Occupational Therapy Process PDF

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Occupational therapy OT process...

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Occupational Therapy Process The care pathway (Creek, 2003) The occupational perspective (Fisher and Marterella, 2019)    

Seeing the person and not the illness – who are they and how do they define their occupational identity? Understanding what matters to the client – what are their priorities? Professional focus upon occupational engagement and participation Remembering the dynamic interaction between person, environment and occupation

Creek (2003) – the care pathway that is know to us and to other professions such as nursing – a helpful view of the journey of the service user through key stages of assessment, intervention and outcome/discharge. Fisher and Marterella (2019) – the unique occupational perspective that maps across Creeks OT process and helps us to see more about what each stage of the process needs to consider as part of the occupational therapy service user journey. Phase 1: information gathering  Referral  Gathering initial information  Performance analysis (assessment)  Finalize evaluation (outcomes of assessment)  Collaborative goal setting Fisher and Marterella (2019) talk about the importance of understanding top down and bottom up perspectives throughout the OT process and so it is important to look at this now as it helps us to understand the type of information that we need to gather in order to build a picture of the person as an occupational being. Dunn (2017) wrote that “we have learned that isolated skill development may not generalize to everyday activities and settings. We have come to appreciate the important contribution of context, motivation and interests to a person’s participation in life routines and activities”. This reflects current evidence and professional opinion in occupational therapy practice that says we cannot understand the occupational nature of human beings by deconstructing them to only consider the ability to perform isolated skills – we need to start by viewing people from the ‘top down’ looking first at how people engage with and participate in everyday activities of daily living. “The occupational therapist begins the evaluation process by gathering information needed to understand the client and/or occupational strengths and concerns…” A top down perspective  Looks at the occupational performance within situational contexts, identifying key strengths and concerns of the client

"The occupational therapist implements evaluation of body functions, environmental factors, or other situational elements in order to determine potential reasons for the client's occupational challenges." A bottom up perspective  Looks at body structure and functions along with situational / environmental factors to 'speculate' about the impact upon occupational performance Novak (2019) - Systematic review identifying the positive outcomes of interventions with children that take a ‘top down perspective’ Professional thinking values both top down and bottom up perspectives but the starting position of the occupational therapist is to look at occupational need and risk so it is important to gather information from the top down perspective that seeks to understand performance and participation in everyday occupations in context, taking into account situational and environmental factors. Once problem areas have been identified is important to understand why this is the case and often this will require breaking down the task sequentially to see where things go wrong and this includes looking at the underlying performance skills required as the building blocks of occupational performance. This part of 'digging deeper' into understanding why things go less well for our client is usually part of the evaluation/assessment stage of the process and comes after initial information gathering. Sometimes the information gathering stage can include insights into performance at skill level e.g. the referring classroom teacher would often report problems with fine motor skills and posture as part of the referral or initial conversation about the needs of the child. Schell et.al. (2014) introduce the term 'occupational profile' to describe the elements that constitute building a full picture of the person and participation in everyday occupations. This again emphasises the situational contexts/environments and life experiences/past and present occupational patterns. In addition to this they also specify gathering information about;  

Strength (assets) and problems Client desired outcomes and priorities

It addition to building an occupational profile of the person in terms of individual lived experience, it is also important to gather information about the nature of the condition or diagnosis of the person in order to understand expected pathology, symptoms, prognosis and impact). Establishing an occupational profile is deemed to be a comprehensive approach and it is proposed that this is a 'scientific' process and necessary to design therapeutic interventions (Schell and Schell, 2008)   

Occupational history (life experience and past occupational patterns) Current strengths (assets) and problems in daily occupations and participation in society Situational contexts (environments in which the person performs occupations)

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Client desired outcomes and priorities in occupational performance (life experiences, needs and values) Information about the condition or diagnosis (pathology, symptoms, prognosis)

Gathering initial information:  A collaborative process with the client – 'Conversational interviews' and 'Semi-structured interviews' with the client that are occupation focussed  Involves asking questions of others - client advocates (family/significant others, caregivers, and members of the MDT)  Requires review of existing client records - including the referral information and any other relevant and accessible written record  Requires researching the literature – reviewing condition /diagnosis Client outcomes: Storytelling and gathering the personal narrative are important to understand occupational history, client desired outcomes and priorities for therapy. "They provide a way of understanding and interpreting experience – sharing what is meaningful and important at a particular moment in time...stories are temporally and contextually situated." "Occupational storymaking" is where the occupational therapist engages the client in story telling past, present and future to "rewrite, revise, or recreate their life story" (Crepeau and Cohn, cited in Boyt Schell et.al., 2014: 97) Being able to elicit the clients occupational history and begin to gather information about the clients desired outcomes and priorities for therapy starts here. Storytelling is an important mechanism for gathering this information and is a well documented approach for understanding and interpreting peoples experiences. Significantly, it also allows us to understand what is meaningful and important to the client, both in the past, present and for the future. Occupational storymaking is where we as the therapist engages the client in telling their past/present story and begin to talk collaboratively about how to rewrite, revise, or recreate a life story after a significant event such as illness or injury. Perhaps the client has not been able to or required to think about how they want their life to unfold, and it is our job to help them begin to think about their occupational lives ahead of them. This information about future aspirations helps the therapist to understand desired outcomes and priorities – what matters most to the client for their future? This then informs decision making throughout the rest of the OT process. Taking a strengths based approach: "A strengths-based approach is an effective way to support people to live their own version of a satisfying life..." (Dunn, 2017: 395)  

An emphasis on peoples interests and talents A focus upon authenticity and inclusion

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Seeing all behaviours and characteristics of the person as neutral or positive features Acknowledges the possibilities Traits perceived as 'deficits' are useful and informative about who the person 'is' Captures the full complexity of the person Dunn (2017) says that “A strengths-based approach is an effective way to support people to live their own version of a satisfying life” To foster an emphasis on people’s interests and talents rather than their ‘deficits’. When planning strengths-based strategies, professionals focus on people’s lives

A strengths-based occupational therapy approach invites us to see all aspects of people within their authentic lives; all behaviors and characteristics are neutral or positive features. Instead of seeing Tommy as ‘inattentive’ during school, we might say ‘Tommy has many interests that attract his attention during class instruction’. With strengths-based language, people see that we, as professionals, acknowledge who they really are, and that we see possibilities with them. A strengths-based approach invites us to consider even those traits we might have labeled ‘deficits’ as useful and perhaps informative as to who a person actually ‘is’ – it also allows us to appreciate more about the complex nature of a person. Ultimately, the call to take a strength based approach to occupational therapy is part of contemporary practice across health, education and social care systems and as an overarching approach to our thinking it must inform the questions that we ask about people when we gather information. Adopting a strength-based approach in understanding the person does not mean we cannot identify problems in everyday life – it just means we can approach the problems with a positive set of assets!    

Acknowledging: Occupational concerns and challenges of the client Asking about the quality of performance: How well things go, help needed, safety, effort required, and timely/organised Asking about the quality of participation: purpose, importance, Asking about the quality of experience: feelings, meaningfulness, satisfaction, enjoyment

(Fisher and Marterella, 2019)

Occupational risk: "The occupational therapy profession is concerned to ensure that people have access to opportunities and resources to participate in culturally defined, healthbuilding occupations" (Boniface and Seymour, 2012: 176) Occupational risk factors are things that threaten participation in meaningful and purposeful activity and therefore threaten the individuals state of health and wellbeing.

Gathering information about the concerns and challenges that the client faces can be considered in terms of occupational risk – asking questions about opportunities and resources to participate in meaningful and purposeful occupations can help to define the occupational risk and forms a clear need or rationale for occupational therapy. Some of this information may be apparent on the referral to the service but often we need to go back to the referrer to ask more questions. RCOT Code of ethics: The purpose of occupational therapy is to enable people to fulfil, or to work towards fulfilling, their potential as occupational beings. Occupational therapists promote activity, quality of life and the realisation of potential in people who are experiencing occupational disruption, deprivation, imbalance or isolation.

Situational contexts and environments: Occupational environments and situational factors – help and hinder occupational performance “ As occupational beings, people are intrinsically active and creative, needing to engage in a balanced range of activities in their daily lives in order to sustain health and wellbeing. People shape, and are shaped by, their experiences and interactions with their environments.” RCOT (2015). Occupational science also provides us with insight into the importance of gathering information about environmental contexts in which people live, work and develop. It helps us to understand how the physical, social and cultural environments among others can shape and be shaped by occupational performance. Environments and situational factors are enablers or disablers – they help or hinder occupational engagement and participation. RCOT code of ethics: As occupational beings, people are intrinsically active and creative, needing to engage in a balanced range of activities in their daily lives in order to sustain health and wellbeing. People shape, and are shaped by, their experiences and interactions with their environments. They create identity, purpose and meaning through what they do and have the capacity to transform themselves through conscious and autonomous action.

Condition/diagnosis Not about the persons lived experience... and has a focus upon the underlying impairments at body structure and function level (Duncan, 2012)  Generalised and not individualised  Offers predicted typical insights into the nature and impact of the condition Helpful in understanding some of the likely impacts at occupational level to guide the information gathering stage. Gathering information about the condition or diagnosis of the client is important. It helps us to understand what the client could typically be experiencing: symptoms, prognosis, progression, impact. It can help us to frame questions to test out the scientific hypothesis about the condition/diagnosis. It can help us to frame questions sensitively and with insight e.g. degenerative conditions. 

When clients cannot report themselves:

“To be client centred requires the occupational therapist to gather and take into consideration the client’s perspective.” (Fisher and Marterella, 2019: 148)  The client who is unable to verbally report  The client who is unable to give a reliable report Strategies: 1. Dependable others 2. Best professional guesses 3. Observation of the client 4. Trying out options 5. Applying core values; respect, dignity, choice, empowerment Sometimes our clients are not able to give us the information we need to understand who they are and what matters to them in their occupational lives. This may be due to an inability to verbally communicate or language barriers. It may also be because they are not able to give a reliable account of themselves due to intellectual disability or mental capacity. In any of these circumstances we need to find alternative ways to ensure that we can build to most reliable client centred picture of the person. This will often include involving dependable others who can either enable the client to communicate their needs effectively or be able to offer reliable information on their behalf. In addition to this we can also use our best professional judgement, observe the client for cues, offer them choices and options - ultimately ensure a values driven interaction that seeks to place the client at the centre of practice....