Facilitating client-centred practice: insights from clients

BACKGROUND: This paper adds to the established importance of client-centred practice in mental health programs by reporting on the outcome of client interviews in one community setting in England. PURPOSE: The purpose of these interviews was to determine the opportunities for, and barriers to, the application of a definition of client-centred practice. METHODS: Purposive sampling was used to obtain 9 clients who participated in structured interviews. A combination of methods, including template analysis and the editing approach, were employed to determine themes and sub themes that are presented within the context of the clients'reasons for attending these programs. RESULTS: These themes included initiating client-centred practice with the sub themes of providing information to enable choice, participate in negotiating goals, overcoming fear and the severity of illness. Other themes related to the therapist's response to the client's illness and the client's knowledge about client-centred practice. PRACTICE IMPLICATIONS: It was clear from these interviews that client-centred practice was important to this group of clients and there were both opportunities and barriers to be considered by therapists.     

Evaluation of effectiveness and satisfaction outcomes of a mental health screening and referral clinical pathway for community nursing care

The study aimed to explore the effectiveness of a mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia on outcomes of client self-reported mental health, quality of life, and client and carer satisfaction. The pathway was developed by literature review and consultation, then trialled and evaluated. Validated screening tools were embedded within the pathway to support generalist nurses' mental health decision making. Pre- and post-measures were applied. Clients on whom the pathway was trialled were invited to complete an evaluation survey questionnaire, as were their informal carers. Most clients and carers who responded to these questionnaires were highly satisfied or satisfied with care provided through application of the pathway. This study adds understanding about one way that community nurses might identify people with mental health difficulties. The trialled pathway, which was modified and refined following the study, is now available on the Internet as an evidence-based resource for community nurses in Australia to guide practice and maximize holistic care for war veterans and war widow(er)s where that care is funded by Department of Veterans' Affairs.     

The client-centred approach as experienced by male neurological rehabilitation clients in occupational therapy. A qualitative study based on a grounded theory tradition

Purpose To explore the perspectives of male clients in a neurological rehabilitation setting with regard to the occupational therapy they have received and the client-centred approach. Method This study involved a qualitative research design based on the grounded theory tradition. Individual in-depth interviews were used to collect data. Data were analysed using a constant comparative method. Seven male participants from an inpatient neurological setting were included using a theoretical sampling technique. Results Three themes emerged to describe the approach of the therapists to client-centred practice: (a) a shared biomedical focus as the start of the rehabilitation process, (b) the un-simultaneous shift from a biomedical towards a psycho-social focus and (c) formal versus informal nature of gathering client information. Conclusion A client-centred approach entails a shift from the therapist focussing on recovery from the short-term neurological issues towards the long-term consequences of the disease. According to the client, this shift in reasoning must occur at a specific and highly subjective moment during the rehabilitation process. Identifying this moment could strengthen the client-centred approach.

• Implications for Rehabilitation

• Client-centred practice entails a shift from recovering the short-term neurological issues towards the long-term psycho-social consequences of the disease.

• To be effective in client-centred practice, the clients expect from the professional to be an authority with regard to biomedical issues and to be partner with regard to psycho-social issues.

• Client-centred practice is most likely to be successful when client is susceptible to discuss his psycho-social issues and finding this moment is a challenge for the professional.

• Using formal methods for goal setting do not necessarily cover all the information needed for a client-centred therapy programme. Rather, using informal methods could lead to a more valid image of the client.

     

Reflection as a means to foster client-centred practice

BACKGROUND: Client-centred practice embraces important concepts about partnership and justice that promote client participation in meaningful occupations. It is important to understand how occupational therapists can engage in and continue to develop client-centred practice within the constraints of everyday settings. PURPOSE AND METHODS: An action research study was undertaken by a group of four occupational therapists to describe insights gained, and to show the effectiveness of participation in reflective education to help foster client-centred practice. RESULTS: The six main insights generated by the group involve: congruence, understanding the potential, environmental factors, personal factors, expectations, and lifelong learning. PRACTICE IMPLICATIONS: Although actual change to daily practice was limited, group members felt the reflective group discussion provided them with a launch pad to start a journey toward more client-centred practice. This may be the key to moving beyond simply changing the face and language of occupational therapy practice toward a deeper understanding and implementation of client-centred practice to improve client outcomes. Suggestions are provided for implementing reflection to help continue to develop your own practice.     

Development of the client-centred care questionnaire

Aim. This paper reports the development and testing of the Client‐Centred Care Questionnaire, aimed at evaluating the client‐centredness of professional home nursing care from a client perspective. Background. Client‐centred care has become an important theme in health care. To evaluate the client‐centredness of care and services from a client's perspective, there is a need for measurement instruments. Method. The questionnaire was developed on the basis of a qualitative study into client perspectives on home nursing care. Items were formulated that closely followed the aspects clients mentioned as central to client‐centred home care. A pilot study was conducted with a sample of 107 clients in three home care organizations in 2003 and 2004. These clients had chronic diseases and were expected to receive care for at least another 6 months. The questionnaire comprises 15 items. Findings. Principal components analysis and internal consistency analysis show strong internal consistency of the items. All items had strong factor loadings on one dimension, and Cronbach's alpha was 0·94. Clients tended to be most critical about their say in the practical arrangements and organization of care: which person came, how often and when? Clients of the three organizations differed in their perceptions of client‐centredness, which may indicate that the questionnaire is capable of differentiating between respondents. Conclusion. The results of this pilot study are promising. The validity of the questionnaire needs further testing.     

A review of evidence on the conceptual elements informing client-centred practice

BACKGROUND: Client-centred practice is a central concept in occupational therapy in Canada. Since 1980, Canadian occupational therapy publications have discussed the elements of a client-centred practice approach. PURPOSE: The purpose of this paper is to enhance the understanding of key elements of a client-centred approach and to highlight the implications for practice that arise from this discussion. METHOD: Literature about client-centred practice in health care from 1990 - 2005 was reviewed regarding thoughts and ideas about client-centred practice. The content was analyzed for thematic focus about client-centred practice conceptual ideas and their influence on practice. RESULTS: Thematic conceptual elements emerging from the review include an overarching theme of power, with important underpinning themes of listening and communicating, partnership, choice, and hope. Selected definitions of client-centred practice and the link to best practice provide the context for the presentation of the concepts and recommendations for the implementation of client-centred practice. PRACTICE IMPLICATIONS: The paper concludes with a discussion of practice implications through the presentation of questions for therapists to consider as a quick reference tool and suggestions for further research and dialogue concerning client-centred practice.     

Perceptions of the impact of health-care services provided to palliative care clients and their carers

A wide range of services are provided to palliative care clients to alleviate pain and improve their quality of life. The purpose of this study was to explore the perceptions of clients and their carers regarding palliative care services in New South Wales, Austalia. Ten patients and their carers (n = 7) were randomly selected from a sample of palliative care clients and were informed of the study and interviewed. Interview data were coded independently by three researchers and thematic analysis was undertaken. The themes identified were similar for both clients and carers and included: access to services; service provision; impact on way of life; usefulness of services; and staffing. An additional theme identified by clients was the burden of caregiving on carers. Knowledge of perceptions and concerns of client and carers is important to consider when planning palliative care services.     

Reconstructing mental health nursing in home care

BACKGROUND: Psychiatric care for people in Sweden with long-term mental health problems has shifted from institutional to community and home settings. AIM: The aim of this study was to explore and describe mental health nurses' experiences of how structural changes in mental health nursing influence interaction when providing home care to patients with long-term mental health problems. METHOD: We conducted interviews with 11 mental health nurses who provided home care to people with long-term mental health problems. The constant comparative method of grounded theory was used for data collection and analysis. FINDINGS: The process of attempting to reconstruct mental health nursing by entering into the everyday reality of people with long-term mental health problems was identified as the core category. Central to this process was a change in perspective from nurse-controlled to client-centred care. This led to changes in moral values, assessment of client needs, and ways of meeting clients and establishing relationships. However, attempts to reconstruct mental health nursing according to a client-centred perspective became problematic when clients were at risk of harming themselves. In these situations, respondents felt the need to make decisions for clients, and this was experienced as burdensome and lonely. CONCLUSIONS: Our study indicates that the process of reconstructing mental health nursing in line with a client-centred perspective is incomplete. Opportunities to interact with people with mental health problems in the home environment may lead to a broader perspective on the daily lives of these people, but also to a realization that home care cannot be modelled on institutional care.     

Involving clients in programme evaluation and research: a new methodology for occupational therapy

Eliciting client satisfaction with services has become common in mental health settings and in the planning of service delivery systems. It is also compatible with the client-centred practice of occupational therapy. The traditional approach to collecting satisfaction information involves staff interviewing clients using questionnaires developed by staff. However, there is often a lack of variability in responses and the vast majority of clients report being satisfied. A review of the literature reveals that these favourable reports may be a result of social desirability and of clients being interviewed by treatment providers who have the power to give or withhold care. This paper reviews the relationship between occupational therapy and client involvement, examines the rationale for involving clients in programme evaluation and research, reviews the limitations with traditional methods of collecting information about client satisfaction, and discusses how clients are involved in evaluation and research in today's mental health care setting.     

Factors influencing the adoption of home telecare by elderly or chronically ill people: a national survey

Aims and objectives. The primary aim is to provide insight into client characteristics and characteristics of home telecare contacts, which may influence the adoption of home telecare. Secondary aim is to examine the applicability of four perceived attributes in Rogers’ diffusion of innovations theory, which may influence the adoption: relative advantage, compatibility, complexity and observability. Background. Western countries face strongly increasing healthcare demands. At the same time, a growing nursing shortage exists. The use of home telecare may be instrumental in improving independence and safety and can provide support to older and chronically ill people, but a precondition for its uptake is that clients consider it as a useful and helpful technological tool. Design. A survey conducted among clients of seven home care organisations in the Netherlands connected to a home telecare system. Methods. In 2007, a postal questionnaire was distributed to 468 older or chronically ill clients: 254 responded (54%). The data were analysed by regression techniques, employing a theoretical model. Results. This study showed that clients’ perceived attributes – relative advantage, compatibility, complexity and observability – have a significant effect on adoption of home telecare explaining 61% of the variance. The chance of adoption is higher when a client already receives long‐term personal and/or nursing care, he/she lives alone and when there are fixed daily contacts via the home telecare system. The perception of possible benefits can still be enhanced. Conclusions. The concept of perceived attributes, derived from Rogers’ diffusion of innovation theory, has been useful to explain clients’ adoption of home telecare. Relevance to clinical practice. Home care organisations can best focus on clients already in care and people living alone, in offering home telecare. Nurses, who aim to enhance the client’s adoption of home telecare, have to take into account clients’ perceived attributes of such new technology.     

The clinical effectiveness of healing touch

OBJECTIVES: (1) to determine the clinical effectiveness of Healing Touch (HT) on variables assumed to be related to health enhancement; (2) to determine whether practitioner training level moderates treatment effectiveness. DESIGN: Mixed-method repeated measures design with quasi-experimental and naturalistic approaches, paired with nomothetic and idiographic analyses. SETTING/LOCATION: Practitioner's offices or client's home. SUBJECTS: Twenty-two (22) clients who had never experienced HT. Interventions: Three treatment conditions: no treatment (NT), HT only (standard HT care), and HT+ (Standard HT care plus music plus guided imagery). OUTCOME MEASURES: Secretory immunoglobulin A (sIgA) concentrations in saliva, self-reports of stress levels, client perceptions of health enhancement, and qualitative questionnaires about individual effects. RESULTS: Clients of practitioners with more training experienced statistically significant positive sIgA change over the HT treatment series, while clients of practitioners with less experience did not. Clients reported a statistically significant reduction of stress level after both HT conditions. Perceived enhancement of health was reported by 13 of 22 clients (59%). Themes of relaxation, connection, and enhanced awareness were identified in the qualitative analysis of the HT experience. Pain relief was reported by 6 of 11 clients (55%) experiencing pain. CONCLUSIONS: The data support the clinical effectiveness of HT in health enhancement, specifically for raising sIgA concentrations, lowering stress perceptions and relieving pain. The evidence indicates that positive responses were not exclusively as a result of placebo, that is, client beliefs, expectations, and behaviors regarding HT.     

A literature review on perception of the providers and clients regarding the use of the client centered approach in psychiatry

BACKGROUND: This article presents a literature review based on the following question: According to service providers and clients, is the approach adopted by service providers in psychiatry, centred on client needs? PURPOSE: To compare the perceptions of clients and service providers regarding the use of a client-centred approach and the identification of the intervention needs in psychiatry. METHODS: Medline, PsycInfo and CINAHL databases were consulted; eight studies were selected. RESULTS: Service providers and clients agree to the fact that the client-centred approach is not priorized in psychiatry. Different reasons are given by both parties. There is little agreement between clients and service providers regarding the intervention needs. Many clients needs seem to be unsatisfied (interpersonal relationships, independent life skills, productive activities, coping with illness, health care). PRACTICE IMPLICATIONS: Occupational therapists must adopt a client-centred approach to their interventions by evaluating the global needs of the clients, by developing services to encourage clients to engage in social or productive activities and by consulting the clients and their families in order to evaluate the quality of the services.     

Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy.

OBJECTIVE: The purpose of this study was to describe changes of health status as perceived by clients with hand or wrist impairments who received rehabilitation in acute, orthopedic outpatient facilities from occupational therapy or physical therapy personnel. METHOD: One thousand three hundred ninety-nine adults with wrist (n = 692) or hand (n = 707) impairments who were treated between July 1996 and June 1997 were selected from the Focus On Therapeutic Outcomes, Inc. (FOTO) national rehabilitation database. Each client completed a health status questionnaire on intake and discharge. Data consisted of number of outpatient visits, duration of treatment episode, and health status scores for six functional scales. Measures of intensity, global health status, global utilization, and client satisfaction were calculated. Outcomes were evaluated across occupational therapists and physical therapists. RESULTS: Clients perceived improvement (p < .05) in their health status over the course of therapy. Number of visits and measures of health status and client satisfaction were similar across type of therapist. Episode duration was longer (p < .05) and intensity was less (p < .05) for clients seen by occupational therapists. CONCLUSION: Clients receiving rehabilitation in acute orthopedic outpatient centers perceived improvement in their functional abilities and health and well-being (global health status and individual functional scales) over the time during which treatment was provided. Results confirm the responsiveness of the outcomes instrument to clinical change in the clients' perception of their health status over the course of therapy and support the use of health status as a measure of clinical outcome.     

Implementing a client-centred approach in rehabilitation: an autoethnography

Purpose: Client-centred practice is widely considered a key element of rehabilitation. However, there is limited discussion of how it should be implemented. This study explored how client-centred practice was operationalized during a clinical trial of innovative goal-setting techniques. Method: This study drew on principles of co-autoethnography. The personal experiences of three clinical researchers were explored to identify insights into client-centred practice, and seek understanding of this within the broader socio-cultural context. Data were collected through group discussions and written reflections. Thematic analysis and coding were used to identify the dominant themes from the data. Results: The primary way that client-centred practice was operationalized was through listening in order to get to know, to uncover and to understand what was meaningful. Four strategies were identified: utilizing mindful listening, allowing time, supporting clients to prioritize what is meaningful and viewing the therapists’ role differently. Conclusion: While technical competence in rehabilitation is important, our study suggested a starting point of ‘being with’ rather than ‘doing to’ may be beneficial for engaging people in their rehabilitation. We have highlighted a number of practical strategies that can be used to facilitate more client-centred practice. These approaches are consistent with what clients report they want and need from rehabilitation services.

Implications for Rehabilitation

• At face value, clinical practice may appear to be client-centred. However, critical reflection of existing practice suggests that in reality, it is not well operationalized.

• Prioritizing getting to know the client, their story and what is meaningful to them appears fundamental to client-centred practice. A number of strategies may facilitate this process, including mindful listening on the part of the clinician and allowing time.

• Structures and processes need to be instituted to support implementation of client-centred practice.

• Autoethnography is an approach that may support clinicians’ to reflect on their practice.

     

Occupational therapists chart a course through the health record

The absence of clear and practical guidelines for documenting on the health record often makes charting a disorganized and unsatisfying experience for occupational therapists. Like the health record, the occupational therapy process is structured to reflect a problem solving process that promotes clinical reasoning. The model described in this paper was developed to reflect the occupational therapy process as identified in the Occupational Therapy Guidelines for Client-centred Practice and proposes an additional section on problem naming. It is viewed as an open loop through which the client may move one or more times while learning to cope with change until enough momentum is gathered to move into adaptation. Emphasis is placed on naming and validating each problem with the client, and negotiating responsibilities and expected outcomes. This feedback loop summarizes the steps required to practice occupational therapy from a client-centred stance. Occupational therapists who develop competence in using this model, chart in an organized, client-centred, and therefore more satisfying manner.