PROFESSIONAL TRENDS IN ASIA

Pranayama: Potential Tools to EnhanceOccupational Performance
Venthan J MAILOO1, BSc (Hons) MCSP CertMgmt
13rd year occupational therapy student, Osterley Campus, Brunel University,

Borough Road, Isleworth, Middlesex TW7 5DU, England UK

Abstract: It has recently been suggested that yogic philosophy provides a model for
occupational therapy and that meditation and pranayama (yogic breathing exercises) can
facilitate occupational performance. This literature review was undertaken to determine
whether there is any evidence to support the use of pranayama to facilitate occupational
performance. A literature search using AMED, BNI, CINAHL, HMIC, Medline and Old
Medline for the term ‘pranayama’, limited to English language human research uncovered
seven articles clinically applicable to occupational performance. The evidence suggests
pranayama can influence, arousal, metabolism and exercise tolerance. Slow alternate
nostril breathing should be considered when anxiety impairs occupational performance,and right nostril breathing should be considered for obesity, lethargy, and symptoms ofhypothyroidism or similar metabolic disorders that inhibit function. Further research is
required for evidence-based application of other pranayama techniques.
Key words: exercise, breathing, yoga, pranayama, evidence-based practice(Asian J Occup Ther 5: 1–10, 2006)

1. Introduction
Pranayama are breathing exercises
traditionally used in yoga; an Asian system oflifestyle regulation (Mailoo, 2005). Yoga firstdeveloped in India thousands of years ago and has
branched into four different paths. These aretermed Karma, Jnana, Bhakti and Raja (Sivananda
Yoga Vedenta Centre, 1999). The traditional
purpose of all of these paths was spiritualReceived: February 8, 2006 Accepted: April 4, 2006
Corresponding to: Venthan J Mailoo, 3rd year occupational
therapy student, Osterley Campus, Brunel University,
Borough Road, Isleworth, Middlesex TW7 5DU, EnglandUKphone: 44-781-125-1624 fax: 44-20-8959-3376
e-mail: servantofvishnu@gmail.com

advancement. Karma yoga is a process of selflessaction to avoid incurring sin. Jnana yoga is aphilosophical path to spiritual evolution based
upon discrimination and dispassion. Bhakti yoga
consists of devotional service to God, and cantherefore be considered a religious form of yoga.
Raja yoga is considered the scientific path because
it based on psychology and physiology (Sivananda
Yoga Vedenta Centre, 1999).
Bhakti is considered by some to be the branchof yoga most suited to spiritual advancement inmodern times (Swami Prabhupada, 1982). Raja
yoga however is the best known branch in theWest, and is practiced worldwide for its healthbenefits. Raja yoga has eight steps. These areabstention (from harming others), observance (ofself-discipline), steady body postures, pranayama

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PRANAYAMA: POTENTIAL TOOLS TO ENHANCE OCCUPATIONAL PERFORMANCE

Table 1. Pranayama Methods (Sivananda Yoga Vedenta Centre, 1999, Khlasa, 2005)
Description

Name

Full yogic
breathing

MethodPossible clinical applications

1. On inhalation, expand the abdomen
first, then the ribcage, then the upper
portion of the lungs. → 2. Breathe out fully
allowing the abdomen to cave in.

Currently used by physiotherapists
to prevent atelectasis.

Close the left nostril and breathe throughthe right.

Sympathetic nervous system andmetabolic stimulation. Treatmentof lethargy and obesity.

Right nostril
breathing

Surya anuloma
vilomaLeft nostril
breathing

Chandra anuloma Close the right nostril and breathe throughvilomathe left.

Anxiety management

Alternate nostril Nadi Shodhana
breathing

1. Inhale through the right nostril, →2. Hold breath, → 3. Exhale through theleft, → 4. Hold breath, → 5. Inhale throughhe left, → 6. Hold breath, → 7. Exhale throughthe right → Repeat the cycle

Loud breathing

1. Inhale fully through both nostrils with
Autonomic nervous systema partially closed glottis.→ 2. Hold the breath
modulation. Metabolic modulation
with upper cervical spine flexion and lower
cervical spine extension (chin lock) and the pelvic
floor muscles contracted (root lock). → 3. Exhale
through the left nostril with a partially closed glottis.
→ 4. Hold the breath, contracting transverses abdominus.

ujjayi(breath control), withdrawal from senseg r a t i f i c a t i o n , c o n c e n t r a t i o n o f t h e m i n d,meditation and universal consciousness(Sivananda Yoga Vedenta Centre, 1999). Yoga
has been recommended in Western occupational
therapy literature to promote wellbeing (Kelly &McFarlane, 1991; Bracegirdle, 1997; Stein &Cutler, 1998; Taylor, 2001; Kluge, 2004).
Raja yoga has been used by occupational
therapists with psychiatric patients as a relaxation
technique, to increase attention span, selfconfidence, coping skills, body awareness, andself-concept while providing a sense ofachievement (Anderson & Winterbone, 1979;
Taylor, 2001). Eakin (1979) reported decreased
reliance on medication amongst psychiatricpatients practicing yoga. Occupational therapists
have also used yoga for stress management, tobuild strength, endurance and flexibility (Giles,
1985; Kluge, 2004) and to increase service-users’
awareness of their own occupational risk factors(Kluge, 2004). Occupational therapists have

Anxiety management

specifically used pranayama to facilitate physicaland mental relaxation (Anderson & Winterbone,1979), enhance energy flow and reduce pain
during performance of activities of daily living(Kluge, 2004).
While there is a growing evidence base foryoga, application of research findings is difficult,because there are several different schools of yoga
and a multitude of different techniques. Testing ofeach individual yogic technique is arguably
needed for evidence based practice. This literature
review was undertaken to determine whether there
is any evidence to support the use of pranayama tofacilitate occupational performance. There areseveral pranayama techniques. Those discussed inthis literature review are summarised in Table 1.
The brief descriptions in the first column are notstandard, but intended to ease reading for those
unfamiliar with yoga terminology.
For single nostril breathing techniques, theright thumb is used to close the right nostril or theright 4th and 5th digits are used to close the left

Asian J Occup Ther 5: 1–10, 2006

Mailoo VJ

3

3. Literature Analysis
3.1. Pranayama for arousal modulation
Arousal modulation is used by occupational
therapists to facilitate occupational performance,
control pain (Beresford, 1996; Hammond, 1996)
and reduce health risks (King, 1996) in bothmental (Duncombe, 1998) and physical settings(Cicinelli, 1996). Modalities advocated in
occupational therapy literature include
biofeedback (Stein & Cutler, 1998), visualisation(Levitt, 2005) progressive muscle relaxation(Finlay, 1997; Levitt, 2005), tai chi (Stein &Cutler, 1998), meditation (Bracegirdle, 1997;
Abreu 1998; Stein & Cutler, 1998), yoga
(Anderson & Winterbone, 1979) and breathing
exercises (Levitt, 2005). As autonomic function,
arousal and metabolism are inter-dependent, they
are considered together in this review.

3.1.1. Pranayama to decrease arousal
Alternate nostril breathing
Fig. 1. The lotus position
The lotus position is a classic yoga sitting pose, used for
mediation and pranayama because it is believed to enhance
concentration (Sivananda Yoga Vedenta Centre, 1999). This
was the position adopted by subjects in the study by Bhargava
et al. (1988).

nostril. Attention is paid to the sensations ofairflow in the nostrils and breath holding between
inhalation and exhalation is common, though theduration of breath holding varies.

2. Method
A literature search using AMED, BNI,
CINAHL, HMIC, Medline and Old Medline forthe term ‘pranayama’, limited to English language
human research articles produced 59 hits. Articles
that did not specifically test pranayama, failed to
specify the types of pranayama tested, or that
could not be directly related to occupational
performance were discounted. Seven articles
remained. These were themed according totherapeutic effect, and analysed for validity.

Bhargava et al. (1988) studied the effects of 4
weeks training in alternate nostril breathing andnormal amplitude hyperventilation, on
cardiovascular, respiratory and autonomic
parameters during maximal breath holding on 10
healthy males aged 19–28. Alternate nostril
breathing was practiced in the lotus position (Fig.
1) for 30 minutes per day, with 1–2 second holds
after each inspiration. Once competent in alternate
nostril breathing, hyperventilation was added to
the regime. The subjects were not permitted toundertake any other form of exercise during thetrial. Breath holding time, heart rate,electrocardiogram (ECG) and galvanic skinresistance were measured with a 4-channel
polyrite (Medicare, India). Blood pressure wasrecorded by the auscultatory method. Subjects
were tested holding their breaths maximally after
normal inspiration, normal expiration, deep
inspiration, full expiration, and deep inspiration
after 5 maximal breaths in 15 seconds. All of thetests were conducted in controlled conditions
before the subjects commenced training, and thenrepeated in the same conditions after 4 weeks ofpranayama training. Before and after differences

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PRANAYAMA: POTENTIAL TOOLS TO ENHANCE OCCUPATIONAL PERFORMANCE

were analysed with the paired t-test.
Baseline blood pressure decreased by anaverage of 8.8 mmHg (7%) systolic (p<0.001) and
4.8 mmHg (7%) diastolic (p<0.05). Heart rate
(p<0.01) and blood pressure (p<0.08) at the end
point of maximal breath holding, decreased for allof the breath holding tests. All breath holding
times significantly increased (p<0.05) but there
was no change in ECG except for heart rate, and no
identifiable pattern of changes in galvanic skinresistance.
Bhargava et al. (1988) believed theobservable changes were due to increased vagal
tone, decreased sympathetic activity and possibly
increased tolerance to raised pCO2 and low pO2.
As there was no control group, the validity of thisresearch is not assured. The results may reflect a
Hawthorne effect (Polgar & Thomas, 2000),
unregulated influences or physiological
adaptations to sitting in the lotus position. As
Bhargava et al. (1988) combined two breathing
techniques in their trial, changes cannot bescientifically attributed to either technique
individually, so this research cannot support
evidence based practice. Finally, the abstract ofBhargava et al. (1988) states 20 subjects wereused, while the methodology states only 10 wereused. This discrepancy casts doubt over thejournal review process and quality of the article.
Despite its methodological flaws, the work of
Bhargava et al. (1988) suggests decreased
sympathetic activity at baseline and in response to
the stress of breath holding results from somecomponent of alternate nostril breathing combinedwith hyperventilation. Research on alternate
nostril breathing used alone is required to validate
its use.
Pal et al. (2004) studied the effect of threemonths of regular alternate nostril breathing on 30
healthy male non-smoking first year
undergraduate medical students (aged 17–20).
The sample was randomly divided into an
experimental group (n=15) and control group(n=15). Experimental subjects underwent 15 daysof training in alternate nostril breathing followedby 1/2 hour practice sessions every morning andevening under expert guidance for 3 months.
Breathing was timed so that subjects would inhalefor 6 seconds, hold their breaths for 6 seconds,
exhale for 6 seconds and then hold for 6 seconds at
end exhalation before inhaling again. The control
group was given no instruction and was not
permitted to practise pranayama. All of thesubjects were on a controlled diet and were notpermitted to partake in yoga or any other physicalexercise for the duration of the trial.
Heart rate responses to standing, deep
breathing and the valsalva manoeuvre were
measured at the start and end of the experimental
period to assess the effects of alternate nostril
breathing on autonomic function. Heart rate wasmonitored with a lead II ECG Nihon Kohden
multi-channel polygraph (UK). Subjects wereasked to lie supine for 5 minutes and then stand.
Means of recordings from 3 repetitions ofexperiment were taken for statistical analysis.
Subjects were then asked to take a full deep
inspiration followed by full expiration sitting in achair. The biggest heart rate change reading of 3
repetitions was used for statistical analysis.
Change of heart rate during forced expiration
against 40 mmHg of resistance (through amouthpiece) was then recorded. Longest heartbeat
interval after the manoeuvre was divided by theshortest heartbeat interval during the manoeuvre.
Highest ratio after 3 attempts was used forstatistical analysis. Data was analysed with thestudents’ t-test and analysis of variance(ANOVA).
In the experimental group after 3 months,
when compared to their pre-exercise values andthe control group, basal heart rate wassignificantly reduced (p<0.05)(12%). Maximum
heart rate in response to standing was significantly
reduced (p<0.05)(7% compared to pre-exercise,
4% compared to controls) and was achieved after
fewer beats (p<0.001)(20% compared to preexercise, 22% compared to controls), minimum
heart rate was achieved sooner (p<0.001)(24%compared to pre-exercise, 23% compared tocontrols), and time taken for heart rate to stabilise
was less (P<0.001)(9% compared to pre-exercise,
13% compared to controls). There were no
significant valsalva ratio changes in either group.
Pal et al. (2004) concluded that slow
breathing improves vagal activity and regularAsian J Occup Ther 5: 1–10, 2006

practice of slow breathing exercise for 3 months
improves autonomic functions. Although Pal et al.
(2004) randomly assigned subjects to theirexperimental and control groups, the two groups
were well matched for the parameters used in theirexperiment. Unfortunately scientific conclusions
cannot be drawn about alternate nostril breathingfrom this research because the effects noted may
have been due to the speed of breathing. A slow
breathing control group would have been more
appropriate to test this type of pranayama. As
significant effects were only measured after 3
months, this research does not support the use ofslow alternate nostril breathing for the immediate
treatment of acute anxiety. It does however
support the use of this technique to treat trait
anxiety or for prophylactic anxiety management incases where anxiety impairs occupational
performance.

Left nostril breathing
Telles et al. (1994) used a sample of students
from the Vivekananda Kendra Yoga Research
Foundation (Bangalore India) to compare theautonomic and metabolic effects of right nostril
breathing (n=12) with left nostril breathing (n=12)
and two alternate nostril breathing control groups(n=12 each). All groups were randomly selectedfrom the sample and completed 27 cycles of their
exercise 4 times per day for one month. Volargalvanic skin resistance of the ring and index
fingers, heart rate and respiratory rate were
measured with a 4-channel polygraph (Lafayette,USA). Oxygen consumption was measured using
the closed circuit Benedict-Roth apparatus (INCO,
India). All measures were taken at 4:00 am, once
before training commenced and once after one
month of pranayama training. Data was analysedwith Wilcoxan’s paired signed ranks test.
The left nostril breathing group showed asignificant (p<0.05) increase (145%) in volar
galvanic skin resistance while no comparable
change was seen in the control group. Thissuggests reduced sympathetic stimulation of thepalm sweat glands (Telles et al., 1994). None ofthe other parameters significantly changed in theleft nostril breathing group, but resting heart rateincreased significantly in the control and right

Mailoo VJ

5

nostril breathing groups. Telles et al. (1994)
concluded that left nostril breathing modulates
some sympathetic outflows but not others.
Telles et al. (1994) could have increased thepower of their statistical testing by allocating 16
subjects to each of two experimental groups andone control, instead of 12 to each group with 2
separate controls. They looked for statisticallysignificant differences within each group, but did
not analyse the significance of differences
between the groups. The groups were subjected toa controlled lifestyle and diet for the duration of
the trial, but were randomly selected and notdeliberately matched by physiological variables.
Alternate nostril breathing is not a suitable control,
because it involves repeated periods of left nostril
breathing. Normal breathing may have been moresuitable. All of the subjects underwent generalyoga training during the trial. This may havecomplicated the physiological changes identified
in the groups. Due to these factors, while thisresearch suggests left nostril breathing may reduce
arousal, the evidence presented is weak andinconclusive. Even if the difference in galvanic
skin resistance was due to the effect of left nostril
breathing on sympathetic outflow, that difference
may not be clinically significant for occupational
therapy.

Loud yogic breathing with long breath
holding
Telles & Desiraju (1991) studied breath
holding during loud breathing (ujjayi) without
chin lock, in 5 healthy males. Subjects wereselected because they normally practised thisbreathing technique. The time ratio of
inspiration:holding:expiration was 1:4:2. Tidal
volume, and respiratory rate were measured with aspirometer. Oxygen consumption was measured
with Benedict-Roth apparatus. Telles & Desiraju(1991) utilised a same-subject controlled repeatedmeasurements design. Readings of 4 minutes
duration were taken before, during and after eachpranayama practice. The duration of eachpranayama practice may have been 4 minutes, but
this was not clearly described by the authors. Test
sessions were repeated 10–15 times each. The
averages of the measurements for each subject

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PRANAYAMA: POTENTIAL TOOLS TO ENHANCE OCCUPATIONAL PERFORMANCE

from all of the test sessions were used for data
analysis.
DuBois formula was applied to estimate
metabolic rate and data was analysed with thematched t-test and 2-way ANOVA. There was amean 19% decrease in oxygen consumption
during loud yogic breathing (t-test p<0.05
ANOVA p<0.03; F 5.8, df 2,8) but parameters
returned to baseline in the post pranayama test
period. Telles & Desiraju (1991) concluded thatloud yogic breathing with long breath holding
reduces metabolic rate by 20%. This conclusion
was based on the fact that parameters returned tonormal immediately after pranayama, indicatingthat no oxygen debt occurred despite decreased
oxygen consumption.
Telles & Desiraju (1991) used parametrictests that are arguably too sensitive for theirsample size of 5. There is little evidence to support
use of the DuBois formula to estimate metabolic
rate (Gibson & Numa, 2003) so the extrapolations
made may not be accurate. The reason forvariation between subjects of the numbers of
repeat test sessions is not clear, and this could havebeen influenced by experimenter bias. Telles &Desiraju (1991) considered the before-pranayama
measurements of each test session to be a control.
This did not eliminate the possibility of ordereffects. Neither does it validate the use of yogic
loud breathing instead of breath holding alone.
Finally, because anxious and hyperactive people
are the main target groups for arousal reducing
techniques, loud yogic breathing with long breath
holding requires expert instruction, and the effects
of pranayama in this study did not last beyond theduration of its practice, Telles & Desiraju (1991)
proved no applicability of this technique tooccupational therapy.

3.1.2. Pranayama to increase arousal
Loud yogic breathing with short breath
holding
Telles & Desiraju (1991) studied short breath
holding during loud breathing (ujjayi) without
chin lock, in 5 healthy males who usually used thistype of pranayama. Telles & Desiraju (1991) used
the same methodology as described for their

testing of loud yogic breathing with long breath
holding (described above), with two exceptions.
The time ratio of inspiration:holding:expiration
was 1:1or less:1, and test sessions were repeated
only 7–14 times each. Oxygen consumption
increased significantly (t-test p<0.025, ANOVA
p<0.01; F 8.7 df 2,8) by an average of 52% during
pranayama but returned to baseline in the post
pranayama test period. Telles & Desiraju (1991)
concluded that short breath holding loud yogic
breathing increases metabolic rate by over 70%.
The methodological weaknesses of Telles &Desiraju (1991) are summarised above. It is
possible that the breath-holding component of thisbreathing exercise does not contribute towards its
positive effect on metabolic rate. If Telles &Desiraju’s (1991) findings are accurate loud yogic
breathing could possibly be used to treat obesity or
hypothyroidism. Confirmation is required byindependent research with a larger sample. As theeffect of loud yogic breathing on metabolism did
not last beyond the duration of the exercise
practice, it is unlikely this technique could
enhance short-term occupational performance.
Current English language research evidence does
not therefore justify its use as an occupational
therapy tool.

Right nostril breathing
Telles et al. (1994) (methodology describedon page 12) found that resting oxygen
consumption increased by 37% (p<0.05) after amonth of four-times-daily practise of right nostril
breathing, but did not change significantly withleft or alternate nostril breathing. Heart rateincreased significantly (p<0.001) with right (10%)
and alternate (7%) nostril breathing, but not withleft nostril breathing. Telles et al. (1994)
concluded that right nostril breathing increases
metabolism. As heart rate is a function of arousal,
it is possible that right nostril breathing affectedwaking arousal levels as well as metabolism.
Telles et al. (1994) failed to specify the durationsof their oxygen consumption measurements, so it
is difficult to gauge the reliability of their findings.
It is possible that yoga training which all of thesubjects were exposed to was responsible for theincrease in metabolism and this adaptation wasAsian J Occup Ther 5: 1–10, 2006

inhibited in some way by left nostril breathing.
Telles et al. (1996) tested right nostril
breathing on 8 female and 4 male volunteer yoga
students (n=12) free of major illnesses with arandomised crossed-over same subject controlled
tri al. Normal breathing was the co ntrol.
Experimental and control assessments were taken
on two separate consecutive days. Oxygen
consumption over 5 minutes was measured using
the closed circuit Benedict-Roth apparatus (INCO,
India). Heart rate, volar galvanic skin resistance ofthe ring and index finger tips, and respiratory rate
were measured over 10 minutes using a 10channel polygraph (Medicare India). Bloodpressure was measured with a stethoscope andmercury sphygmomanometer. Digit pulse volume
was measured with a photoplethysmograph on thevolar surface of the distal phalanx of the left
thumb. Baseline measures were taken as soon as
the subjects woke. The experiment or control wasthen practised for 45 minutes and then themeasures were repeated. Data was analysed withthe 2-factor ANOVA, multiple comparison Tukey
test and t-test for paired data. A 17% averageincrease in oxygen consumption (p<0.05), 9.4mmHg average increase in systolic blood pressure(p<0.05) and 45.7% decrease in digit pulse volume(p<0.05) were apparent in the experimental trials,
but there were no significant changes in thecontrol. These haemodynamic changes are
consistent with increased arousal. Telles et al.
(1996) therefore concluded that right nostril
breathing stimulates increased metabolism, andmay increase cardiac sympathetic tone or reduce
vagal tone. The equipment used by Telles et al.
(1996) is respected as standard for the parameters
measured. If the subjects were normally
distributed for the parameters tested, this research
trial was well constructed and supports the use ofright nostril breathing to arouse and increase themetabolic rate of healthy individuals. Trials ofright nostril breathing on patient groups with poor
arousal or metabolic deficiencies are required to
fully validate its clinical use.

3.2. Pranayama for Exercise tolerance
Exercise tolerance and fatigue can be major
limiting factors of occupational performance.

Mailoo VJ

7

Traditionally, occupational therapists manage
fatigue with practical adaptations and energy
conservation (Mailoo & Williams, 2004). Kluge(2004) however recommended yoga to increaseenergy levels and endurance.

Full yogic breathing combined with alternate
nostril breathing
Raju et al. (1986) tested the effect of 20 daysof pranayama training on exercise tolerance in 12
h eal th y vo l un te ers (6 ma le, 6 fe ma le ) ofcomparable age undergoing a yoga training
certificate course. All of the subjects were fromsedentary backgrounds.
Submaximal exercise testing was conductedusing Balke’s protocol, which was widely
considered the most appropriate method (Roca etal. 1997). Each subject was tested on a motorised
treadmill (Venky, India) on an empty stomach inan air-conditioned room. Heart rate and ECG were
measured with a cardiac monitor (Olli-Finland).
Blood pressure was measured with asphygmomanometer. Minute ventilation andfractional oxygen in expired air were measured by
the Morgan Transfer Test (P.K. Morgan Ltd,England). Fractional expired CO2 was measured
with Haldane’s apparatus. pO 2 and SaO2 fromcapillary blood were measured with an AVLMicro Blood Gas Analyser (Switzerland). The
above parameters were initially recorded at rest
and then during every 4th minute of sub-maximal
exercise. Urine samples were taken before andafter exercise to measure urinary lactate, and bloodtaken from the antecubital vein before andimmediately after exercise was used to measure
blood lactate and pyruvate. Lactate was estimatedwith the Barker & Summerson method (Barker,
1983). Pyruvate was estimated using theFriedemann Haugen method, which was widely
recognised as simple and accurate (Wolcott,1985). Rate of oxygen consumption (VO2) was
estimated from the minute ventilation, fraction of
expired CO2 and fraction of O2.
Following initial exercise testing, subjects
practised full yogic breathing, full yogic breathingwith breath holding, alternate nostril breathing andalternate nostril breathing with breath holding
sequentially for 10 minutes each, followed by 20

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PRANAYAMA: POTENTIAL TOOLS TO ENHANCE OCCUPATIONAL PERFORMANCE

minutes of supine relaxed lying, daily for 20 days.
After 20 days exercise testing was repeated. Data
was analysed with the student’s paired t-test. In
the male subjects immediate post-exercise pO2
was significantly (p<0.05) increased (9%) after
pranayama training compared to pre-training, andthere were significant (p<0.05) reductions (41%)
in minute ventilation and VO2. Urinary lactatesignificantly increased with initial exercise testing
but not with exercise testing post training. In
females, immediate post-exercise pO 2 wassignificantly (p<0.05) increased (29%) after
pranayama training compared to pre-training.
The Barker & Summerson method was oncethe most respected way of estimating lactate
concentrations, but it is easily contaminated due toits high sensitivity (Barker, 1983). It has therefore
been superseded by spectrophotometric analysis
with lactic dehydrogenase (Barker, 1983). The
Raju et al. (1986) methodology would have been
more reliable if they used up-to-date technology.
It is also unclear why they considered data formales and females separately. This may simply bebecause some differences were not statisticallysignificant when the sample was considered as awhole. The individual sex sample sizes of 6 may
be too small to ensure external validity. As there
was no control group, the changes seen may havebeen due to unrecorded influences. The periods ofrelaxed supine lying may also have facilitatedadaptation, but this is unlikely to have beensignificant, considering that many people adopt
supine lying during sleep. The only relevant
conclusion that can be drawn from this research isthat that training in a combination of full yogic andalternate nostril breathing with breath holding may
increase post exercise pO 2 , thus facilitating
recovery from exercise. Repetition of thisresearch design with a control group, separate
experimental groups for each technique, modern
technology and a larger sample size might provide
more solid evidence for the use of either alternate
nostril breathing, full yogic breathing, or both toincrease exercise tolerance.

3.3. Pranayama for strength
Raghuraj et al. (1997) tested the effects ofleft, right and alternate nostril breathing on grip

strength in right-handed children aged 11 to 18. A
sample of 130 was randomly divided into fivegroups. These were right nostril breathing (n=30),
left nostril breathing (n=30), alternate nostril
breathing (n=30), breath awareness (n=30) andhand positioning (as normally used to close
nostrils n=10). All breathing exercises werepracticed for 27 repetitions 4 times a day. Left andright hand grip strength (best of three attempts)
measured with a grip dynamometer (Anand
Agencies, India) at the beginning and end of a 10
day yoga camp.
Right grip strength increased significantlywith alternate nostril breathing (t=3.19 p<0.005),
right nostril breathing (t=2.69 p<0.05) and left
nostril breathing (t=2.95 p<0.01). Left grip
strength also increased significantly withalternate nostril breathing (t=2.13 p<0.05), rightnostril breathing (t=3.45 p<0.002) and left nostril
breathing (t=2.31 p<0.05). The breath awarenessand hand posture groups showed no significant
increases.
Raghuraj et al. (1997) concluded right, left
and alternate nostril breathing can increase hand
grip strength, but proposed no physiologicalmechanisms behind their findings. The long term
effects of single or alternate nostril breathing on
grip strength were not determined by this study.
The groups were not matched, and as the results
are not explainable in physiological or medical
terms independent research is required to confirm
or reject the validity of the results.

4. Cautions
Complete review of all pranayama related
literature is beyond the scope of this paper.
Pranayama practice based on the information
provided in this paper alone is not advised and may
not be safe. Hyperventilation can cause fainting
and contributes to bowel disorders (Limb, 2005).
No adverse effects from any of the otherte c h n iq u e s m e n t i on e d in th i s p a pe r w e r ehighlighted in the literature reviewed. Anotherpranayama technique has however been
anecdotally associated with pneumothorax(Johnson et al., 2004). Techniques have been
described in this document to aid estimation ofAsian J Occup Ther 5: 1–10, 2006

their physiological effects only. Therapists andmembers of the public wishing to learn pranayama
should seek authoritative instruction.

5. Summary
Much of the published research on
pranayama, does not support evidence based
practice due to poor specificity. Evidence fromone research publication weakly suggests that loudyogic breathing without breath holding may
increase metabolism during periods of practice.
No evidence to the contrary was uncovered. Thereis also weak evidence from one research paper thatalternate nostril breathing practiced 4 times daily
in conjunction with full yogic breathing may
increase exercise tolerance. Reasonable evidence
from one publication suggests that three months
practice of slow alternate nostril breathing
increases vagal tone and improves aspects ofautonomic nervous system function. It is not clear
which properties of slow alternate nostril
breathing are responsible for these effects, but thistechnique may be a useful tool for occupational
therapists in the treatment of trait anxiety. There isstrong evidence from one publication that rightnostril breathing increases metabolic rate during
the period of practice, and weak evidence fromanother paper that this effect may be prolonged.
Other research not analysed in this review suggests
health benefits from pranayama that are notdirectly related to occupation.

6. Conclusions
Occupational therapists who integrate yoga
into their practice and use pranayama, should
consider choice of technique based on thepathology and physiological needs of eachindividual service-user, and the evidence oftherapeutic effect for each technique. Slowalternate nostril breathing should be consideredwhen anxiety impairs occupational performance,and right nostril breathing should be considered
for obesity, lethargy, and symptoms ofhypothyroidism or similar metabolic disorders if
these inhibit function. Further research is required
for evidence-based application of other pranayama

Mailoo VJ

9techniques.

7. Acknowledgements
The author would like to thank Rhiannon
Lawrence (model).

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PRANAYAMA: POTENTIAL TOOLS TO ENHANCE OCCUPATIONAL PERFORMANCE

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442.

REVIEW ARTICLE

The Effectiveness of Interprofessional
Education in the Health Sciences:
Implications for Occupational Therapy
Education
G. Ted BROWN1, PhD, OT (c), OTR, AccOT,Louise FARNWORTH1, PhD, AccOT, Rebecca ALLEN1, MBus, AccOT,
Pamela KIRKE1, MOT, AccOT
1Occupational Therapy Department, School of Primary Health Care, Faculty of Medicine,

Nursing and Health Sciences, Monash University–Peninsula Campus, Melbourne,
Victoria, Australia

Abstract: Teamwork in health care settings is assumed to be beneficial for the client since
it allows for a more holistic, comprehensive, co-ordinated approach. It is essential, therefore,
for team members to have an adequate knowledge of, and respect for one another’s professions.
Traditionally, the different health care professions know little about each others specific skillset and their roles as health care practitioners, whereas in interprofessional education (IPE),
clinicians and/or students become familiar with the knowledge, skills and attitudes of eachother to be effective team members. Changes in the current health care environment require
well-versed, flexible, collaborative clinicians who work for the client’s best interests.
Traditional professional silos are no longer viable. IPE both at the undergraduate/preemployment level and postgraduate/post-employment level is seen as one means to foster
effective cross-professional communication, collaboration and client-centred care. IPE assists
students to increase their knowledge of the roles and functions of other related professionals
and enable an integrated approach to both in the workplace and in collaborative practice.
Given that IPE is resource intensive, a question that can be posed is “how effective is IPE?”
Many evaluation studies examining the effectiveness of IPE in health care contexts (mainlywith physicians and nurses) have been completed. Only a few investigations have included
other health professions such as occupational therapy, pharmacy, social work or physiotherapy.
All of the IPE effectiveness studies report some form of positive benefit or outcome, but noneof the studies are definitive or have been replicated. Many of the published health science IPE
evaluation studies lack adequate rigor in terms of poor or unclear research design used, small
sample size, non-randomisation of participants, lack of comparison control group, lack of
acknowledgement of bias, non-standardised instruments used and/or statistical analyses
completed. Several systematic reviews have been completed dealing with the published healthscience IPE evaluation literature, but the results have been largely inconclusive. Ongoingevaluation of the effectiveness of IPE in the health sciences is required.
Key words:

occupational therapy education, students, curriculum, learning models

Received: March 17, 2006, Accepted: May 7, 2006
Correspondence to: G. Ted Brown; Occupational Therapy
Department, School of Primary Health Care, Faculty of
Medicine, Nursing and Health Sciences, Monash
University–Peninsula Campus, Melbourne, Victoria,
3199, Australia.
phone: 613-9904-4462 fax: 613-9904-4812
e-mail: ted.brown@med.monash.edu.au(Asian J Occup Ther 5: 11–27, 2006)

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THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

1. Introduction
Changes in health service delivery haveblurred the boundaries that have traditionallydefined the roles and responsibilities of the various
health professional groups. Multi-professional
teamwork and/or multi-skilled health care
professionals have become the preferred model ofpractice promoted by health care policy makers,
state and commonwealth government departmentsof health, professional colleges and regulatory
bodies, professional associations, funding bodies
and regional health provider organisations(Freeman, Miller, & Ross, 2000; Makely, 1998;
Pew Health Professions Commission, 1994;
Salvatori, 1997). The assumption is that theserequirements and models are based on theassumption that when professionals with specialist
knowledge working in health care teams pool theirexpertise, the work will be done more efficiently
and effectively and that clients in turn will receive
better care. However, research indicates that while
there has been a generally held belief thatprofessional teamwork and collaboration aredesirable, there is little evidence to substantiate theview that teamwork and collaboration lead to anincrease in the quality of care and well-being ofclients, service users, and caregivers (Leathard,1994).
There is an assumption that multiprofessional team work will happen automaticallyin the workplace, although structural,organisational, and attitudinal factors may all
potentially inhibit effective team development andcollaboration (Farrell, Schmitt, & Heinemann,
2001). Structural and organisational barriers are
difficult to overcome and may reflect in part theattitudes of individuals within institutions.
Interprofessional pitfalls, including conflicting
professional and organisational boundaries andloyalties, and negative mutual perceptions andprejudices are still prevalent (White, 1989).
Interprofessional education (IPE) has been
proposed as one means to minimise barriers byincreasing knowledge and understanding aboutother professionals’ specific contributions to clientcare; such understanding can improve
relationships, increase trust and dispelling ofstereotypes. Changing profession-specificapproaches to undergraduate health scienceeducation in universities by introducing IPE as
part of students’ curriculum maybe one way toameliorate this situation. As Barr and colleagues(1999) stated “interprofessional education was
invoked to modify reciprocal attitudes andperceptions, to cultivate mutual respect and to
explore ways in which collaboration could bemade real” (p. 534). This new understanding has
lead to a major paradigm shift in the education andworking relationships of medical, nursing, andallied health students; one from a focus on learningand practicing in professional isolation to teachingand practicing alongside one anothercollaboratively (Freeth, 2001; Gilbert et al., 2000).
This paper will present an overview of IPE by
first defining what IPE is and how widely it has
been adopted in the medical and health sciences
arena. The advantages, disadvantages, facilitating
factors and barriers to IPE will be discussed. Theu s e o f I P E i n t h e m ed i c a l e d u c a t i o n a n doccupational therapy education fields will be
discussed and critiqued. Finally, the efficacy of
IPE in health science education with students andprofessionals will be reviewed.

2. What is IPE?
Many health care professionals profess toengage in IPE, but the concept is not well definedin the literature. Although some writers note that
there are differences between the following terms–
interdisciplinary, interprofessional, collaboration,
partnerships, cross-disciplinary, multip r o f e s s i o n a l l ea r n i n g , m u l t i d i s c i p l i n a r y ,transdisciplinary, integrated and shared learning–they are often used interchangeably. “Different
prefixes–multi, inter, cross, joint and shared–are
attached to different adjectives–disciplinary andprofessional–which are in turn attached todifferent nouns–education, training, learning andstudy” (Barr, Hammick, Koppel, & Reeves, 1999,
p. 536). ‘Multi’ describes the broad range ofprofessional practitioners who undertake aparticular project. ‘Inter,’ on the other hand, refers
to the nature in which those professionals work
together to complete a project. Hammick (1998)

Asian J Occup Ther 5: 11–27, 2006

Brown GT et al.

13

Table 1. Dimensions of IPE*
* Implicit or explicit in the educational process or in everyday practice* Discrete, as free-standing modules or integrated into other modules* All or part of a program (more likely to form portion of postgraduate qualification or continuing
professional development program)* General or particular* Positive or negative in its impact on relationships and collaborative work
* Individual or collective in its focus and assessment* Work / employment-based or college-based* Shorter or longer* Sooner or later (different stages in qualifying / post qualifying learning)* Based on common learning needs or comparative learning about respective roles, responsibilities,
powers, duties and perspectives* Interactive or didactic in approach (there is a predominance of the former)* Source: Barr, 1996.

made a distinction between ‘multi’ and ‘inter’
when she described multiprofessional education as‘simply learning together’ (e.g., in the sameclassroom) and interprofessional education as‘learning together to promote collaborative
practice’ (e.g., working on the same case study toresolve issues posed).
Oxley and Glover (2002) defined IPE as “alearning process in which different professionals
learn from and about each in order to develop
collaborative practice” (p. 2). Barr (1998)
maintains, that by definition, IPE aims toencourage collaborative practice, but suggests thatthe objectives vary including: modifying attitudes
and perceptions, enhancing motivation, securingcommon knowledge bases, reinforcing
collaborative competencies, and effective change
or improvement in practice. In this way, IPE
assists students to increase their knowledge of theroles and functions of other related professionals
and enables an integrated approach to both theworkplace and collaborative practice. Using thesedefinitions, IPE is a subset of multiprofessional
education distinguished by its purpose and themethods that it employs to achieve it. Barr (1996)
identified a number of core ‘dimensions’ of IPE
and these are located on Table 1.
West (1997) described the characteristics ofeffective IPE as being: attainable / evolving sharedvision; clear, shared objectives; mutual support;e f f e c t i v e p a r t i c i p a t i o n ; t as k o r i e n t a t i o n ;information and appr opriate management
structures; and support for innovation. Parsell andBligh (1999) identified six principles to guideinterprofessional learning: (1) detailed planningand organisation involving all stakeholders, (2)integration of theory with practice and relevance towork, (3) interactive student-centred learning
activities, (4) teachers as role-models for multiprofessional working, (5) establishment of acomfortable learning climate, and (6) rigorous
evaluation for research and further development.
A report from the UK Central Council for Nursing
and Midwifery (2000) states that IPE should:* reflect the needs and interests of the user;* be derived from an integrative approach;* complement profession-specific knowledge;* have its main focus in practice, supported byinterprofessional learning in academic
components of programs; and* allow practitioners to identify and maintain theirown philosophies, professional values andbeliefs within interrprofessional working
environment.

3. How extensively has IPE been
adopted?
In 1976, Bloom and Parad reported that only
36% of mental health training programs in the US
included any form of IPE. In 1982, McPherson
and Sachs reported that less than 30% of Canadian

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THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

Table 2. Professions Where IPE Has Been Used
* Medicine (Carpenter, 1995; Barr, 2001)* Nursing (Barr, Freeth, Hammick, Koppel, & Reeves, 2000; Horsburgh, Lamdin, & Williamson, 2001)* Social work (Carpenter, 1995; Connoer & Rees, 1997)* Pharmacy (Greene, Cavell, & Jackson, 1996)* Physiotherapy (Hilton, Morris, & Wright, 1995)* Occupational therapy (Tryssenaar, Perkins, & Brett, 1996)* Palliative care (Macleod & Nash, 1994)* Dentistry (Parsell, Spalding, & Bligh, 1998)* Psychology (Hall & Weaver, 2001)* Midwifery (Mires et al., 1999)* Dietetics (Hall & Weaver, 2001)* Health & public administration (Hall & Weaver, 2001)

and American medical schools had any IPE
involvement. However, the scope and range of
IPE activities and evaluation research has
increased dramatically over the last two decades(Barr, Freeth, Hammick, Koppel, & Reeves,
2000). A number of fields, both inside, andoutside, of the health sciences have discussed andevaluated IPE over the last two decades (see Table
2).

4. What Are the Advantages of IPE?
There are several advantages in IPE. For
example, Rance (1996) in his assessment of theextent and value of IPE, claims that IPE provides
added value in that it offers a “broader perspective
to complement specialist professional expertise,
and will ultimately make students more capable ofsecuring employment” (p. 5). Freeth et al. (1998)
listed the following benefits of IPE for employers:
a reduction in the occurrence of communication
breakdowns, an increase in morale and efficiency,
and a decrease of ‘unhelpful protectionism.’ Barr
(2000) maintains that IPE enhances personal andprofessional confidence, promotes mutual
understanding between professions, facilitates
intra- and inter-professional communication, andencourages reflective practice.
IPE can promote creativity in teaching andresearch and foster interprofessional co-operation.
Additionally, another positive outcome
documented in the literature is cost-effectiveness.
IPE can lead to the development of skills required

to operate effectively within multi-disciplinary
team contexts. McCroskey and Robertson (1999)
outline a number of benefits for individual
university staff members: an exposure to new
ideas, an opportunity to work with different
people, an increase in cultural sensitivity, anenhanced flexibility in working with students, abetter sense of co-operation and networking
between departments and an impetus to discover
more community resources.
For studen ts, it has been argued thatmeaningful interprofessional learning experiences
can better prepare students for encountering thecomplexities of real-life interprofessional
problems in the work environment. Theseexperiences help to develop a holistic approach toworking, based on common knowledge between
disciplines and an awareness of diversity issues.
Rance (1996) maintains that IPE leads students torecognise the overlap of professional functions
and those activities that fall between professional
areas. He also believes that IPE assists to break
down professional roles within the development
process which can lead to competition and conflict
between professional groups. “This creates anenvironment in which students can develop a
critical awareness of the limitations ofprofessional roles and values” (Rance, 1996, p. 5).
The IPE process challenges stereotypes, but also
allows students to strengthen their own
professional identities. O’Neill, Wyness,
McKinnon, and Granger (1999) also state thatstudents gain a greater understanding of otherAsian J Occup Ther 5: 11–27, 2006

Brown GT et al.

15

Table 3. Advantages of IPE* Enhances multi-disciplinary team functioning and communication* Increases mutual understanding, support and respect of team members* Facilitates and promotes collaborative practice thus limits the demands made on any one profession* Reduces stress and increases job satisfaction and in turn improves staff morale, recruitment and retention* Enhances client care since a combination of health care professionals working in unison is better placed tomeet the users needs* Allows for joint training in areas that have been identified as common skills such as ethics, report writing,communication skills, and clinical reasoning* Creates potential for joint student fieldwork placements* Creates research and development opportunities for staff and students* Shared resources including faculty workload, classroom facilities and equipment* Collaboration among students and faculty such as sharing ideas and goals and simulating the workplace

professions’ roles and skills, begin to develop
skills in interprofessional teamwork and gain
knowledge and skills in relation to complex
conditions that require intervention from a rangeof professionals.
Barr et al. (2000) summarised the four main
benefits of IPE as providing: enhancement ofmotivation to collaborate, changes to attitudes andperceptions, cultivation of interpersonal, groupand organisational relations and establishment ofcommon value and knowledge bases. McGrath(1991) identified several advantages ofinterprofessional education: (1) more efficient useof human resources by enabling specialist staff toconcentrate on specialist skills; (2) more effective
service provision, by encouraging overall planningand goal orientation; and (3) a more satisfying
work environment, through promoting a more
relevant and supportive service. Further
advantages of IPE are listed in Table 3.

5. What Factors Contribute to Effective
IPE?
A number of factors favouring IPE have been
cited. Parsell, Spalding, and Bligh (1998)
suggested that the following factors promote
effective IPE: balanced membership between
professions, an attractive program for theparticipants, pre-event information, clear learning
outcomes, interactive learning methods and aphysically and psychologically comfortablelearning environment. Parsell and Bligh (1999)

grouped the characteristics and conditions neededto achieve positive outcomes for IPE under four
key dimensions: (1) relationships between
different professional groups (values and beliefs
that people hold); (2) collaboration and teamwork(knowledge and skills needed); (3) roles andresponsibilities (what people actually do); and (4)benefits to patients, professional practice andpersonal growth (what actually happens). Barr
(2001) cites a number of traits of effective IPE andthese are listed on Table 4.

6. What Are the Disadvantages of andBarriers to IPE?
Not all IPE initiatives have been successful.
According to Gilbert et al. (2000), many
universities have developed courses forinterprofessional groups of students, however,
implementing them has proven to be challenging
and problematic. One key challenge associatedwith IPE that Gilbert et al. identified was finding,co-ordinating, and scheduling time in professional
curricula across disciplines. IPE courses often
require small group experiences which can be both
expensive and labour intensive. Other barriers are
external and outside the control of individuals suchas the requirements of professional bodies andcourse funding arrangements. Internal barriers
such as location of departments and schools,
timetables, individual course content andorganising fieldwork placements can all makeshared learning opportunities challenging to16

THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

Table 4. Factors Contributing to Effective IPE*
* Putting service users and carers at the centre: involves clients in designing, teaching, participating and assessing
programs* Promoting collaboration: apply IPE principles to collaborative practice during placements or work-related
assignments, collaboration within and between professions, within and between organisations and with
communities, service users and their carers* Reconciling competing objectives: ensure that these principles are protected as the essential qualities of IPE while
ensuring that they are compatible with other objectives and their implications for program design, content andlearning methods* Reinforcing collaborative competence: reach beyond modification of attitudes and securing common knowledge
bases to reinforce collaborative competencies necessary to cope with the complexity of contemporary practice* Relating collaboration in learning and practice to a coherent rationale: gives reasons why interprofessional learning
improves interprofessional practice grounded in theory* Incorporating interprofessional values: such as inclusion, equality, openness, humility, mutuality, generosity andreciprocity* Including common and comparative learning: treat comparative content as essential to inform learning from andabout each other, to enhance understanding about respective roles and responsibilities and intelligent co-working* Employing a repertoire of interactive learning methods* Counting towards qualifications: assess IPE for awards to add value.
* Evaluating programs: subject IPE to systematic approval, validation and research* Disseminating findings: inform other developments in IPE* Source: Barr, 2001.

Table 5. Disadvantages of IPE* Issue of accountability in practice following graduation would need to be addressed* Maybe incompatible relating to professional identity and differences in preparation for clinical practice* Resource constraints including scheduling and time challenges* Competition between students including differing workloads and program rigor* Relevance of combined courses to each profession including providing the right amount of material, offering
suitable examples and establishing the appropriate content emphasis including choosing textbooks, evaluating
student performance and willingness to compromise

administer and organise. Other disadvantages of
IPE are listed in Table 5.
There are several other types of barriers to thepromotion and development of IPE including
attitudinal, educational, financial, andorganisational (Williams & Wilson, 1998).
Negative stereotypes and prejudices create divides
between professional groups. Profession-specificrequirements inhibit IPE despite the coordinatedefforts of regulatory bodies and professional
associations to overcome them. As well, funding
models for educational courses undermine IPE
efforts. “Multiprofessional education favours
large classes and common curricula which inhibit
interactive interprofessional learning that relies

upon small groups, generous staff/student ratios
and facilitators with special training andexperience as leading exponents reported” (Barr,
2000, p. 14). Logistics, geography and tensions
between employers and universities createorganisational barriers. Other barriers to IPE arelisted in Table 6.

7. Should IPE Be Taught at theUndergraduate or Postgraduate Level?
Within the occupational therapy field, it is
now possible to complete one’s professional
education at either an undergraduate or graduatelevel (e.g., bachelors or masters level). It is also

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Brown GT et al.

17

Table 6. Potential Barriers to IPE*
* Historical interprofessional and intraprofessional rivalries* Differences in history and culture of professions and educational institutions* Differences in language and jargon between professional groups* Limited university staff time for preparing and implementing IPE courses* Lack of commitment of university staff to teach IPE courses* Faculty attitude including resistance to compromise* Resource constraints & limitations* Curricular differences between professions* Failure of past attempts to mount an IPE course successfully* Scheduling conflicts and timetabling difficulties for IPE courses that are part of a larger curriculum* Discrepancies in numbers of students from different student professional groups* Contrasting learning and assessment methods between professional groups* Varying levels of preparation, qualifications and status of students who undertake IPE* Fears of diluted professional identity* Differences in requirements, regulations and norms of professionally education* Differences in accountability, payment and rewards* Attitudinal: negative stereotypes and prejudices* Educational: profession specific requirements* Financial: multiple funding streams* Organisational: large classes, common curricula, experienced facilitators, geography, tensions
between employers and universities*Source: Williams & Wilson, 1998.

possible for already qualified occupational
therapists to complete postgraduate studies atmasters and doctoral level. The literature on thetiming of learning about different professionalroles is not clear. Harden (1998) suggests thatwhat is most important is a pedagogical approachthat is most appropriate for the phase or stage ofthe students’/clinicians’ learning. Other writers
suggest that the timing of IPE is best left to a
postgraduate level or when students can undertake
clinical practice together (Poldre, 1998). It is
recognised that undergraduate IPE is very
different from postgraduate IPE. However, the useof problem-based multidisciplinary cases andopportunities for small group learning can provide
a basis for undergraduate IPE (Horsburgh,
Lamdin, & Williamson, 2001). On the other hand,
Barr (2000) suggests that IPE be offered at the
postgraduate level. He states that “part-time
programmes enable participants to draw uponwork experience and to apply theirinterprofessional learning concurrently. As seniorpractitioners, participants have experience toexchange, including interprofessional experience,and may be in positions where they can influencechanges in practice” (p. 11). It should also be
noted that work-based IPE is much more likely
than university-based to result directly in changes
in practice or benefit to patients (Barr, 2000).
However, Tope (1996) suggests that postgraduate
education is problematic because it offered analternative view in that negative attitudes towards
other professions are reinforced during preregistration education, making them more difficult
to shift. Yet as Barr (2000) observes, IPE is still
predominantly offered at postgraduate level with agrowing preference for work-based learningfacilitated by consultants.
Several studies suggest that IPE should occur
early in the education of health care professionals.
Horak, O’Leary, and Carlson (1998) suggest thatthe experience of IPE at an early stage (such as topre-employment or undergraduate students) may
better facilitate interdisciplinary collaboration andmulti-disciplinary teamwork among future healthcare professionals. Headrick, Wilcock, andBatalden (1998) as well as Headrick, Richardson,
Priebe, and Bergman (1998) both recommend
involving medical students in interdisciplinary
projects with other health care students which are

18

THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

relevant to their needs, scheduled as part of theircore program and begun early in their education to
optimise their learning experience about working
with other professionals in a collaborative manner.
Petrie (1976), on the other hand, suggests thatclinicians must initially be secure in theircompetency in their chosen profession before
embarking on interdisciplinary teamwork.
Mariano (1999) also states that a thoroughknowledge of one’s profession is essential tounderstand the contributions of other teammembers in the context of client care. Thissuggests that IPE should only be introduced toboth senior students and practicing clinicians tohave an optimal impact on client care,interprofessional relationships and collaborative
team work. Barr (2000) stated that “universitybased and work-based interprofessional education
can be seen as different but complementary, eachcapable of reinforcing the other” (p. 22). Thisissue remains unresolved and continues to bedebated at this point in time.

8. How Extensively Has IPE Been Used in
Medical Education?
Few evaluations of IPE have involved only
medical students or practitioners. They are often
partnered with at least one other health care
professional group. Reviewing every IPE
evaluation study that included medical students
and/or practitioners as subjects was beyond thescope of this paper, therefore, only a few
illustrative studies are described below. TunstalPedoe, Rink, and Hilton (2003) evaluated how
four health science professional groups of students(medicine, nursing, radiography, andphysiotherapy) from the UK experienced learning
together during the first term of their training
courses when a new curriculum referred to as aCommon Foundation Programme was
implemented.
Students’ attitudes to the new curriculum andto each other were surveyed at the beginning andend of their first term. The results demonstrated
that students arrived at university with stereotyped
views of other health care professional student
groups and that students thought that theirinterprofessional skills improved after being
involved in IPE courses. Tunstal-Pedoe, Rink, andHilton found that students whose parents worked
as health care professionals (e.g., doctors or
nurses) held stronger stereotyped views thus
challenging the notion that it is possible to start a
professional course without preconceived ideas
about other professions. This would indicate thatthe use of IPE in the initial part of a students’
education might be help to dispel or modify thesepreconceived ideas. Several limitations were
inherent in this study including the use of a nonstandardised survey instrument as well as thestudents only being from one university setting.
Student participants were not randomly selected
and no control group was included for comparison
purposes.
Horsburgh, Lamdin, and Williamson (2001)
attempted to quantify the attitudes of first-year
medical, nursing, and pharmacy students (n=180)
towards IPE at the beginning of a course at the
University of Auckland, New Zealand. Students
completed the Readiness for Interprofessional
Learning Scale (RILS) (Parsell & Bligh, 1999)
with the majority of them reporting positive
attitudes towards shared learning. However,professional student groups did differ. Nursing
and pharmacy students indicated more strongly
that an outcome of learning together would be
more effective for teamwork. Medical students
were the least sure of their professional role, andconsidered that they required the acquisition of
more knowledge and skills than nursing or
pharmacy students.
The benefits ofinterprofessional learning cited by the students
included the acquisition of teamwork skills andenhanced professional working relationships.
Students acknowledged that teamwork skills werean essential part of their learning, and that learning
together in an IPE context improved working
relationships after graduating. Two strengths ofthis study were the use of a standardised scale(RILS) with well documented psychometricproperties and an adequate sample size tocomplete the data analyses.
Freeth and Nicol (1998) described the use of
IPE with newly qualified staff nurses and final
year medical students. The program took place inAsian J Occup Ther 5: 11–27, 2006

an interprofessional clinical skills teaching unit.
Each session was led by an experienced nurse
lecturer and academic physician. A qualitative
methodology using interviews was used to gather
the IPE evaluation data. Freeth and Nicol foundthat the style of learning was participative withsmall interprofessional groups addressing a rangeof client management issues. The results indicatedthat both nurses, final year medical students, andtheir clinical managers were positive about the IPE
program results. Limitations of this study
included the fact that the sample size was notreported in the study, participants only included
nurses and doctors and no other healthprofessional groups, research methodology waspoorly described in terms of how the data was
obtained, and no information was reported about
how the trustworthiness and consistency of theinterview data obtained was ensured.
Tucker and colleagues (2003) evaluated thefeasibility and effectiveness of shared learning ofclinical skills for medical and nursing students.
Clinical skills were learned by both sets ofstudents by having them rotate though a series ofskills stations taught by multi-professional
facilitators. Quantitative and qualitative methods
were used to gather the course evaluation data.
The evaluation results indicated positive outcomes
for the two groups of students including increased
confidence levels, increased understanding ofothers’ professional roles and personal
development.
Mires et al. (1999) completed an evaluationof an IPE program involving a group of Scottish
medical students (n=141) and midwifery students(n=35). The two groups of students completed
three different questionnaires: a knowledge
questionnaire, an attitude scale, and a course
evaluation form. No information was provided
a bo u t h ow th e t hr e e qu e s ti o n na i r e s we r edeveloped and whether they were reliable and/or
valid. Before the students started the course,
significant differences between the medical andmidwifery students were noted in their attitudes
towards the roles and responsibilities of bothprofessions in the management of pregnancy andnormal labour. However, after the completion of
the IPE program, the evaluation results indicatedBrown GT et al.

19that both the medical and midwifery students
gained knowledge about pregnancy and childbirth
as well as a better understanding of each other’srole in the care of the women having babies. Thec h a n g e i n a t t i tu d e s t o w a r d s p r o f e s s i o n a l
responsibilities was most evident among medical
students. Differences in professional attitudes
between medical and midwifery students at thestart of the course were less marked following
completion of the course. Mires et al. concluded
that IPE has a legitimate and valuable role inmedical and nursing education when the intended
educational objectives are clearly defined and theeducational strategy and learning objectives
selected are appropriate. Overall, this was a welldesigned study except there was a notabledifference in the sample sizes of the twocomparison student groups with the ratio of
medical to midwifery students being almost 4 to 1.
In summary, all of the studies reported
positive outcomes for medical students andpractitioners being involved in IPE. The studies
used a combination of research design approaches
to gather their evaluation data. Both quantitativeand qualitative methods (or a combination of both)were used. Few of the studies used standardised
scales (such as the Interprofessional Education
Perception Scale, Interprofessional Education
Survey, Attitudes Toward Health Care Teams
Scale or the RILS) with established reliability andvalidity. This is a notable limitation. In terms ofsampling, most of the studies had small sample
sizes that were not randomly selected and did notinclude comparison matched control groups.
Again, this is a notable limitation for quantitative
studies. Little or no effort was made to control fordifferent types of bias. In conclusion, while thepublished studies reported several positive
outcomes, the results must be viewed in thecontext of research studies with notable inherent
methodological weaknesses and thus be viewed
with caution.

9. How Extensively Has IPE Been Used in
Occupational Therapy Education?
A number of published manuscripts reporting
IPE evaluation research results have included

20

THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

occupational therapy (OT) students or clinicians as
one of a number of health science participantgroups. Hughes, Hemingway, and Smith (2005)
discussed the issues related to the development ofinter-disciplinary training at the undergraduate andpostgraduate level for nursing and OT in the UK.
A number of studies have involved OT students inthe field of geriatrics promoting IPE (MacKinnon& MacRae, 1996; Miller, Ishler, & Heater, 1999;
Thomas, Reigart, & Trickey, 1998). Tryssenaar,
Perkins, and Brett (1996) presented an overview of
IPE from an undergraduate OT student perspective
while Paul and Peterson (2001) discussed
interprofessional collaboration in the context of
OT practice and research.
Cleary and Howell (2003) completed asurvey that examined the educational interaction
between American physiotherapy (PT) and OT
students by mailing questionnaires to all the
directors of directors of PT and OT educational
programs (n=206). The response rates were 68%
for OT and 66% for PT. The results indicated thatnearly two thirds of PT and OT students had
experienced at least one type of common learningsome type of course work during their professional
training. Cited benefits of IPE according to theeducation program directors included sharing
resources, collaboration, learning about the otherprofession, and gaining respect for the otherprofession. Challenges to shared learning
included resource constrains, curriculardifferences, competition and differences between
disciplines, relevance of course work and different
faculty expectations. None of the PT and only
13% of the OT directors reported that students
shared clinical fieldwork experience. Barriers
reported by program directors whose students did
not take part in interdisciplinary education wereresource constraints, curricular differences, faculty
attitude and failure of past attempts. Cleary andHowell (2003) concluded that “most students inentry-level PT and OT programs in the UnitedStates do not currently have the opportunity topractice the teamwork that will be essential when
they enter their respective professions” (p. 71).
The results of the Cleary and Howell survey arecontradictory since PT and OT students appear to
be largely educated separately while after they

graduate, PT and OT clinicians often work
together on client treatment teams.
Mu, Chao, Jensen, and Royeen (2004)
evaluated the perceptions of a group of American
OT, PT, and pharmacy students before and after
they participated in an interprofessional training
project (n=111). Using the Interprofessional
Education Perception Scale (IEPS), the results
indicated a significant increase in students’positive perceptions of IPE and the significant
increases were independent of the duration of the
training. The researchers found that students who
participated in long-term training reported weremore positive attitudes about IPE. Strengths ofthis study were the use of the IEPS which has
documented reliability and validity (Hayward,
Powell, & McRoberts, 1996; Luecht, Madsen,
Taugher, & Petterson, 1990). As well, qualitative
data was gathered through the use of a preobservation assessment, post-observationassessment, student reflection journal, and weekly
inquiry and experience debriefing sessions.
Pollard, Miers, and Gilchrist (2004)
completed a study that examined students’attitudes to IPE and collaborative working, both
before and after qualification at one British
university. Ten different health professional
student groups were involved in the study sample(n=852) including OT students (n=30). Students
completed four sets of questionnaires that dealt
with communication and teamwork,
interprofessional learning, and interprofessional
interaction. The results indicated that most healthscience students rated their communication andteamwork skills positively and had positive
feelings towards IPE, but held negative feelings
a bo u t i n te rp r of e s s i o na l i nt e r a c ti on . T heinvestigators noted that two student professionalgroups, OT and social work, held particularly
negative views of interprofessional interaction.
Strengths of this study were the large sample size,
the range of health professional students included,
and the use of a three scales with preliminarylevels of documented validity and reliability(Entry Level Interprofessional Questionnaire,
Interim Interprofessional Questionnaire, andFinal Interprofessional Questionnaire).
Limitations of the study were the fact that student

Asian J Occup Ther 5: 11–27, 2006

participants were not randomly selected, were only
from one educational institution and no control
comparison group was used.
Reynolds (2003) evaluated the contributionof problem-based learning (PBL) to IPE. First
year OT and PT student completed evaluations of
their participation in PBL during an IPE module
focussing on communication skills and clientfocused approaches to care. Reynolds used aquestionnaire that included attitude ratings andqualitative evaluations of PBL with a sample of
157 students. The findings indicated that students
were positive that PBL contributed to both
personal learning and team-working skills.
Students felt that their understanding of therapists’roles within the multidisciplinary team context
increased. Reynolds concluded that PBL made apositive, well-received contribution to learning
during an IPE module. A positive feature of thisstudy was that it used a mixed researchmethodology approach (quantitative andqualitative approaches). However, the student
participants were from only one British university,
were not randomly selected, and were not matched
to a control group for comparison purposes.
Ponzer et al. (2004) reported on a group of
Swedish medical, nursing, PT, and OT students’
perceptions of IPE on clinical training wards(n=962). Students completed a self-report, nonstandardised questionnaire. The study findings
indicated that clinical education ward contexts
provided students with realistic clinical practicescenarios in terms of training in their own
professions as well as in learning more about theroles and responsibilities of other health care
professional student groups. The importance ofgood communication for teamwork and for client
care was also recognised by student participants.
T h e q ua l i ty of s u p e r vi s io n a nd s t ud e n ts’perception of their own professional roles were
found to be si gnifi cant facto rs regarding
satisfaction with regards to the clinical education
ward course. No psychometric information wasreported for the questionnaire that was used byPonzer et al. As well, a sample of convenience ofstudents from one education institution were usedas participants.
Walhstrom and Sanden (1998) described theBrown GT et al.

21

evaluation of students participating in a training
ward from an IPE perspective. A total of 454
Swedish students from medicine (n=93), nursing(n=187), PT (n=74), OT (n=60), laboratory
technology (n=26), and social welfare (n=16) wereinvolved. The training ward offered students
clinical training opportunities within the areas of
medical and rehabilitation educational programs.
The students reported that the training ward
provided IPE opportunities in terms of team work,
leadership, and clinical skills. “The placement
clarified their future professional role andcontributed to their understanding of the skills andoccupational tasks of the other professionals”(Walhstrom & Sanden, 1998, p. 229). The main
limitation of this study was the fact that the methodof data collection and analysis was not specified.
This made it challenging to judge the quality of
research methodology used and how valid thereported results. Two strengths of this study werethe large sample size and the fact that students
from six different health disciplines were included
as participants.
Parsell, Spalding, and Bligh (1998) described
the outcomes of 28 British students from sevendifferent health care professions (OT, PT,orthoptics, radiography, nursing, medicine, anddentistry) attending a two day IPE course. Preand post-course evaluation questionnaires wereused assess the course format, content and learning
methods. Students were able to identify issues
surrounding multiprofessional teamwork andcollaboration. Evaluation results showed that theIPE course increased knowledge andunderstanding of other health care professions,developed more positive attitudes, anddemonstrated the importance of multiprofessional
teamwork and communication. The students
reported that they believed that early and regular
opportunities for shared learning should be
essential aspects of health science undergraduate
courses. The major limitations of this study were
the small sample size, non-standardised
questionnaire used, and lack of a comparison
control group. A positive feature of this study was
the fact that student participants from sevendifferent health care professions were included in
the sample.

22

THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

Reeves, Freeth, McCrorie, and Perry (2002)
completed an evaluation of IPE that took place in a
training ward placement with medical, nursing,PT, and OT students. The authors used aqualitative methodology where 19 clinicalsupervisors and 36 students were interviewed toelicit their views about the potential gains anddrawbacks of implementing the training ward
placement model and its influence on IPE. The
students had to plan and deliver interprofessionalcare to a group of orthopaedic and rheumatology
clients in the training ward setting. This context
enabled students to develop professional specificskills and competencies when dealing with clients.
At the same time, it also allowed students toenhance their teamwork skills in aninterprofessional environment. Evaluation
methods included questionnaires, interviews, andobservations. The study results indicated thatstudents valued the experiential learning theyreceived on the training ward and felt the teachingward context prepared than more effectively for
future practice. More detail about the methods
used to obtain the research data and whether it waschecked for consistency and trustworthinesswould have been helpful. It was challenging forthe reader to make any definitive judgements
about the rigorousness of the qualitative researchmethodologies used.
In summary, occupational therapy students
and clinicians have been involved in a number of
IPE evaluation studies. All of the studies citedhere reported some type of positive benefit forparti cip ant s from b ein g in vo lv ed i n IPE.
However, it should be noted that the majority ofthe studies had methodological limitations
including sample small sizes, participant groups
not being randomly selected, not including acontrol group for comparison purposes, participantgroups being from one educational institution, andusing questionnaires or scales with little or no
documented reliability or validity. As with the
medical student/physician IPE evaluation studies
mentioned previously, the influence of different
types of bias were also not clearly considered in
the occupational therapy IPE evaluation literature.
This would result in many of the studies notmeeting the inclusion criteria for any systematic

reviews or meta-analyses. This would in turn limit
the generalisability of the results of these studies.

10. What Is the Effectiveness of IPE?
A number of systematic reviews have been
conducted evaluating the effectiveness of IPE.
Barr and Waterton (1996) completed a review of
the UK literature and found only 19 publishedevaluations of IPE. The evaluation studies varied
widely in form, methodology used, purpose, andlevel of rigour. The study results indicated that
under favourable circumstances, interprofessional
learning methods can improve reciprocal
perceptions of health care professionals, but thiswas not always so. Only one of the studies
followed students up and found that improvements
were not in fact sustained in the longer term.
Therefore, none of the studies in the Barr andWatson systematic review demonstrated a benefitof IPE to clients who received services from healthcare professionals based pm the criteria used.
In 1999, Barr and colleagues set out tocomplete a Cochrane Collaboration systematic
review of the effectiveness of IPE. Initial searches
produced 1,062 abstracts of which 99 wereidentified as potentially meeting the systematic
review inclusion criteria. However, upon closer
examination, none of the 99 papers fulfilled the
Cochrane Collaboration selection criteria.
Similar to the Barr et al. (1999) systematic review,
Mattick and Bligh (2003) completed a systematic
review of the effectiveness of IPE by searching the
medical literature since 1998. A total of 24
research papers and 36 literature review papers
were identified. It was found that the research
papers generally described IPE initiatives andevaluated their success by collecting data in termsof participant knowledge or attitudes. After
reviewing the 60 papers in detail, Mattick andBligh concluded that “none of the studies
identified conformed to the Cochrane
Collaboration guidelines for a rigorous source ofquantitative information on an intervention’s
effectiveness” (p. 1008).
In another systematic review ofinterdisciplinary learning, Cooper, Carlisle, Gibbs,
and Watkins (2001) found 141 studies. In the end,

Asian J Occup Ther 5: 11–27, 2006

only 21% were used in their review due toconcerns about poor methodological rigour andpoorly developed outcome measures. Based on
their findings, Cooper et al. concluded that healthscience students benefited from IPE with outcome
effects mainly relating to changes in knowledge,
skills, attitudes, and beliefs, in particular related tothe understanding of professional roles and teamwork. It was also found that early learning
experiences for students were most beneficial todevelop favourable attitudes towards
interprofessional working and that IPEinterventions required detailed and committed
team planning and increased resources. It was also
found that IPE approaches generally centredaround the principles of adult education using
PBL, small group learning, case studies, andexperiential work. Finally, IPE outcomesprimarily represented short-term effects only
while few studies provided evidence of longerterm outcomes, in particular effects upon
professional practice. Unlike the systematic
reviews completed by Barr et al. (1999) andMattick and Bligh (2003), Cooper et al. provided
some preliminary empirical evidence of thebenefits of IPE and it is presumed that similar
benefits could be generalised to OT students.
Zwarenstein et al. (2001) completed a
Cochrane Collaboration systematic review withthe purpose of assessing the usefulness of IPEinterventions compared to education in which
professions were learning separately from one
another. A total of 1,042 studies were located ofwhich 89 were retained. Despite searching
Medline, CINAHL and the grey literature, none ofthese studies met the strict Cochrane
Collaboration inclusion criteria. The authors
indicated that despite finding a large body ofliterature on the evaluation of IPE, they all lacked
the methodological rigor needed to begin toconvincingly understand the impact of IPE on
professional practice and/or health care outcomes(Zwarenstein et al., 2001). However, a more
recent inclusive review suggested thatinterventions may be more effective at improving
client care if they are: of longer duration, deliveredin the work place, and were provided as part ofcontinuing professional education rather than in

Brown GT et al.

23

the earlier stages of professional develop (Koppel
et al., 2001).
Freeth, Hammick, Koppel, Reeves, and Barr
(2002) completed an extensive review of
evaluations of IPE based on a systematic review ofarticles reported on the following electronic
databases: Medline, CINAHL, and British
Education Index. Initially 417 studies wereidentified. After the studies were reviewed forresearch quality and rigor, only 217 met the final
inclusion criteria. Upon review of the 217 selected
IPE evaluation reports, it was found that moststudies focused on post-registration continuing
professional development, the learning was almost
always formal (such as a workshop or seminar)a nd n ur s i ng a n d m ed i c i n e w e r e t h e m o s tfrequently represented professions. The primaryresearch designs used by IPE investigators were
before-and-after studies and longitudinal studies.
Based on the critical review results, Freeth et al.
suggested that more prospective studies and more
longitudinal studies are required as well as moreinterpretive and critical studies. It was alsosuggested that since most IPE initiatives were
multi-faceted, implementing a great number of
mixed method studies would be appropriate.
In the 217 selected IPE evaluation studies,
Freeth et al. (2002) reported outcomes of IPE insix categories: (1) learners’ reactions, (2) changes
in attitude or perception, (3) changes in knowledge
or skill, (4) behavioural changes, (5) changes in
the organisation or delivery of care, and (6) benefit
to clients. The results indicated that half of thestudies dealt with learners’ reactions. The
acquisition of knowledge and skills, and changes
in organisational practice were the next mostcommonly identified outcomes. Fewer studies
measured attitudinal changes, benefits to clients,or changes in practitioner behaviour. Positive
outcomes reported from evaluations of IPE basedin higher education were overwhelmingly in theform of reactions to the learning experience,changes in attitude, or perception and theacquisition of knowledge and/or skills. Positive
outcomes reported for work-based IPE included
changes in the organisation of practice and effects
on clients. This difference may reinforce
assertions that IPE is only effective when it is24

THE EFFECTIVENESS OF INTERPROFESSIONAL EDUCATION IN THE HEALTH SCIENCES

work-based.
Some researchers conclude that systematic
reviews of IPE have failed to demonstrate a
causative link between educational intervention
and improvements in client care (Zwarenstein etal., 2001) while others express an alternative view
(Cooper, Carlisle, Gibbs, & Watkins, 2001). “Theemerging evidence suggests that it [IPE] can, infavourable circumstances and different ways,
contribute to improving collaboration in practice”(Barr, 2000, p. 22). However, attempts togeneralise the systematic review results must be
tempered. First, the number of studies thesystematic reviews are based on is small since
many of the studies did not meet the systematic
review or Cochrane Collaboration inclusion
criteria. Second, bias must be taken into
consideration at every step in the process of having
an IPE evaluation or IPE outcome study published.
For example, in most journals, manuscripts
reporting successes are more likely to be acceptedfor publication than an article reporting failures.
As well, Medline, which is used to list articles hasa bias towards evaluations that include medical
doctors and that are published in American
journals. Finally, if systematic reviews included
more of the IPE evaluation studies that used aqualitative research design or a combined
qualitative-quantitative methodology approach,the body of knowledge would be much richer.
A number of recommendations can be madeto improve the quality of IPE research studies
completed including use of control groups, use of
randomised controlled trials, use of prospective
studies and using combined qualitative methods toevaluate outcome with quantitative methods tomeasure change resulting from IPE. As well,important research questions such as the costeffectiveness of IPE and the impact of IPE on
professional practice and health care outcomes
have not been rigorously studied (Cleary &Howell, 2003).

11. Conclusion and Summary
There is one notable limitation in this reviewof the effectiveness of IPE. The medical andoccupational therapy literature were the main

sources of information consulted. It would havebeen helpful to include IPE evaluation studies
from other fields such as education, business, andengineering. However, the majority of medical
and occupational therapy studies cited did include
other health care professions (such as nurses,
socialworkers,
pharmacists,
andphysiotherapists).
The drive towards community care for the
benefit of clients is demanding different patternsof working, including the need to integrate(services), to collaborate (with other agencies andprofessionals), and for teamwork (share the sameclient-centred goals). As a result, there is a need to
produce clinicians who are adaptable, flexible,
collaborative team m embers, with highly
developed interpersonal skills. This is providing
the impetus and justification for IPE. IPE can beviewed as one way of providing clinicians with thenecessary knowledge, skills, and attitudes to meetthe demands of a challenging and dynamic healthenvironment (Parsell & Bligh, 1999).

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ORIGINAL ARTICLE

Occupational Therapists’ Decision Making
in Three Therapy Settings in Australia
Mehdi RASSAFIANI1 BS. OT, MS. PhD candidate,
Jenny ZIVIANI1 AppSc (OT), BA. MEd, PhD,
Sylvia RODGER1, B. OT, MEd, PhD
1The University of Queensland, Brisbane, Queensland, Australia

Abstract: Can a work setting with its organizational, cultural, and practicalconsiderations influence the way occupational therapists make decisions regarding clientinterventions? There is currently a paucity of evidence available to answer this question.
This study aimed to investigate the influence of work setting on therapists’ clinicalreasoning in the management of clients with cerebral palsy and upper limb hypertonicity.
Specifically the study aimed to examine therapists’ objective and stated policies, and theirintervention decisions using Social Judgement Theory methodology. Participants were 18
occupational therapists with more than five years experience with clients with cerebral
palsy who were asked to make intervention decisions for clients represented by 90 casevignettes. They worked in three settings, hospitals (5), schools (6), and community (6).
One participant from private setting was not included in the analysis because of lack ofparticipants in this setting. The results indicated that therapy settings did influence
therapists’ decisions about intervention choices but not their objective and subjective
policy decisions.
Key words: therapy setting, clinical reasoning, cerebral palsy, social judgment theory(Asian J Occup Ther 5: 29–39, 2006)

Introduction
Clinical reasoning or thinking associated withclinical practice is the fundamental cognitive
process used by therapists to plan, direct, perform,
and reflect upon client care (Chapparro & Ranka,

Received: April 30, 2006, Accepted: May 16, 2006
Corresponding to: Mehdi Rassafiani; Division of
Occupational Therapy, School of Health & Rehabilitation
Sciences, The University of Queensland, Brisbane Qld
4072 Australia
phone: 617-3365-3008 fax: 617- 3365-1622
e-mail: s4019578@student.uq.edu.au

2000; Schell, 1998). It has been suggested that thesetting in which therapists work may influence
their clinical reasoning, (Barnitt & Partridge,1997), facilitate or inhibit certain intervention
choices (Schell & Cervero, 1993) andconsequently influence therapy outcomes forclients (Chapparo & Ranka, 2000).
Therapy setting refers to the place in which atherapist works and provides services. The
practice model adopted in different settings may,by its very nature, impact decision making. For
example, therapists working in hospitals may be
influenced by the medical model (Fleming, 1991a,
1991b). Furthermore, within hospital settings

30

THERAPISTS’ DECISION MAKING AND THERAPY SETTING

doctors can influence therapists’ decision making
as they retain the overall responsibility for client
treatment (Crabtree & Lyons, 1997). Subjective
norms, however, can also influence therapists’decision making. Subjective norms include
therapists’ perceptions of the expectations of otheroccupational therapists, as well as those of clientsand carers. These perceptions can generate a
motivation to want to fulfill these expectations(Chapparo, 1997).
Barnitt and Partridge (1997) reported thattherapy settings influenced experienced
occupational therapists’ ethical reasoning.
Therapists in their study were influenced by theapproval of others. In contrast, Feder, Majnemear,and Synnes (2000) did not find that work settings
influenced the treatment approach chosen by 50
pediatric occupational therapists who had morethan three years of clinical experience. There are
two possible reasons for these discrepant findings.
First, the former study examined ethical reasoning,which is a type of clinical reasoning, while thelater focused on therapists’ treatment choices thatare the end product of therapists’ decision making
processes. Second, the studies employed different
research methods. While Barnitt and Partridge(1997) employed a phenomenological method
relying on observation and interview, Feder,
Majnemear, and Synnes (2000) used a quantitative
approach based on a questionnaire.
To date no studies have attempted todetermine the effects of therapy settings on
different aspects of therapists’ decision making
such as the information used by therapists, and theintervention options recommended for theirclients. Understanding what information is usedby therapists in their decision making in different
settings can help identify the specific assessmentand evaluation procedures considered importantand result in more effective use of time. If
intervention strategies chosen by occupational
therapists for their clients vary on the basis ofclinical setting then it also brings into question theissue of best practice. Social Judgment Theory(SJT) method seems to be appropriate in studying
information used and intervention choices
employed by occupational therapists in theirdecision making.

Social Judgment Theory (SJT) is a cognitive
decision making theory (Doherty & Kurz, 1996)
which is most relevant in situations where no
optimal decision exists (Cooksey, 1988). There
are two assumptions underlying the nature ofdecision makers’ thinking processes in SJT. First,
a n y d e c i s i on m u s t b e b a s e d o n p i e c e s o f
information or factors (Cooksey & Freebody,1986). Second, decision makers integrate thesefactors and synthesize them, trade off factors
against one another, set limits for factors, selectand attend to only those factors having perceived
importance to arrive at their final decisions(Hammond, 1978, 1981 cited in Cooksey &Freebody, 1986). In other words, decision makers
are influenced by the specific features of the
problem confronting them. In this process theydifferentially weigh factors in their clinicalreasoning and this is called strategy or policy
capturing (Wigton, 1996). This process is notentirely analytical, that is applying mathematically
logical rules, but largely intuitive based onclinicians’ hunches, impressions, and feelings(Hammond, 1996). Two kinds of policies are
identified in SJT: objective (statistical) and stated(subjective) policies (Cooksey, 1996a). Objective
policy is based on intuitive aspects of cognition
and refers to identified levels of importanceattached to the factors or how therapists actually
use factors (information) in their decision making.
Objective policies are identified when a large
number of case vignettes or real cases aredeveloped and presented to the decision makers
who are then required to respond to a clinicalquestion. General linear analysis is used toanalyse the relationship between the factors(information) presented in the cases and theperson’s response and this determines what has
been called the statistical factor weights (Cooksey,
1996b). Stated policies, on the other hand refer toan individual’s stated impressions of levels ofimportance (weights) attached to factors or how
they think they use factors (information) when
they make decisions. It is based on the analyticalaspects of cognition and identified when thefactors are presented to the decision makers who
are then asked to identify a factor’s weight (e.g.,
by factor ranking). In the present study, weAsian J Occup Ther 5: 29–39, 2006

Rassafiani M et al.

31

Fig. 1. A simple model in clinical reasoning (Chapparo, 1997)

examine the impact of therapy settings ontherapists’ decision making in the management ofclients with cerebral palsy and upper limb
hypertonicity in terms of therapists’ objective andstated factor weights, as well as therapists’intervention choices.
The management of upper limb hypertonicity
of clients with cerebral palsy (CP) was chosen as
the focus of this study for two main reasons. First,
the incidence of CP is high, manifesting in
between 1.4 and 2.4 of 1000 live births (Parkes, etal. 2001; Pirpiris & Graham, 2001; Sanger, 2003).
Second, people with CP are one of the major clientgroups referred to occupational therapy clinics as
outpatients (Dudgeon, 2001).
Chaparro’s frame of reference (1997) is used
to further clarify the aims of this study. She
suggested a model for therapists’ clinicalreasoning within a personal internal frame ofreference. She proposed that knowledge related tocontext, clients, other professionals, intervention
as well as self-beliefs and professional beliefs
produced the knowledge content of clinicaldecision making and these all form a complex
personal internal frame of reference. Therapists
use this knowledge within the internal frame ofreference to build a “personal theory for eachclinical encounter. She suggested that this frameof reference manages clinical judgments. Figure 1
illustrates Chapparo’s model in which therelationship between the internal frame ofreference and clinical reasoning is shown. This
study focused on weights attributed to knowledge
and information (factors) in two ways including

objective and stated policies, and therapists’intervention choices.

MethodThis study used the capacity of SJT to
investigate and understand the impact of therapy
settings on individual therapists’ decision making
policies and their intervention choices in the
management of upper limb hypertonicity in clientswith CP.

Task development
On the basis of a comprehensive literature
review, discussion with two expert therapists, anda survey of 12 further experienced clinicians, 12
factors were considered to be influential whentherapists make decisions in the management ofupper limb hypertonicity of clients with CP (seeTable 1). These factors were the basis for thedevelopment of case vignettes used in this study.
First, factors were defined and measurement scales
for each determined. The 12 identified factors andtheir scales of measurement formed the basis of
the information used to develop 10 sample casevignettes. A manual containing instructions foranswering the case vignettes, as well as the factor
definitions and the scales of measurement was also
developed to provide appropriate information fortherapists. The manual included three sections.
The first section provided information about theprocess of identifying the factors. The second
section included explanations about the identified
factors and their scales of measurement. The last

32

THERAPISTS’ DECISION MAKING AND THERAPY SETTING

section comprised a sample case vignette andstudy questions (Rassafiani, 2006).
Therapists were asked to identify the mostappropriate treatment method for the client
represented in the case vignettes among sevenchoices that were ordered on the basis of how
invasive they might be considered: no therapy,
hands-on approach, splinting, constraint-induced
movement therapy, casting, refer for Botulinum
Toxin Type A (BTX-A), and refer for surgery.
These intervention options were based on the workof Copley and Kuipers (1999).
A pilot study was conducted with four
experienced occupational therapists to determine:(1) whether the administration manual (i.e., thefactor definitions, and the scales of measurement)
was readily understood; (2) if the sample casevignettes were perceived as realistic; and (3) thetime requirement for reading the manual andanswering case vignettes was acceptable. The
pilot study enabled the administration manual andcase vignettes to be refined enabling the next
phase to proceed which was the generation of casevignettes for this study.
The statistical program SPSS version 11 wasused to help generate random values for each of
the factors included in the case vignettes. In
generating the data, a uniform distribution waschosen for each factor in which the values ranged
from the lowest to the highest to make sure that
there would be a wide spread in the final selectedcase vignettes mimicking the real world. Four
hundred case profiles were generated and thesewere then reviewed by two occupational therapists
experienced in the management of upper limb
hypertonicity as well as the research team to
exclude implausible client profiles. From theoriginal 400, 90 case vignettes that wereconsidered to be representative of real clients (seeAppendix A for an example). This was considereda reasonable numbers of case vignettes to use injudgment analysis (Cooksey, 1996a).
All chosen case vignettes were collated into abooklet. The booklet was bound and accompaniedby the manual guiding the participants in how toanswer case vignettes. Moreover, the manualcontained explanations and definitions of thefactors along with their scales of measurement.

Procedure
Ethical approval was gained from The
Behavioural and Social Sciences Ethical Review
Committee (BSSERC), The University of
Queensland. All questionnaires, answer sheets,and demographic information were labelled withappropriate codes related to participants and kept
in a locked filing cabinet. When a participant
agreed to take part in the study, an appointment
was made for two and half hours at her/his
convenience. During the meeting the participants
were told about the study and the process ofidentifying the factors, their scales ofmeasurement, and their definitions, as well as
development of the case vignettes. Then, they
were asked to read the manual and makeinterventions choices for three example casevignettes. In the meantime, any queries regarding
the various aspects of the study were clarified.
They were then provided with the case vignettes
booklet and an answer sheet and asked to complete
90 case vignettes. They could refer to the manual
when they were answering the questions.
Refreshments were provided during a break after
they completed the first 60 case vignettes. Whenthey finished all the case vignettes they were asked
to rank in order of priority the 12 identified factorsof the study. These factors were written on
individual cards which participants could
manipulate until they were satisfied with the order.

Participants
Occupational therapists with more than five
years experience with clients with CP working incentral and south-east Queensland (Australia)
were invited to participate in this study. They had
to satisfy the following criteria: (a) have aminimum qualification of a Bachelor of
Occupational Therapy; (b) possess additional
formal training (such as workshops or courses onCP); and (c) be acknowledged by professional
colleagues as having experience in the
management of upper limb hypertonicity inchildren and adults.
Participants were recruited by advertising in
the Occupational Therapy Australia QLD
Newsletter; distributing flyers about the project topaediatric interest groups; and by snowballAsian J Occup Ther 5: 29–39, 2006

sampling. Eighteen occupational therapists (16females and 2 males), mean age of 36.7 years(SD=7.6 years) who had worked with people with
CP for a mean of 10.4 years (SD=6.0 years)
participated. All possessed a Bachelor degree in
occupational therapy and one had a PhD. On
average, the participants had attended 5.8(SD=3.1) continuing education workshops (e.g.,
NDT, sensory integration, and conductive
education). Participants worked in various
settings including: (a) five in hospitals; (b) six inschools; and (c) six in the community. One
participant was from the private sector and was notincluded in the subsequent analysis.

Statistical Methods
Data from the answer sheet and therapists’decisions for the 90 case vignettes were analysedusing Chi-square test to determine whether thetherapists’ work setting (i.e., Hospital, school, or
community) influenced the intervention choices
favoured. Multiple linear regression models were
employed to examine therapists’ objective
policies. To examine the relative importance ofthe factors the square semi-partial correlations for
12 factors resulting from multiple linear regression
models were used and the relative weighting of thefactors were identified by the following equation.
sr2
RWui=
Σsr2
RW is the objective weight and sr2 is thesquare semi-partial correlation resulting from thelinear regression coefficient (Cooksey, 1996a).
The results show how therapists have used factors
to decide about the management of upper limb
hypertonicity for clients with CP. In addition, toexamine stated relative weights of factors
influencing therapists’ decision making, the
SMARTER (Simple Multi-Attribute Rating
Technique Extended to Ranking) procedure was
employed (Barron & Barrett, 1996). Participants
ranked the twelve judgment factors used in the
study from 1 to 12 with 1 being the most importantand 12 the least. Then, by using the SMARTER,
stated weights were calculated for each factor.
Finally, One-way Analysis of Variances

Rassafiani M et al.

33(ANOVA) was carried out to determine whether
there was any significant difference in therapists’objective and stated policies in respect to theirwork settings.

Results
Intervention choices
Figure 2 reports the percentage of therapists
who chose specific interventions based on theirwork settings. The Chi-square test showed thattherapists’ treatment choices were significantly
different (χ2=399.9, df=12; p=0.000).
Inspection of Fig. 2 reveals that hands-on
techniques, splinting, casting, and referral for
BTX-A injection were the main treatment choices
within all settings. While hands-on techniques andsplinting were the most commonly chosenintervention methods for participants working inthe school settings, splinting and casting weremainly chosen by participants in community
settings. Intervention choices favoured casting
and referral for BTX-A for participants working in
hospitals. Intervention methods including notherapy, CIMT, and referral for surgery werechosen less frequently than other methods andtheir percentages among the three groups ofparticipants were comparable.
To further clarify the differences in treatment
choices depending on settings, CIMT was
removed from the analysis. CIMT was among theleast favoured treatment options and this may bereflective of its clinical novelty. Figure 3
illustrates the treatment choices after removal of
the CIMT option. The treatment choices fortherapists practicing at schools were hands ontechniques and splinting, this shifted to casting fortherapists working in the community setting andreferral for BTX-A injections for those working in
hospitals. These differences were statisticallysignificant (χ2=384.1, df=10, p=0.000).

Therapists’ objective and stated policies
The objective polices of the participants
working in the three therapy settings were thencompared using ANOVA. The results revealed nostatistically significant differences among groups
in relative weights for the 12 factors of the study.

34

THERAPISTS’ DECISION MAKING AND THERAPY SETTING

Fig. 2. The frequency of treatment methods chosen by therapists based on work
settings
Note. T1: No therapy; T2: Hands-on techniques; T3: Splinting; T4:
Constraint-induced movement therapy (CIMT); T5: Casting; T6: Referralfor BTX-A injection; T7: Referral for surgery.

Fig. 3. The frequency of treatment choices by therapists in three setting withremoval of constraint-induced movement therapy as an option
Note. T1: No therapy; T2: Hands-on techniques; T3: Splinting; T5:
Casting; T6: Referral for BTX-A injection; T7: Referral for surgery.

The p values for all factors were more than thecritical value of 0.05 (df=2, 14). Table 1
summarizes these results.
ANOVA was used to examine whether there
was any difference in the stated relative weights offactors among the three groups. Results indicatedno statistically significant difference among thethree groups. The p values ranged between 0.2 and0.99 for the twelve factors (Table 2).

Asian J Occup Ther 5: 29–39, 2006

Rassafiani M et al.

35

Table 1. Comparison of objective policies of therapists working in three work settings
FactorCommunity
Mean
SD

SchoolMean
SD

Hospital
Mean
SD

F

p

Age
PT1
OG2
SS3
LP4
LA5
LD6
WFP7
TP8
PC9
AM10
FB11

5.7
4.5
10
15.3
2.3
4.2
2
10.8
4
5.3
16
19.5

18.5
3.5
1.7
23.5
2.8
6.3
1.8
23
2.5
3.3
5.2
7.8

1.4
12.2
2.2
45.8
5
1.2
5.6
4
11.2
5.2
4.8
1

2.1
2.1
0.9
3
0.8
0.8
1.8
1.3
3.3
0.3
2
1.9

0.15
0.15
0.45
0.08
0.49
0.47
0.2
0.29
0.07
0.77
0.17
0.19

5.8
3.7
20.2
16
3.1
5.7
2.4
7.2
5.1
5.7
14.4
24.4

23.4
4.1
2.4
28.6
2.1
9.6
1.6
31.8
1.9
3.6
8.8
11.6

1.7
12.6
2.2
13.7
5.6
1.6
5.9
3.8
9.3
6.1
6.7
1.4

Note. 1Previous Treatment; 2Occupational Goals; 3Severity of Spasticity; 4Limitation in Passive Range of Movement;
5Limitation in Active Movement; 6Limitations in Developmental Gross Movement; 7Wrist and Finger Posture; 8Thumb
Posture; 9Practice Context (time limitation, treatment priority); 10Associated Medical Factors; 11Client & Family
Background.

Table 2. Comparing stated policies of therapists working in three therapy settings
FactorCommunity
Mean
SD

SchoolMean
SD

Hospital
Mean
SD

F

p

Age
PT1
OG2
SS3
LP4
LA5
LD6
WFP7
TP8
PC9
AM10
FB11

8.1
5.6
16.7
13.8
7.5
9.7
2.6
4.6
3.8
3
13.2
11.7

12.1
5.3
18.3
14
10.4
9
2
8.5
5.2
6
3.3
6.1

8.3
5.5
16.9
15.2
11.3
8.3
1.7
4
4.6
6.5
7.6
10.2

0.46
0.01
0.07
0.07
0.57
0.11
0.43
1.9
0.53
0.54
1.84
0.86

0.64
0.99
0.93
0.94
0.58
0.89
0.66
0.19
0.6
0.59
0.2
0.44

6.3
4.7
8
7
3.4
3.4
2
3.4
2.8
2.3
11.3
10

11.1
4.1
7.5
6.6
8.9
6.8
1.9
6.1
2.6
2.6
2.4
4.8

5.4
3.4
8.4
7.8
5.1
3.2
1.1
1.7
1.5
10.8
10.7
7

Note. 1Previous Treatment; 2Occupational Goals; 3Severity of Spasticity; 4Limitation in Passive Range of Movement;
5Limitation in Active Movement; 6Limitations in Developmental Gross Movement; 7Wrist and Finger Posture; 8Thumb
Posture; 9Practice Context (time limitation, treatment priority); 10Associated Medical Factors; 11Client & Family
Background.

Discussion
Participants in this study were employed in
one of three clinical settings—hospital, school, or
community. When asked to identify influential
factors in their decision making therapists
regardless of work settings chose similar factors.

Therapists in the three work settings were alsosimilar in their objective policies. However, eventhough they identified similar factors as being
influential they varied in how they used thisinformation when determining the intervention
choices for clients represented in the casevignettes.

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The most frequently identified interventions
by participants working in school settings werehands-on techniques and splinting. For therapists
working in community settings, splinting andcasting were the primary choices, while for thoseworking in hospitals, casting, and referral for
BTX-A injection were preferred. Paradoxically,
however, these variations did not significantly
influence therapists’ objective and stated policies.
Ryan (2000) has stated that the focus of health careis predominantly intervention and medical
strategies in hospitals and that this changes
towards prevention and social ways of working incommunity and school settings. Therefore,
different thinking and clinical reasoning for thesesettings is required. On the basis of studies inmedicine and nursing, she further divided aspects
of clinical reasoning into generalized (e.g.,interpersonal skills, technical skills, selection ofdata) and specific (e.g., problem solving, numberof hypothesis, physical examination) to the setting.
The findings of this study seem to support Ryan’s(2000) proposition.
The results of this study are in contrast to
those of Feder, Majnemear, and Synnes (2000) in
which they concluded that work settings did not
influence choice of treatment approach for 50
pediatric occupational therapists with more than
three years of experience. This might be due to thedifferences in the methods of these studies. Bothstudies employed quantitative methods, however,this study used case vignettes to explore theintervention options, but Feder et al. employed aquestionnaire asking directly about intervention
methods.
Several reasons might help explain thevarious interventions used by therapists indifferent clinical settings. Chapparo (1997) statedthat “therapists were less likely to participate intherapy that was perceived by them to be‘difficult’ or ‘impossible’ in their particular work
context” (p.333). Participants working in
hospitals could have been more influenced by the
medical context of their setting (Mattingly, 1994).
Fleming (1991a, 1991b) suggested two otherreasons why therapists are strongly influenced by
the medical model: the type of education they havereceived, and their exposure to medical lecturesand case studies. Occupational therapy education
may therefore encourage therapists to employ the
medical model. This may have been the caseparticularly for therapists who trained more than
five years ago. Moreover, the medical model iseasy to understand as it includes concrete
information and therapists can follow theprocedures in a step by step method; such a modelis used in scientific reasoning (Chapparo & Ranka,
2000). Therapists working in hospitals also
usually take part in lectures and case discussions
run by physicians such as in grand rounds. This
may also increase their knowledge about medical
interventions and consequently influence theirown intervention choices.
The concept of subjective norms is anotherinfluential factor in clinical decision making(Chapparo, 1997). Subjective norms refer to “theperceived social pressure to perform or not to
perform various forms of therapy” (Chapparo,
1997: p. 279). Subjective norms evolve from: (1)therapists’ perceptions of the expectations of otheroccupational therapists, and (2) therapists’perceptions of clients’ and carers’ expectations
and can result in a motivation to fulfill these
expectations. In this research, subjective norms
relating to specific settings may have influenced
therapists in choosing particular intervention
options. In the schools, occupational therapists
mostly had interactions with teachers, physicaltherapists and speech and language pathologists,
while in hospitals this extended to nurses, anddoctors. In each setting, therefore different
professionals had various expectations and could
potentially influence therapists’ choice ofinterventions. Finally, difference in therapists’intervention choices may not be related to therapy
settings but therapists may simply choose to workin settings consistent with their view of healthcare, or a combination of these factors may cause
differences.

Limitations and future research
For the participants in this study place of
employment impacted intervention choices. Thismeans that for the same client, different clinicaldecisions were made if therapists were in different
settings. In other words, if a client obtained advice

Asian J Occup Ther 5: 29–39, 2006

from an occupational therapist in a school setting,this might be different from the intervention
advice of a therapist who worked in a hospitalsetting. If a client goes to different settings andreceives different suggestions, this may produce
conflict in choosing the most appropriate
intervention methods. However, because of thesmall numbers of participants in this study thisissue requires further investigation to examine
what currently happens with those clients who arereferred to different settings.
This study was conducted with the casevignettes. Further investigation with real clientswould help to clinically understand the influenceof therapy setting on therapists’ decisions.

Conclusion
This study found that therapists’ intervention
strategies were influenced by the therapy setting inwhich they were employed. In contrast, objective
and stated policies remained statistically similar
across settings. These findings suggest thatdifferent processes are at work in the clinicaldecisions made by therapists depending on theirplace of employment. Understanding the impactof therapy settings on therapists’ decision making
is an important consideration when looking at bestpractice. In this study therapists in three settings
used different intervention options for clients. It isnecessary to do further study with therapists inother settings and investigate the influences oftherapy settings on all aspect of therapists’ clinicalreasoning.

Acknowledgment
The authors would like to thank all therapists
who participated in various phases of this study.
Appreciation is extended to Dr Jodie Copley and
Kathy Kuipers for their expertise in the area ofupper limb hypertonicity.

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Appendix A - Example of case vignette

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