RESEARCH ARTICLE

AUTHORS Occupational therapists’ perspectives on

Azette Swanepoela
https://orcid.org/0000-0002-0939-0776 knowledge transfer in clinical practice in
Corlia Janse van Vuurenb the Free State, South Africa
https://orcid.org/0000-0002-4146-6937
Shoba Nayarc
https://orcid.org/0000-0002-9777-5915
ABSTRACT
AFFILIATION
aOccupational Therapy Department, Faculty of
Health Sciences, University of the Free State, South Background: The transfer of all types of knowledge in occupational
Africa therapy practice is complex, and there is little agreement globally on the
bSchool of Health and Rehabilitation Sciences, most important types of knowledge that inform clinical practice. This
University of the Free State, South Africa study aimed to uncover the perspectives of occupational therapists in the
cIndependent academic Free State, South Africa on knowledge transfer in clinical practice.
Methodology: Q methodology was used to collect data from 14
CORRESPONDING AUTHOR occupational therapists utilising Q Method Software.
Azette Swanepoel Results: Factor analysis revealed two factors with eigenvalues of greater
Email: [email protected] than 1. Factor 1 had an eigenvalue of 2.97, and factor 2 had an eigenvalue
of 1.48. These two factors were constructed from six and five participants’
KEYWORDS Q Sorts respectively, with the highest factor loads for factor 1 and factor 2.
Q methodology, theory and research, practice Thematic content analysis of these two factors identified two themes,
experience, patient–therapist relationship, patient namely: client-centred philosophy and practice informed through clinical
voice, occupational therapy clinical practice reasoning.
Conclusion: The strategic use of Q methodology presented empirical
HOW TO CITE THIS ARTICLE evidence of the transfer and utilisation of all types of knowledge in
Swanepoel A, Janse van Vuuren EC, Nayar S. clinical practice in the Free State, South Africa. The results indicated the
Occupational therapists’ perspectives on knowledge transfer of propositional, procedural, personal, and client knowledge
transfer in clinical practice in the Free State, South strengthens client-centred practice and manifests in clinical reasoning.
Africa. South African Journal of Occupational Furthermore, the results indicate an interdependence between the types
Therapy. Vol 54 No 1. April 2024. DOI: https:// of knowledge, meaning that it is important that therapists utilise all types
orcid.org/10.17159/2310-3833/vol54no1a7 of knowledge and not rely on only one form of knowledge when they
work with patients to promote well-being.
ARTICLE HISTORY Implications for Practice
Submitted: 23 May 2023 • Q Methodology is an ideal research method to identify the
Reviewed: 8 November 2023 subjective perspectives of participants where different opinions on
Revised: 18 January 2024 a topic might exist.
Accepted: 19 January 2024 • Clinicians hold a wealth of practice experience and personal
knowledge that should be shared and captured through research.
DATA AVAILABLE • The client’s voice needs to be heard more often to ensure client-
Upon reasonable request, from corresponding
centred practice is not only an idea on paper.
author

EDITOR
Blanche Pretorius
https://orcid.org/0000-0002-3543-0743 INTRODUCTION AND LITERATURE REVIEW
Various processes describe how knowledge is used to inform clinical
practice. These processes include knowledge transfer, knowledge
FUNDING
translation, and knowledge exchange1,2. Much has been published on the
The study from which this manuscript originated
different concepts of knowledge-to-action and authors have argued
was funded by the University of the Free State Staff
about the difference between the often-interchangeable use of the terms;
Doctoral Programme (USDP).
knowledge translation, knowledge transfer, and knowledge exchange.
Published under an International Creative Common LIsence 4.0
Table I (below, page 55) provides an overview of some of the definitions
of knowledge transfer indicating the different perspectives that exist.
Knowledge transfer, which is the focus of this paper, is seen as a
subcategory of the knowledge translation process which occurs in clinical
practice. The authors furthermore argue that knowledge transfer consists
ISSN On-line 2310-3833
of all types of knowledge not only research evidence.

54 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
Table I. Definitions of knowledge transfer types of knowledge to ensure meaningful occupational
engagement for the client. This is achieved by recognising the
relationship between the person, environment, and
occupation and the types of knowledge arising from it.
Over the past few decades, researchers have strongly
advocated for the use of propositional knowledge (evidence-
based knowledge) to inform clinical practice13,16–18. These
authors argue that, to inform practice and ensure quality
service delivery evidence-based knowledge is necessary.
However, the knowledge that is transferred to clinical practice
might also include (or be derived from) clinical skills, cognitive
skills such as judgement, problem-solving, and decision-
making that developed from occupational therapy practical
experience2, contextual knowledge acquired from clients
(client-knowledge)1⁵, and the personal values and beliefs of
the occupational therapist. It could, thus, be dangerous to
focus on a single form of knowledge transfer, furthermore, to
ignore the interrelated nature of knowledge transfer.
Knowledge transfer in clinical practice is a dynamic
process that involves occupational therapists, their clients,
other relevant stakeholders, such as other team members,
family, and/or caregivers accessing and sharing all types of
knowledge. The transfer of knowledge is, therefore,
According to the literature, the transfer of knowledge is considered to be a bilateral activity or a “two-way process”2:16
considered to be a bilateral activity or a two-way process2 of of knowledge informing practice, which suggests
knowledge informing practice, and can include any collaboration between the occupational therapist and client in
combination of the types of knowledge described in literature clinical practice1⁹. Davis and Polatajko1⁴ and Park et al.2⁰ also
(see below). If compared with some of the definitions of refer to the value of collaboration, where the occupational
knowledge translation and exchange, knowledge transfer uses therapist acknowledges the clients’ occupational stories, and
both, empirical evidence to guide practice, procedural - as well use it to inform contextually relevant occupation-based
as personal knowledge. Knowledge is, therefore, not practice. Indeed, it has been argued that it is often the transfer
transferred to practice by researchers; rather transferred in of the expert knowledge of a client or their caregivers about
practice between clinicians, clients, and other stakeholders. their context and occupational realities that informs
Because of its all-encompassing nature, knowledge transfer as practice1⁹,21 as well as allows for client-centred service
a method to inform practice was the focus of the study. delivery.
Occupational therapists use diff Yet, understanding the interrelated nature of knowledge
erent types of knowledge to understand the complexity of hu transfer is a complex undertaking, especially given the varied
man occupation to guide clinical perspectives on the transfer of the different types of
reasoning for assessment and intervention and inform ethical knowledge in clinical practice. What authors do agree on,
practice7–9. Often, in clinical practice, the occupational therapis however, is the importance of knowledge for informing
t draws on a combination of the types of knowledge to inform clinical practice. To date, limited documentation exists on the
their clinical reasoning10,11. These interrelated types of knowle perspectives of South African occupational therapists on the
dge include propositional (or theoretical/empi type and content of the different types of knowledge that are
rical) knowledge,⁸,12 , procedural knowledge (practice experien transferred in clinical practice. The aim of this article is to
ce)⁵,12, personal theory (referred to as personal knowledge h determine the perspectives of occupational therapists
enceforth)⁸, practicing in the Free State, South Africa, regarding knowledge
12, and espoused knowledge2. Propositional knowledge includ transfer in clinical practice.
es theoretical knowledge and research evidence⁸,12; while pro
METHODOLOGY
cedural knowledge refers to the occupational therapist’s
Ethical approval for the study was received from the Health
clinical experience⁸,
Science Research Ethics Committee (UFS-HSD2021/1454/2610)
13. Fish and Boniface⁸ describe personal theory as the clinician’
of the University of the Free State.
s values and beliefs that influence their practice,
while espoused knowledge is propositional knowledge that th Study Design
erapists agree with because of their personal knowle To determine the occupational therapists’ perspectives on
dge. It is, therefore, the theory they understand or feel comfor knowledge transfer in clinical practice, a mixed method Q
table with and which they will use in practice. Client knowled methodology was utilised. Q methodology was developed by
ge refers to the knowledge a client has of their o psychologist William Stephenson in 1935,22 and identifies
ccupational profile, context, likes, and dislikes1⁴. participants’ subjective perspectives regarding a specific topic
There are, however, differing perspectives on what is the of interest, about which different opinions may exist23,2⁴.

SA Journal of Occupational Therapy SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 55
The Q methodology consists of six steps, and the work of
Webler et al.2⁵ is referenced in this study.
Step 1: Determine the objective of conducting the Q methodology
The objective was to determine the perspectives of
occupational therapists in the Free State, South Africa on
knowledge that is transferred in their clinical practice.
Step 2: Preparation to create the concourse
A concourse is a collection of possible statements that, for this
study, related to the occupational therapists’ knowledge
transfer in clinical practice. To build the concourse for the Q
sample, published resources and semi-structured interviews
are included, as recommended2⁴. For this study, a scoping
review was undertaken to determine the landscape of
knowledge transfer in occupational therapy clinical practice.
Figure 1: Q Grid
The scoping review was followed by semi-structured, digitally
audio-recorded interviews with nine occupational therapists (https://app.qmethodsoftware.com/admin/study/dashboard/
from different practice settings (see Table II, adjacent, page 57) 10407/structure)
in the Free State, South Africa, to gain insight into the content
of the knowledge that is transferred in their clinical practice. QMethod Software provide a forced normal distribution with
Interview participants were provided with a definition and an an equal number of blocks on either side of the neutral
explanation of each of the four types of knowledge that had column. Statements must be placed in each block before the
been identified in occupational therapy literature, namely, survey continues. This normal distribution forces participants
propositional knowledge (theoretical/empirical), procedural to carefully reflect on their perspectives of knowledge transfer
knowledge (practice experience), personal knowledge (own in their specific clinical practice2⁶ and place a statement in the
world view, values, and beliefs), and client knowledge. applicable block of the Q grid (see Figure 1, above).
Inductive thematic analysis was performed to extract
statements made by participants in the interviews, to form the Step 4: Recruit participants
concourse2⁵. Statements were also extracted from the Convenience and snowball sampling were used to recruit
literature identified by the scoping review. From the participants. Twenty occupational therapists known to the
concourse, a Q sample of statements was developed. researcher and practicing in the Free State, South Africa were
Including only participants from the Free State, South Africa invited via email to take part in the Q method survey. Through
was a limitation of this study. It is recommended that a follow- snowball sampling the participants were requested to share
up study is conducted amongst occupational therapists the invitation with colleagues who might be interested in the
practicing in the whole of South Africa. study. The researcher did not specify the number of invitations
to be shared with colleagues. Webler et al.2⁵ suggest that
Step 3: Identify, select, and edit Q statements participants should hold various perspectives on the topic
The concourse initially consisted of 80 statements under investigation. For this reason, occupational therapists
representing the four types of knowledge: propositional (n = were recruited from various clinical fieldwork settings in the
20), procedural (n = 32), personal (n = 14), and client (n = 14) Free State, South Africa. Table II (below) shows the clinical
knowledge. To identify, select and edit the Q statements, the practice setting of the two groups of participants of the semi-
researcher and a co-coder, who is familiar with Q structured interviews and the Q method survey.
methodology, went through all the statements to retain,
combine, or remove statements. The included final Q Table II: Practice settings of participants
statements adhered to the qualities of a “good Q statement” in
(a) being meaningful to the participants (occupational
therapists), (b) understandable, (c) having the potential to be
interpreted in various ways, and (d) giving participants
something to think about2⁵:1⁶. The final Q sample consisted of
42 statements relating to the four types of knowledge:
propositional (n = 8), procedural (n = 15), personal (n = 10),
and client (n = 8) (see Table II page 58).
After finalising the Q sample, each statement was allocated a
number between 1 and 42. The study was set up using
QMethod Software2⁶ and the statements were loaded onto
the platform in the same sequence as each statement had
been numbered during the preparation phase. A Q grid was
set up in an inverted pyramid comprising 42 blocks (Figure 1,
adjacent)

56 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
 statement — from most to least applicable to the participant’s
clinical practice. Statements could be removed and replaced
until the participants were satisfied with the placement of
their statements. The final placement of the statements by
each participant is known as the participant’s Q sort placed
from most to least as applicable to their clinical practice. The
last landing page of the survey, a short post-sort section,
invited participants to comment on their Q sorts and the
placements of the statements on the Q grid. Participants were
given the option to provide feedback by commenting in the
QMethod software, or to send a reflection to the researcher
via email or to have a short online discussion with the
researcher. Only six participants provided feedback, which is a
limitation of the study. The researcher recommends in person
reflection with each participant take place to ensure the
valuable input from participants are not lost.
Step 6: Using factor analysis to arrive at perspectives of
knowledge transfer in clinical practice
Factor analysis was used to identify patterns from the Q sorts
of each participant2⁵. The final sorts, also known as factors, are
combinations of the different participants’ Q sorts.
The first step of the factor analysis was to decide on a method
Step 5: Conducting the Q sorts to extract the factors, either centroid or principal components
Participants used a link provided by the researcher to access analysis. In this study, centroid analysis was used2⁵ to account
the QMethod Software platform and were requested to for the indeterminacy of its solutions. This means that the
provide an individualised participation code (also provided by same participants would not have the same Q sort twice2⁷.
the researcher). The first landing page of the survey requested The second step was to choose a rotation method to ensure
participants to consent to participation in the study by the best results. In this study, Pearson correlation and Varimax
choosing between the options ‘agree’ or ‘not agree’. In the rotation were done to ensure that participants’ Q sorts were
next step, participants were instructed to rank each of the considered for only one factor2⁵. The last step of the factor
statements by choosing an icon (thumbs up, neutral, thumbs analysis was to decide on the number of factors. The Kaiser-
down) with regard to the applicability of the statement to Guttman criterion was used to determine the number of
their clinical practice setting (Figure 2, below). The statements factors to be extracted. Two factors with eigenvalues greater
were automatically placed in three piles, to be used in the than 1.002⁶ were chosen, the statements from these two
next step. factors with sort values of four, three, and two (Table IV, page
58) were thematically analysed by the researcher to
determine the participants’ perspectives on knowledge
transferred in their clinical practice.
Q methodology was designed as a rigorous method to
determine participants’ subjective opinions or perspectives on
specific matters2⁸, which made this the most suitable research
method for this study. Content validity was assured by using
literature and interviews to compile the final Q sample. The
natural-language statements extracted from the semi-
structured interviews and statements from literature assured
face validity. A pilot study was conducted to further assure
content and face validity. No changes were required, and the
results of the pilot study were included in the main study. Q
sort validity was obtained, and each participant’s Q sort
represented their own perspectives. Reliability had been
confirmed through test-retest procedures in previous
Figure 2: Example of Statements with Icons studies2⁹. Regarding trustworthiness of the study; credibility
(https://app.qmethodsoftware.com/admin/study/dashboard/ was ensured through method, data, and theory triangulation.
10407/codes) Transferability was ensured through a description of
knowledge transfer in clinical practice as well as a specific
Once the initial sorting had been done, participants continued procedure of data collection and analysis were utilised.
to a page where the Q grid appeared (Figure 1, page 56). Each Dependability was ensured though audit trails and systematic
of the statements in the three piles were subsequently placed documentation, management, and storage of data.
on the grid, by each participant, according to perception of a

SA Journal of Occupational Therapy SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 57
RESULTS Table III: Factor Matrix with Defining Sorts Flagged
Results of the two data collection processes described above
are included in this paper (see Table II, page 56). The first set
of results was obtained from the Q methodology survey itself,
with 14 occupational therapists practicing in the Free State,
South Africa. The second is based on the qualitative data
obtained from the semi-structured interviews conducted with
nine experienced occupational therapists, to determine
the initial Q statements.
In total 20 occupational therapists in the Free State, South
Africa, indicated their interest in taking part in the Q method
survey and were sent an information document. This was
accompanied by a link to the QMethod Software web page,
and a different participation code for each participant
randomly created by the platform. In the end, only 14
occupational therapists from different clinical practice settings Table IV (below) shows the final factors with the z-scores
completed the Q sort and were included in the study. Webler and sort values of each statement that contributed to the
et al.2⁵ recommends recruiting one participant for every three factor. A sort value of 4 represents a statement that is most
Q statements; therefore, 14 participants were deemed applicable to a participant’s clinical practice. Only statements
sufficient for this phase of the study. Six participants provided with a sort value between 4 and 1 are included in Table IV
written reflective feedback regarding their Q sorts. At this statements with sort values of 0 to -4, which
stage, it was not known whether a participant’s Q sort would represent neutral or least applicable to a participant’s clinical
be flagged for inclusion in the final factors. practice, are not included.
Two factors with eigenvalues greater than 1.00 were The results indicate a low correlation of 0.334 between
extracted. Factor 1 had an eigenvalue of 2.97, while Factor 2 factors 1 and 2. This is of importance, because it indicates that
had an eigenvalue of 1.48. A factor represents the collective there are differences between the two sets of factors. The z
perspectives of a group of participants2⁷. The final factors are sores in Table IV (below) indicate the priority statements of
combinations of the statements used in the study. Factor 1 was each factor. The final factors represent participants’
constructed by Q sorts of participants 3, 9, 10, 12, 13, 14 while perspectives and include all the types of knowledge
Factor 2 was constructed by Q sorts of participants 1, 4, 5, 7, 8. transferred in occupational therapy clinical practice in the Free
(see Table III, adjacent). Automatic flagging of a Q sort is done State, South Africa. The thematic analysis of the statements
to, first, indicate which participants’ Q sorts have the highest with sort values of 4, 3, and 2 delivered two themes namely:
factor loads and, second, to correlate a participant’s Q sort client-centred philosophy (Factor 1) and practice informed
with the final factor2⁵,3⁰. through clinical reasoning (Factor 2).

Table IV: Factor scores

58 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
The qualitative findings, as shown in Table V (below), were referred to as I participants, whilst data from participants
extracted from the semi-structured interviews and the post- included in the post survey comments of the Q methodology
survey comments of the Q methodology. The verbatim quotes referred to as Q participants. The verbatim quotes of the
obtained from the semi-structured interviews is participants support the two themes identified from Factors 1
and 2.
Table V Qualitative findings

SA Journal of Occupational Therapy SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 59
DISCUSSION their patients. Embodying the client-centred philosophy of the
Q methodology was designed to measure the participant’s occupational therapy profession might lead to a patient–
subjective perspectives on an issue, and to challenge therapist relationship developing. This relationship is,
participants’ thoughts on the matter2⁵. Participants had to however, dependent on the engagement of both the patient
carefully consider what type of knowledge was most or least
and their therapist. Where pathology allows, shared problem-
applicable in their clinical practice setting, which confirms the
solving gives autonomy back to the patient and restores their
existing perspective that different types of knowledge inform
clinical practice7–9,19. The thought processes facilitated by the dignity, because patients contribute to discussions about the
Q methodology re-affirmed the importance a client-centred total care process of which they are the recipient. Sumsion
philosophy and clinical reasoning for occupational therapists and Law3⁴ argued, in a patient–therapist relationship, the
in clinical practice, through the two themes identified and therapist should be aware of the power relationship in the
discussed below. therapeutic process. By collaborating and communicating
treatment goals, the balance of the power relationship might
Client-centred philosophy
be more equal3⁵. Participants stated that, in this collaborative
The client-centred philosophy, firstly, manifests in clinical
relationship, they used examples from their own experiences,
practice through the utilisation of propositional knowledge
(theory and research) of the patient’s pathology. Designing which further demonstrates the equalisation attempt
interventions relevant to each patient’s needs by choosing suggested by Sumsion and Law3⁴.
theory ensures evidence-based practice. Utilising theory Fourthly, patient might transfer their expert client
pertaining to pathology, combined with applicable theoretical knowledge of their own occupational stories, contexts, and
frames of references, allows occupational therapists to support systems to clinical practice. Each patient’s
understand the impact of a pathology better, and provide environment and context are unique, and intervention plans
them the opportunity to work towards functional treatment should not be blindly duplicated from one patient to the next
outcomes with their patients3. based on similar pathology or geographical context1⁴. A
Secondly, “Putting the patient first” (Factor 1, statement no patient’s occupational engagement is often guided by their
15) reflect participants’ world views, values and beliefs, and cultural roles, rituals, and/or routines. Differences in, amongst
ethical perspectives which inform and influence the way they others, role expectations, cultural practices, spirituality,
approach their patients⁸,12. This personal knowledge develops contexts, and environments, should always be considered,
through reflective practice that influences and might even whereby ensuring occupational justice for each patient33.
change a therapist’s personal beliefs of patients, their contexts
Therapist often rely on practice experience while being
and challenges31. The complex integration of procedural
cognisant of the client knowledge transferred by their patient
knowledge (experience) and personal knowledge occurs as a
result of reflective practice. The integration enables a therapist to ensure client-centred service delivery.
to identify best practice, transfer contextual relevant Practice informed through clinical reasoning
propositional knowledge to their clinical practice while The skill of applying clinical reasoning is the product of clinical
maintaining a holistic view of the patient32. experience and develops throughout the occupational
Restall and Egan33, thirdly, urged therapists to realise the therapist’s profession. It informs the occupational therapy
importance of collaborating and building relationships with

60 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
process from the evaluation-, intervention planning-, who conducted the semi-structured interviews, and Jani du
treatment implementation-, and outcome measure phases. Preez, who assisted in compiling the final Q sample of 42
Furthermore, propositional knowledge forms the foundation statements from the original concourse of 80 statements.
of occupational therapists’ knowledge base, and influences
Conflicts of interest
their clinical reasoning, which manifests in clinical practice.
The authors have no conflicts of interest to declare.
Each therapist holds personal world views, values and beliefs,
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