Role for Occupational Therapy in Community Mental Health: Using Policy to Advance Scholarship of Practice

ABSTRACT

Occupational therapists must be aware of professional and policy trends. More importantly, occupational therapists must be involved in efforts to influence policy both for the profession and for the people they serve (Bonder, 1987). Using the state of Illinois as an example, this article reviews the policies and initiatives that impact service decisions for persons with psychiatric disabilities as well as the rationale for including occupational therapy in community mental health service provision. Despite challenges in building a workforce of occupational therapists in the mental health system, this article makes the argument that the current climate of emerging policy and litigation combined with the supporting evidence provides the impetus to strengthen mental health as a primary area of practice. Implications for scholarship of practice related to occupational therapy services in community mental health programs for individuals with psychiatric disability are discussed.     

Beyond good practice: Issues in working with people with intellectual disability and high support needs

Many more people with an intellectual disability now live in the community as a result of de-institutionalization. Occupational therapy is one service that assists people with intellectual disabilities to participate as fully as possible in their local communities. Despite the potential benefits of occupational therapy, there is little written about the types of interventions used and the effectiveness of their outcomes with people with intellectual disabilities. The present interview study about current occupational therapy practice with people with intellectual disabilities and high support needs was conducted with experienced Australian clinicians. Positive outcomes for clients with high support needs were achieved in two ways: (i) by what therapists do; and (ii) by the features of the therapy relationship. In addition, interventions that indirectly empowered clients and changed others' perceptions were seen to have the most positive effect. The findings are discussed with regard to current occupational therapy literature and implications for occupational practice and education are presented.     

Occupational therapy and people with intellectual disability from culturally diverse backgrounds

The multicultural nature of Australian society creates a need for occupational therapists to become aware of the issues facing people from culturally diverse backgrounds. People with intellectual disability from culturally diverse backgrounds may experience a 'double disadvantage' due to issues of their culture and their disability. This research aimed to identify the experiences, issues and strategies used by occupational therapists working with people with intellectual disability from culturally diverse backgrounds. A semistructured group interview and three individual interviews were conducted with occupational therapists from both metropolitan and rural locations in Queensland. It was found that communication and residential services present some unique issues for people with intellectual disability from culturally diverse backgrounds. Strategies suggested by therapists to address a range of issues are listed. Implications for occupational therapy are discussed, and suggestions for future research are provided.     

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.     

Is occupation missing from occupational therapy in palliative care?

Background/aim: The role of occupational therapists in palliative care is largely undocumented in Western Australia (WA). Little is known about the services occupational therapists provide or the needs of people who are dying and their carers in relation to these services. The aims of this study were as follows. First, to determine the number of occupational therapists employed and the range of services they provide in palliative care in WA. Second, with particular reference to self care, leisure, productive roles and occupations, to explore the daily experiences of people who were dying as well as their primary carers to determine the services that might be offered by occupational therapy to this population. Methods: Semi‐structured interviews were used to gather information from carers (n = 10 metro, n = 4 rural) and occupational therapists (n = 13 metro, n = 5 rural). Data were analysed qualitatively using grounded theory to develop categories. Themes were defined using the constant comparison method. Results: Four themes emerged that impacted people who were dying and their carers. These were; ongoing disengagement from usual activities with resultant occupational deprivation; disempowerment of both people who are dying and their carers within palliative care services; ‘occupation’ not being addressed adequately in palliative care and occupational therapists experience frustration with limited opportunities to contribute to the care of people who are dying. Conclusions: This paper highlights gaps in service provision in WA to people who are dying and their carers. It provides direction for occupational therapists to offer an occupation‐focussed approach to the care of this vulnerable group.     

Time use and importance of instrumental activities of daily living

This study investigated time use and the importance of instrumental activities of daily living (IADL) tasks to an older community-dwelling population. In addition, the study compared occupational therapists' and older people's perception of importance of IADL tasks for maintaining community living. Thirty-three subjects completed a time diary and an interview-based questionnaire to ascertain their time use and the importance of IADL tasks. It was found that older people living in the community spent most of their time at home and alone, with nearly half the day being spent on IADL tasks. The subjects indicated that the three most important tasks were use of the telephone, use of transportation (including driving) and reading. Differences were found when the results from an earlier study of occupational therapists were compared with results from the present study of older people. The occupational therapists also considered use of the telephone as most important but then rated medication management and snack preparation as the most necessary activities for continued community living. These results emphasize the differences in the perception of 'important' between the two groups studied. The results from this research confirm the importance of IADL to both the occupational therapy profession and older people living at home in the community. Further, these results confirm the need for client-centred practice and collaborative intervention planning for occupational therapy.     

Driver Rehabilitation and Community Mobility Principles and Practice

Achievement of independent living skills training is described as the foundation for successful role enactment which is a fundamental concept of occupational science. A review of the literature suggests that this is the most needed and least addressed service for those persons who are physically disabled and living in the community. A research study was designed and a survey conducted to determine the (current) use of independent living skills training by occupational therapists who were practicing in rehabilitation settings with adults who were physically disabled. The results showed that the occupational therapists participating in the survey spent an average of 14.1 percent of their direct treatment time providing this training. This was considered to be a low amount by a panel of experts convened to provide content validity for this study. The results of the study and implications for occupational therapy are discussed.     

Utopian visions/dystopian realities: exploring practice and taking action to enable human rights and occupational justice in a hospital context

Aim: This article reports some preliminary findings of an Australian action research project that aimed to investigate, and affect, occupational therapists’ understanding of human rights theory and occupational justice philosophy in everyday occupational therapy practice. Method: Over the course of one year, nine therapists from a range of practice areas in a major metropolitan hospital participated in monthly discussion groups. Narrative data was collected through audio‐recording and transcribing the discussions. Data was qualitatively analysed using line‐by‐line coding and theme‐building. Results: Two preliminary themes are discussed herein: the invisibility of human rights issues in an Australian occupational therapy setting and the dissonance between the ideal and the reality of human rights practice in occupational therapy. Conclusion: The authors suggest that through discussion, and with the support of a community of practice dedicated to exploring human rights and occupational justice issues, occupational therapists can increase their awareness of human rights challenges. And, therapists can increase their actions to better enable occupational justice in their practice.     

Treatment approaches for clients with a stroke‐affected upper limb: Are we following evidence‐based practice?

Stroke rehabilitation is an area of practice that many occupational therapists encounter during their career. The literature promotes a wide range of management techniques and support devices for people who have a stroke-affected upper limb, but little is known about the validity of those that occupational therapists actually use in practice. A questionnaire was sent to occupational therapists working in Queensland and northern New South Wales facilities (n = 35), in which adults with a stroke were likely to be treated. Eighteen respondents answered questions about the management techniques and support devices used in their facility, and their perception of the benefit of these devices in the reduction of hemiplegic shoulder pain. Results are discussed with reference to evidence-based practice and indicate an urgent need for the collation and dissemination of the best current evidence available for the management techniques and support devices used in this area, as well as further research to extend this evidence.     

Understanding Occupational Therapy: Nursing and Physician Assistant Students' Knowledge About Occupational Therapy

Until very recently, occupational therapy services have been provided in institutional settings and have followed the medical model. The escalating costs of hospital care have been the primary incentives for moving patients out of acute settings and thus increasing the need for occupational therapy services in the community. Yet, relatively few therapists have moved from the medical model even though the need exists and legislation encourages that service be provided in the least restrictive alternative. Further, occupational therapists have been slow to adopt distinct strategies for planning with patients for their roles and needs after treatment even though the heart of the occupational therapy philosophy centers on adaptation to life roles. This paper explores the current trends away from institution-based health care and towards a continuum of health and social services, and the roles for occupational therapists in community settings. Occupational therapists are urged to act as facilitators in assisting patients to move successfully from active treatment to independence in whatever settings they find themselves.     

Developing and Implementing a Senior Community Based Fall Prevention and Home Safety Program

Occupational therapists are primary candidates in taking a proactive role in meeting the community dwelling senior citizen's safety, environmental, and cognitive needs through the development of community based programs in conjunction with aging organizations. The purpose of this paper is to provide recommendations to occupational therapists in developing, implementing, and marketing a senior community based fall prevention and home safety program in conjunction with a Council on Aging and occupational therapy outpatient private practice.     

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.     

Occupational science: a renaissance of service to humankind through knowledge

The context for the development of occupational science, the study of the human as an occupational being, included the worldwide increase in the population of people with chronic impairments, decreased resources for people with handicaps, growth in the complexity of daily life and the global maturation of the profession of occupational therapy. Occupational science promises that occupational therapists will define the knowledge base of the profession and its appropriate scope of practice through scholarly work. Occupational scientists need to develop a fresh synthesis of ideas from those scholarly disciplines that view the human as a complex being who interacts with the environment by using occupation over the three time spans of evolution, human development and learning; occupation as agency; and viewing the person served as Homo occupacio, a dynamic, open human system. The occupational human engages in daily life through development of a repertoire of skills which adheres to the rules of culture. Such study will need to include the contexts in which people carry out their rounds of occupation. The ‘detective work’ of occupational scientists, contributing to but not bound by the immediate demands of occupational therapy practice, will be guided by the values and traditions of the field to ensure its relevance and ethical foundation. The most important tool of the world community of occupational therapists will be the mind of the occupational therapist, who, through knowledge of occupation, will foster human capability and influence health. Copyright © 2000 Whurr Publishers Ltd.     

Practical strategies for working with indigenous people living in Queensland,Australia

Internationally, occupational therapists have recognized the need to provide culturally appropriate services for indigenous people. This study explored experiences, perspectives and practical strategies of occupational therapists working with Aboriginal and Torres Strait Islander people living in rural and remote areas of Queensland, Australia. Semi-structured interviews were conducted with eight occupational therapists who had at least 12 months' experience providing services to Aboriginal and Torres Strait Islander people in health, rehabilitation or education services. Key themes identified in the data focused on strategies for facilitating effective communication with individuals and families, and collaborating with other service providers. The role of Aboriginal Liaison Officers or Indigenous Health Workers was emphasized by participating therapists. Participants identified resources that they perceived as useful in their practice, such as cross-cultural training and access to indigenous health workers. Other resources suggested for further development included information about learning styles of indigenous people and information about cultural variations between specific Aboriginal and Torres Strait Islander communities. The small number of participants limits generalizability of the findings. However, therapists can decide on the relevance of strategies to their own workplaces. Suggestions for further research focused on improving occupational therapy services for indigenous people in Australia. These include an investigation of therapy goals with indigenous people, and interviews with indigenous Australians and indigenous health workers about their experiences and perceptions of occupational therapy.     

Employment trends for occupational therapists: An analysis of employment advertisements in the Sydney Morning Herald 1984–90

Despite rapid growth in the number of occupational therapy graduates in Australia, almost no data are available concerning the demand and the expectations of employers. This study surveyed 6298 advertised positions available to occupational therapists, social workers, psychologists and counsellors in the state of New South Wales during the years 1984–90. Over this period the demand for occupational therapists grew by 53%, which exceeded the growth in demand for social workers and psychologists, but was less than that for community and mental health workers and counsellors. The employment base was found to be reasonably broad and 8% of jobs were in the private sector. The number of duties required of occupational therapists increased over time, and there was an increase in the demand for programme promotion, administration and supervision skills. The results are discussed in terms of the employment base and defining strengths of the profession, recommendations for strengthening the profession, and implications for the Australian Association of Occupational Therapists.     

Occupational Therapy and the Patient with Pain

The characteristics, implications, consequences and costs of pain, particularly those of chronic benign pain syndrome, are presented, and current approaches to treatment are briefly discussed. Contributions which occupational therapists are uniquely qualified to offer are described. Occupational therapists are grounded in the concept that mind, body and spirit are integrally related and that the patient must participate actively in the planning and implementation of any treatment program. The occupational therapist is a specialist in role functions and is skilled in assisting clients to plan and re-create structure for their lives that has been lost by virtue of their illness, disability, or pain. The occupational therapist provides an environmental laboratory in which people can experiment with new behaviors and attitudes to restructure and regain control of their lives and to reestablish hope, competence, confidence and success as part of their daily activities. These concepts are basic to the successful treatment of the patient with chronic benign pain syndrome.     

Discharge decision-making with older people: The influence of the institutional environment

Background/Aim:  Occupational therapists often participate in decision-making about postdischarge accommodations. This paper presents the findings of a study that identified and explored institutional factors influencing discharge accommodation decision-making with older people, from the perspective of occupational therapists.
Methods:  Qualitative, semistructured, face-to-face interviews were conducted with 10 occupational therapists. Interviews were recorded, transcribed, coded and analysed for the presence and emergence of themes.
Results:  Decision-making processes were influenced by the institutional environment. The medical model and pressure for fast decisions seemed to impede client-centred processes in acute settings.
Conclusions:  When possible, decision-making about long-term care needs to occur in community or longer-stay rehabilitation settings that allow time for negotiated client-centred processes.