Using the word "Occupation"

Has anybody find it difficult to promote OT? that may be because people(OT's) are afraid to use "Occupations" when they are promoting or explaining OT to MDT or to clients.  Everybody explains it in their own way and they are forgetting the essence and the main core and most simple word....Occupation!!!  It is what sets us apart so we have to market it.  we should use it in our day to day language as  professionals.  People always say " ordinary people will not understand it if we use Occupation so let us not use it and use something else." well excuuuuse me.  That will be the beginning of the death of the profession. there was an article in the OT news.  If I am not mistaken it may be professor Turner( I may be corrected if I am wrong) who, in essence, felt the profession is in its adolescence stage.... a stage of Identity crisis.  OT's are not yet proud to shout out " I am an Occupational Therapist and I deal with Human Occupations!!!" do people feel embarassed?

Until we are prepared to commit to promotong "Occupation" in Occupational Therapy, we will all remain to be JUST "Therapist" to the eyes of everybody.

ECOLOGY of HUMAN PERFORMANCE

This is a Model of Practice that has been around for many years now and I have seen it come up in OT Spackman 9th Edition.  Now I could not remember seeing it in Spackman 8th Edition when I was a studen many years ago. 

Unlike famous models of Practice for Occupational Therapy e.g. MOHO, COPM (Though I have my most respects for these examples), this model sees human performance as being effective and successfull ONLY IF the CONTEXT allows. what are these contexts? These are:

I. Environmental Context (Often the famous and remembered by most practitioners)
  1. Physical - home, physical environment, natural terrain etc
  2. Social Context - family, friends, demands of the society
  3. Cultural - customs, beliefs, political beliefs.....DEMANDS of NHS

II. Temporal Context (Often the neglected contexts that has a HUGE BEARING on our decision Making as OTs)
  1. Chronological : Individual's age
  2. Developmental : person age 35 who has the developmental age of 5 years old(mental health)
                                 - child age 12 can only crawl (physical development)
  3.  Life Cycle
  4. Disability Status - Place in the continuum of the disability , or the terminal nature of the illness (AOTA, 1994)
  5. Period

In the end, no matter how good you are with your treatment techniques as a therapist, you can only be as good if those CONTEXTS would allow you to create a change in a person.

people are really not free!!!! we like to think we are but there are laws that govern everything and these are the paramenters of performance and occupational independence and these basic Laws are the Laws of Context.  They are like the gravity on earth.

Hat's up to the proponents of this model: Winnie Dunn, Linda Mc Lain, Catana Brown and Mary Jane Youngstrom

Barriers to OT goal Setting

In my practice I have seen many OT’s getting trapped in the wrong goal setting and that most of the time, the goal setting is based on what they intend to do.  Sometimes, goal setting is very theoretical that it is impossible to be achieved by the patient because the client centeredness of goal setting has disappeared.  Most OTs are afraid of breaking old habits and it is quite difficult for my thoughts and ideas to be put across.   Problems in breaking the habit of old goal setting may be due to the following:

1. Most OT’s are not using any framework – although frameworks are taught at the universities, it is sometimes difficult to actually use it in practice and in my experience, few to none uses framework in their practice.
2. No unified understanding of the domain of concern of the profession – Most OT’s are specialised in the detailed treatment approaches and because of this, I feel that the basic domain of concern of the profession has been forgotten and it does affect an OT’s ability to promote oneself.  In effect, OT’s are sometimes considered – equipment provider, commode provider, tea making profession, and many more that is really degrading and insulting professionally.
3. Goals are limited to a person’s ability and disabilities rather than, ‘occupational concerns’ of both the client and their family.  – most of us are hooked on making goals only relevant to the client because the client is ‘our’ patient.  We are forgetting that the client is an ecological entity and he is attached to a bigger unit e.g. his family.  Any Occupational changes in him will have an effect on his social circles  like his family, friends, work.  The client is a part of a whole so, it should not just be the client’s goals that an OT should be considering but also the concerns of the social group he is a part of.  The client, as an individual, is not only the OT’s ‘client’.  His Social group also becomes and OT’s client so intervention and goals for the group also matters significantly.
4. No use of Uniform Terminology -
5. Unconscious method of clinical reasoning -   Clinical reasoning is suppose to be easy and simple if everybody knows the formula.  To my observation, clinical reasoning is mostly relied on experience and on what is available within the arena of practice but if you take one practitioner to another arena, it will be difficult for the practitioner.   And, a more major barrier to unified clinical reasoning is the fact the most of the junior’s clinical reasoning is only as good as what their supervisors have instructed them to do.
6. People are afraid to do something different than others – this explains why we OT’s persists on using disability scales even if we know that they are not measuring what we are doing. We tend to duplicate what other trust’s assessment forms.  Unless OT, as a critical mass agree that something different needs to happen, we will always be in a loop of status quo.
7. OT service is Free – Though not totally bad on its own, having the cost of the OT department subsidised by the NHS puts a lot of people complacent about the service provision and development. People ( I emphasise that not everybody!!!!) are happy of status quo or just happy to meet targets like KSF.  Some reason out ‘work hard or less, at the end of the month, you get the same amount of compensation/salary’. So, in the end, why bother changing.

TOOLS OF OCCUPATIONAL THERAPY

A carpenter's tool is a hammer, a photographer: camera.  A Doctor: perhaps stethoscope, A painter: brush and canvas.  Most of the profession has a tool that they use for their trade. As an Occupational Therapist, what would it be?  I am tempted not to write them down as I always enjoy watching most OT's not knowing the tools of their trade. However, I have a commitment to remind a lot of "sleeping" OT's.  Tools of practice can define the profession. So what would define OT? In the UK, I realise it is commode, raised toilet seat, perching stool, kitchen practice, relaxation, bed lever and many others.  These equipment are what defines an OT sad to say.  This is why a lot of other professions, or even assistants think that they know how to be an OT. Well excuuuse me. NO! Tools of OT are these:

1. Use of Self
2. Use of Environment
3. Activity Analysis
4. Use of Group
5. Teaching Learning
6. Purposeful Activity

An OT will come up with a decision because he/she unconsciously used the above list of Tools which are all very abstract which is why they get lost very easily in the depths of memory.

PRAGMATIC ASPECT OF CLINICAL REASONING

I have written in my previous blog, the 4 facets of clinical reasoning: narrative, scientific, ethical and pragmatic.

As a clinician, your clinical reasoning will always be spot on if you are able to balance these 4 aspects before you make a decision on any case.  The limitation as to what you and your client can do together is dependent on the pragmatic aspect of the case. 

The pragmatic aspects can be rules and regulations of the facility, protocols and guidelines, criteria of admission, target time of stay in the hospital, scope and boudarries of your profession. discussions can go on and on but in the end, the Pragmatic aspect of Clinical reasoning is the playing field that an OT can play at or the canvas that an OT can paint at.

Examples:
1. you think that a patient can benefit from a bath trasfer training because he is not yet sae with it... would you keep them in a hospital becasue they havent acheived this? Definitely not!!!! community therapy team(intermediate care, reablement, community OT can folow this up - if it is their role to do so).

2, You feel a Stroke client is not yet safe to prepare their own meals and you want to spend time doing this with the patient even if there is somebody who can do it for them. Will you do it? YES... if you are in a stroke rehab facility or neuro rehab facility. NO... if you are in an acute stroke/neuro facility. YES if you are in the community rehab team.

3. Somebody asked you to order a hospital bed for a patient. will you do it?  YES...if it is a job designated for an OT to do in a county or borough that you are working at.  NO.... if the borough/county's policy is that district nurses should be ordering it.

4. Can you teach a person with total hip replacement to step trasfer to and from bath while standing up? YES if safe to do so and the clent can manage (scientific) and if the client wanted to do it (narrative) and because you have and obligation to empower clients to be independent (ethical). 
NO.... if the department has an agreed protocol and guideline that everybody should be transferring using a bath board.

5. can you allow a person with total hip replacement to remove his shoes by having him push the shoe off the other foot using his other foot (Leg Crossing Doffing Method).
YES - this method will not cause internal rotation to the hip joint (scientific)
        - if the person wants to be independent and is willing to explore many waus of being independent (narrative)
NO - if your manager tell you not to!!!(pragmatic) "ha ha ha"
       - if the there is a departmental guideline that this method is banned (pragmatic)

6. Will you order a perching stool for client to be able to wash?
YES - if client cannot sustain standing and if they cannot maintain balance or if the effort of standing is a strain to their respiratory system (Scientific)
NO - if they already have a perch stool, if they have an alternative stool, if they are fine washing whilst seated on the toilet( pragmatic)
- if they choose to just have a strip wash by the bed (narrative)


So you see. in every question and decision an OT has to make, there are always opposing anwers.  Most of the decision though is affected by the pragmatic aspects of the case.  Remember though that the pragmatic aspect of clinical reasoning can only be outweighed by the ETHICAL merits of the case.

Parameters of OT assessment

We assess ADLs as OTs and after treatment or intervention, we compare progress to the initial information we obtain during initial assessment. We are very attuned to assessing independence level of the clients and we set goals generally based on this. Sometimes, an OT will come to a point where he/she cannot obtain outcome based on independence of the client.  So what other parameters should we be looking for and what other aspects do we need to assess apart from level of independence of the clients?  We tend to miss these other parameters and if you keep them in mind, your assessment will be more holistic and you will be able to Identify problems better which can aid in your goal setting.  The parameters of assessment has an acronym of VISA.

1. Value - Level of value or importance the task is to your client
2. Independence - this is self explanatory
3. Safety - How safe is the client while he/she engages in the desired occupation?
4 Adequacy or Quality - you probably have improved the quality of performance the client engages in

more detail can be read in Willard and Spackman

PROMOTING OCCUPATIONAL THERAPY:USE UNIFORM TERMINOLOGY

There is a problem promoting Occupational therapy.  This is because we are dealing with human occupation that is very difficult to label and quantify. 

Imagine this situation, if you are an OT and you are asked by a TV advertiser to promote or endorse a product, what product would it be? Though eh?  If you have a suggestion, pass it around to colleagues and it will surely stir up conversation.

A basic way of promoting OT is if we OTs talk the same talk. If we use the same words and termonologies in our daily documentation. ( Dont get me started on writing SOAP. We'll get to SOAP eventually.)  Today I am just focusing and highlighting OT Uniform Terminologies. Basic. Simple.

Think of these:

Do we use uniform terminologies in our day to day documentation?
Do we use it when discussing cases with MDT?
Which Countries have a set and well defined OT uniform termonology?
Are we mandated to use it or to come up with a list?
Do you think life will be easier if all OTs use the same terminology?
Would it not be easier to talk to other professions about OT if we have the same Lingo? If we all speak as one? If we speak in uniform?

Let's look at ADLs of self maintenance tasks.  What does it mean?What does it encompass?

Here's a list of Activities of Daily Living or self maintenance tasks. Hope it helps.

Grooming, Oral Hygiene, Bathing/showering, Toilet hygiene, Personal Device Care, Dressing, Feeding and eating,Medication Routine, Health Maintenence, Sicialisation, Functional Communication, Functional Mobility, Community Mobility, Emergency Response, and sexual expression.

........just a food for thought....just a food for thought.

REQUIREMENT FOR DISCHARING A PERSON HOME

the basic occupational requirement that a person needed to go home are:

1. he/she should be able to transfer safely from bed to toilet/commode to chair- home can be set up where the chair is close to the bed and commode so walking is not really essential for discharge from hospital.  This can be improved by follow up services such as reablement team, intermediate care team or community physios etc.
2. client should have access to toiletting facility - e.g. commode if unable to walk to the toilet safely
3. client should be independent with toilet hygiene - this usually the make or break if a person is going to be independently safe at home. Unless client was incontinent prior to admission. On which case, client only needed to have regualr and frequent checks daily
4. client should have means of nourishment - either carers assist in setting up breakfast or client should have meals on wheels
5. client should'nt have any behaviour that will cause them or anybody at home any harm - this refers to cognition of the client, behaviour of wandering of psychosocial behaviours that could harm themselves or other peple in the house
6. client should have access to a sleeping facility - bed should be brought downstairs if client cannot manage stairs

these are basic requirement and could be made successfull with appropriate support either from family, carers, reablement services, intermediate care, meals on wheels

OT ROLE IN HOSPITAL SETTING

You have a simple role if you are working in a hospital setting in the UK. You have to get the person out of the hospital as soon and as safe as possible.  Your options are simple and few and you must decide as to which option is fastest and safest in getting the person out of the hospital. 

Here are your options: You have to aim either discharge home, rehab facility, step down bed, residential or nursing home, home with support, home with intermediate care, home with reablement services, home with care package, home with family support.

In terms of Clinical reasoning, the facet that will dictate your judgement and options is the pragmatic aspects of the situation and hospital/NHS's general rule of getting people out ASAP tends to pull a lot of weight in your decision making.

Clinical reasoning

I have encountered many people talking about clinical reasoning. It is a well used term but not a lot of people know how to break down their clinical reasoning.  Here in the UK, I have commonly come across with people or colleagues who are quick to question a clinical reasoning of another colleague when the Colleague was only asking bout the procedure how to order equipment - that is not a problem with clinical reasoning.  It is a problem with procedural know how. What does Clinical reasoning actually mean?  Check the books people. It's there.

facets of CLinical reasoning are these:
1. clinical aspects of the case
2. narrative(personal aspects of the case)
3. ethical aspects of the case
4. pragmatic aspects of the case

( you can find details about this in willard and spackman ---- 8th edition)
try using these four areas if you want to make a decision about your cases.  I will be blogging about this in detail as we go along

What is OT in a nutshell

Occupational Therapy (OT) is a profession that is concerned with "human occupation" - anything that a person does or thinks. Anything that prepoccupies the person.  An Occupational therapist (OT) would, after medical condition of illness/accident, will try to get a person back to their occupations by either resolving the physical problems brought about by the condition or by adapting the environment to allow the person to be as independent as possible

What this blog is for

Im very new in blogging.  I actually just learned about the definition of it from travelling colleagues so I'm giving this a go.

This Blog is intended as an outlet of my thoughts and views that are not a representation of the whole OT community.
 I will try to be as responsible as I can be but if I get very passionate about some topics, I beg apologies.

This is intended for students and other colleagues