Achieving a higher level of expertise.
Occupational therapy (Health aspects)
Occupational therapy (Analysis)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: Feb, 2009 Source Volume: 72 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
I read with pleasure the letter from Gillian Murphy ('Using theory', BJOT January 2009). Murphy describes the Disability and Older People's Services at Wokingham Social Services as delivering what she calls 'process-driven practice' (p43), in contrast to the 'theory-driven practice' (p42) presented in the article to which her letter is a response (Boniface et al 2008). In fact, Murphy's letter provides an elegant description of expert occupational therapy practice.
The nature of expertise in a practice discipline was explored in a classic study, commissioned by the United States Air Force, of how pilots learn their complex, high level skills. A mathematician and a philosopher (Dreyfus and Dreyfus 1980, cited in Benner 1982), looked at the learning process in chess players and pilots and produced a model of the acquisition and development of complex skills that involve experience as well as education. They suggested that the learner passes through five levels of proficiency: novice, advanced beginner, competent, proficient and expert. As the practitioner becomes more skilled, two types of change occur in his or her performance. First, he or she moves from reliance on abstract principles and theories to using past experience as a guide. Second, his or her perception and understanding of work situations change from seeing a compilation of bits in which all aspects are equally relevant to viewing a complete whole in which only certain features are relevant (Benner 1982).
A series of studies at the University of California School of Nursing demonstrated that the performance of nurses can be understood using this model (Benner 1982, Benner and Tanner 1987). For example, the novice nurse has no experience of the situations in which he or she will be working but learns rules to guide action. The competent practitioner is able to see his or her actions in terms of long-term goals and to make plans to meet them. He or she is comfortable using standardised procedures and routines to guide his or her actions. The expert practitioner does not rely on rules or guidelines to connect his or her understanding of the situation to the choice of appropriate action, but is able to know intuitively what is important and what needs to be done.
Benner and Tanner (1987) found that the performance of expert nurses is based on 'flexible understanding in diverse situations' (p25) and that 'flexibility is gained as a result of a deep background understanding of the situation' (p27). These findings are echoed in Murphy's description of how the occupational therapists in Wokingham Social Services 'did not want to fit our clients into one way of thinking and one style of working' (p42) but 'strive to find a practical compromise that considers the pragmatics of the situation within the current constraints, boundaries and resources' (p43).
The definition of occupational therapy as a complex intervention, published by the College of Occupational Therapists (Creek 2003), offers a description of expert occupational therapy practice, in which:
This definition, like Benner's findings, emphasises the flexibility and responsiveness of expert practice. However, Benner warned that expert judgements may be devalued 'because of an apparent lack of concrete evidence' (Benner and Tanner 1987, p29) and that many employers perceive 'the standardisation and routinization of procedures' seen in competent practice as the ideal (Benner 1982, p405). She pointed out that professional education tends to be aimed at the competent level of performance rather than the proficient or expert levels.
For many years now, occupational therapy students have been taught that using a model for practice represents the highest level of skill of the occupational therapy practitioner. That is why it is a pleasure to read in Murphy's letter of an occupational therapy service that supports practitioners in achieving a higher level of expertise for the benefit of their clients.
Benner P (1982) From novice to expert. American Journal of Nursing, March, 402-07.
Benner P, Tanner C (1987) Clinical judgement: how expert nurses use intuition. American Journal of Nursing, January, 23-31.
Boniface G, Fedden T, Hurst H, Mason M, Phelps C, Reagon C, Waygood S (2008) Using theory to underpin an integrated occupational therapy service through the Canadian Model of Occupational Performance. British Journal of Occupational Therapy, 71(12), 531-39.
Creek J (2003) Occupational therapy defined as a complex intervention. London: College of Occupational Therapists.
Jennifer Creek, Freelance Occupational Therapist, North Yorkshire.
the occupational therapy process is not linear. At each stage, the therapist combines thinking about the situation, negotiation with the client and negotiation with relevant others in order to determine what action to take within a particular context. The context of the intervention modifies the occupational therapy process and the therapist's thinking, negotiation and action (p17).
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