The myth of participation in occupational therapy: reconceptualizing a client-centred approach

Abstract

Participation is often the comprehensive objective of treatment but also an indication of the extent to which the process of occupational therapy is client-centred. The purpose of this study was to explore levels of participation during occupational therapy among clients in the area of mental health from the occupational therapists' perspectives. Additionally the authors sought to identify factors that might hinder client participation. Postal questionnaires were sent out to 670 Swedish occupational therapists working with persons with mental illness and learning disabilities. The questionnaire required therapists to rate clients' levels of participation during occupational therapy. Findings indicated that the most common level of participation for the clients was interdependent, meaning that problems, goals, and plans were identified jointly and collaboratively with the occupational therapist. However, more than 20% of the clients were described as being dependent. Almost 90% of the occupational therapists rated client participation in therapy to be very important and nearly 70% claimed that client participation in general needed to be increased. Occupational therapists rated the primary barriers to participation as being clients' inability to participate and organizational and financial problems. Implications of these findings for education in client-centred practice approaches are discussed.     

The myth of participation in occupational therapy: reconceptualizing a client-centred approach

Participation is often the comprehensive objective of treatment but also an indication of the extent to which the process of occupational therapy is client-centred. The purpose of this study was to explore levels of participation during occupational therapy among clients in the area of mental health from the occupational therapists' perspectives. Additionally the authors sought to identify factors that might hinder client participation. Postal questionnaires were sent out to 670 Swedish occupational therapists working with persons with mental illness and learning disabilities. The questionnaire required therapists to rate clients' levels of participation during occupational therapy. Findings indicated that the most common level of participation for the clients was interdependent, meaning that problems, goals, and plans were identified jointly and collaboratively with the occupational therapist. However, more than 20% of the clients were described as being dependent. Almost 90% of the occupational therapists rated client participation in therapy to be very important and nearly 70% claimed that client participation in general needed to be increased. Occupational therapists rated the primary barriers to participation as being clients' inability to participate and organizational and financial problems. Implications of these findings for education in client-centred practice approaches are discussed.     

Occupational therapists’ perceptions of gender – A focus group study

Background/aim: Women and men are shaped over the courses of their lives by culture, society and human interaction according to the gender system. Cultural influences on individuals’ social roles and environment are described in occupational therapy literature, but not specifically from a gender perspective. The purpose of this qualitative study was to explore how a sample of occupational therapists perceives the ‘gender’ concept. Method: Four focus group interviews with 17 occupational therapists were conducted. The opening question was: ‘How do you reflect on the encounter with a client depending on whether it is a man or a woman?’ The transcribed interviews were analysed and two main themes emerged: ‘the concept of gender is tacit in occupational therapy’ and ‘client encounters’. Results: The occupational therapists expressed limited theoretical knowledge of ‘gender’. Furthermore, the occupational therapists seemed to be ‘doing gender’ in their encounters with the clients. For example, in their assessment of the client, they focussed their questions on different spheres: with female clients, on the household and family; with male clients, on their paid work. Conclusions: This study demonstrated that occupational therapists were unaware of the possibility that they were ‘doing gender’ in their encounters with clients. There is a need to increase occupational therapists’ awareness of their own behaviour of ‘doing gender’. Furthermore, there is a need to investigate whether gendered perceptions will shorten or lengthen a rehabilitation period and affect the chosen interventions, and in the end, the outcome for the clients.     

Australian occupational therapy practice in acute care settings

Anational sample of occupational therapists was surveyed to explore the nature of Australian occupational therapy practice in acute care settings. Self-care was the major client need that therapists reported they addressed, with an initial interview being the most common assessment procedure. Client education was the most frequently used intervention. The most important skills therapists reported for effective practice in acute care were time management, quick clinical reasoning and lateral thinking. Important workplace characteristics included a cooperative healthcare team and early referral. Therapists reported that their most important resources were supportive senior therapists and a well-resourced equipment pool. Three attitudinal factors emerged. Therapists in interdisciplinary teams and those with more experience had more positive attitudes. Younger therapists experienced more concern about not being able to do more for their patients. Results suggest a need for graduates to be better prepared in some skill areas and to have more realistic expectations of practice in this area. Department managers need to ensure younger therapists receive adequate support from senior therapists. Further research is needed to determine how best to provide this support and to further examine the influence of the education experience on practice expectations.     

A survey of Israeli occupational therapists' definitions of the profession

The broad definition of occupational therapy, its holistic basis and its unifying characteristics enable occupational therapists to treat their clients as whole human beings. Yet, the holistic basis of occupational therapy and the divergence of its specialty areas seem to be polarised. This study explores Israeli occupational therapists' perceptions of their professional role and boundaries, and how it is affected by professional background; 265 Israeli occupational therapists participated in the study. A two-part questionnaire was constructed: (1) an attitudinal questionnaire including statements on issues that concern occupational therapists regarding the definition of the profession and its role; (2) nine items representing the main unifying characteristics of occupational therapy. Results indicate seven factors underlying the main issues concerning occupational therapists in Israel. From the seven factors two main sources of tension were revealed: strong sense of self-value as compared to lack of recognition by others and the advantages and the pitfalls of the holistic definition of occupational therapy. The most unifying characteristic of occupational therapy was the holistic definition, and the least important was the use of arts and crafts. In addition, occupational therapists from developmental disabilities area of specialty were distinct from others in their perceptions of the profession.     

Ethical Dilemmas Encountered by Community-based Occupational Therapists in Home Care Settings

This study of occupational therapists practising in the field of gerontology was conducted to determine the subjects' conception of Instrumental Activities of Daily Living (IADL). and current practice in relation to assessment and treatment of their clients. A survey method was used to obtain data from 135 practising occupational therapists. The results showed that many of the subjects were unfamiliar with the term “instrumental activities of daily living.” In addition, the study showed that occupational therapists actually did spend a considerable portion of their practice time in the area of IADL, reporting that the most common tasks for intervention were meal preparation, light housework, transportation, shopping and use of the telephone. When reporting on methods and accuracy of assessment procedures, subjects agreed that “observation of performance” and standardized assessment tools were the most accurate forms of assessment. With the rapidly ageing population, and government policy for keeping people in their own homes for as long as possible. IADL is set to become a significant part of occupational therapy (OT) evaluation and intervention.     

Occupational therapy practice with clients from non-English speaking backgrounds: A survey of clinicians in south-west Sydney

Australia is a multicultural society and this has important implications for the health care worker. The aim of this study was to investigate the experiences of occupational therapists who work with clients from non-English speaking backgrounds (NESB). The ‘cross-cultural therapy questionnaire’ was developed by the author and distributed to 65 occupational therapists employed in either the South-Western Sydney Area Health Service or Western Sydney Area Health Service. Issues explored in this questionnaire included barriers to cross-cultural care, strategies employed to overcome these barriers and theoretical models used to guide practice with ethnic clients. It was found that the majority of respondents experienced a number of obstacles to cross-cultural care within occupational therapy practice. An extensive list of strategies for overcoming cross-cultural barriers was compiled. The implications of these results for the profession of occupational therapy are discussed and future research directions are suggested.     

Health professional partnerships and their impact on Aboriginal health: an occupational therapist's and Aboriginal health worker's perspective

OBJECTIVE: To describe the extent and nature of demonstrated professional partnerships between occupational therapists and Aboriginal health workers in rural and remote communities of North Queensland. The study identifies ways in which professional partnerships improve client services and enhance occupational therapy outcomes through exploring the aspects of communication, collaboration and bridging cultural boundaries. DESIGN: Data collected via in-depth, semistructured telephone interviews. SETTING: Aboriginal and mainstream health and human service organisations in rural and remote North Queensland. Rural and remote areas were identified using the Accessibility and Remoteness Index of Australia codes. PARTICIPANTS: Seven participants working in rural and remote areas of North Queensland, comprising four occupational therapists and three Aboriginal health workers. All participants were female. RESULTS: Participants identified five core themes when describing the extent and nature of professional partnerships between occupational therapists and Aboriginal health workers. Themes include: professional interaction; perception of professional roles; benefits to the client; professional interdependence; and significance of Aboriginal culture. According to participants, when partnerships between occupational therapists and Aboriginal health workers were formed, clients received a more culturally appropriate service, were more comfortable in the presence of the occupational therapist, obtained a greater understanding of occupational therapy assessment and intervention, and felt valued in the health care process. CONCLUSIONS: This study substantiates the necessity for the formation of professional partnerships between occupational therapists and Aboriginal health workers. The findings suggest that participation in professional partnerships has positive implications for occupational therapists working with Aboriginal clients and Aboriginal health workers in rural and remote regions of North Queensland.     

Sex Education and Schizophrenia: Should Occupational Therapists Offer Sex Education to People with Schizophrenia?

Adult sexuality contributes significantly to an individual's identity, self-esteem and relationships. Since occupational therapy is practised from the perspective of holistic care, sexual behaviour can be a legitimate area for therapists to consider when working with clients. For people with schizophrenia there are particular issues that may need to be addressed by the therapist. This paper summarizes the results of a study examining whether occupational therapists regard sex education as a valid topic to teach, as part of a treatment package, to people with schizophrenia. Forty-nine therapists responded to a questionnaire. The results suggest that the majority of occupational therapists believe sex education to be within the domain of their profession. They are not, however, providing sex education for their clients. The factors that influence this decision include length of time qualified, theories of practice and the expectations of employers.     

Experiences of ethical dilemmas in rehabilitation: Swedish occupational therapists’ perspectives

The aim of this study was to describe Swedish occupational therapists’ experiences of encountering ethical dilemmas in rehabilitation and strategies they used to handle the situations. Twelve occupational therapists who work with adults with developmental disabilities were interviewed using a semi-structured interview design. Data were analysed using qualitative content analysis. The results showed that ethical dilemmas were common in the occupational therapists’ daily work within rehabilitation. Many situations that created ethical dilemmas were related to occupational therapists who worked with clients and their relatives, and other healthcare providers. The results showed further that occupational therapists found it difficult to make decisions and to optimize clients’ participation in decision-making, to set limits and act professionally, and to best handle the situation for the client and avoid ethical dilemmas. This study indicates the importance of illustrating experiences of ethical dilemmas within occupational therapy praxis and the meaning of discussing ethical dilemmas with different healthcare providers to reach a divided view of the client in order to develop successful and healthy strategies that will optimize the rehabilitation of clients with developmental disabilities.     

Use of creative activities in occupational therapy practice in sweden

The aim of this study was to describe the prevalence of creative activities in occupational therapy in Sweden and how often Swedish occupational therapists use creative activities as a means of intervention. A web‐mail survey was sent to 2975 Swedish occupational therapists working in health care at regional, county council or primary health care level, and those working in vocational rehabilitation. A total of 1867 (63%) answered the questionnaire and showed that 44% did use creative activities as a means of intervention and most often by practitioners working in psychiatric health care. The most commonly used form of creative activity was arts and crafts followed by gardening. This web‐mail survey was based on a limited amount of items regarding creative activities. Further research should focus on in‐depth inquiries about how occupational therapists and their patients perceive the use of creative activities as a means of treatment in occupational therapy. Copyright © 2012 John Wiley & Sons, Ltd.     

Agreement Between Occupational Therapists and Clients with Stroke on Three Outcome Measures

In recent years, the occupational therapy profession has been under increased pressure to document the outcomes of interventions in order 10 improve the quality of client care and to provide evidence of the effectiveness and efficiency of services to recipients and sponsors. The literature to date has focused primarily on establishing therapy outcomes from a therapist perspective. However, attention must also be paid to the views of our consumers regarding the outcomes of therapy. The purpose of this study was to determine whether clients and therapists agree regarding client scores on three outcome measures. The study included 4 occupational therapists and 20 clients with stroke who rated clients' status in terms of personal activities of daily living, instrumental activities of daily living and quality of life, at admission of clients as well as discharge from rehabilitation. The results indicated that there was generally only moderate agreement between therapists' and clients' ratings at both admission and discharge. These findings suggest that therapists should continue to spend time exploring client status with their clients so that both parties have the best possible understanding of the clients' capabilities, and the outcome of therapy. The findings also suggest the need to administer client outcome assessments as well as to utilize client self-reports.     

Levels of empathy in undergraduate occupational therapy students

Empathy is an important attribute for occupational therapists in establishing rapport and in better understanding their clients. However, empathy can be compromised by high workloads, personal stressors and pressures to demonstrate efficacy. Occupational therapists also work with patients from a variety of diagnostic groups. The objective of this study was to determine the extent of empathy and attitudes towards clients amongst undergraduate occupational therapy students at one Australian University. A cross‐sectional study was undertaken using a written survey of the Jefferson Scale of Physician Empathy (JSPE) and the Medical Condition Regard Scale. Overall, a strong level of empathy was reported amongst students. Four medical conditions that occupational therapists work with (stroke, cerebral palsy, traumatic brain injury and depression) were held in high regard. Substance abuse, however, was held in comparatively low regard. Overall, the year of study appeared to have no significant impact on the students' empathy. Despite having a lower reported empathy level than found in health professions from other studies using the JSPE, occupational therapy students were found to have a good level of empathy. Of concern, however, was the bias reported against the medical condition of substance abuse, highlighting that the there may be a need to reinforce that patients from this diagnostic group are equally deserving of quality care irrespective of their clinical condition. Recommendations for future research include completing a longitudinal study of occupational therapy students' empathy levels and investigating the empathy levels of occupational therapists working with different client groups. Limitations of the study include the convenience sampling of occupational therapy students enrolled at one university which limits the generalizability of the results to groups of participants with similar characteristics. Copyright © 2010 John Wiley & Sons, Ltd.     

The potential role of occupational therapy in acute care with clients with HIV/AIDS

As medical interventions aimed at prolonging the lives of people with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) are implemented, HIV/AIDS is evolving into a chronic disease with associated disability. People with HIV/AIDS can experience numerous occupational performance problems and occupational therapists need to examine and develop their role in helping to meet the needs of this population. Acute-care occupational therapists work with clients with HIV/AIDS who experience multiple admissions and who present with varying levels of occupational function. This paper outlines the potential role of occupational therapy in acute care with clients with HIV/AIDS using the Model of Occupational Performance (Canadian Association of Occupational Therapists, 1991) as a conceptual framework. The results of a retrospective chart review that investigated the role of two occupational therapists working with clients with HIV/AIDS in an acute-care setting are presented and compared with the potential role. Practice and research recommendations to address the discrepancies between the potential and present role are presented. Copyright © 1998 Whurr Publishers Ltd.     

Clinical Application of Low Vision Rehabilitation Strategies After Completion of a Computer-Based Training Module

This study evaluated changes in occupational therapists’ practice behaviors after completion of an online continuing education (CE) program delivered over a hospital Intranet system. The setting was a large rural medical system covering parts of two southeastern states. A convenience sample of 28 occupational therapists and occupational therapy assistants was recruited from the facility therapy staff. A CE module on low vision assessment and treatment was delivered using the hospital Intranet and a follow-up survey assessing practice change was carried out 8 weeks later. Most participants reported an increase in their comfort level when treating clients with low vision after course completion. Fifty percent of participants reported screening for vision impairments, increased use of environmental modifications, and more referrals to other vision specialists. Outcomes suggest that Internet-delivered CE programs can improve knowledge and affect practice.     

Utilization of the iPad application: Aid for Decision-making in Occupation Choice

The purpose of the study was to develop and evaluate an iPad (Apple) application, Aid for Decision-making in Occupation Choice (ADOC), so as to promote shared decision-making in an occupation-based goal setting. This application involves the client choosing from 94 illustrations describing daily activities related to the category of "activities and participation". One hundred occupational therapy clients evaluated the ADOC for goal setting; the clients and 37 occupational therapists underwent a survey to determine their perceptions of decision-making in the goal setting. More than 90% of the clients felt that they could give their opinions using the ADOC regarding goal setting. The majority of the occupational therapists (>90%) felt that ADOC would be useful in their clinical practice for setting client goals. The results indicated that ADOC is a useful and acceptable tool for both clients and occupational therapists in shared decision-making in occupation-based goal setting.     

ICIDH-PR: A potential model for occupational therapy

Occupational therapists frequently work with clients who are challenged by chronic disabilities that may often lead to handicaps. Consequently, chronicity and possible resulting handicaps are matters of concern for occupational therapists in all domains, including: practice, research and education. In 1980 the World Health Organization put forth a classification scheme to capture the long-term consequences of disease: the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). Its use within occupational therapy was advocated. They showed that the constructs of this classification system mirrored those of occupational therapy's occupational performance model. More recently, a proposal for the revision of the ICIDH (ICIDH-PR) has been advanced. This proposal is consistent with the enablement and occupational competence models. Within this proposed model, occupational therapy is concerned with enabling clients to interact optimally within their chosen environments. This paper presents a brief review of a selected portion of the international literature on the ICIDH and introduces the proposed revision of the ICIDH for occupational therapy. The structure of this proposed classification is compared with the occupational therapy models. The implications that the use of the ICIDH-PR will have for occupational therapy are also addressed.     

Community occupational therapists' clinical reasoning: identifying tacit knowledge

Background: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community‐dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions. Aim: To synthesise current knowledge about community occupational therapists’ clinical reasoning. Method: A scoping study of the literature on community occupational therapists’ clinical reasoning was undertaken. Results: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists’ clinical reasoning, were reviewed. Community occupational therapists’ clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists’ clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear. Conclusion: Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.