Justice.
TBC…….
Occupational Justice
Category: OT Theories
Focusing on Occupation: looking at some OT News articles
Adapting recipes
People with LD struggle with more complex or abstract elements of recipes, and recipes often assume certain knowledge such as preheating the oven or how to prepare the vegetables. The OT devised a cook book specially for LD that they could follow easily. They involved different experts to consult on areas outside of her expertise, eg food safety or nutrition.
An OT by another name?
An OT is based at carpal tunnel syndrome clinic, and is performing surgical procedures such as steroid injections usually carried out by nurses. Blurring of the traditional OT role scope…. but OT cannot prescribe so she needs a prescription authorised by another health professional before she can carry out injections. Benefit of the role is that it increases access for patients to this treatment. Patients can discuss treatment and leave feedback on an innovative website, which also has a self-diagnosis questionnaire for CTS. (www.carpal-tunnel.net)
From OT to case manager
Ot went from to spinal injury case manager. She used her transferable skills as discharge planner to organise care for spinal injury patients. It involves a lot of liaising with other agencies such as DWP, councils, etc, and beiong able to advocate on the patients’ behalf if they re vulnerable (eg homeless, MH).
Let me in
Self-care is not just hygiene, it has therapeutic benefits like motivation, self-soothing and confidence. In a MH inptaient ward, should males be allowed to join in on female self-care sessions? Do they have a right to that as an occupation, or is it ruining the safe space for females to discuss their bodies without judgement? Self care is large part of our daily routine and intrinsically linked to our sense of self and confidence.
Discussion points
- –What did you learn?
- –What did you want to know more about?
- –What is the innovative element?
- –Why is it needed?
- –What added value comes from occupational therapy involvement?
- –Has an occupational perspective shaped the innovation? To what extent?
+++++++++++++++++++++++++
References- articles from OT News magazine
Delaney K (2014) Adapting recipes. OT News July, 38-39
Kaile E (2014) An OT by another name? OT News November, 30-31
Newland J (2014) From OT to case manager. OT News November, 30-31
Vickerstaffe R (2014) Let me in. OT News. July, 40
Article review: “Articulating an Occupational Perspective” by Njelesani et al (2014)
This article investigated uses of the term “occupational perspective” in order to clarify a standard definition for use in occupational science. This should make it easier to apply occupational science research findings in practice, the authors argue. In the end they came up with
“a way of looking at or thinking about human doing”
What is an occupational perspective then? According to the authors it’s not an occupational therapy perspective, since this term was one of the exclusion criteria in the Method section. The authors describe in the Findings the term as being used in relation to employment until the 90s when it became associated with Occupational Therapy and Occupational Science. Research investigating it is mainly qualitative suggesting it is something abstract perhaps also explaining why there were so many different interpretations of the term in the articles Njelesani et al (2014) shortlisted. The research on occupational perspective covered a wide variety of client populations indicating it’s a concept that applies to all people with disabilities/illness.
Therapeutic use of Occupation
Interventions in occupational therapy use occupation (that is, any activity which is meaningful to an individual person) in order to achieve a particular therapeutic outcome. The same activity could be used by different therapists but in different ways to achieve different therapy goals. The same activity could be carried out by the SAME therapist with different clients in order to achieve different goals! To illustrate this point, consider gardening; an occupation which many people find meaningful.
The activity of planting seeds in a greenhouse. For one therapist, this could be creating repetitive upper limb and grasp movements in the low-tone limb of a stroke patient, to therapeutically restore neural connections for motor movement via neuroplasticity theory. For another therapist this could be teaching a learning disabled patient new skills in communicating with others and managing frustrations appropriately, in order to make successful socialising in the community and gaining employment more likely, via behavioural theory.
The same activity, but carried out with different end goals that the therapist wants the patients to achieve, and therefore different clinical reasoning behind it.
In this sense, it is not what you do, but why you do it.
Interventions can be grouped according to the type of goal they’re achieving:
- Preparatory
- Purposeful
- Occupation-based
Therapeutic use of self
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
Article review: “Biopsychosocial Model – The integrated approach to health and disease” by Havelka, Lucanin & Lucanin (2009)
In this article, Havelka et al point out that the biomedical model was a valid model while infectious diseases caused by one factor prevailed and were the main healthcare problem for humanity, but now that chronic, lifestyle & non-infectious diseases with multiple influencing factors are the main health issue it is no longer effective or appropriate as the default model for healthcare. They are in favour of the biopsychosocial (BPS) model and say its implementation is taking too long. Their criticisms of the current biomedical model are:
- the dehumanisation between healthcare staff and patients
- continual improvement of increasingly advanced medical techniques leading to a rise in expenditure where only rationing of healthcare would allow for the continuation of technology-led healthcare (as opposed to psycho-social led)
- reductionist i.e. reduces people to the smallest component -their cells- and separates mind and body in order to do this despite evidence to the contrary
Just what IS occupation?
No, it’s not your job.
Although in a way that can be part of one! It’s any activity or task carried out which has an end goal and provides meaning to you. There are many definitions put forwards, all slightly different, which does make it hard to compare different articles or pieces of research effectively. However it is generally agreed there are certain aspects of any occupation:
- Form – the observable aspects of the occupation: what how & when
- Function – the way the occupation influences health, and its purpose or intended outcome
- Meaning -the entire subjective experience of an individual who is engaging in the occupation
Considering occupations broken down in this way helps practitioners to understand why people choose to participate in certain occupations.
Analysing someone’s ability to carry out an occupational activity in order to assess where problem areas lie is the cornerstone of occupational therapy. The American Occupational Therapy Association (AOTA) has created a useful guide to the standardised terminology that should be used when documenting activity assessments (it can be found here for BAOT members).
Occupational science seeks to answer questions about the nature of occupation, such as:
- WHO engages in occupations?
- WHAT occupations are there?
- WHEN do people engage in occupations?
- WHERE do people engage in occupations?
- HOW are occupations performed?
- WHY do people engage in occupations?
++++++++++++++++++++++++++++++++++++
Sources:
American Journal of Occupational Therapy, March/April 2014, Vol. 68, S1-S48. [Access at: http://ajot.aota.org/article.aspx?articleid=1860439 for BAOT members]
How does sociology and culture affect occupation throughout someone’s life?
Sociology is the study of human social life, groups, and societies (Giddens et al 2013:4). The type of society around us greatly influences our thoughts and actions whether we are aware of it or not. How does our behaviour (what we think, feel and say) as social creatures influence or affect the occupations we choose, and how we carry them out? Sociology can help OTs to understand whether something is a social/public issue, or a personal problem.
Some prominent sociological theorists are Durkheim, Marx and Weber. Emile Durkheim studied the effects of capitalism on increased suicide rates in the newly industrialised European countries. He attributed this to:
- increased individualism where rewards from good decisions are enjoyed by the individual alone, but so too are the consequences of bad ones. Previously the blame would be shared between other members of a family or group because the decision on whether to become say, a baker, was influenced by family tradition or the need for a baker in the village, rather than someone’s individual choice to strike out and open a patisserie in Hull.
- too much aspiration and subsequent disappointment when what is theoretically possible isn’t achieved. What we have isn’t actually all that bad but when compared to Khloe Kardashian, our life is a turdburger.
- too much freedom meaning there aren’t the same connections to other people as there used to be when social norms were around to tell us who to marry, what to do on a Sunday or how much ankle to show. People can often feel more anonymous and less connected now as a result of increased personal freedom.
- increased atheism – while religions are based on questionable facts with a propensity for inciting prejudice and war, they do offer an important sense of community and shared experiences to draw people together; something capitalism doesn’t offer a replacement for.
- decrease in national pride and family – national identities and family ties are more diffuse and no longer give people the feeling they are part of something bigger than themselves.
A rough history of OT
Or the origins of Occupational Therapy in a socio-economical context
OT is obviously awesome so the ideas behind it have pretty much always been present throughout time in one way or another.
Below is a summary of Occupational Therapy’s position throughout the ages.
Primitive age There was an emphasis on community support within tribes, with Shamans providing ‘interventions’. Nature imposed occupations on people in order for them to survive- if you did not find occupation through making fires, hunting food or making shelters you would not survive for long.
Biblical age Jesus is described as valuing all people equally. There was an awareness of the importance of all forms of health. With mental health this could be raising self esteem and equality, such as talking face to face being preferred over letter writing in John chapter 2. Physical health is mentioned eg the use of therapeutic baths, such as in John chapter 5 where Jesus heals using the Pool of Bethesda, and of course spiritual health was a running theme since Jesus was a fairly spiritual guy and frequently took time out for meditation.
Classical age Philosophers proposed the idea of body and mind being restored or maintained in perfect harmony. A balance between physical activity/occupation and rest was encouraged. The physician Aesculapius founded treatment health centres which had gyms, spa baths, horse riding activities and theatres, providing a holistic approach to treating both physical and mental illness ahead of its time. Spiritual cures such as snake venom were also frequently used (incidentally this is where the medical symbol of a serpent on a staff originates).
However in seeking this perfection, infants with disabilities which could not be cured were killed as there was no hope of restoration, and perfect harmony was impossible. Read more
Occupational Models: PEOP (Person-Environment-Occupation Performance)
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.
++++++++++++++++++++++++++++++
Sources:
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
Lifelong Learning with OT 