A comparison of Canadian and Australian paediatric occupational therapists

Paediatric occupational therapists were surveyed regarding their practices in Canada and Australia. Two hundred and eighty-nine Canadian occupational therapists and 330 Australian occupational therapists participated representing response rates of 28.9% and 55% respectively. The majority of respondents were female (98%), between 30 and 49 years of age (69%), had a bachelor's degree, worked on average 10.5 years in paediatrics and spent well over 50% of their work time in direct client care. The largest client diagnostic groups in both countries were those with developmental delays, learning disabilities and neurological disorders. Diagnostic groups were used as an organizing framework to portray theory, assessment and intervention use. Overall, the theoretical models cited most frequently in both countries were: Sensory Integration, Sensory Processing/Sensory Diet, Client-Centred Practice, and Occupational Performance Model. Australian therapists employed the Occupational Performance Model (Australia) for all groups, while it was rarely utilized in Canada. Common assessment tools in both Australia and Canada were the Peabody Developmental Motor Scales, Developmental Test of Visual Motor Integration, and the Bruininks-Oseretsky Test of Motor Proficiency. Intervention methods focused on: parental/care-giver education; activities of daily living/self-care skills training; client education; environmental modification; assistive devices; sensory integration techniques; sensory stimulation and sensory diet treatment methods; and neurodevelopmental techniques.     

Test of Visual Perceptual Skills--Revised: An Overview and Critique

Paediatric occupational therapists frequently assess and treat children and youth presenting with visual perceptual problems. Difficulties in this skill area can have a negative impact on a number of occupational performance and functional skill areas for children and youth including their ability to successfully complete activities of daily living, participate in play/recreational activities, complete school-related work and accomplish age-related developmental tasks. Therefore, it is important for occupational therapists to utilize visual perceptual assessments that possess sound measurement properties (such as validity, reliability, responsiveness and clinical utility). The Test of Visual Perceptual Skills--Revised is an instrument frequently used by paediatric occupational therapists to evaluate children and youth presenting with visual perceptual dysfunction. Occupational therapists need to be cognizant of the measurement properties of the assessments they use in order to provide the best quality care for the paediatric clients they serve. Therefore, a review and critique of the Test of Visual Perceptual Skills--Revised is presented.     

Quality and quantity of paediatric research: An analysis of the OTseeker database

Aim:  This study aimed to analyse the quantity and quality of paediatric research evidence contained in the OTseeker database and to compare the findings with surveys of paediatric occupational therapy practice.
Methods:  In June 2005, systematic reviews and randomised controlled trials contained in OTseeker were analysed according to year of publication and the client diagnostic groups and interventions addressed. The internal validity scores of the trials were determined (according to the PEDro scale (partitioned)) and the outcome measures used extracted.
Results:  Of 3294 papers contained in OTseeker, 372 (11.3%) were related to paediatrics. The mean internal validity score of the trials was 2.5/8. The five most frequently studied diagnostic groups were mental health/psychosocial issues, neurology, learning disabilities, developmental delay and 'other'. There was much variation in the outcome measures used, with a large number of outcome measures used in only one or a few studies. The five most frequently studied interventions were behavioural interventions, consumer education, psychosocial techniques, interventions for carers/parents and developmental therapy.
Conclusion:  OTseeker contains a considerable amount of research relevant to paediatric occupational therapy practice. There was some congruence between the papers and practice surveys regarding client diagnostic groups and interventions, but little between the outcome measures used in research and those used in clinical practice.     

How and why do occupational therapists use the OTseeker evidence database?

Background:  OTseeker is a free online bibliographic database containing systematic reviews and methodological ratings of randomised controlled trials relevant to occupational therapy. The database aims to help therapists efficiently identify high quality pre-appraised research.
Aim:  This study explored the search practices of therapists who regularly used OTseeker, what they did with the information retrieved and their perceptions of the database.
Sample:  A purposive sample of 11 occupational therapists was recruited in 2004. All had visited OTseeker at least five times in the previous 12 months.
Study design:  Qualitative.
Methods:  A semistructured interview was conducted with each participant. Grounded theory methods were used for analysis.
Findings:  Five distinct categories were identified: reasons for visiting OTseeker, learning about OTseeker, search times and locations, using information from OTseeker, and improving OTseeker. Therapists used the database to teach or model evidence-based practice, answer clinical questions and keep up-to-date. Suggestions for improvement focussed on search functionality, access to abstracts and the location of the PEDro rating scale. Only two participants synthesised information from OTseeker into a summary, and/or used it to inform client reports.
Conclusion:  This study suggests that OTseeker is helping to increase research utilisation by occupational therapists. Further research is needed to help therapists apply research evidence to change practice and policy.     

Understanding where we come from: Occupational therapy with urban Indigenous Australians

Background:  This article outlines issues of service provision for Indigenous families in Brisbane, Australia. It presents guidelines for the development of a socially and culturally appropriate occupational therapy service for urban Indigenous children.
Methods:  A mixed methodology was used in two independent components of the research. Part 1 comprised a survey of paediatric occupational therapists in Brisbane. Part 2 consisted of focus groups and interviews with recipients of a newly established occupational therapy service for Indigenous children.
Results:  Survey findings indicated that very few Indigenous families access mainstream occupational therapy services. Issues and strategies for developing culturally appropriate practice emerged around five main themes. These were the need to develop effective relationships, develop particular personal qualities, understand the background of both the client and the therapist, both gain and give knowledge, and address logistical issues of service delivery.
Conclusions:  Service providers need to understand the social and cultural context of both their Indigenous clients and themselves. Recommendations for future education and practice are provided.     

Management of patients with cognitive impairment after stroke: A survey of Australian occupational therapists

Background/aim: Cognitive impairment is a common and often debilitating consequence of stroke. The current practice patterns of Australian occupational therapists who work in this area are not clearly known. The aim of this study was to investigate the theoretical approaches, assessments, interventions and research evidence used by Australian occupational therapists who work with patients who have cognitive impairment poststroke.
Methods: A self-administered, purpose-designed online survey was used.
Results: Survey responses were received from 102 occupational therapists. The client-centred approach was the most commonly used theoretical approach, with 81.3% and 72% using it often or all of the time with inpatients and outpatients, respectively. Assessments that were most frequently used were the Mini Mental State Examination (63.7% of participants), the Lowenstein Occupational Therapy Cognitive Assessment (45.1%), the Functional Independence Measure (57.8%, and the Assessment of Living Skills and Resources (10.0%). Interventions involving functional activities were used more frequently than compensatory techniques, such as diaries, alarms, or other electronic devices, and paper and pencil remedial exercises. Few (16%) participants used computer programs specifically designed for cognitive rehabilitation. Although 60.8% of the participants reported using research literature when making decisions about interventions, a higher percentage reported relying on their past experience (88.3%) and colleagues' opinions (77.4%).
Conclusion: This study provides an insight into the current practices of Australian occupational therapists who work with people who have cognitive impairment after stroke. Client-centredness is emphasised in current practice; however, the use of research evidence to inform practice appears to be limited.     

Are we applying interventions with research evidence when targeting secondary complications of the stroke-affected upper limb

Background/aim:  This study aimed to survey occupational therapy practice with reference to the current evidence for management of secondary complications of the stroke-affected upper limb.
Methods:  A questionnaire was developed to identify the clinical practice of occupational therapists in managing the client's stroke-affected upper limb. Participants were recruited via an email to the national occupational therapy neurology listserve. Occupational therapists working in stroke rehabilitation were invited to complete the questionnaire online or to print off and return.
Results:  Fifty-five occupational therapists completed the questionnaire. Results revealed that treatment techniques with little to no evidence were used frequently, including pillow cushion supports (98%), positional stretch (94%) and slings (61%). Alternatively, treatment techniques with significant supporting evidence were used at a lower frequency, such as electrical stimulation (39%).
Conclusions:  The results of the questionnaire highlight an inconsistent application of evidence within clinical practice and the consistent application of treatment techniques with poor supporting evidence. This result does not represent poor clinical practice. Rather, it highlights the need for the research literature to articulate the clinical reasoning underpinning clinicians' selection of treatment techniques and to determine the effectiveness of frequently used, but poorly supported treatment techniques.     

Reliability of the Perceive, Recall, Plan and Perform System of Task Analysis: A criterion-referenced assessment

Objective:  To conduct preliminary examination of the rater and test-reliability of the Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis, an ecological measure designed to assess task-embedded information processing capacity during occupational therapy assessment of confused and agitated adults following traumatic brain injury.
Methods:  Occupational therapists observed and scored client performance using the PRPP System of Task Analysis. Correlational analysis and measures of agreement were performed to determine interrater and intrarater reliability. Test procedures were examined for reliability and internal consistency.
Results:  Interrater and test reliability considered three factors: therapists, clients and tasks. A moderate level of interrater reliability was achieved between trained therapists (intraclass correlation coefficient (ICC) = 0.60). Test procedures were highly reliable (ICC = 0.88). Across two measurement occasions, therapists showed a tendency towards harder rating on the second test occasion (      –4.5%; 95% confidence interval for     : –10.67%→ 3.17%).
Conclusion:  The findings of this study support the use of criterion-referenced tests in the area of occupational performance measurement. Occupational therapists achieved moderate interrater reliability when measuring the performance of adults with brain injury on various activities of daily living. Test procedures were found to be highly reliable in measuring the occupational performance of adults demonstrating confusion and agitation typical to the stage of post-traumatic amnesia following head injury.     

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.     

Occupational therapists' perception of their practice: A phenomenological study

Background:  International literature seems consistent in reporting that occupational therapists value their methods. However, little empirical evidence has been generated supporting the basic system of belief for occupational therapy. Few studies have explored the nature of the occupational therapists' experiences and thoughts about their use of occupation as means and ends, and which strategies they use to implement their tools in their current practice. Accordingly, the aim of this study was to explore how occupational therapists understood and presented their practice and interventions.
Methods:  A sample of six occupational therapists graduated in different decades, from diverse client populations and health-care settings was selected to participate in a semistructured interview.
Results:  Three main themes were developed: 'To make the client's potentials visible', 'reaching a position one values' and 'looking with other eyes'. Whatever their specialities, the participants were unanimous in the way they described their role. Their common focus was 'activities of daily living'. However, they had problems describing their therapeutic tools, and were not able to clearly articulate the 'common sense aspects' of their own methods. The participants were engaged in constructing their professional identities, and stressed the need to construct professional boundaries relevant to their particular work.
Conclusion:  The occupational therapists perceived their practice and interventions as distinctly different from other team members, thus, they provided a 'counterpoint'. The participants used various ways of marketing their perspectives. While the novices tended to go along with the team, the experienced therapists tended to assert their own special contribution.     

Four years after graduation: Occupational therapists' work destinations and perceptions of preparedness for practice

Objective:  The present study sought to identify the work destinations of graduates and ascertain their perceived preparedness for practice from a regional occupational therapy program, which had been specifically developed to support the health requirements of northern Australians by having an emphasis on rural practice.
Design:  Self-report questionnaires and semistructured in-depth telephone interviews.
Participants:  Graduates ( n =  15) from the first cohort of occupational therapists from James Cook University, Queensland.
Main outcome measure:  The study enabled comparisons to be made between rural and urban based occupational therapists, while the semistructured interviews provided a deeper understanding of participants' experiences regarding their preparation for practice.
Results:  Demographic differences were noted between occupational therapists working in rural and urban settings. Rural therapists were predominantly younger and had worked in slightly more positions than their urban counterparts. The study also offered some insights into the value that therapists placed on the subjects taught during their undergraduate occupational therapy training, and had highlighted the differences in perceptions between therapists with rural experience and those with urban experience regarding the subjects that best prepared them for practice. Generally, rural therapists reported that all subjects included in the curriculum had equipped them well for practice.
Conclusions:  Findings suggest the need to undertake further research to determine the actual nature of rural practice, the personal characteristics of rural graduates and the experiences of students while on rural clinical placements.     

Translating knowledge to practice: an occupational therapy perspective

Background/Aim:  Translating knowledge to practice, also called ‘knowledge translation’, is increasingly recognised as a driving force to strengthen and improve the healthcare system. How knowledge translation fits with occupational therapy practice deserves examination. Methods:  This paper will explore how an action process model, the Knowledge‐To‐Action Process, may advance knowledge translation in occupational therapy. Occupational therapists typically view knowledge in a broad sense, encompassing research, tacit knowledge, expert opinion and client evidence. The Knowledge‐To‐Action Process facilitates application of client, therapist and research knowledge to occupational therapy practice. Results:  Examination of knowledge translation through the lens of the Knowledge‐To‐Action Process creates awareness of the value of client, therapist and research knowledge. It also highlights opportunities as practitioners to implement knowledge translation. Conclusions:  Models able to flexibly reflect an occupational therapy perspective of knowledge have a potentially vital role in successful knowledge translation. Furthermore, these models allow therapists and other stakeholders to analyse complex situations and identify targeted knowledge translation strategies.     

Language, identity and representation: occupation and occupational therapy in acute settings

Aim:   This article presents findings from a participatory action research study into the experience and use of occupation, theory and evidence in the everyday practice of a group of occupational therapists working in a large metropolitan hospital delivering a range of acute services, in Melbourne, Australia.
Methods and findings:   Narrative data gathered from 11 individual interviews and 10 group discussions were analysed through numerous iterative cycles to explore research issues and evaluate research actions. This article discusses why the participating occupational therapists chose to change the language they used to describe their practice from a focus on 'function' to a focus on 'occupation'. This change improved the therapists' levels of confidence, strengthened their professional identities and provided for a sense of renewed empowerment within the organisation.
Conclusions:   The findings suggest that occupational therapists in acute settings can utilise language more effectively to augment their ability to promote the vital and unique contribution that occupational therapy has to make. Such small, yet powerful changes can empower occupational therapists to address long-standing dilemmas of representation and enable transformative practices.     

The Tree Theme Method as an intervention in psychosocial occupational therapy: Client acceptability and outcomes

Background/aim:  The Tree Theme Method (TTM) is an intervention in which the client paints trees representing certain periods in his/her life. The intervention comprises five sessions, using trees as a starting point to tell one's life story. This study, which is part of an implementation project, aimed to examine the therapeutic alliance and client satisfaction, in relation to perceptions of everyday occupations and health-related factors, with clients going through a TTM intervention.
Methods:  Nine occupational therapists recruited 35 clients, at general outpatient mental health care units, for the TTM intervention. Self-rating instruments, targeting therapeutic alliance (HAq-II), different aspects of daily occupations (Canadian Occupational Performance Measure, Satisfaction with Daily Occupations), health-related factors (Sense of Coherence measure, Mastery Scale, Symptom Checklist-90-R) and client satisfaction (Client Satisfaction Questionnaire), were administrated before and after the intervention.
Results:  A good initial therapeutic alliance, experienced by both therapists and clients, was correlated to increased changes regarding occupational performance and self-mastery. According to the therapists' ratings, a good initial therapeutic alliance was correlated to increased sense of coherence and a decreased level of psychiatric symptoms. The results showed positive significant changes in occupational performance and health-related factors. High ratings of the therapeutic alliance by the therapists were also related to high client satisfaction.
Conclusions:  The TTM seemed to function well in psychosocial occupational therapy, but there is a need for further implementation studies to deepen our understanding of the treatment process, comprising both technique and formation of the therapeutic alliance.     

Reliability reconsidered: Cronbach's alpha and paediatric assessment in occupational therapy

Background/aim:  Using reliable outcome measures is a necessity for the occupational therapy profession in enabling valid assessments of clients. Although Cronbach's alpha is the most widely applied index of internal consistency reliability, there are misconceptions about its use and interpretation. This paper aims to guide assessment developers in paediatric occupational therapy, as well as practitioners who are evaluating outcome measures in using and interpreting the Cronbach's alpha estimates appropriately. This will enable them to decide on the tools' clinical value and incorporate them into their practice with children.
Method:  Previously published papers reporting on internal consistency issues of outcome measures in paediatric occupational therapy were searched through the Allied and Complementary Medicine database. These papers were used as a basis to discuss possible reasons for reporting of low internal consistency.
Results:  The analysis demonstrates that Cronbach's alpha reports are not always interpreted in a sound way. The paper emphasises that one should be cautious about judging estimates of internal consistency. Low size of the coefficient alpha might not always indicate problems with the construction of the tool; whereas large sizes do not always suggest adequate reliability. Instead, these reports might be related to the data characteristics of the construct.
Conclusion:  In judging an outcome measure's internal consistency, researchers and practitioners in occupational therapy should report and consider the nature of data, the scale's length and width, the linearity and the normality of response distribution, the central response tendency, the sample response variability and the sample size.     

A survey of recruitment and retention issues for occupational therapists working clinically in mental health

Background:  Mental health services Australia-wide have difficulty recruiting and retaining clinical occupational therapists.
Methods:  A survey of occupational therapists to identify factors that could influence their retention or loss from clinical mental health practice was undertaken.
Results:  Typically, respondents were female, aged 30 years or younger, working full-time at a grade 2 or 3 level, and had worked entirely in mental health. The main positive aspects that respondents identified about their positions were the 'social/emotional environment', 'aspects/nature of their roles', and 'using occupational therapy skills'. The main position constraints were 'insufficient time/workload' and 'insufficient use of occupational therapy skills/generic nature of work'.
Conclusions:  Recruitment and retention strategies are required to retain occupational therapists in clinical mental health positions.     

Workers' compensation insurance agents' satisfaction with occupational therapy activities of daily living assessments

Background and Aim:  Little is known about insurance agents' (insurers) satisfaction with the services provided by occupational therapists when they assess injured workers' activities of daily living (ADL). Demonstration of accountability and provision of high-quality services are important to the occupational therapy profession. The aim of this study was to evaluate insurers' overall satisfaction with occupational therapy ADL assessments for injured workers, including communication, timeliness of reports, equipment provision, knowledge of insurers' requirements and the workers' compensation process, and provision of a professional opinion. Relationships between insurers' overall satisfaction with ADL assessments, degree of experience in their job, formal qualifications and roles within their organisation were also investigated.
Method:  A telephone survey was developed and administered to a sample of 40 claims officers and injury management advisors from 10 Victorian Work Cover Authority authorised agents.
Results:  Insurers were generally satisfied with occupational therapy ADL assessments. They were less satisfied with occupational therapists' knowledge of workers' compensation system requirements and how occupational therapists made decisions when recommending household services.
Conclusion:  To improve services to the insurance industry, occupational therapists need to better understand relevant legislative frameworks.