Meanings that occupational therapists attribute to narrative reasoning in the evaluation and intervention processes within critical care units

Abstract

The article analyzes how a group of occupational therapists in a critical care unit gives meaning to the use of narrative reasoning in the evaluation and intervention of patients with critical illnesses. The research used a qualitative methodology with a phenomenological approach and non-probabilistic sampling. Information was collected through in-depth interviews with occupational therapists who work in a critical care unit. Dialogues from which texts emerged that were coded, identifying themes, categories and subcategories that allowed the interpretation of the collected data from a hermeneutic perspective. Among the most relevant results obtained, it can be shown that occupational therapists in a critical care unit attribute great importance to the implementation of narrative reasoning and strategies that involve the creation and telling of stories in the evaluation, intervention, and recovery processes of patients with critical illnesses. This is because narrative reasoning facilitates the therapeutic process by allowing occupational therapists to understand the meaning of the illness and the influence of the environment, grounding the therapeutic actions used in the evaluation and intervention within these units. In conclusion, it is possible to establish that the application of narrative reasoning and its two branches, storytelling and story creation, are essential for the evaluation and intervention of critical patients. This acknowledges the patient's experience, allowing for the expression of everyday life and reducing socio-cultural barriers in a biomedical context.

Keywords:
Professional Practice; Critical Care; Narrative; Occupational Therapy

Resumen

El artículo analiza cómo un grupo de terapeutas ocupacionales en una unidad de cuidados críticos otorga significado al uso del razonamiento narrativo en la evaluación e intervención de pacientes con enfermedades críticas. La investigación utilizó una metodología cualitativa con un enfoque fenomenológico y un muestreo no probabilístico. La información fue recolectada mediante la aplicación de entrevistas en profundidad a terapeutas ocupacionales que desempeñan sus funciones en una unidad de cuidados críticos. Diálogos de los cuales emergieron textos que fueron codificados, identificándose a partir de ellos, temas, categorías y subcategorías que permitieron interpretar los datos recolectados, desde una perspectiva hermenéutica. Entre los resultados más relevantes obtenidos se puede evidenciar la importancia atribuida por terapeutas ocupacionales de una unidad de cuidados críticos, a la implementación del razonamiento narrativo y las estrategias que consideran la creación de cuentos y el relato de historias en los procesos de evaluación, intervención y recuperación de pacientes con enfermedades críticas. Esto, porque el razonamiento narrativo facilita el proceso terapéutico al permitir a los terapeutas ocupacionales comprender el significado de la enfermedad y la influencia del entorno, fundamentando las acciones terapéuticas utilizadas en la evaluación e intervención dentro de estas unidades. Como conclusión, es posible establecer que la aplicación del razonamiento narrativo y sus dos vertientes: la narración de cuentos y la creación de historias son esenciales para la evaluación e intervención de pacientes críticos. Pues rescata la experiencia del paciente, permitiendo la expresión de la cotidianidad, reduciendo las barreras socioculturales en un contexto biomédico.

Palabras clave:
Práctica Profesional; Cuidados Críticos; Narracione; Terapia Ocupacional

Resumo

O artigo analisa como um grupo de terapeutas ocupacionais em uma unidade de cuidados críticos atribui significado ao uso do raciocínio narrativo na avaliação e intervenção de pacientes com doenças crônicas. A pesquisa utilizou metodologia qualitativa com uma abordagem fenomenológica e uma amostragem não probabilística. As informações foram coletadas por meio da aplicação de entrevistas em profundidade com terapeutas ocupacionais que atuam em uma unidade de cuidados críticos. A partir dos diálogos, dos quais emergiram textos, que foram codificados, foram identificados temas, categorias e subcategorias que permitiram interpretar os dados coletados, a partir de uma perspectiva hermenêutica. Entre os resultados mais relevantes obtidos, pode-se evidenciar a importância atribuída por terapeutas ocupacionais de uma unidade de cuidados críticos à implementação do raciocínio narrativo e das estratégias que consideram a criação de contos e a narração de histórias nos processos de avaliação, intervenção e recuperação de pacientes com doenças críticas. Isso ocorre porque o raciocínio narrativo facilita o processo terapêutico ao permitir que os terapeutas ocupacionais compreendam o significado da doença e a influência do ambiente, fundamentando as ações terapêuticas utilizadas na avaliação e intervenção dentro dessas unidades. Como conclusão, é possível estabelecer que a aplicação do raciocínio narrativo e suas duas vertentes: a narração de contos e a criação de histórias são essenciais para a avaliação e intervenção de pacientes crônicos. Isso porque resgata a experiência do paciente, permitindo a expressão do cotidiano e reduzindo as barreiras socioculturais em um contexto biomédico.

Palavras-chave:
Prática Profissional; Cuidados Críticos; Narração; Terapia Ocupacional

Introduction

Narrative reasoning emerged as a concept in cognitive psychology, with subsequent application to the field of medicine (Moruno-Miralles, 2002). Its purpose is to understand how people process information through stories or narratives, and how they use these stories to solve problems and make decisions (Moruno-Miralles et al., 2020).

This approach has been applied in occupational therapy for the creation, interpretation, and application of stories and narratives for the purpose of understanding individual experiences and personalizing therapeutic interventions, rather than just collecting data and facts (Higgs & Jones, 2019).

In this context, narrative reasoning becomes a crucial dimension of professional reasoning in occupational therapy, allowing the occupational therapist to understand the meaning of the problem from the perspective of the person's own narrative and guide the intervention toward specific goals (Haines & Wright, 2023).

Currently, narrative reasoning is integrated as a dimension of professional reasoning. Professional reasoning studies allow us to identify known and emerging forms of occupational therapists’ decision-making processes and thus to understand the possible implications for practice. Furthermore, these studies allow us to test new models and frameworks, to recognize iterative, dynamic and contextualized reasoning processes, and to become attuned to the reasoning process in specific contexts. All of this helps to focus on the client and the occupation (Silva Araujo et al., 2022).

Similarly, it has been established that narrative reasoning is essential in all stages of the therapeutic process of occupational therapy, including assessment, goal setting, treatment and discharge (Bonsall, 2012). It is important for occupational therapists to develop strong skills in narrative reasoning to apply it effectively in their clinical practice, especially in emerging contexts such as critical care units (Bombarda et al., 2016). This type of reasoning proves to be especially valuable in contexts of uncertainty, complexity and indeterminacy in clinical practice (Silva Araujo et al., 2022).

The concept of narrative in occupational therapy involves the use of storytelling and personal experiences to understand and address the needs of individuals. This approach allows occupational therapists to gain insight into their clients' lived experiences and adapt their interventions, which are introduced as a shared approach, focused on specific events that unfold in time and space, with actors and scenes that are co-constructed collaboratively (Elliot & Bonsall, 2018).

Professional reasoning is defined as a transaction between personal and the therapist perspectives, the patient perspectives, and the demands of the practice context, where a broader sphere of construction is translated than just the therapist's intervention in a clinical context (Schell et al., 2016). It is considered a process that involves all the ways of thinking that the occupational therapist develops during his/her work, including the thoughts that move within, through, and outside the therapeutic relationship and the processes of occupational therapy itself (Unsworth & Baker, 2016). Therefore, it can be considered a fundamental element of the evaluation and intervention process, capable of generating effectiveness and competence in professional tasks (Talavera-Valverde, 2015).

The relevance of this field is evidenced through studies that have been published to document and explore professional reasoning, highlighting its intrinsic importance for the development and practice of the profession (Márquez-Álvarez et al., 2019).

Occupational therapy trains individuals to rethink their lives through a wide range of activities used as a therapeutic resource. Among them, narrative stands out, which creates many opportunities for encounters with others and between others and themselves (Brandão et al., 2014). Narratives promote the humanistic aspect of patient care by uncovering aspects of their environment and/or situation, expanding clinical thinking and facilitating a contextualized medical environment (Greenfield et al., 2015).

The therapeutic relationship in occupational therapy emerges as an essential element that shapes both the direction of the intervention and the outcomes experienced by the client (Williams & Paterson, 2009). This critical component not only has an impact on the treatment outcomes but also on the client satisfaction, involving the development of a strong bond and collaborative agreement on therapeutic goals and tasks (Paulraj et al., 2021).

Within the context of occupational therapy, the therapeutic relationship stands out as a critical concept for understanding the patient’s needs and setting clear goals (Yazdani et al., 2021). This approach is characterized by a collaborative perspective, focused on consensus on therapeutic goals, agreement on tasks, and strengthening the bond between the client and the therapist (Flückiger et al., 2018). The quality of this therapeutic connection becomes a determining factor, where agreement on treatment goals and tasks, along with the general bond, play a crucial role (Fan & Taylor, 2016).

In this context, the recognition of the clients’ interpersonal characteristics by the occupational therapists becomes imperative. The intentional use of self in occupational therapy is configured as a key element to nurture an effective and enriching therapeutic relationship (Wong et al., 2022).

Occupational therapy has identified diverse user profiles that could benefit from its professional interventions. In order to broaden its scope of action, it has expanded to new areas, including critical care units, which has presented new challenges for both the occupational therapy professional and the people in these units.

Occupational therapy practice in critical care units focuses on patients with serious illnesses who have dysfunction in vital organs and a high risk of imminent death if they are not provided with adequate care. To address this situation, it is necessary to apply critical care through surveillance techniques, monitoring and initial and sustained support to vital organ functions (Kayambankadzanja et al., 2022). In addition, these patients suffer from physiological decompensation and have a high probability of presenting impaired consciousness, respiratory failure, edema, limited limb movement (Costigan et al., 2019), neuro-orthopedic malformations (Weinreich et al., 2017), deterioration in motor and cognitive skills (Carmo et al., 2020), with a higher risk of developing delirium (Álvarez et al., 2017).

To perform occupational therapy in these units, it is important to understand the medical complications and monitoring, surveillance, management and life support procedures, as well as to integrate the experiences and narratives of the patients. However, the latter is a difficult aspect to address due to the health condition and the presence of monitoring and support systems.

Among the interventions carried out by occupational therapists in critical care units are strategies that involve rehabilitation and early mobilization, actions focused on patient self-care, cognitive approaches, prescription of devices for the adaptation of activities and systems for positioning in bed and sitting (Bittencourt et al., 2021).

The literature has documented that many of the experiences associated with the care of critically ill patients are negative. These include loss of autonomy in decision-making, disruption of daily life, decreased bodily function, physical, mental and spiritual suffering, as well as pain and discomfort (Kjeldsen et al., 2018). In addition, the presence of breathing difficulty, cognitive and bodily alterations, anxiety, delusional or fragmented memories, feelings of abandonment, loneliness, anguish in the face of death, feelings of invalidity, dependence and loss of privacy is documented (Gaete Ortega et al., 2020).

Although its use is not widespread, occupational therapy is essential in functional rehabilitation and coping with illness in critically ill adult patients. Its wide repertoire of resources demonstrates its importance in this context and it is recognized by other health professionals (Bombarda et al., 2016).

Based on the above, the fundamental purpose of this research has been to understand the meaning that occupational therapists give to narrative reasoning during the evaluation and intervention in critical care units. These concepts are relevant, as they favor to individualize the interventions and the generation of new treatment strategies to address in a more comprehensive way the challenges posed by critical illnesses.

Method

In this research, the methodology used was a qualitative design, which is suitable for analyzing the perception and experience of individuals in relation to the phenomena that surround those (Hernández Sampieri & Mendoza Torres, 2023). This type of methodology allows for a deeper understanding of people's points of view, interpretations, and meanings, which is important in occupational therapy.

In this study, a phenomenological research approach has been used, which, as described by Hernández Sampieri & Mendoza Torres (2023), seeks to understand phenomena from the individual perspective of each participant and from the collectively constructed perspective.

The scope of this study was descriptive, since its purpose was to describe in detail certain phenomena or experiences of a group of people, without necessarily seeking causal explanations or explanatory theories (Hernández Sampieri & Mendoza Torres, 2023). In this way, it was intended to deepen, describe, and interpret the meanings related to narrative reasoning, based on the voices and experiences of the occupational therapists who participated.

The research was carried out in a critical care unit, belonging to a high-complexity hospital that belongs to the healthcare network of the metropolitan health service (Santiago de Chile) and is recognized as a healthcare and teaching establishment, which aims to be at the forefront of medical, therapeutic and surgical processes.

The participant selection strategy used corresponded to a non-probabilistic sampling of a theoretical or intentional type, in which the choice was given by the characteristics that the participants presented and not by the probability they had to be chosen (Bedregal et al., 2017).

From this approach modality, four participants were available, who were considered as key informants, because they had valuable and relevant information on the researched topic, and had specialized knowledge that was important for the research (Sukmawati et al., 2023). These participants were carefully and intentionally selected, taking into account their ability to provide in-depth and detailed information on the topic of interest, as well as elements of feasibility, access and voluntariness in their participation.

Data collection stopped once the field of study was saturated, that is, when no new elements emerged in the interviews or additional observations (Tracy, 2021). This provided the basis for analyzing the data and building a comprehensive theory on the topic.

The research participants were selected according to the following inclusion criteria:

1. Having the title of occupational therapist.

2. Working in an intervention context focused on the care of critically ill patients.

3. Working in Santiago - Chile.

4. Having at least one year of seniority working in this context, which could be full-time or part-time.

5. Using narratives as elements of evaluation and/or intervention.

Each participant responded to an in-depth interview, as this technique favors an extensive and unstructured personal conversation, allowing the interviewee to freely express their opinions on the topic. Its approach highlights a collaborative process between the interviewee, the researcher, and other inherent elements, generating knowledge from personal encounters enriched by aspects such as relationality, context, location, embodiment, and affectivity (Osborne & Grant-Smith, 2021).

These interviews lasted 120 minutes divided into two sessions of 60 minutes each. These were conducted at a place, date, and time that were convenient for the interviewee and previously agreed upon with the research team. Both interviews were recorded by audio recording and subsequently transcribed. Once the data for the study was collected, a content analysis was carried out. This analysis consisted of the identification, coding and categorization of patterns of meaning in the content of the text, with the purpose of analyzing and describing its thematic content, as well as understanding the way in which words and language are used in relation to the research topic or problem (Vaismoradi et al., 2016).

The interpretation of the data used a hermeneutic perspective, focusing on unraveling the underlying units of meaning in the messages and texts. The historical, cultural, linguistic, and social contexts in which this data was produced were taken into account (Rojas et al., 2022).

The research was approved by the human research ethics committee of the Faculty of Medicine of the University of Chile (Project No. 89-2018; Act No. 97) and had the informed consent of all participants, thus respecting the bioethical aspect of autonomy in voluntary participation. In addition, the confidentiality of personal data was safeguarded, thus respecting the bioethical aspect of non-maleficence.

Results

Four occupational therapists working in the Critical Care Unit of a high-complexity hospital that belongs to the healthcare network of the metropolitan health service in Santiago de Chile were recruited as study participants. The characteristics of the participants are presented in Table 1.

Table 1
Description of the participants.

Informant	Age	Gender	Employment	Position	Experience in the CPU	College degree
Occupational therapist N° 1	57 years old	Male	Full-time	Occupational therapist in Intensive Care Unit.	10 years.	Graduate and specific courses.
Occupational therapist N° 2	23 years old	Male	Part-time	Occupational therapist in the Medical Intermediate and Medical Surgical Intermediate Unit.	1 year.	Specific courses.
Occupational therapist N° 3	34 years old	Male	Part-time	Occupational therapist in Intensive Care Unit, Intermediate Treatment Unit, Hospitalized in other services.	5 years.	Master’s degree, Graduate and Specific courses.
Occupational therapist N° 4	33 years old	Female	Part-time	Occupational therapist in the Intermediate Medical and Intermediate Medical-Surgical Unit, Hospitalized in other services.	9 years.	Graduate and Specific courses.

Regarding the categories and subcategories of analysis obtained after the coding process, the following categories were defined: (1) meanings of narrative reasoning in critical care practice, (2) Storytelling in the evaluation and intervention of patients with critical illnesses, and (3) story creation in the evaluation and intervention of patients with critical illnesses, which are developed in greater depth below:

1. Meanings of narrative reasoning in critical care practice.

From the perspective of the participants, narrative reasoning is associated with the way the occupational therapist addresses the problems of the critical patient through the incorporation of the narrative or life story, thereby facilitating the therapeutic process such as rehabilitation. It is expressed in the therapeutic encounter between the occupational therapist and the critical patient, establishing itself in a practical way in the therapeutic process, influencing the evaluation, the definition of the objectives, the selection and the implementation of activities in the treatment. In this regard, the occupational therapist #1 points out:

The narrative can influence clinical decisions and questions the practice by seeing reality from the patient's point of view, and invites a greater personal connection with the case.

As a key element for this to happen, professional reasoning is nourished by contextual elements specific to critical care units. An example of this is what the occupational therapist #2 says about being hospitalized in this type of units and the meaning that this context can have for the person who must be hospitalized due to an illness or traumatic event:

So, to start with, you have to understand that being in a CPU¹is something rough, it is a very invasive context, full of stimuli, full of machines, with little stimulation. But in truth, people understand that the CPU will never be pleasant in life for anyone, not even for the people who are hospitalized, and for someone who sees a person who is suffering, who is in pain, who is bothered by everything, who is far from their family, deep down you have to understand that they are in a context that is out of or disruptive to someone's life and their daily activities, their occupations.

It is common for negative situations to be experienced in critical care units that affect both the occupational therapy professional and the patient. These experiences include loss of autonomy, compromised bodily functions, physical and mental suffering, pain and discomfort, among other aspects. These negative factors are considered by occupational therapy professionals when carrying out treatment actions, such as the evaluation and discovery of the patient's abilities, with the aim of minimizing the impact that the critical care unit environment may have on them. It is important that professionals working in these units, especially occupational therapists, are aware of how environmental, social and cultural conditions influence the patient's experience and do not normalize negative experiences as something immutable that cannot be modified.

On the other hand, it is through the narrative established in the therapeutic relationship between the occupational therapist and the critical patient that the impact that the environment has on the person's experience can be modulated. This narrative seeks to accompany, contain and guide the intervention process, making the therapy process a positive experience for the person. An example of this can be what the occupational therapist #2 refers to:

[…] for me, the therapeutic aspect is the relationship, it is the company of being with someone, doing something, talking about something. I don't know about early rehabilitation, although I consider it very important. Perhaps, the focus has to be on what we are talking about now, perhaps it is not going to be on a person... getting dressed, maybe in the long term they will work on it, […] what I have seen, at least is that a good bond, a good relationship favors the person being well and being able to work with you.

With this example, it is observed that narrative reasoning is essential in the therapeutic approach to critical patients since it allows establishing a relationship of companionship and understanding with the person, which favors their well-being and participation in the treatment. Regarding this, the occupational therapist 4 states:

[…] the intervention will be determined by elements that differentiate each person and that will also be determined by the interests and narrative of the person, but it will also be determined by how well the therapeutic bond is achieved and what adherence to the intervention they have, their willingness to work, many aspects that you can manage.

This type of reasoning, based on an understanding of the patient's life history and experiences, provides a basis for therapeutic intervention at different stages of hospitalization. Through this approach, functional treatment goals can be defined and bridges can be established between concrete actions and future possibilities, allowing occupational therapists to accompany the person in their process of returning to their daily lives.

1. Storytelling in the evaluation and intervention of critically ill patients.

The storytelling process in the evaluation and intervention of critically ill patients involves listening to and collecting personal stories from the patient and their experience in the critical care unit. According to the interviewees, this technique allows for consideration of the patients' experiences of illness and provides key elements for assessment and intervention in occupational therapy. In this regard, the occupational therapist #2 points out:

I believe that the experience that I can understand from people who are in a critical care unit, I do so through the… story that the patients have, and from other patients who have left the critical care unit, telling me what they felt and what they experienced in that unit.

What the occupational therapist #1 adds:

The prognoses are sometimes very bad, so many times the survival of that patient is zero and from there you see the conditions of how he/she will end up.

To set up the meaning of “critical illness”, the occupational therapist uses the experience of the patient or of other patients who have gone through the same situation. In this regard, the occupational therapist #3 during the interview:

A lot of what patients tell you, that before they were independent and did so many things and now they are not able to even drink water or take a glass […] They go from being a completely independent person to a person who is moved, to have their genitals cleaned, to be bathed, to have their teeth cleaned, to have their mouth cleaned, it is something extremely invasive

This allows for the establishment of an identity that reflects what it means to be a critical patient from their point of view and the development of an intervention plan that gives positive meaning to the fight against critical illness, as pointed out by the occupational therapist #3:

The therapy considers aspects that are relevant to the person, but that they consider significant, that they consider important, that they see as transcendental.

However, by having an identity of “helpless”, occupational therapists generate therapeutic actions to reverse this and build an identity that reflects the capacity and sense of survival, valuing the human as a fundamental characteristic of the process. The stories are used as a transformative element that allows the patient to tell their stories, constructing and deconstructing events to recover from the traumatic event of having been in a critical care unit. In this way, the established narrative serves as a channel through which people find meaning in their struggles against critical illness and can create meanings from it.

Faced with this, the occupational therapist #1 states:

[…] the patient is always considered helpless, he often has no option to express his needs, he is a patient who often depends 100% on you, on your ability to meet those needs that are minimal”, with which the occupational therapist #3 projects to the process of fighting critical illness: “I believe that, by considering significant aspects of the person, on many occasions, it is there where the person can feel valued, and feel that the intervention that is being carried out is taking all the edges, all the aspects that are important to him.

The therapeutic bond becomes a space for exchanging stories between the patient and the occupational therapist. In each session, it is possible to get to know the person who is being treated and the possibilities that they have in relation to their medical condition are transmitted. An example of this is given by the occupational therapist #3:

[…] you have to achieve the therapeutic bond, establish it with the user and through very serious conversations or very common conversations and making them funny, it helps a lot, it helps a lot, if one takes things very seriously, or really does not have a very close bond with the person, it is unlikely that the person will be able to tell you or expand on any kind of personal conversation and their personal life”, re-arranging this idea in a concrete way “through specific strategies, such as laughing together, finding what really matters to them, gaining their trust, that they tell me their sorrows, their sadness and their joys, I think that this transfer of trust by the patient is much easier.

The patient's experience story and the construction of an identity that reflects their capacity and sense of survival are fundamental in the evaluation and intervention of occupational therapy to give meaning and positive meaning to face critical illness.

1. Creating stories in the evaluation and intervention of critically ill patients.

According to the interviewees, the process of creating stories in the evaluation and intervention of critically ill patients involves collaboration between the critically ill patient and the occupational therapist to create experiences that link the therapy with the context and future possibilities. Narratives are not used only to interpret, but to promote actions that generate results and correct the patient's situation of dependency. In this regard, the occupational therapist #4 points out:

They extrapolate it to the fact that they will remain like this for the rest of their lives, and therefore, the fact that someone achieves basic and small goals helps the person to recover their motivation, to recover their effort to go ahead and realize that... it may be a transitory situation and if it is not, they can see the possibility of how they can adapt and achieve the greatest independence and autonomy that is possible depending on the diagnosis.

This process takes place during therapy sessions, in which the therapist organizes the patient's stories in relation to his/her past experiences and present situation. The stories are continually constructed and reconstructed in each session, developing a therapeutic plot that links meanings with concrete actions to achieve rehabilitation goals and overcome occupational challenges.

Many times, it happens that the patient needs to be able to test the limits of his/her abilities to reconfigure his/her expectations in his/her recovery; as the occupational therapist #1 points out:

[…] generally, you see it day by day, patients get tired, fatigue is very high, then hopefully they do what you asked them to do, it seems that suddenly doing more is difficult, it is complicated for them to set ambitious goals, there are many who say I want this, and it lasts 3 seconds and then they get back to reality, and they start to listen to you more and say I'm going to start paying more attention to this person who is caring for me.

During the therapeutic process, links are established between the patient's current situation and his/her desired goal, maintaining a realistic perspective on his/her functional capacity and health status. The occupational therapist must adjust and focus the patient's current performance to reduce the gap between what is expected and what can be achieved nowadays.

The therapist coordinates the patient's actions with the functional possibilities that he or she presents, along with his or her desires and commitment in therapy, structuring the narrative to achieve the proposed short-term goals. The use of small experiences of achievement by the patient, after his or her admission and stabilization, allows the construction of a story that enables the achievement of independence in the future.

Regarding the construction of possibilities, these depend on the daily evaluation that the occupational therapist can do. In this regard, the occupational therapist #1 points out:

It depends, we usually talk about it day by day, but if the patient is more active, then you can work, if he wants to get more involved in the process, you can work on it together, if you want to achieve this, we must achieve this first.

In the case of an unfavorable prognosis, the established narrative is one of caution and reserve, waiting for the patient's evolution to take intervention actions and focusing in the first instance on the survival of the critical illness.

In relation to this, the occupational therapist #4 points out:

[…] with caution, maintaining caution, because in the end the prognoses are sometimes very bad, so many times the survival of that patient is zero and from there we see the conditions of how he will be, so we protect that with great care until the patient is stabilized and one feels that he is progressing in the evaluations, then one can have a clearer idea of ​​what is coming.

Secondly, if the patient survives, the disability will be detected early in order to propose a rehabilitation program, since many of these patients will have a long stay and will be configured as chronic critical patients.

Discussion

Although the literature on the subject is abundant in descriptions of professional reasoning and its applied modalities in various contexts of occupational therapy intervention, this study is distinguished by exploring the influence of narrative reasoning in the evaluation and intervention of occupational therapy in critical care units.

From its results, it is established that there is an influence of narrative reasoning in occupational therapy practices towards critical patients, which are manifested as application strategies that are reflected during the evaluation, by highlighting the significant elements of daily life before entering the critical care unit together with the construction of the experience of illness and experiences within the critical care units, a process known as storytelling, as well as the stories that are generated collaboratively between the occupational therapist and the critical patient to create experiences that link the action of therapy in the critical care unit and its future possibilities, known as story creation.

Márquez-Álvarez et al. (2019) highlight the growing importance of professional reasoning in occupational therapy, in specialized fields and specific modalities. The present research is consistent with this perspective, by addressing the need to delve into the processing of reasoning modalities in a field of specialization such as intensive medicine, detailing the process and development of strategies focused on narrative reasoning. This approach leads to the construction of an explanatory model that demonstrates the close relationship between theoretical knowledge and the concrete actions undertaken by occupational therapists. These actions, in turn, offer solutions to the occupational problems presented by critically ill patients and allow for practical implementation in specialized environments.

This idea is shared by a study by Shafaroodi et al. (2017), which points out that a clear understanding of how the professional reasoning process is established makes interventions more efficient, as it supports problem-solving processes by making underlying theories, assumptions and values ​​more explicit. Along with this study, Schell & Schell (2017) argue that it is important for occupational therapists to receive the most appropriate theoretical training possible in professional reasoning, so that this subsequently facilitates the development of their clinical practice.

Another point to highlight is the strong relationship observed in this research on narrative reasoning and the therapeutic relationship established between the occupational therapist and the critical patient, so considering this variable as part of narrative reasoning may be beneficial for future conceptualizations of narrative reasoning in critical care units. In this regard, Taylor (2020) proposes an occupational therapy care model focused on intentional relationships, which encompasses these processes from the interpersonal aspects established by the occupational therapist, to promote occupational commitment, considering the relationship between the occupational therapist and the client. This model could contribute from its conceptual framework to the process of developing narrative reasoning, which could provide a new line of research that establishes a relationship between narrative and therapeutic relationship.

Due to the uncertainty in the evolution of critical illness, the patient's narrative focuses primarily on the past and present, with caution regarding future options. This idea is proposed by Haydon & van der Riet (2016), who consider narrative as a fundamental means of understanding human experiences, intrinsically linked to temporality, sociality and spatiality. In this critical environment, where access to the future may be limited and attention is focused on the immediate present, the importance of the interaction between past and future takes on unique relevance. Past narratives, shaped by experiences in the health system, impact patients' current perception, while anticipation of the future becomes complex due to the urgency of the present. This idea reveals how occupational therapists might adapt to the temporal and social complexities inherent to the therapeutic experience in critical environments.

Gutiérrez Monclus (2011), for his part, points out that narrating involves a discursive act with particular properties that puts the speaker in a special relationship with the content and/or referent of his statement. This necessarily establishes a temporal and interdependent relationship between the event and the speaker. That is, the narrative establishes a relationship between the occupational therapist and the critical patient, who, by managing the stories or tales about his life story, his illness experience or future wishes, understood as occupational fiction, generates a construction of interdependence through the plot of actions that leads to possible results during his stay inside the critical care unit, which are consistent with the results obtained in this research.

Portal (2021) affirms that narration is a fundamentally human way of giving meaning to experience, by either expressing or interpreting it. Narratives act as mediators between the internal world of thoughts and feelings and the external world of observable actions and situations. The creation and listening of narratives are active and constructive processes that depend on personal and cultural resources. What can be expanded from Sutton's (2016) proposal on narratives of suffering is that, to fully understand them, it is essential that they incorporate elements such as corporality, identity, memory, one's own life trajectory, the relationship between past-present-future, social belonging and intersubjective interactions.

That is, stories are powerful means of learning and facilitate understanding of the other, allowing contexts for understanding what has not been personally experienced. For listeners, knowing a story triggers the search for possible meanings and results in a co-constructed narrative between the world of the story and the world in which it is narrated. These ideas are consistent with intervention strategies influenced by narrative reasoning, which focus on the therapeutic relationship of the critical patient, considering specific contextual elements of critical care units, as well as on the relationship between the occupational therapist and the patient in the roles of narrator and listener.

From a historical perspective, Mattingly (1991) highlighted the narrative nature of professional reasoning by emphasizing the importance of discourse in practice. He stressed that this element is underestimated and made invisible by occupational therapists. It is interesting that when carrying out a systematic review in occupational therapy and intervention in critical care units (Costigan et al., 2019; Weinreich et al., 2017), studies with high value in scientific evidence focus on technical-scientific components and do not consider narrative components in their variables, which could contribute enormously to disciplinary development and be configured as a new proposal for knowledge in this area.

As an additional fundamental element to consider, it is necessary for the profession to incorporate new bodies of knowledge and the consequent theoretical progress. Therefore, considering the narrative perspective in occupational therapy actions in critical care units can be a step towards generating knowledge in an emerging area of ​​the discipline, which has traditionally been built from a scientific perspective of professional reasoning, forgetting in its development the influence of the narrative on its action.

In addition to this, if the traditional scope of professional practice of occupational therapy in critical care units is to be tensioned, the new ideas must be valid and argued, since they do not necessarily mean that each new idea that arises is valid just because it exists or because it simply questions the previous one (Greber, 2018), which is why this research can contribute to this field and can generate a substrate for future research that supports this new aspect of occupational therapy care for critical patients.

At this point, it is necessary to mention that the knowledge of isolated information and data has proven insufficient to deal with the complexity of the human condition, which is why the occupational therapist's action must move from illness and dysfunction to the analysis of reasons, values ​​and beliefs, that is, the world of meaning and sense (Galheigo, 2020). From this point, the narrative allows understanding and interpreting individual stories and thus jointly building with users, possible results that represent this reality.

In this research, the level of experience of the participants was not analyzed, so, in future research, considering this element could provide another perspective on the topic. According to Unsworth & Baker (2016), learning professional reasoning depends on the level of experience of occupational therapists, since research has shown that there are differences in the performance of novice and expert clinicians due to their professional reasoning skills. Knowing how experts and novices structure their professional reasoning allows explaining the complexities of practice and helping novices think like experts.

Such an approach would lead to the identification of new channels for occupational therapists to promote recovery in their critical patients through storytelling and story creation, which makes it interesting to generate new research initiatives on the subject, as well as positioning professional reasoning studies as studies specific to the work within a critical care unit.

Conclusion

This research analyzed the meaning of using narrative reasoning in the evaluation and intervention of patients with highly complex diseases in critical care units. It was found that the application of “narrative reasoning” in these care units is a fundamental clinical process in the evaluation and intervention of patients who are in this situation.

The results show that narrative reasoning in this experience is divided into two branches: storytelling and story creation. Both branches overlap and mix to support the professional reasoning of the occupational therapist in this area. Thus, storytelling allows the development of the patient's life story, minimizes the power disparities between the therapist and the patient, improving communication and reducing cultural barriers. For its part, the creation of stories focuses on the possibilities of co-constructing the patient's future, depending on the estimation of skills, performance expectations, health condition and care requirements, as well as the execution of activities within critical care units.

In this study, the analyses reveal that the intervention processes in highly complex patients in which this type of reasoning is applied allow for the delivery of care focused on the needs of the person and consistent with their life story. This is because the narrative in professional reasoning mediates clinical decisions, questioning expert work, considering reality from the point of view of the critical patient. It also allows for the recovery of the patient's occupational history by integrating it into the intervention context, enhancing the manifestation of everyday life in a biomedical environment.

Narrative reasoning contributes to the professional development of occupational therapists, placing the intervention and evaluation with critical patients on a biopsychosocial and occupational level, which allows for the recovery of the patient's life stories, generating intervention strategies between participants, establishing horizontal and democratic communication processes between the patient and the therapist.

The implementation of narrative reasoning in critical care units promotes openness to the internal world of experience, expanding the historical boundaries of occupational therapy in physical health towards the body, as it considers multiform elements in people's ways of thinking, feeling and acting.

• 1
  CPU: Critical Patient Unit.
• How to cite: Hernández Lanas, O., Sepúlveda Carrasco, C., & Gutiérrez Monclus, P. (2024). Meanings that occupational therapists attribute to narrative reasoning in the evaluation and intervention processes within critical care units. Cadernos Brasileiros de Terapia Ocupacional, 32, e3573. https://doi.org/10.1590/2526-8910.ctoAO274535732

• Funding Source

  This research was developed within the context of the Master's program in Occupation and Occupational Therapy at the University of Chile.

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Edited by

Section editor

Profa. Dra. Jaqueline Cruz Perdomo

Publication Dates

• Publication in this collection
  09 Sept 2024
• Date of issue
  2024

History

• Received
  16 May 2023
• Reviewed
  26 May 2023
• Reviewed
  04 Dec 2023
• Accepted
  20 May 2024