SchellConsulting

Barbara first began to explicitly explore clinical reasoning when she was an occupational manager at Harmarville Rehabilitation Center in Pittsburgh, Pa. In that capacity, she had oversight of a large department, including over 30 occupational therapy personnel, and additional related staff. When she first came to Harmarville, there was a great deal of work aimed at focusing departmental efforts and developing systems to orient and support staff in their professional development (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. It was also a time when new programs were developing in areas such as chronic pain management, return to work, substance abuse, assisted living, adult daycare, and the like, along with the typical rehabilitation programs for people with strokes, head injury, spinal cord injury, hand injury, and other conditions that affected both mental and physical abilities to participate effectively in daily life.

In her role as a manager, Barbara realized that it was important for practitioners to develop mental models or internal guides that would help them to negotiate the changing patient populations, programs and payment systems. The American Occupational Therapy Association’s (AOTA) Uniform Terminology I (and then II) served as a useful template for documentation, but were not comprehensive guides for practice (AOTA-COP, 2002). The Model of Human Occupation was in the early stages of development (Kielhofner, 2002) and was beginning to challenge practitioners to focus less on mechanistic ideas derived from medicine and more on occupational behavior (Kielhofner, 2002, p. 6); however, the actual implementation of the model was unclear.

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 AOTA funded the research project, which came to be known as the Clinical Reasoning Study (Fleming & Mattingly, 1994). This study came out of discussions between Nedra Gillette of AOTF and Stephanie Hoover of AOTA with Donald Schön, a noted social scientist at MIT, who provided guidance on how to study clinical knowledge and expertise (Mattingly & Fleming, 1994, p. ix). 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 as a research consultant to assist the department 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 indeed clinical reasoning.

From this early beginning, Barbara went on to become what she called a “clinical reasoning groupie,” closely following the unfolding research of the Clinical Reasoning Study. Subsequently, Barbara moved on to pursue her doctoral work in Adult Education, where she was fortunate to have Ron Cervero as her advisor. Ron pushed Barbara to articulate her concerns with the limitations of clinical reasoning as it had been described to date. That effort ultimately resulted in her introduction of the concept of pragmatic reasoning to the field.

Since her doctoral degree completion in 1994, Barbara has continued to review and synthesize the literature in numerous publications, and to provide continuing education to managers and educators on how to support effective clinical reasoning in practice.