Clinical Reasoning to Support Participation: How Occupational Therapists Make Decisions in the Schools

Occupational therapy is a blend of both art and science. The decisions that occupational therapists make appear, on the surface, to be the result of intuition or trial and error. However, occupational therapists employ a complex clinical reasoning process to make decisions regarding the services that they provide to their clients. There is a dearth of evidence regarding how occupational therapists use clinical reasoning in school-based practice. The purpose of this phenomenological study was to examine how occupational therapists use clinical reasoning when making decisions in RtI initiatives through the use of semi-structured interviews with 10 occupational therapists who worked with problem solving teams to implement RtI in Illinois. Data analysis was completed using the constant comparative method. The findings from this study suggest that occupational therapists begin their decision making by considering a child’s participation in his or her student role. They examined the fit between the student, the environment, and the task. They considered a teacher’s readiness to implement their suggestions before making their recommendations. In addition, the occupational therapists reported that they maintained a holistic view of the student by considering how life at school and life at home influenced one another. They tacitly used an ecological frame of reference, along with other conceptual practice models, to inform their clinical reasoning. Further, the occupational therapists identified common reasons why students were referred to them through RtI and problem solving teams. These reasons included issues related to handwriting, sensory processing, and inattention and off-task behaviors. The therapists discussed ways that they were involved in RtI across tiers and provided specific examples of ways that they supported students and teachers in general education at Tier 1. Finally, the therapists identified the itinerant nature of their work in schools and a lack of understanding by teachers and other education professionals as barriers to their continued participation in RtI. The results of this study have implications for future research related to the clinical reasoning of occupational therapists in school-based practice, as well for pre-service and in-service training.