Using cultural-historical activity theory to study clinical reasoning in context

The aim of this paper is to describe sources of conflict and congruence in critical areas of practice with caregivers of persons with dementia, using cultural-historical activity theory as an analytic framework. Findings are drawn from an ethnographic study that described the context of occupational therapists’ (OTs’) clinical reasoning in a funded, home-based environmental skill-building program designed to help caregivers manage the daily care of a family member with dementia. Data were gathered through observation of intervention sessions, debriefing sessions, semi-structured interviews with therapists, and review of intervention documentation. Primary sources of conflict and congruence within the identified practice context included conflicts between therapists and caregivers concerning which environmental strategies were best for addressing problems in caregiving and expectations regarding OT and caregiver roles. Areas of congruence included the fit between intervention protocols used to guide treatment and the approaches therapists developed to help caregivers modify care receivers’ living environments. The study revealed the complexity of OT practice and demonstrated that practice contexts can be systematically analyzed using cultural-historical activity theory to determine key factors influencing clinical reasoning. The approach also presents an alternative perspective on clinical reasoning that more directly integrates clients/caregivers and therapists as co-constructors of OT intervention.     

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.     

Clinical practice standards and ethical issues applied to a virtual group intervention for spousal caregivers of people with Alzheimer's

Advances in technology have improved access to health and social services by offering more abundant and convenient choices for clients. In particular, the use of technology for delivering services to older adults and their families offers new possibilities for service delivery, by reaching people who are often isolated, and have difficulty accessing traditional services. Despite the continued advances in technology development and its integration into healthcare delivery, health care practitioners need to consider how to adapt and uphold clinical practice standards and address ethical issues in an e-health environment. Given the gap in the literature with respect to discussing these issues, this paper illustrates relevant issues in the context of developing and evaluating an Internet-based intervention for spousal caregivers of persons with dementia. Based on a four year project, a psychotherapeutic group intervention was delivered via the Internet to three groups of spousal caregivers. This article identifies some of the key practice standards and ethical issues that arise when using computer technology to deliver a psychotherapeutic group intervention. The article will also provide examples of relevant issues related to maintaining practice standards and ethical procedures that need to be addressed during the application of a computer-based psychotherapeutic group intervention for spousal caregivers of people with dementia.     

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.     

Clinical Practice Standards and Ethical Issues Applied to a Virtual Group Intervention for Spousal Caregivers of People with Alzheimer's

Abstract

Advances in technology have improved access to health and social services by offering more abundant and convenient choices for clients. In particular, the use of technology for delivering services to older adults and their families offers new possibilities for service delivery, by reaching people who are often isolated, and have difficulty accessing traditional services. Despite the continued advances in technology development and its integration into healthcare delivery, health care practitioners need to consider how to adapt and uphold clinical practice standards and address ethical issues in an e-health environment. Given the gap in the literature with respect to discussing these issues, this paper illustrates relevant issues in the context of developing and evaluating an Internet-based intervention for spousal caregivers of persons with dementia. Based on a four year project, a psychotherapeutic group intervention was delivered via the Internet to three groups of spousal caregivers. This article identifies some of the key practice standards and ethical issues that arise when using computer technology to deliver a psychotherapeutic group intervention. The article will also provide examples of relevant issues related to maintaining practice standards and ethical procedures that need to be addressed during the application of a computer-based psychotherapeutic group intervention for spousal caregivers of people with dementia.     

Service Learning in an Occupation-Based Curriculum: Student Commentary

Recent trends toward occupation-based practice and the move toward masters-level occupational therapy (OT) education has forced OT educators to reevaluate their programs to meet the needs of the contemporary health care environment. Service learning is one way to bridge the gap between theory and practice. The Master of Occupational Therapy (MOT) Program at Cleveland State University (CSU), in keeping with its focus on occupation, incorporates three service-learning components into its curriculum. This paper, written by a second-year MOT student at CSU, discusses two of these experiences in depth. The first, which took place at a homeless shelter, included both a didactic and “clinical” component, with an emphasis on community-based mental health OT services. The second, which included a training component and a structured program, involved co-leading after-school social-emotional learning groups for low-income urban youth. Both experiences served to expand the clinical skills and reasoning of the MOT students while introducing both the students and agencies to the role of OT in non-traditional community settings. Based on these experiences, the author highly recommends that all masters-level OT programs should, if they have not done so already, institute service learning as a core component of their curricula, in order to prepare their students for contemporary OT practice.     

Clinical Reasoning of a Novice versus an Experienced Occupational Therapist: A Qualitative Study

The clinical reasoning process is an important aspect of occupational therapy practice. The purpose of this critical, focused ethnography was to compare the clinical reasoning process of an experienced and novice therapist. Individual semi-structured interviews were conducted with an experienced and a novice therapist after each had reviewed a sample case study to help elicit the clinical reasoning process. Observations in the clinical setting were conducted. Themes which emerged include definitions of clinical reasoning, sources used when reasoning, factors influencing clinical reasoning, ability to prioritize, patient viewed as an individual, patients' role in treatment, and clinical reasoning as an evolving process. Similarities and differences between the therapists are noted and discussed. Implications for practice, education, and future research are identified.     

长期护理机构老年痴呆照顾者积极感受与虐待倾向的相关性分析

目的 探讨长期护理机构老年痴呆照顾者积极感受与虐待倾向的关系,为预防虐待的发生提供参考。方法 采用自编一般情况调查表、老年痴呆照顾者积极感受问卷、虐待老年人评估量表对307名长期护理机构老年痴呆照顾者进行调查。结果 长期护理机构老年痴呆照顾者虐待倾向检出率为49.8%;老年痴呆照顾者积极感受问卷得分（33.31±6.76）分;积极感受与虐待倾向呈负相关（ρ = - 0.137,P = 0.017）,独立影响水平总体变异的20.9%。结论 照顾者积极感受是老年痴呆照顾者虐待倾向的重要影响因素,加强对老年痴呆照顾者积极感受重视和干预,有助于预防老年痴呆照顾者虐待倾向的发生。     

Caring for a Relative With Dementia in Long-Term Care During COVID-19

ObjectivesThe COVID-19 pandemic created unique stressors for caregivers of persons with dementia living in long-term care (LTC) facilities. The purpose of this qualitative study was to identify the challenges associated with caring for a relative with dementia in LTC during the pandemic, as well as resources, strategies, and practices caregivers found helpful in coping with COVID-19.DesignThis study was conducted within the context of an ongoing randomized controlled trial of a psychosocial intervention to support caregivers. Open-ended survey responses (n = 125) and semistructured interviews with a subset of the sample (n = 20) collected between June 2020 and June 2021 explored caregivers' experiences during COVID-19.Setting and ParticipantsParticipants included 125 family caregivers of persons with dementia living in residential LTC.MethodsThematic analysis was used to identify themes capturing caregivers' experiences.ResultsIn addition to concerns about COVID-19 infection, participants reported key challenges such as the difficulty of maintaining contact with relatives because of visiting restrictions, lack of information about relatives' health and well-being, worries about overburdened LTC staff, impossibility of returning relatives home from the LTC facility, and fears about relatives dying alone. Participants also identified resources, strategies, and practices that they perceived as helpful, including effective infection prevention within the LTC facility, good communication with LTC staff, and creative strategies for connecting with their relatives.Conclusions and ImplicationsThis qualitative analysis informs recommendations for practice within LTC facilities, as well as supports that may help caregivers manage stressful situations in the context of COVID-19. Vaccination and testing protocols should be implemented to maximize family caregivers' opportunities for in-person contact with relatives in LTC, as alternative visiting modalities were often unsatisfactory or unfeasible. Informing caregivers regularly about individual residents' needs and status is crucial. Supports for bereaved caregivers should address complicated grief and feelings of loss.     

Evaluation of an Organisational Intervention to Promote Integrated Working between Health Services and Care Homes in the Delivery of End-of-Life Care for People with Dementia: Understanding the Change Process Using a Social Identity Approach

In the United Kingdom, approximately a third of people with dementia live in long-term care facilities for adults, the majority of whom are in the last years of life. Working arrangements between health services and care homes in England are largely ad hoc and often inequitable, yet quality end-of-life care for people with dementia in these settings requires a partnership approach to care that builds on existing practice.This paper reports on the qualitative component of a mixed method study aimed at evaluating an organisational intervention shaped by Appreciative Inquiry to promote integrated working between visiting health care practitioners (i.e. General Practitioners and District Nurses) and care home staff. The evaluation uses a social identity approach to elucidate the mechanisms of action that underlie the intervention, and understand how organisational change can be achieved.We uncovered evidence of both (i) identity mobilisation and (ii) context change, defined in theory as mechanisms to overcome divisions in healthcare. Specifically, the intervention supported integrated working across health and social care settings by (i) the development of a common group identity built on shared views and goals, but also recognition of knowledge and expertise specific to each service group which served common goals in the delivery of end-of-life care, and (ii) development of context specific practice innovations and the introduction of existing end-of-life care tools and frameworks, which could consequently be implemented as part of a meaningful bottom-up rather than top-down process.Interventions structured around a Social Identity Approach can be used to gauge the congruence of values and goals between service groups without which efforts to achieve greater integration between different health services may prove ineffectual. The strength of the approach is its ability to accommodate the diversity of service groups involved in a given area of care, by valuing their respective contributions and building on existing ways of working within which practice changes can be meaningfully integrated.     

The Rights of Persons With Dementia and Their Meanings

Concern about the lack of human rights afforded to persons living with dementia has emerged in recent years. Although the literature addresses certain rights, it does not include a holistic framework of rights in terms of the lived experience of older persons with cognitive impairment. Inspired by the 20 rights advocated for children by physician-educator Janusz Korczak, this article analyzes his formulation of rights in the context of persons with dementia, linking them to the ethical principles of Beneficence, Autonomy, and Justice. The analysis thus provides a holistic framework for addressing the human rights of persons with dementia, and their meanings for the lived experiences of persons with dementia and their caregivers. It offers new insights into the philosophy and practice of care, with implications for dementia care research, public health policy, practice guidelines for health care professionals, and the instruction of family and other caregivers of persons with dementia.     

The structure of novice and expert occupational therapists' clinical reasoning before and after exposure to a domain-specific protocol

Background/aim:  The research aimed to determine the influence of a protocol designed for use in the domain of upper limb hypertonia due to brain injury on novice and expert occupational therapy clinical reasoning.
Method:  Individual, structured repertory grid interviews were completed with 13 novice and eight expert occupational therapists prior to, and following, exposure to a domain-specific clinical reasoning protocol. Data were subjected to quantitative analyses (Principal Components Analysis, Generalised Procrustes Analysis).
Results:  Novice participants demonstrated statistically significant change in the structure of their clinical reasoning following exposure to the protocol ( P  < 0.004). Prior to exposure, novices relied on therapy tasks, the problem-solving process, environmental factors and standard practice to structure their reasoning. Following exposure, novices' clinical reasoning changed to more closely reflect experts' reasoning. Thus, a 'structured approach' and (theoretical) practice perspectives became evident. Prior to exposure to the protocol, experts structured reasoning in terms of (personal and theoretical) practice perspectives, therapy tasks and the scope of such tasks (either 'general' or 'specific'). Following exposure, therapist/client collaboration and upper-limb-related constructs emerged as being used to structure experts' reasoning, although these changes were not statistically significant.
Conclusion:  A protocol designed for guiding clinical reasoning in the context of upper limb hypertonia was perceived to be conceptually useful by novice and expert occupational therapists.     

Scholarship of Practice in the Care of People with Dementia: Creating the Future Through Collaborative Efforts

ABSTRACT

A scholarship of practice approach sets the stage for collaborative partnerships across academic and clinical practice settings that result in positive gains for all stakeholders. These gains include an enhanced ability to generate and apply relevant evidence in practice, disseminate knowledge and innovation, and ensure best practice is relevant to and effective for, people receiving services and their caregivers.

?This paper discusses national and international examples of collaborative, research-based practice initiatives that have implemented a scholarship of practice approach. The exemplars described here are framed within the Model of Human Occupation, which addresses the importance of volition, habits, roles, environment, and performance capacities in facilitating engagement in occupation for people with dementia. Research that focuses on how therapists adopt and use evidence in practice, as well as the opportunities and challenges for supporting therapists and their use of theory and evidence are discussed.     

Using the Model of Human Occupation to Nurture an Occupational Focus in the Clinical Reasoning of Experienced Therapists

Best ooccupational therapy practice requires a commitment to ongoing learning to enhance clinical reasoning. This paper describes a five-step cooperative learning process to advance clinical reasoning based on the Model of Human Occupation (MOHO). During the five-step process the MOHO concepts and assessments provide opportunities for therapists to develop occupation-focused clinical reasoning and deepen their knowledge of the theory and its application in practice.     

Knowing the diagnosis and counselling the relatives of a person with dementia: the perspective of home nurses and home care workers in Belgium

Home nurses and home care workers share the care for a person with dementia with family caregivers, and are confronted with their needs for medical and service-related information, for advice on how to cope with the behaviour changes, and for emotional support. The first objective of the present study was to describe some of the conditions for effective counselling, such as the perception that knowing the diagnosis has positive consequences for the formal caregivers. A second objective was to describe the formal caregivers' counselling practice, and ascertain its relationship with the psychological variables of attitudes, self-efficacy and subjective norm. A postal questionnaire was sent to 287 home nurses and 1259 home care workers in a defined region of Belgium; the questionnaire was returned by 169 home nurses (58.9% response) and 665 home care workers (52.8% response). The Theory of Planned Behaviour was the organising framework which underpinned the development of the instruments. Only the 168 home nurses and 601 home care workers reporting experience with caregiving to people with dementia were included in the analysis. Formal caregivers indicated that knowing the diagnosis was important, but it could facilitate or hinder caregiving. They were able to describe behavioural characteristics which are indicative of dementia, but only in a limited way, and their strategies to uncover the diagnosis were also limited. Formal caregivers reported that they supported family members emotionally, advised about communication with the person with dementia and informed family caregivers about services. However, providing family caregivers with information about dementia lagged behind these forms of support. In general, nurses scored higher than home care workers. Multiple linear regression analysis was used to investigate the relationships between self-reported practice and the concepts of the model. In both professions, attitudes and self-efficacy were found to be strong independent predictors, and the implications for practice are discussed.     

Decision Aid Interventions for Family Caregivers of Persons With Advanced Dementia in Decision-Making About Feeding Options: A Scoping Review

ObjectivesWe provided an overview of the literature on decision aid interventions for family caregivers of older adults with advanced dementia regarding decision making about tube feeding. We synthesized (1) the use of theory during the development, implementation, and evaluation of decision aids; (2) the development, content, and delivery of decision aid interventions; (3) caregivers’ experience with decision aid interventions; and (4) the effect of decision aid interventions on caregivers’ quality of decision-making about feeding options.DesignScoping review.MethodsWe conducted a scoping review of peer-reviewed studies published January 1, 2000–June 30, 2022, in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science databases. The process was guided by Arksey and O’Malley’s methodological framework, which includes identifying the research question, choosing related studies, charting the data, and summarizing results. Empirical articles concerning the decision aid interventions about feeding options were selected.ResultsSix publications reporting 4 unique decision aid interventions were included. All the interventions targeted caregivers of older adults with advanced dementia. Three decision aids were culturally adapted from existing decision aids. The Ottawa Decision Support Framework and the International Patient Decision Aid Standards Framework were used in these 6 publications. Interventions aimed to improve decision making regarding tube feeding for caregivers through static delivery methods. Caregivers rated these decision aids as helpful and acceptable. Decisional conflict and knowledge of feeding options were the most common outcomes evaluated. Reduction in decisional conflict and increase in knowledge were consistently found among dementia caregivers, but no intervention effects were found on preferences for the use of tube feeding.Conclusions and ImplicationsDecision aid interventions effectively improve decision-making regarding tube feeding among the target population. Cultural adaptation of an existing decision aid intervention is the main strategy. However, the lack of guidance of a cultural adaptation framework in this process may lead to difficulties explaining caregivers’ behavioral changes. Moreover, merely providing information is not enough to change caregivers’ preferences or behavior of use of tube feeding. A systematic approach to cultural adaptation and interactive intervention is needed in future studies.