoning, 203 Barbara A. Boyt Schell


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Ethical Reasoning, 223 Regina F. Doherty


Interactive Reasoning, 239 Merrill J. Turpin and Jodie A. Copley



Context and Reasoning, 255 John W. Schell and Barbara A. Boyt Schell Interprofessional Reasoning, 263 Cortni Krusemark and Soren Grieve Clinical Reasoning in Acute Care, 287 John Lien Margetis




Neonatal Intensive Care, 299 Jenene Woods Craig and Deanna Gibbs


Home Modifications, 319 Suzanne Perea Burns, Rochelle J. Mendonca, and Noralyn Davel Pickens


School-Based Practice, 335 Yvonne Swinth


Public Education Systems and Populations, 353 Patricia Laverdure and Yvonne Swinth


Palliative and End-of-Life Care, 373 Kathrine Hammill and Rosalind Bye


Screening and Assessing Older Drivers, 389 Anne Baker and Carolyn A. Unsworth


Mental Health, 407 Jennifer Allison and Mary P. Shotwell


Health Promotion for Community Dwelling Adults 425 Kay Graham


Supervision and the Development of Professional Reasoning, 439 Karina Dancza, Stephanie Tempest, and Anita Volkert


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Development of Professional Reasoning, 459 Angela Benfield




Improving Practice Through Reflective Strategies, 491 John W. Schell and Barbara A. Boyt Schell


Epistemology: Knowing How You Know, 519 John W. Schell Learning and Teaching for Reasoning, 549 John W. Schell



Learning Professional Reasoning in Practice Through Fieldwork, 583 Merrill J. Turpin and Debra J. Hanson Professional Reasoning in Occupational Therapy Management, 609 Brent Braveman Research and Scholarship in Clinical and Professional Reasoning, 625 Carolyn A. Unsworth



Glossary, 639

Index, 653

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CHAPTER OUTLINE Managing Self and Relationships Emotional Intelligence Developing and Maintaining Therapeutic Relationships The Importance and Use of Interactive Reasoning in Practice

Understanding Clients as People Within Specific Life Contexts Engaging the Client and Significant People Creating a Shared Vision of Hope



After reading this chapter, the learner will be able to:

1. Understand the importance of interactive reasoning for provision of high-quality occupational therapy. 2. Reflect on aspects of their own emotional intelligence and how this affects their interactive reasoning in practice. 3. Draw from a variety of verbal and nonverbal strategies to develop and maintain therapeutic relationships. 4. Be aware of and incorporate interactive reasoning into information gathering, intervention planning and implementation, and evaluation processes.

KEY TERMS Interactive reasoning Therapeutic use of self Interpersonal reasoning

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UNIT II Aspects of Professional Reasoning


If one, as an observer, were to witness effective interaction between an occupational therapist and a client, it may look like nothing special. From the outside, it might simply look like a conversation between two or more people who know each other to some extent (sometimes quite well, sometimes as new acquaintances). It would bear features of a constructive or purposeful exchange, with giving and receiving of information, discussing that information, and reaching conclusions or making agreements. Although purposeful, warmth would be observed, along with other emotional responses—concern, compassion, empathy, thoughtfulness, humor, understanding, and gratification.

Case Study 11-1

I could sense that he was holding back. His manner seemed guarded, reluctant. My questions about his medical history were met with one-word answers and brief eye contact. He had told this story over 20 times to a bunch of different profession als. The referral from the physical therapist indicated that he had received a number of interventions, such as casts, injections, and mirror therapy, to improve the movement in his affected arm since his stroke, but he felt that none had worked. He had recently been prescribed exercises to do daily. I asked him to tell me about how the exercises were going. He explained that he thought he was getting stronger but was frustrated it wasn’t yet making a difference in what he did every day, like getting up and dressed in the morning or making his lunch. He said, “My wife still needs to help me with these basic things while she is running the whole household. And I can’t contribute.” He shook his head as he said, “Doesn’t she have to do nearly everything now since the stroke? How is a man supposed to get on with things when he has to have help with every little thing?” The look of frustration on his face was clear; his voice was wavering. I kept eye contact and nodded as he spoke. Then I stopped asking questions. I leaned for ward, tried to keep a calm and steady tone of voice, and said that I could see that he had had to deal with some big changes and it must be hard to adjust to that. I recounted my understanding—that he was frustrated that he often needed help and couldn’t give back to the family in the way he wanted to. I checked that I had it right. He nodded and said, with re solve in his voice, that he wanted to be able to “pull his weight and not be a burden.” I commented jokingly that I suspected his wife would love some help with the housework! He smiled and said that housework had never been his forte before, but “wouldn’t that get me some brownie points!” We both had a quiet chuckle. I said that we could talk about what activities he wanted to do at home, I could visit the house and look at how we could change the setup of the kitchen or the laundry so that he could use his current abilities to do more around the house. To help him make progress more quickly, we could even work out how he could incorporate the move ments he was practicing in his exercises into his daily tasks. As I spoke, he sat up straighter in his chair and started nodding. I could see that we were finding a way forward.

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