Let's think about practice? The applicability of a reflective tool to support professional reasoning in occupational therapy¹

Abstract

Introduction

Reflection on practice, from the epistemology of practical rationality perspective, favors gaining awareness of tacit aspects of the practice, such as professional reasoning. Studies focusing the reflection on practice to support occupational therapists' reasoning have emerged. However, they are still incipient, especially in Brazil.

Objective

To analyze the content and applicability of a reflective tool to support professional reasoning in the process of situated analysis of the needs of the assisted person in occupational therapy.

Method

Action research, with the participation of 11 occupational therapists working in Primary Health Care, was developed following the steps: previous development of the tool; use of the tool by the participants and analysis of its content and structure; individual interviews after its use; descriptive and thematic analysis; tool suitability; validation workshops and construction of the final version of the tool. The data were produced through a participants characterization form, an agreement questionnaire to analyze the content and structure of the tool, and individual interviews about its applicability. Data were analyzed descriptively and thematically. The reflective tool was adjusted based on the participants' suggestions. Validation workshops were held with the participants to build the final version of the tool.

Results

The suggested modifications in the tool included changes in terms, and also additions and integration of different domains. Its final version was structured on 20 questions, organized in seven domains. The applicability possibilities were: to give visibility to the specificities of occupational therapy in interprofessional teams; to enable reflection on practice and to improve professional reasoning; to use the tool in other contexts of practice; and for teaching of professional practice.

Conclusion

The tool has practical applicability, contributing to strengthening the professional core in occupational therapy and for interprofessional dialogue, facilitating the reflection on practice, and increasing the awareness about professional reasoning processes.

Keywords:
Occupational Therapy; Health Knowledge, Attitudes, Practice, Thinking, Professional Practice

Resumo

Introdução

A reflexão sobre a prática, na perspectiva da epistemologia da racionalidade prática, favorece o ganho de consciência sobre seus aspectos tácitos, como do raciocínio profissional. Estudos que focalizam a reflexão sobre a prática para sustentar o raciocínio profissional de terapeutas ocupacionais têm emergido; porém, eles ainda são incipientes, especialmente no Brasil.

Objetivo

Analisar o conteúdo e a aplicabilidade de uma ferramenta reflexiva para sustentar o raciocínio profissional no processo de análise situada das necessidades da pessoa em acompanhamento em terapia ocupacional.

Método

Pesquisa-ação, com participação de 11 terapeutas ocupacionais atuantes na Atenção Básica à Saúde, desenvolvida com as seguintes etapas: elaboração prévia da ferramenta; utilização da ferramenta pelas participantes e análise de seu conteúdo e estrutura; entrevistas individuais após a utilização; análise descritiva e temática; adequação da ferramenta; oficinas de validação; e construção da versão final da ferramenta.

Resultados

As modificações sugeridas abarcaram alterações de termos, acréscimos e integração de diferentes domínios. A versão final da ferramenta se estruturou em 20 questões, organizadas em sete domínios. As possibilidades de aplicabilidade foram: dar visibilidade para as especificidades da terapia ocupacional no trabalho em equipe; possibilitar a reflexão sobre a prática e melhorar o raciocínio profissional; utilizar a ferramenta em outros contextos de prática e no ensino da prática profissional.

Conclusão

A ferramenta apresenta aplicabilidade prática, contribuindo para fortalecer o núcleo profissional em terapia ocupacional e o diálogo interprofissional, facilitando a reflexão sobre a prática e ampliando a consciência sobre processos de raciocínio profissional.

Palavras-chave:
Terapia Ocupacional; Conhecimentos; Atitudes e Prática em Saúde; Pensamento; Prática Profissional

Introduction

This article shows a tool built by occupational therapists in Primary Health Care (PHC) to support the situated analysis of the needs of the person being accompanied in occupational therapy, favoring reflection on the practice and sustaining the process of professional reasoning. Reflection on practice is one of the most valued skills for professional development, as it allows professionals to become aware of the tacit, complex, and uncertain aspects that are characteristic of practice and to transform their actions. Reflection on practice is a skill linked to situated action and favors access to embodied processes and professional thinking about a specific individual or collective case to structure their actions (Marcolino & Mizukami, 2008; Kinsella, 2018), with powerful movements of articulation between theory and practice, between yourself and the other, between limits and possibilities.

For the epistemology of practical rationality developed by Schön (1983), professional practice is a tacit process, difficult to put into words, which occurs in complex, singular situations, full of uncertainties and conflicts of values. Such situational characteristics limit understanding the knowledge that is relevant to practice only as an application of theories or techniques. Schön (1983) argues that it is possible to build knowledge from practice through the processes of reflection in practice (while it happens) and on practice (after its occurrence). It occurs as the professional chooses certain elements of the situation (which surprise them or make them uncomfortable), seeking to build new meanings, which incorporate theoretical and technical knowledge, and which help them to return to practice. This perspective inspired the first major research on clinical reasoning in occupational therapy, The Clinical Reasoning Study, conducted in the late 1980s, funded by the American Occupational Therapy Association and the American Occupational Therapy Foundation (Mattingly & Fleming, 1994).

Since then, clinical reasoning in occupational therapy has been understood as a process in constant development, which is characterized by being tacit, imagery, and deeply phenomenological, used to plan, carry out and evaluate interventions (Mattingly & Fleming, 1994). According to Ferigato & Ballarin (2011), the therapeutic process, as well as clinical reasoning, is sustained by the needs, limitations, and possibilities presented by the assisted person and according to the possibilities offered by the occupational therapist. The reflection on this process of complex encounters can be triggered, strengthened, and problematized, based on the interactive use of reflective instruments, which instigates the production of new encounters, pointing out clues for transformation processes (of the people and the process).

Recent literature reviews indicate the need for research that investigates methods of access to reasoning, as tools that favor the development of professional reasoning and that can provide better evidence of its functioning (Márquez-Álvarez et al., 2019; Unsworth & Baker, 2016). In this direction, some recent studies (Schaaf, 2015; Stark et al., 2015) propose methods to systematize information based on evidence and professional experience to facilitate reasoning and decision-making processes. The Data-Driven Decision Making structure, for example, allows to systematically organize information for guided decision-making, based on steps to organize clinical reasoning, such as identifying factors that interfere with the client's participation, generating hypotheses, and carrying out the intervention (Schaaf, 2015). The guide developed by Stark et al. (2015) describes 16 factors in the reasoning construction process, with a specific focus on care related to changes/adaptations at home. The scale to foster evidence-informed professional thinking, proposed by Benfield & Johnston (2020), was developed through a systematic review and expert consultation and consists of explaining the clinical decisions made by professionals, emphasizing two dimensions: critical clinical reasoning and evidence-based practice.

The tool presented in this article was built on collaborative research between researchers and occupational therapists (Marcolino et al., 2021), seeking to build knowledge relevant to situated practices through critical and reflective processes, from the perspective of the Scholarship of Practice (Hammel et al., 2015). As discussed in Marcolino et al. (2021), research-based on Scholarship of Practice favors the exchange of knowledge between researchers and professionals through the critical analysis of practice (Hammel et al., 2015). This type of research opens up space for the construction of situated knowledge that responds to the needs of practice – like the tool analyzed in this research – offering a type of evidence-based practice (Gélinas, 2016).

Between 2013 and 2017, a community of practice was developed, consisting of researchers and seven occupational therapists who worked in the PHC in a city in the interior of the state of São Paulo/Brazil. In this process, the main difficulty identified by the professionals in their practice was the lack of a specific language for the professional core, mainly because they mostly adopted terminology from other professions or an interprofessional area². To face this difficulty, the professionals set out to investigate their practice, especially the process of identifying the needs of people under their care, based on the study of narrative reasoning in occupational therapy (Mattingly & Fleming, 1994) and of the everyday life, as a common term that aggregated the different theoretical perspectives of the professionals (Galheigo, 2003). In this process, it was possible to understand aspects inherent to the reasoning aimed at identifying needs and build two tools, one to collect information and the other to help them reflect on the practice.

The development of the reflective tool took place in the context of PHC, an area that has been demanding research on the practice of occupational therapists (Cabral & Bregalda, 2017; Silva & Oliver, 2020). Although occupational therapists have already developed local actions in primary care since the 1990s, only in 2008, with the creation of the Family Health Support Center (Núcleo de Apoio à Saúde da Família - NASF), that the insertion of the profession in PHC was institutionalized by the Ministry of Health, mainly to support teams of generalist professionals with specialized knowledge, expanding the scope of actions and the resoluteness of PHC (Cabral & Bregalda, 2017).

Silva & Oliver (2020) indicate that occupational therapy in PHC has challenges related to the absence of theoretical-practical systematization and lack of knowledge of teams, managers, and the population about the potential of occupational therapy, generating a lack of understanding and security in the professionals. The same authors reinforce that occupational therapists who work in PHC are still equipped with knowledge from different fields of knowledge, assimilated in initial training or previous experiences in services at other levels of care. These findings highlight that this field of action has issues that require investigation. Investigating the applicability of the reflective tool could contribute for a better understanding of the development of the area and the professional core (Silva & Oliver, 2020), of the professional reasoning process in this context of practice and teamwork at PHC, aiming to increase the resolution of the followed cases (Egry et al., 2009), as well as strengthen the techno-political arguments that support the need for permanence and amplification of these professionals in PHC.

Although the tool was well evaluated by the occupational therapists who participated in its construction, understanding its applicability and validating it for the wide use of the professional community demands its analysis by a greater number of professionals. Thus, this article shows the final version of the reflective tool, resulting from the process of validation of its content, and explores its applicability through the concrete experience of occupational therapists who work in the context of PHC.

Methodology

The research was characterized as an action research, a type of qualitative research, which intends to improve practice through a systematic cycle of acting in the field of practice and investigating about it (Tripp, 2005, p. 446). This research encompasses the tool's content validation – one of the steps that make up the process of validating instruments in the health area (Coluci et al., 2015) – its analysis depends on the engagement of professionals to reflect on their practice. The object of the research is professional practice and its improvement, and not the construction of knowledge, positive or critical, about the practice – which places it under a broad theoretical-methodological framework of action research (Tripp, 2005). Toledo et al. (2014) point out that, for the objectives proposed by action research to be achieved, there is a need to use a variety of research instruments and techniques, providing the flexibility and dynamism necessary to ensure such engagement. Thus, the methodological procedures adopted sought to offer ways to understand the analysis of professionals on the use of the reflective tool, aiming at its improvement and better adaptation to the reality of practice, to obtain subsidies to develop a new version of the reflective tool that can be used by the professional community.

The reflective tool

The tool to reflect on the practice was built in a matrix format and structured into 12 domains: 1. Perceptions about the assisted person, 2. Interpersonal relationships, 3. How the problem is perceived and narrated; 4. Impacts of the problem in everyday life; 5. Territory and City; 6. Activities that the person is considered to do well and those that the person is considered not to do well; 7. Activities that are good for the person and those that are not good for him/her; 8. Activities that he/she does no longer perform; 9. Prospective vision and projects for the future; 10. How to improve, what to solve; 11. How occupational therapy can help; 12. Integration of Professional Reasoning.

Inspired by the situational diagnostic proposed by Benetton et al. (2021), the tool aims to support the situated analysis of the needs of the person assisted in occupational therapy, with information from the person and also from other relevant people in their everyday life, from family members to the health team or other services (always obtained with the consent of the patient/client/assisted), in addition to information and observations from the occupational therapist. Thus, each domain has three triggering questions to help in the process of reflection on aspects that favor or impede the doing of activities and social participation of people assisted in occupational therapy from the perspective: (1) of the assisted person of the intervention, (2) from the other people who live with them, and (3) from the occupational therapist. As an example, domain 1, which seeks to encourage reflection on the person's perceptions, had the following questions: (1) How does he/she see themselves? (2) How is he/she seen by the people who live with him/her?; and (3) How do you see him/her?

Participants

As this research focused on the analysis of the content and applicability of a reflective tool, previously developed in a collaborative process centered on reflection on the practice of occupational therapists in the context of PHC (Marcolino et al., 2021), we decided to invite occupational therapists who worked in this same context of practice with the following inclusion criteria: being occupational therapists working in the PHC in the State of São Paulo, in any services formally linked to the National Primary Care Policy or referenced by it – and who voluntarily agreed to participate. The “Snowball” sampling was used to identify the participants, as it is a non-probabilistic sampling that uses key informants, locating people with the necessary profiles to carry out the research, forming chains of reference (Vinuto, 2014).

The key informants were researchers (researchers and graduate students) from the Occupational Therapy and Mental Health Laboratory at UFSCar, LaFollia. We nominated and invited a total of 36 occupational therapists. Of these, two refused the invitation, 17 did not respond and 15 accepted to participate, but only 11 professionals participated in the research. All participants are female, three of them are up to 29 years old, six are between 30 and 40 years old and two participants are over 40 years old. All have postgraduate training, seven of them have completed specialization and two are still doing a multidisciplinary residency. Three have a master's degree and one participant has a completed doctorate. Four participants work in the municipality of São Paulo, two work in Campinas, and each of the others belong to a municipality in the interior of the state. Five participants have worked at a PHC for a period between 5 and 10 years, four have worked for less than 5 years, one has worked between 11 and 20 years, and one participant has worked for more than 20 years. Eight of them work in NASF, two in Family Health Units, and one participant in Basic Health Unit.

Ethical aspects

The research was approved by the Ethics Committee for Research with Human Beings (CEP) of the Federal University of São Carlos, under number 3,658,067 on 10/23/2019. Participants signed the Informed Consent Form (ICF), sent in digital format, and are identified by the abbreviation OT followed by a numeric code to preserve their identities.

Data production

Data production took place between June and August 2020. After acceptance, each participant received the following email address: the ICF; an characterization form for personal, professional, and training information; the reflective tool manual; an explanatory video about its use; and the reflective tool in editable text format, to be used for one month. Due to changes in health care due to the Covid-19 pandemic, professionals could use the reflective tool to think about cases that they had followed before, without the need to be a current case. Two participants reported using the tool with cases in recent follow-up, and the others used the tool reflecting on cases they had been following for some time and/or for a long time. A group was created in a virtual messaging app for discussion, clarification of doubts, and facilitation of communication.

Although the reflective tool is not characterized as a measurement instrument, procedures for content validation were implemented (Coluci et al., 2015). Thus, after using the reflective tool, the participants received an online questionnaire in Likert format, with questions on the level of agreement to analyze domains and their questions. Aiming to understand whether the content present in the domains proved to be appropriate and representative of what is intended to be identified, there was an indication of agreement regarding its importance. If the domain questions were written understandably, they expressed what is expected to be analyzed and if they reflected the concepts involved, there was an indication of full agreement, disagreement, or whether the question required large or small reviews (Coluci et al., 2015). In addition, there was an open question so that participants could write comments regarding each domain and its questions.

After answering the questionnaire, we conducted semi-structured interviews with nine participants, recorded and later transcribed, using a virtual meeting app, lasting from 15 minutes (the shortest interview) to 38 minutes (the longest one). Four participants sent recorded audios to the researcher, briefly telling the experience of using the tool, and two of them were unable to participate in the interview but participated in the other stages.

Data analysis

The data from the agreement questionnaire were organized and descriptively analyzed, using simple statistical analysis to identify agreement for each domain and question. We organized the qualitative data from the questionnaire to identify reflections consonant with the domain/question, dissonant reflections with the domain/question, and suggestions for changing the tool.

The transcripts of individual interviews and audios were organized and analyzed using thematic analysis, one of the stages of content analysis, which includes pre-analysis, material exploration and data processing, inference, and interpretation, aiming to identify thematic meaning cores on the textual material (Minayo, 2014). The contents of suggestions for improving the reflective tool were organized in a spreadsheet and added to the data from the questionnaire. After this step, the analysis and alteration of the tool took place following the suggestions received.

Research that involves collaborative participation requires feedback for participants in the analysis carried out by the research team to enable a new layer of analysis (Toledo et al., 2014). Thus, two validation workshops were held - one with three participants and the other with two participants, video and audio recorded and later transcribed, between November and December 2020, in which the new format of the reflective tool was presented. With the data from the validation workshops, a new adaptation of the reflective tool was carried out, specifically in the use of some terms.

Results

Suggestions for improving the reflective tool

The analysis of the questionnaire showed that the domains were considered appropriate and representative for thinking about the practice of occupational therapy, as all participants indicated agreement regarding their importance. As suggestions for improvement, from both the questionnaire comments and individual interviews, audios, and validation workshops, the participants indicated the need for better integration between some domains, such as OT7. She said that when she is reflecting on the domain as the problem is perceived and narrated, her attention is also focused on mastering the impact of the problem on everyday life, a question that was complemented by OT11, mentioning that the focus of reasoning must be first on the impact of the problem, and then understanding what is the problem.

Regarding the 35 questions, most of the participants agreed: one total agreement, 13 questions with 10 agreements, 13 with nine agreements, six with eight agreements, and two questions with seven agreements. A small review was indicated for 32 questions, 17 of them by just one participant, nine questions by two participants, and seven questions by three participants. A major review was indicated by just one participant on seven questions. One of the participants disagreed with two questions about the perception of people who live with the person being assisted, questions with indications of the need for improvement by other participants. The participants understood that, as described, this issue seemed to refer exclusively to family and friends, and indicated the need to expand the issue to the perceptions of the team and professionals from other services that accompany the person, highlighting the importance of considering the entire social support network. They further emphasized that it is not always possible to access these people and that this could defeat the purposes of a person-centered practice. Thus, we added the sentence when there is this information, at the beginning of the questions, and relevant people in their life (family, friends, team), to explain the scope of the question.

There were suggestions: on how to approach the person's desire to carry out activities, not only as a matter of projects for the future; and on the replacement of the expression “acting in the world”, which, although broad, was not recognized as a common expression for the practice, with “carrying out meaningful activities” being preferred as an expression of the profession. Thus, all questions related to the activities were organized in the same domain, integrating information and reflections on the person's relationship with their everyday activities. Such activities may be the ones carried out in occupational therapy sessions or in everyday life, including more explicitly the desire to resume or start new activities.

The term target subject/person was not well accepted by the participants, who were also unable to indicate terms that satisfied them, as can be seen in the excerpt from OT7 when reflecting on the terms patient and user: “[...] we, unfortunately, use patient, [...] we use these terms a lot, which are terms inherited from medical practice [...] so I don't even think it's cool to reply, but “user” [...] [some people] think they are drug users [...].” With these results, the research team suggested the term target person. The target term was also not accepted by the professionals, with the justification that the term seems to specify that the care is aimed only at one person, which goes against the PHC family and community care proposals. Thus, the term assisted person was chosen, which seemed to indicate greater generality, in addition to, as it is a feminine noun (in Portuguese), it facilitates more concise and inclusive writing.

At various times, the participants asked for clearer indications about all the aspects that could be encompassed in certain questions, such as the domain of perceptions about the assisted person, with requests to specify which characteristics should be analyzed, or about the domains that addressed the activities, with suggestions to specify the concept of activities (carried out in the setting and/or in everyday life). As the reflective tool is characterized by the effort to be guided by what can be considered common to professional practice, seeking broad questions for professionals with different theoretical-methodological references, an expression was included in the various relevant aspects, without further details. Only one of the suggestions of this nature, made by OT9, was incorporated into the tool as a footnote, encouraging reflection to incorporate social markers of difference – an increasingly relevant issue, especially in countries with great social inequality, in terms of class, race, and gender (Biroli & Miguel, 2015), as well as region and nation.

Figure 1 shows the final version of the reflective tool.

Figure 1
Reflective tool to support professional reasoning in occupational therapy.

The QR code in the figure gives access to the manual, with guidelines for its practical use. The reflective tool indicates to be used only by occupational therapists and that it was not developed to be attached to medical records or public documents, being just a tool for reflection on the practice. Its construction does not aim at its applicability as a data collection instrument, such as anamnesis. This was the main reason for changing the term instrument to reflective tool, so that its purpose becomes clearer.

Applicability of the reflective tool

The thematic analysis of the qualitative data identified three major action points that indicate possibilities of applicability of the tool in occupational therapy practice: (1) Giving visibility to the specificities of occupational therapy in teamwork; (2) Enabling reflection on practice and improving professional reasoning; and (3) Using the tool in other contexts of practice and in teaching professional practice.

Giving visibility to the specificity of occupational therapy in teamwork

The participants highlighted that the use of the tool enabled to rescue a terminology specific to occupational therapy - such as doing activities, everyday life. This emphasizes the value of the professional core in the context of PHC, which excels in interdisciplinary work, in which often specifics aspects of the professional core end up being diluted. Also, the reflective tool was analyzed in its potential to communicate what occupational therapy does both to other professionals, patients/service users and managers.

[...] because this proposal [...] rescues much of what occupational therapy is and [...] ends up helping [...] to [...] show [...] other professionals what occupational therapy is (OT1).

[...] on the impact of the everyday problem, on the activities, I think this brings a lot [...] to our specificity, that many times in primary care, some things end up diluted, we will look at the needs of the field, more general health needs, so [...] it brings some more specific points, I think that's cool (OT4).

[...] I think [...] it helps [...] us talk to the teams, [...] with users, in a meeting of the local health council... I think [...] that [...] in this way, with the domains... I think it's a strategy for us to make this dialogue (OT2).

Some participants valued the use of the reflective tool to have more security, organize information about their practice and be able to present it to the team. Again, the participants highlight the generality of PHC and the difficulty of perceiving and affirming the specifics of occupational therapy – which often leads them to question whether what they do can be called occupational therapy.

[...] I could managed to affirm my skills within the case, but also to organize this information to be able to pass it on to the team [...] it was a very positive point [...] even to make me feel a little better because sometimes when I looked at the case, I was like '[...] I can't move forward, [...] what I'm doing is not occupational therapy, [...] so what is it?' (OT8).

[...] it helps us to bring these specificities closer, because [...] composing NASF, we get mixed up [...] I even wonder if I'm doing occupational therapy? [...] (OT9).

Improved communication with the multidisciplinary team was also an indication of the applicability of the reflective tool, not only to show what occupational therapy is but to facilitate the understanding of why occupational therapists need multiple information to perform their care work.

[..] it was very interesting because we started to question the teams, nurses, community agents a little more, and sometimes [...] some are very bothered when we start to ask [...] in a technical way, [...] it seems like a demand! And [...] the instrument is in a simpler form [...] it was of a different reception (OT1).

[...] some of these questions have even helped the team to think, you know? Is this case for occupational therapy? If yes, what are the demands, or if not what are the demands that I should observe to forward to discuss with the occupational therapist? [...]. (OT8)

To enable reflection on practice and improve professional reasoning

The second theme addressed the applicability of the reflective tool to support professional reasoning processes. Two professionals highlighted the tool's potential to help professionals become aware of their thoughts, as the practice happens dynamically, everything is “in the head” (OT2), implicitly, and it is not always clear about all aspects present in practice. The reflective tool, by presenting the various aspects of practice in an organized and didactic way, allows for greater awareness of their reasoning.

[...] when you come with everything structured, [...] we use it a lot in practice, but [...] there are some details [...] that sometimes escape from us (OT1).

[...] we make some groupings in our heads [...] to think, [...] where do you start, where are you going, [...] and the instrument [...] goes dismembering in a didactic way, but it goes through everything [...] an instrument to support the professional's reasoning, I think it's to give support, it's not a guide, it's not for you to follow [...] you have to go through these things, and they will help you build your reasoning [...] (OT2).

Participants also highlighted how the reflective tool was useful to reflect on the cases they were following, enabling them to broaden the understanding of difficult cases and organize information that was previously confused, offering them greater security to make decisions in practice.

[...] I think it helps to think about [...] more complex cases, I used it with[...] a case that I was having difficulty thinking about [...] in intervention proposals, so […] it helped me to broaden this view of the case (OT4).

[...] I often got lost [...], I no longer had the focus, [...] I [...] was a little confused, so I thought I had to put it on paper and think about the instrument, as hard as it seems difficult [...] sometimes we can't fit things in, it takes a little more time... But I found it very valid, [...] it helped to clarify the thinking and [...] to be more sure [...] of what I saw as a need and how far I can go [...] (OT5).

Also, the participants mentioned how the reflective tool facilitates the identification of different information and perceptions, whether from the assisted person, from all those involved, and who is important in the case, and from the occupational therapist. The tool also allows dialoguing with the team about the cases and thinking broadly about the intervention.

[...] it makes our reasoning much easier [...] what is mine as a therapist, what I assess, but what the patient thinks about their condition, what is important to them, and what I think that's important to them (OT6).

[...] how the team feels about that person, how they feel about them because a lot of what the team feels is what that person causes, not only in the team, but in us, [...] maybe this helps guide the conduct also with the team (OT8).

[...] when I think specifically about primary care, I will think more broadly and [...] the instrument allows me [...] to look at situations, not [...] only at the family, [...] in the domains [...] it gave [...] this idea more extended, [...] it makes more sense for primary care, the network articulation [...] (OT4).

Using the tool in other contexts of practice and in teaching professional practice

The third theme addressed the applicability of the tool to other contexts of practice but valued the tool's construction scenario: the PHC. The OT7 highlights the relevance of the tool for the visibility of the contribution of the occupational therapy whole practice developed in PHC to the field of occupational therapy, as well as for facing the reality of dismantling and the loss of work positions, difficulties experienced in the current Brazilian context.

[...] for me, again, it's not focused on PHC [...] But I think it's important to point out that it was an tool produced with the participation of professionals at PHC because I think we are at this moment... [...] with the extinction of the NASF, needing to discuss the specifics of occupational therapy in PHC, [...] it has to do with the expanded clinic that this tool brings, it has to do with the integrality of care that the tool also brings [...] make it clear that these values of occupational therapy in PHC can be taken to practices [...] of occupational therapy [...] it includes very important aspects of the general practice of occupational therapy in PHC [...] because it's usually the opposite, PHC is appropriating more specific instruments and more specialist niches, right? [...] so it's nice to go the other way around and value this practice that we are needing to name! (OT7).

Another applicability was suggested by OT4 when reflecting on its use in teaching-learning processes of professional practice, as the reflective tool may have the potential to help students understand the different dimensions of practice to think about the elaboration of intervention proposals.

While using this tool for the clinical reasoning of a case, I thought that it could be very interesting [...] for the teaching-learning process (for example, in fieldwork training in which I work as a tutor - it can be very useful to help the student to have a greater dimension of what is important [...] brings security about what to look at - not as an interview guide, but when thinking about the case and intervention proposals; it brings important terms for therapy occupational, and the more nuclear role of the profession (drawing attention to everyday life and activity - considering that we often perform actions in the field of family health, for example) (OT4).

Discussion

In research from the perspective of Scholarship of Practice (Hammel et al., 2015; Marcolino et al., 2021), situated knowledge cannot be understood only by its local aspects since practice is in constant dialogue with what it is global. This type of evidence demands international dialogue, as it resonates in other contexts. Thus, there is no intention that this reflective tool has universal domains, but that its structure can, in the first place, lead to reflection and possibly tension new contexts to find domains, terminologies, and arrangements that better respond to the new situated context. Second, this tool can enhance the intervention construction process, which occurs under the contingencies established by needs, limitations, and possibilities in the therapeutic encounter (Ferigato & Ballarin, 2011), and whose process of reflection on the practice can expand possibilities of transformations.

In this research carried out in Brazil, the analysis of the tool indicated broad agreement with the domains constructed in the previous research (Marcolino et al., 2021). The participants only indicated notes for reviews that, for the most part, referred to a better presentation and integration of domains and a better detailing of the issues. It is interesting to highlight the terminological construction process, since, even though all the participants working in the PHC, each one of them had different theoretical references and perspectives on the practice. One of the terms that mobilized the greatest discussions was the term target subject/person. Coming from productions on situational diagnostic (Benetton et al., 2021), which are an inspiration for the construction of the tool and was present in the original tool, and also from the use of the terms individual and collective subject³, characteristic of the Brazilian collective health area and historical materialism (Campos, 2005), this term was not well accepted by the participants of this research. The term user was indicated but was not recognized as specific to occupational therapy (just as there is no specific term to refer to users of any other health profession), because, although it is common within the Unified Health System, it is also may indicate users of psychoactive substances in other contexts.

As this research was immersed in professional practice in the health field, the term patient was one of the words used by professionals to refer to the person under their care, but with the indication that this term does not satisfy, that it is necessary to move away from medical terminology. In the reality of this research, the term client, common in Anglo-Saxon productions in occupational therapy (Pontes & Polatajko, 2016), was not mentioned. The choice of the word assisted person by the research team, and its acceptance by the participants, can indicate its generality to the field. Although in the research process, we chose to use a consensual term among the participants, we know that this discussion includes techno-political aspects beyond the term's usability. Each term has its specificity beyond the semantic issue, as these names have different historical constructions and induce different ways of understanding the named subjects and their relationship with those who name them (Saito et al., 2013).

Terms such as activity and everyday life were accepted without question as words that belong to the specific practice of occupational therapy, but some participants asked that they be better specified – whether the term activities addressed activities inside or outside the setting, or what aspects of everyday life could be addressed. The term occupation appeared a few times in the qualitative data, reinforcing the wide acceptance of the term activity in Brazilian occupational therapy (Poellnitz, 2018). However, as the number of participants was small and located in the state of São Paulo/Brazil, the research team chose to keep as a footnote the indication of the substitute use of the term occupation when the term activity appears, if it is better suited to the theoretical-methodological frameworks of the practitioner, including the growth in the use of this term in the Brazilian context in the last two decades (Galheigo et al., 2018).

The terminological discussion in the occupational therapy field needs to be accompanied by an epistemological and, consequently, socio-historical discussion. Epistemologically, Brazilian occupational therapy begins to have a better understanding of the paths taken to date, moving away from the exclusively theoretical analysis of the 1980s and 1990s, expressed as methodological currents, criticized for its distance from real professional practice (Mângia, 1998). Recent articles discuss Brazilian terminological choices, seeking to (1) make more complex the discussion of the choice of terms and concepts (Constantinidis & Cunha, 2016; Marcolino et al., 2019); (2) review academic paths that culminated in the choice of certain terminologies (Galheigo et al., 2018), or (3) present processes of transformations in concepts in the work of specific authors (Marcolino & Fantinatti, 2014). Thus, our results indicate the need for further investigations that address the terminology about the practice to provide better adjustments between practice and the discourse about it.

In this sense, the participants' good receptivity to the terms used in the tool to help them think about their practice and to communicate it, especially to other team professionals, demonstrates both the adherence of the words to the professional core, as well as possibilities of overcoming dissatisfactions, identified also in other research on the discourse of specific practice in interdisciplinary contexts, with biomedical hegemony (Lima & Falcão, 2014; Marcolino et al., 2019, 2021; Reis & Vieira, 2013; Rocha et al., 2012; Silva & Oliver, 2020). The ability to produce effective communication between peers, between health professionals, and between professionals and users or the community, in general, is not just a way of naming practices, but a form of good care, since communication is a substance of care and not just its environment (Saraiva & Ferigato, 2021).

The phenomenon of underground practice described in the research on clinical reasoning conducted by Mattingly & Fleming (1994), in which narrative aspects of practice in occupational therapy are not publicly presented and are in constant tension with the biomedical model, has been faced as occupational therapists assume a public discourse that values ​​the importance of doing, occupation (Marcolino, 2017; Pierre, 2009; Turner & Knight, 2015) and the narrative aspects of practice (Bonsall, 2012). In this regard, it is important to emphasize that the tool presented here was built in a collaborative process - between the research team, the occupational therapists who participated in the construction of the reflective tool, and the participants in this research, who worked under multiple theoretical frameworks and with different conceptions of practice – and, even so, it was possible to find common terms, broadly and generically. This seems to us to meet the confrontation of these difficulties.

As discussed by Marcolino et al. (2019), words contribute for organizing, interpreting reality, communicating, and building a system of thought and, we might add, an open system of care. In this sense, the participants valued the experimentation of the tool to think about the cases they follow, favoring the organization of the case information and greater awareness of the tacit information, which was “in their heads”, reflecting on how they can continue to conduct the care. Reflecting on the practice helps the professional to become aware of the tacit aspects, allowing the practice to be evaluated and refined, and through that aiming to produce new knowledge (Marcolino & Mizukami, 2008). Such reflective processes are characterized by being linked to action, which encourages learning centered on current experience, by allowing connections to be made with previous experiences, elaborating assumptions, and expanding awareness of actions (Marcolino & Mizukami, 2008).

Thus, it is important to highlight that the tool was not developed as a guide for anamnesis or assessment, but to support professional reasoning, by making it possible to stop and reflect on what the occupational therapist knows/does, how he/she understands the case, what information he/she still does not have, and what might be the possible paths to practice. These paths can only be produced by relational paths, by tensioning different perspectives of multiple relationships and actions that cross the life of the person or people we accompany. This aspect leads us to affirm an understanding that professional reasoning does not operate in a zone intrinsic to the consciousness and thoughts of the occupational therapist, but in a porous border zone between bodies involved in an intervention, with needs, understandings, and varied premises. The challenge for professional reasoning committed to the ethics of care is knowing how to find community zones in this complex variation that the tool minimally seeks to give way.

There was even an indication that the tool could respond to other contexts of practice, not just PHC. Research on occupational therapy practice in PHC indicates that this is a context that, although it is consolidating as a specific field, with unique knowledge and practices, still uses many references produced in other more specialized fields of practice (Cabral & Bregalda, 2017; Silva & Oliver, 2019). Thus, as the reflective tool was built in the broad and general context of PHC, it can be considered a contribution of PHC to the professional and knowledge field in occupational therapy, as highlighted by one of the participants. This issue favors the political defense, affirmation, and recognition of occupational therapy at this level of health care, evidencing its alignment with the principles of PHC and the Brazilian Unified Health System – currently suffering dismantling managed by neoliberal political-economic forces (Morosini et al., 2018).

Another important applicability of the tool encompasses its potential for teaching practice. Practice reflection skills are highly valued in occupational therapy teaching (Joaquim et al., 2017; Wimpenny & Lewis, 2015; World Federation of Occupational Therapists, 2016), and the use of this tool for this purpose can be explored by opening possibilities for future research.

Final Considerations

This article shows the analysis process of a reflective tool, collaboratively built-in research supported by the partnership between researchers and professionals. Its applicability encompasses to improve the identification of the professional core in occupational therapy and its possibilities in interprofessional dialogue, facilitating both the communication of practice for other professionals and users, and the reflection on practice and awareness of professional reasoning processes.

Some emerging issues arising from this research that can be addressed in future research include: (a) its applicability in other contexts of practice, but with emphasis on the contributions arising from the broad and general context of PHC for the professional field and knowledge in occupational therapy; (b) its applicability for teaching occupational therapy practice; and (c) the clues triggered by the construction and analysis of the tool for investigations into better terminology that better represents what happens in practice.

Finally, we reinforce that knowledge production processes for and about the practice developed with occupational therapists are powerful, as they favor real transformation in the individual and collective scenarios in which interventions occur, qualifying a contextualized care and advancing in the knowledge related to the professional nucleus, strengthening the profession as a whole, consequently, the different fields of practice.

Acknowledgements

The authors thank the occupational therapists participating in the research who contributed to the improvement of the tool and, consequently, to the practice and care in occupational therapy.

• 1
  This work is part of the first author's master's thesis, under the supervision of the last author.
• 2
  Here, we adopt the terms “area and core” as proposed by Campos (2005). They are critical concepts of the postmodern trend of total dilution of professional identities. The core concept demarcates the singularities of each profession, which differentiates it from others. The area concept, on the other hand, would be the space of intersection and professional confluences, in which knowledge and practices merge interdisciplinary.
• 3
  In the historical materialist perspective, the constitution of the subject is always a synthesis between the individual and collective historical construction: “The subject is a singular synthesis resulting from the clash between particular and universal determinants and conditionings and the subject's capacity to change them, through processes of analysis and intervention on these factors” (Campos, 2005, p. 235).
• How to cite: Gomes, L. D., Ferigato, S. H., Araujo, A. S., Cid, M. F. B., & Marcolino, T. Q. (2022). Let's think about practice? The applicability of a reflective tool to support professional reasoning in occupational therapy. Cadernos Brasileiros de Terapia Ocupacional, 30, e2964. https://doi.org/10.1590/2526-8910.ctoAO22462964

• Funding Source

  This work was carried out with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES), financing 001, through the granting of a master's level scholarship, and the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), financing 17/03195-8.

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Edited by

Section editor

Profa. Dra. Adriana Miranda Pimentel

Publication Dates

• Publication in this collection
  11 Mar 2022
• Date of issue
  2022

History

• Received
  23 Feb 2021
• Reviewed
  10 June 2021
• Reviewed
  26 Aug 2021
• Accepted
  01 Sept 2021