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.     

Psychiatric occupational therapists' verbal interaction with their clients

This study reports from a survey investigating psychiatric occupational therapists' (n=292) use of verbal interaction on a regular basis with their clients. Among predefined areas of verbal interaction, routine occupations, self-image and ego-strengthening interventions were among the most frequently given alternatives. Verbal interaction with clients was more common among occupational therapists in outpatient care than among those in inpatient care. Verbal interaction with clients was also more common among occupational therapists with advanced education in psychodynamically oriented psychotherapy. The respondents' use of theoretical frames of reference was related to the focus of their verbal interaction with clients. Interventions to reach certain goals emerged as the most common category of verbal interactions. It was concluded that verbal interaction with clients is essential to the occupational therapy process. Future research needs to investigate the interplay between verbal and non-verbal components of interaction in occupational therapy and how patients benefit from these elements.     

Occupational therapists use of cognitive interventions for clients with Alzheimer's disease

The aim of this study was to establish a profile of occupational therapy practice for cognitive interventions for clients with Alzheimer's disease (AD) in an urban setting. Seventy‐four occupational therapists working with older adults with AD in diverse settings in the city of Montreal were randomly selected and were sent a self‐administered questionnaire by mail. Sixty‐five (87.8%) therapists responded. Findings indicated that 52.3% of occupational therapists are performing cognitive interventions with persons with AD. Of those, 82.4% report using cognitive rehabilitation, 61.8% using cognitive stimulation and 50.0% using cognitive training. Intervention use varied across settings and differed according to severity of AD. The sessions are usually provided individually and often include the client's caregiver. Generalizability of the results is limited to urban areas, and possible differences in service provision should be taken into consideration. Further research is needed to measure the effectiveness of these interventions provided by occupational therapists and to compare occupational therapy practices in urban and rural areas. Copyright © 2009 John Wiley & Sons, Ltd.     

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.     

Effects of profession and facility type on research utilization by rehabilitation professionals

Information about the use of research by rehabilitation professionals to make clinical decisions in everyday practice is limited. This study compared perceived research use and knowledge sources across professions, practice situations, and work environments. Participants were 165 randomly selected Canadian occupational therapists, physical therapists, and speech-language pathologists. Self-report ratings during an interview, an interviewer rating, and questionnaire scores (Edmonton Research Orientation Survey, General Use of Research, Knowledge Acquisition Survey) were compared. Speech-language pathologists had the most education and the highest research use ratings. Research use was highest during program planning. Programs to encourage research use must consider the research available to guide practice and therapists' education level. Facility size and location (rural, urban) do not affect perceived research use.     

Functional capacity evaluation reports for clients with personal injury claims: A content analysis

Functional capacity evaluations (FCEs) for personal injury claimants are rigorously scrutinized by the stakeholders because of their financial implications. This study examined 51 medico-legal FCE reports for clients all of whom suffered with spinal pain attributed to a motor vehicle accident. The FCEs were completed by 14 occupational therapists. Content analysis of the FCE reports identified categories and sub-categories of objective and subjective information on which occupational therapists reported. They included employment, activities of daily living, pain, functional physical capacities and job demands. Recommendations included the suitability of current and future jobs. However, the reasoning behind occupational therapists' recommendations in the FCE reports was frequently not stated. This content analysis demonstrated that these detailed FCE reports had a consistent focus on work capacity; further, the researchers suggest refinements to FCE reporting practices so that findings, recommendations and predictions about work outcomes for clients are interpreted clearly and realistically.     

Integrating research into practice: a challenge for local authority occupational therapy

The aim of this qualitative study was to identify and analyse the experiences of Swedish local health authority occupational therapists with regard to their participation in, and the implementation of, research. Data were collected from three focus-group interviews, with five different occupational therapists in each. The interviews were taped and transcribed and thereafter analysed using broad coding. One core category-"feeling professionally competent"-emerged, comprising three subcategories: "perceiving congruence between research and practice", "having the necessary skills", and "making a contribution". Feeling professionally competent embraces the occupational therapists' definition and delimitation of their professional domain and the obligations related to this. It also embraces the perception of having the skills necessary for participating in research projects and implementing research findings in a scientific manner. The implementation of research was not only perceived as contributing to the knowledge base of the profession, but personal gains could also be made. The knowledge gained from this study can help in the development of strategies to promote the integration of research in local authority occupational therapy practice. This is necessary; otherwise the occupational therapy provided will be based on the knowledge and perceptions of individual professionals, rather than on state-of-the-art knowledge gained through research.     

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.     

What do Swedish occupational therapists feel about research? A survey of perceptions, attitudes, intentions, and engagement

The aim of this study was to identify Swedish occupational therapists' perceptions and attitudes to research-related activities as well as the therapists' present engagement in future plans for research. A follow up design was used, and the study was undertaken between 1997 and 2003. A total of 425 and 442 Swedish occupational therapists responded to a postal questionnaire (response rate 74.4% and 70.4%). Questions regarding research-related activities were measured on a Likert-type scale, whereas questions referring to attitudes towards research used a semantic differential scale. There were small differences between the two surveys. The result showed that occupational therapists considered research-related activities to be an important part of their development of the professional role and status. Reading research literature to update knowledge was the most important research activity and the second most important activity was applying research findings to improve occupational therapy practice. High workload and lack of time were the most commonly mentioned barriers to participation in research- related activities. Occupational therapists read a large variety of journals, preferably in Swedish. The barriers to participation in research-related activities did not change from 1997 to 2003. The fact that occupational therapists reported reading research as rating highly gives hope for the future development of the occupational therapy profession and practice.     

Occupational therapists' decision-making in the management of clients with upper limb hypertonicity

This study applied social judgement theory to the exploration of factors influencing occupational therapists' decision-making when they manage upper limb hypertonicity in clients with cerebral palsy. To achieve this goal, both objective and stated policies were investigated. This quantitative study drew information from a literature review and a survey with experienced occupational therapists to identify 12 factors that could influence decision-making. Based on these 12 factors 110 case vignettes of individuals with cerebral palsy and upper limb hypertonicity were generated. Intervention decisions were elicited from 18 experienced occupational therapists for each of the 110 case vignettes. Therapists were also asked to rank the factors in order of perceived importance. Occupational therapists generally used severity of spasticity, wrist and finger posture, and client and family background information to guide their clinical intervention choices. However, therapists demonstrated poor insight into the nature of their decision-making processes. This was highlighted in the disparity between their stated and objective policies. These findings have implications for both the professional development of therapists and the training of students.     

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.     

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.     

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.     

Concepts in occupational therapy in relation to the ICF

Occupational therapists need an acceptable terminology to describe a client's clinical performance. The language or terminology must be in harmony with common language in the health care system but also reflect occupational therapists' professional responsibility. The aim of this paper is to help clarify similarities and differences between concepts in occupational therapy and the International Classification of Functioning, Disability and Health (ICF). Two studies were completed in which items in the International Classification of Impairments, Disabilities and Handicaps (ICIDH-2) were compared with concepts from the Swedish version of the assessment of Motor and Process Skills (AMPS) and the Assessment of Communication and Interaction Skills (ACIS-S). An expert panel of occupational therapists served as raters and 33 clients with learning disabilities and mental health problems were assessed. The result showed that 12 (60%) of the skills items from the ACIS-S were found to be equivalent to items in then ICIDH-2. In total, 41% (n = 23) of the items in the AMPS or ACIS-S have a correlation higher then 0.60 with the ICIDH-2. The classification can serve as a useful tool for occupational therapists and supports communication between professions, but is not sufficient as a professional language for occupational therapists. Further research is indicated to examine how the ICF can be applied in occupational therapy and its implications on clinical practice.     

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.     

Identifying occupational therapists' referral priorities in community health

Occupational therapists in British community mental health teams have been debating how the most effective services can be targeted at the most needy clients. This paper presents the results of a quantitative study that examined 40 British occupational therapists' referral prioritization policies. Results showed half of the participants felt their generic responsibilities, which involved having care co-ordination responsibilities, were too large. Only 25% of participants co-ordinated care for clients whose needs were related to occupational dysfunction. Judgement analysis, that involved regressing the 40 individuals' prioritization decisions onto the 90 respective referral scenarios, was used to statistically model how referral information had been weighted. Group agreement of prioritization was moderate with the reason for referral, history of violence and diagnosis being given the most weighting. Consistency in policy application, as measured by examining prioritization decisions on identical referrals, showed wide variability. Further research is required to identify the optimal and most stable policies within this group.     

Integrating health literacy into occupational therapy: findings from a scoping review

This paper aims to report ways of integrating health literacy into occupational therapy practice. Health literacy is defined as the ability to access, understand, evaluate, and communicate information as a way to promote, maintain, and improve health in various settings over the life-course. A scoping study of the scientific and grey literature on health and, specifically, occupational therapy and health promotion was done from 1980 to May 2010. Five databases were searched by combining key words (i) "health literacy" with (ii) "rehabilitation", "occupational therapy", or "health promotion". Data were extracted from 44 documents: five textbooks, nine reports, and 29 articles. The literature on health literacy needs enhancing in both quantity and quality. Nevertheless, six ways of integrating health literacy into occupational therapy practice were identified (frequency; %): occupational therapists should (i) be informed about and recognize health literacy (27; 61.4), (ii) standardize their practice (10; 22.7), (iii) make information accessible (37; 84.1), (iv) interact optimally with clients (26; 59.1), (v) intervene (29; 65.9) and (vi) collaborate to increase health literacy (21; 47.7). Since health literacy can directly impact on intervention efficacy, further studies are needed on how to integrate health literacy into occupational therapy practice.     

Experiences with the COPM and client-centred practice in adult neurorehabilitation in Taiwan

The application of a client-centred approach and the Canadian Occupational Performance Measure (COPM) were investigated in a neurorehabilitation unit in Taiwan. Four Taiwanese occupational therapists were trained in the use of client-centred practice and the COPM before using them with 12 clients attending neurorehabilitation. The COPM and the Reintegration to Normal Living Index (RNL) were administered before treatment and after one month of neurorehabilitation to investigate the sensitivity of the COPM in measuring change. Pre and post interviews were also conducted with the participating occupational therapists to ascertain their perceptions of the clinical utility of the COPM, and to determine their views about the client-centred approach. Matched t-tests showed significant increases in clients' self-ratings of performance and satisfaction on the COPM and in RNL scores between pre and post tests. The qualitative findings highlighted issues regard-ing the administration, scoring and identification of problems in the COPM and client-centred practice, such as clients' willingness to manage their own health care and empowerment to participate in intervention, as well as therapists' knowledge of and confidence with this new approach. Although this study was limited by small sample size and the use of only one hospital neurorehabilitation unit, it has shown the utility of the COPM as an outcome measure in this setting. Further research is warranted to investigate cultural influences on client-centred practice.