A Grounded Theory of Intuition among Occupational Therapists in Mental Health Practice
Chaffey, Lisa, Unsworth, Carolyn, Fossey, Ellie, British Journal of Occupational Therapy
Clinical reasoning is a complex notion concerned with the ways in which therapists think in practice (Mattingly and Fleming 1994). As Fleming and Mattingly (1994) observed, therapists may have difficulty in describing clinical reasoning when engaged in therapy. These authors proposed that difficulty in articulating actions is due to a lack of language. Another explanation may be that therapists' clinical reasoning is informed by intuition as well as analysis, and intuition is more difficult to articulate.
Intuition has been defined as 'a whole; immediate possession of knowledge; and knowledge independent of the linear reasoning process' (Rew 1986, p23). This concept has received little attention in the occupational therapy literature. This paper describes a study of occupational therapists' understanding and use of intuition in mental health practice and proposes a grounded theory of intuition drawn from the findings of this study.
In order to understand how intuition may guide practice, it is necessary to understand how therapists think in action. In 1986, a team of researchers in the United States, including Mattingly and Fleming, began the Clinical Reasoning Study (Mattingly and Fleming 1994). This project was a 4-year study combining ethnographic and action research methodologies. From this study, these authors suggested that occupational therapists think in three tracks of reasoning: procedural, interactive and conditional reasoning. Procedural reasoning occurs during problem definition and intervention selection. Interactive reasoning occurs when building collaborative relationships with clients. Conditional reasoning is considering a client's whole condition within broader social and temporal contexts (Mattingly and Fleming 1994). Furthering our understanding of clinical reasoning theory, Unsworth (2004) and Boyt Schell and Schell (2008) have identified a range of environmental and personal factors that influence clinical reasoning. These include extrinsic factors such as workplace protocols and intrinsic factors such as beliefs, values, ethics and motivation.
Mattingly's and Fleming's (1994) study was conducted mostly with clinicians in physical areas of practice, however, with less attention being paid to the clinical reasoning of occupational therapists practising in mental health. Studies in this area have found that occupational therapists practising in mental health place emphasis on interacting with and understanding their clients to guide their clinical reasoning (Fossey 1996, Ward 2003).
The clinical reasoning of experts has also been explored. In the United Kingdom (UK), Roberts (1996) sought to describe the content and process of clinical reasoning in 38 occupational therapists, some practising in mental health. She noted that pattern recognition had a place in expert reasoning, which was likely to influence the speed of problem identification. Roberts' (1996) findings have been supported by further studies of expert reasoning in occupational therapy in physical dysfunction. In an American ethnographic study, Gibson et al (2000) suggested that experts' reasoning was often influenced by patterns in client presentations and that expert therapists were quicker to prioritise important information compared with novices. Unsworth (2001) reported similar findings in a mixed method study involving two novice and three expert occupational therapists in Australia. She reported that experts had a larger bank of clinical experiences from which to draw, generalising from their experiences twice as often as novices. These studies' findings are consistent with those of Dreyfus and Dreyfus (1986), who determined that experts have an intuitive understanding of a situation and the appropriate actions to take, supported by the exploration of Benner et al (1996) of intuition in expert nurses. However, an understanding of the role of intuition in occupational therapy practice is in its infancy. …