How has the therapeutic use of self been used over time throughout Occupational Therapy’s history?
Physiological observations (or “obs” ) are recorded from patients in acute settings at various intervals, depending on how closely they need to be monitored for any potential changes. During and for 24hrs after thrombolysis, a patient’s obs are recorded every 15 minutes. Usually obs are taken every 4 hours although if one physiological aspect is fluctuating this is increased to hourly to keep a closer check on indications of any conditions which may adversely affect the patients health eg infection, dehydration, haemorrhage etc.
Usual obs taken for acute patients are:
- Heart Rate– usually 50-80 bpm, recorded by pulse or heart monitor
- Respiratory Rate (RR)– usually 14-20 breaths/minute, recorded by counting chest movements
- Temperature – usually 36-37’C
- O2 saturation– usually 95- 98% although smokers/COPD may have a lower target saturation set by doctor eg 85%
- AVPU– Alert/responds to Verbal/ responds to Pain/Unresponsive; measuring drowsiness with a shortened version of the Glasgow Coma Scale
- Glasgow Coma Scale (GCS)– patient’s level of consciousness cored out of 15. Note that a coma patient or toaster will have a minimum score of 3. Aphasic patients are scored out of 10, and you should test a stroke patient’s unaffected side since a side with hemiparesis does not truly reflect their level of consciousness.
- Blood Pressure (BP)- usually 120/80 (systolic over diastolic) although expected to be higher in stroke patients. BP is often higher in stroke patients, up to 220/110. A sudden drop in BP can cause patient to faint/collapse, known as syncope. A fluctuation in BP during sit to stand can also cause patient nausea and dizziness, and lying down can reduce these symptoms in this circumstance. According to NICE guidelines, BP should be ideally be 185/100 or lower for patients who are potentially suitable for thrombolysis.
- Blood Glucose– 5-7 mmol/litre is normal, 7-11 mmol/l indicates impaired glucose tolerance. Above 11 mmol/l indicates diabetes. Medication such as steroids can increase the blood glucose level in a patient. Higher blood glucose leads to reduced immunity and increased risk of seizures in stroke patients. According to NICE guidelines, patients with acute stroke should be treated to maintain a blood glucose concentration between 4 and 11 mmol/l.
“Difficult, but important”
Reflection is an important yet ethereal skill that all Occupational Therapists need to master.
Part of completing a reflection is an inner sense of discomfort (in fact the first stage of reflection as described by Boyd & Fales 1983) so it’s no wonder many people put it off and may even try to get by without it, perhaps carrying out token reflections just to comply with CPD or course requirements. To begin with, reflecting on your actions is something that requires conscious effort after the event but eventually, according to Johns (2000), it will become an automatic thought process even when you’re in the middle of experiencing the event. When deciding which model to use, it can helpful to find out what learning style you are according to Honey & Mumford. You can relate these to the knowledge types shown in Carper/Johns’ reflective models.
Below is a rough guide to the different models of reflection out there, and which situations they’re best geared towards. They are ordered (in my opinion) from the easier ones for the beginner who is trying to break down and evaluate a situation, to the more complex ones that build on the basics and hope to elicit a change in your personal beliefs and challenge your assumptions. Gillie Bolton suggests exercises for creative ways to reflect in her book Reflective Practice: Writing and Professional Development (chapter 4).
Like Inception, you’ll naturally find yourself going deeper with your analysis of an event the more experience you gain with reflective models. Enjoy the ride!
Gibbs reflective cycle (1988)
Good for: Good old Gibbs. Basic, good starting point, six distinctive stages. Makes you aware of all the stages you go through when experiencing an event.
Criticisms are: superficial reflection- no referral to critical thinking/analysis/assumptions or viewing it from a different perspective (Atkins & Murphy 1993). Does not have the number or depth of probing questions as other models.
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The OT process is when we apply the theories of occupation in an ordered way to a practical situation. Many different models of the OT process have been developed, and they each attempt to guide a therapist through the stages of applying occupational theory to a practical client situation. Some models may be more useful in particular situations or with particular clients than others.
Part of the artistry of an being an OT, and the difference between being a technician and a professional, is being able to adopt a holistic approach and use a model most appropriate to the individual client’s unique blend of problems in order to achieve a positive outcome. Technicians follow instruction in order to carry out processes whereas professionals use a blend of artistry with science to determine the best model and interventions for each unique patient.
Some examples of OT process models are below:
- PEOP Person-Environment-Occupational Performance
- CMOP-E Canadian Model of Occupational Performance & Engagement
- MOHO Model of Human Occupation
- MoCA Model of Creative Ability
- Biopsychosocial model
- Max Neef model
- Capability approach
- Medical model
- Kawa (river) model
- Social disability model
- European Conceptual Framework for Occupational Therapy
- EHP Ecology of Human Performance
- OA Occupational Adaptation model
- OPM(A) Occupational−Performance Model (Australia)
You may have come across the term before, you may not, but if you’re an OT you’ve probably utilised it without realising already. Therapeutic use of self is a useful technique employed by occupational therapists in order to engage clients and therefore illicit a better outcome during the OT process. Essentially it’s being aware of yourself (your verbal language, body language, which personal information you choose to share…) when you’re interacting with a client, and using your own personality & interpersonal skills in order to build rapport and ultimately make the client feel at ease, motivated, and that they can trust you.
In order to use yourself therapeutically, you must first be aware of your interactions with a client to then be able to adapt them to suit the style of the client. It can be useful to consider some models in order to structure your thoughts, and provide guidance for an occupational therapy student who is just beginning to reflect on their own therapeutic style.
Taylor (2008) has recently proposed the Intentional Relationship model, which categorises the six therapeutic modes -or types of client-therapist interactions- into six categories.
The modes in the Intentional Relationship model (IRM) are: Read more
As a student getting your ideas across in essays is crucial in order to convey you have grasped the ideas and can see both sides. These skills will still be needed when you are writing or reading research papers once you’re qualified, or when you need to convey one or both sides of a treatment approach in a report about patient care to others in an MDT. Any points you make need to be backed up with evidence to make them valid.
Critical thinking requires quite a few skills to be carried out effectively, including observation, categorisation, analysis, judgement/reasoning, making final decision, persuasion, perseverance in repetition of examining facts, and objectivity. This last skill forms the basis of being able to critically analyse both sides of a situation or concept.
Evidence used in essays must be:
Appropriate – Making the same point as you and not similar or just on the same topic. Also must be recent unless it’s a historically seminal piece of work about principles or foundations.
Proportionate – Specific statements about defined populations or findings may only need one piece of evidence, but the bigger the statement the more evidence you need- views from for and against camps are needed to represent the whole debate.
Synthesised – How is it synthsised or worked into the flow of the essay? How does the evidence move your point towards its conclusion? So what if the research shows that ‘banana therapy is most effective for under 30s’ …what statement that you’ve made in your essay is it proving?
Recently I got to represent Occupational Therapy at a postgraduate event, and it was great being able to help future OT students by offering some advice here and there. A lot of them commented that it was really helpful having current students there, as well as the University’s admission tutors, and it made me cast my mind back to the stressful months & weeks before my interview when I’d have sat through the every episode of Big Bang Theory in return for a student godmother to ask three questions to.
Below are some of the most common questions together with the advice I gave:
How do I get OT shadowing experience?
You can try contacting local hospitals’ OT departments and asking them. However in my experience, the success rate for people obtaining shadowing experience this way is low. A better way is to use your existing contacts, and think outside the box. By this I mean think about who you already know, and think about all the places where OTs work (clue: it’s not just hospitals).
Some ideas are:
Traditional settings– hospitals, outpatient clinics, schools, nurseries, supported living facilities, day centres for people with learning disabilities, community health teams, hand clinics.
Non-traditional settings– mental health/psychiatric facilities, equine therapy/animal assisted therapies, assistive technology centres, research labs, prosthetic/orthotic clinics, chronic pain management clinics, palliative care/hospices, oncology depts, military hospitals/rehab centres, private schools, independent practitioners, prisons/criminal justice system, vocational rehabilitation, community-based or mental health outreach teams, A&E.
OTs are generally acknowledged to be the nicest people you’ll ever meet. The ones that I contacted ranged from willing-to-help to bent-over-backwards-to-offer-clinical-contact-and-photocopied-relevant-book-pages-for-me. Even if you don’t have a family member who’s an OT, ask around if anyone knows of one and you will be surprised. Then be shameless in approaching them directly for help! The worst they can do is politely decline, but I guarantee they won’t. Read more
Searching for the evidence
Lots of different information sources are available to OTs when they are searching for evidence to guide their Evidence Based Practice. The different types each have different levels of usefulness related to patient care.
Some example sources and their uses are:
- Guidelines – help OTs to make decisions quickly as you do not need to search and review literature yourself. Someone eg NICE has done this (plus taken into account the cost/benefit) already for you.
- Protocols – defined steps or rules used to describe the process for a particular treatment or assessment. Often specific to local contexts; stricter and hold more weight legally than a guideline.
- Blogs – useful to understand public opinion around a certain issue; can read a wide range of opinions and see what evidence is used to back each up (or question whether any has!). Is this where patients have researched healthcare in the absence of journal access, and does this explain their viewpoints?. Some professional organisations also have blogs, such as this BMJ evidence based nursing blog.
- Theories – explanations of phenomena. They can be tested to see if they work in practice via research hypotheses, so in this way evidence could prove or disprove theory.
This model was developed in 1985 (it was later revised in 2005 and 2015) by Baum and Christiansen in response to a move away from the biomedical model way of thinking which is very practitioner-based. Conversely, the PEOP model is much more client-based.
It considers the factors affecting a client’s occupations, and then groups them as either intrinsic or extrinsic. This is different to other models because it separates factors out as either intrinsic or extrinsic as well as further separating each of these at a personal, social and population level.
In the diagram below, the PEOP model itself is shown in purple and I have added examples of each intrinsic/extrinsic factor in grey boxes around the edge.
It uses the biopsychosocial approach since it takes into account the physical (bio), emotional (psycho), and social factors that can influence someone’s occupational performance. Because of its broad categories it can be applied to populations, groups of people in organisations, or individuals. In the 2015 revision of the model, alongside the model depicted above is a box feeding into the model. The box contains three segments each labelled as personal narrative, organisational narrative, or population narrative. Under each segment it shows example information about what the perceptions, goals and needs for the narratives of an individual, an organisation, or a population would be. In this way it highlights which type of information needs to be elicited, and so which questions an OT would need to ask, from whomever they were assessing in order to create a narrative or ‘occupational profile’.
The OT Process using PEOP
As part of the process when using the PEOP model, the client’s history, perceptions, and short & long-term goals are established which creates information about the client’s strengths and weakness.Then the OT’s evaluation occurs, and finally the OT and client work together to decide on the occupational goals for the client. In this way the model involves taking into account many sources of knowledge, eg practitioner knowledge together with patient preference, so is a good example of evidence-based practice which is a core value of occupational therapy.
What’s good about it?
- Emphasis on the interaction between person & environment, and how this affects occupation (Law et al 1996)
- Client-centred approach, collaborate with patient to establish therapeutic goals
- Top-down rather than bottom-up model, so is holistic and person-centred (Fawcett 2007)
- Comprehensive list of factors; useful guide for a novice OT who leans towards more prescriptive frameworks until they acquire tacit expertise (Robertson 2012)
What’s bad about it?
- No associated assessment tool and so no direct outcome measure (Christiansen et al 2015)
- The challenge of judging the weighting of the different factors yourself, as the model does not make this clear (Duncan & Hagedorn 2011)
- Isn’t a large literature base providing evidence for the model (Law et al 1996)
- The model considers many longer-term factors (eg culture, economic systems, social support systems), may not be relevant if patient’s goals are short-term or resources are limited and the time the OT will have with the patient isn’t long enough to make changes to any of those areas
It is a model that takes a broad and holistic view of a person’s occupations, however the PEOP model places an emphasis on a client-centred approach and how the environment impacts someone’s occupational functioning. It details all the areas where strengths and weaknesses can occur, which can then be assessed together with the client to identify which factors are impacting occupational performance. The client’s own goals together with the OT’s intervention goals are then matched so it encourages collaboration together. Because of this the model is very client-centered as opposed to disability-centred, and encourages exploration in partnership with the client. It has a top-down approach in evaluating the client’s situation which reflects another of occupational therapy’s core values, a holistic approach. A top-down approach would be when you look all the things that cause an effect on occupational performance, whereas a bottom-up approach would be looking at and treating one symptom. Using the case study below as an example, a top-down approach would be looking at Barbara and everything affecting her everyday living tasks in the context of her current situation. A bottom-up approach would be looking at her symptom of restricted leg movement and how this affects her occupations.
Example Case Study using the PEOP model
- ‘Barbara’ is a 72yo female, widow, lives alone but family nearby
- possible chest infection; admitted to A&E
- while in hospital falls and fractures hip
- hip operated on and stays in acute orthopaedic ward there
- seen by a rehabilitation team OT
Because of the scope of the service they work in, an orthopaedic OT’s goal would be to get Barbara to get back to her home in the community.
In order to obtain the information necessary to create Barbara’s version of the PEOP model above, the following assessments are carried out:
- CAM-ICU -Confusion Assessment Method, with either normal or an acute/ICU version (NICE 2008)
- Canadian Occupational Performance Measure/COPM (Carswell et al 2004)
- Barthel Index of ADL/Activities of Daily Living (Barthel & Mahoney 1965)
- Home visit incorporating SAFER-HOME tool (Oliver et al 1993)
Use of CAM-ICU to quickly assess mental state. NICE guidelines state hip fracture patients over 65 are high-risk group for delirium. If positive for delirium, refer her to doctor or nurse for investigation of underlying issue eg chest infection, dehydration or pain.
Assess her occupational performance by using Barthel Index of ADL with activity analysis of washing, dressing, feeding, stairs & transfer tasks (working with physiotherapy and nursing teams).
Use the semi-structured interview tool Canadian Occupational Performance Measure to identify areas of occupational importance to Barbara, and her satisfaction with them. If Barbara wasn’t deemd to have capacity from the CAM-ICU the COPM can still be completed by proxy eg family member or healthcare staff.
Assess her home environment she will be returning to by conducting a home visit (or referral to Community OT/ Early Supported Discharge team), with the possible use of SAFER HOME tool to guide the assessment and to clearly document the limitations & risks.
If appropriate, offer Early Supported Discharge (NICE 2015) for Barbara to complete rehabilitation at home. This involves visits from health professionals at home with equipment loans & a social care package, if family is unable to assist with personal care.
The areas highlighted as important by Barbara will reflect the types of interventions carried out. For example, from feeding and mobility assessments in the Barthel Index of ADL Barbara has poor lower body strength and cannot fully weight bear for any length of time without pain, but is able to independently cut, prepare and eat food. From information obtained via COPM, Barbara reports that she is satisfied with not cooking a hot meal every day. She is used to preparing simple meals since widowed, and having hot meals only when she goes round her daughter’s house. Therefore perching stool in kitchen not necessary for long periods of standing. However difficulty in rising from seated position due to restriction on hip flexion beyond 90° (Randomski & Latham 2008) and poor lower body strength, meant a frame was offered to provide support when rising; together with bed, sofa and toilet heights raised with adaptive equipment.
For articles on other models such as MoCA, KAWA or MoHO, click on ‘OT Models & Process’ under the Categories section, in the menu to the right.
Barthel D & Mahoney F (1965) Functional evaluation: the Barthel index Maryland State Medical Journal 14(1):61-65
Carswell A, McColl M, Baptiste S, Law M, Polatajko H & Pollock N (2004) The Canadian Occupational Performance Measure: A Research and Clinical Literature Review Canadian Journal of Occupational Therapy 71(4): 210-222
Christiansen CH, Baum CM & Bass-Haugen J (2005) Occupational therapy: Performance, participation and well-being (3rd edition) Thorofare NJ: SLACK incorporated
Christiansen CH, Baum CM & Bass-Haugen J (2015) Occupational therapy: Performance, participation and well-being (4th edition) Thorofare NJ: SLACK incorporated
Duncan E & Hagedorn R (2011) Foundations for practice in occupational therapy (5th ed) Edinburgh: Elsevier Churchill Livingstone
Fawcett AL (2007) Principles of assessment and outcome measurement for occupational therapists and physiotherapists. Chichester: Wiley. pp 261-263
Law M, Cooper B, Strong S, Stewart D, Rigby P & Letts L (1996) The Person-Environment-Occupation Model: A Transactive Approach to Occupational Performance Canadian Journal of Occupational Therapy 63(1): 9-23
NICE (2008) Delirium: prevention, diagnosis and management London: NICE
NICE (2015) Transition between inpatient hospital settings & community or care home settings for adults with social care needs London: NICE
Oliver R, Blathwayt J, Brackley C &Tamaki T (1993) Development of the Safety Assessment of Function and the Environment for Rehabilitation (SAFER) Tool Canadian Journal of Occupational Therapy 60(2): 78-82
Radomski M & Latham C (2008) Occupational therapy for physical dysfunction (6th ed) Philadelphia: Lippincott Williams & Wilkins
Robertson L (2012) Clinical reasoning in occupational therapy Chichester: Wiley-Blackwell