What is it like to be the recipient of OT services? This is a question that needs to be asked more often, particularly with regard to older service users, as over 65 year olds represent around 2/3 of hospital in-patients and are main users of nearly all parts of the hospital system (Help the Aged, 2004). To date there is little research exploring how patients experience ADL interventions. Understanding interventions from the patients’ perspective is essential for client-centred practice, (MacKinnon, 2001) and focus group participants have stressed that recipients of OT have a lot to share with service providers about the effectiveness or not, of treatment and rehabilitation strategies, (Corring & Cook, 1999). Some of the research is reviewed here. Studies regarding patient values in ADL interventions and therapist perceptions were included, as well as those regarding patient perceptions, as these provide valuable perspectives on this topic. (Click here to read on..)

Patient values in ADL interventions
Studies of meanings attributed to ADL’s include that of Fricke & Unsworth, (2001) where clients interpreted important IADL’s (Instrumental Activities of Daily Living) as meaningful and enjoyable ones, whereas the therapists described important in terms of what was needed for independent living, giving significantly higher ratings than those of the clients for medication management and snack preparation, and lower ratings for transportation, demonstrating that therapists need to collaborate with their patients in determining which tasks are important to them. Clarke & Rugg (2005) studied patients and therapists in a stroke unit using semi-structured interviews to explore the issue of independence in toileting. Requiring assistance was felt by patients to be undesirable leading to decreased self-esteem and independence was seen as carrying out the activity according to its usual occupational form (privately using a toilet, without adaptive equipment such as commodes), but therapists saw independence as toileting without assistance, using such equipment or techniques as necessary, suggesting that, since patients and therapists viewed independence in this ADL differently, such a difference may exist regarding other ADL’s, and that agreement should be sought that patient goals are being addressed, before intervention.

How patients value OT interventions
Researchers have also looked at patients’ values and satisfaction within OT services which will clearly affect their experience of ADL interventions. McKinnon’s (2000) study involved a cross-sectional telephone survey of 107 community-dwelling adults recently discharged from OT services. Analysis showed patients appreciated good manners, good communication and competence in their therapist, appreciated availability and accessibility of services, and tangible outcomes of interventions. Dislikes were linked to difficulties in accessing services.

Therapists’ perspectives on ADL interventions
Studies of self-care training from the therapists’ viewpoint yield valuable information that can be matched with that of the patient, to improve understanding of what occurs during the intervention. Schemm & Gitlin’s quantitative study, (1998) recorded details of teaching methods for bathing and dressing interventions whilst studying elderly persons’ hospital rehabilitation, finding little variation in method or place of instruction according to patients’ cognitive functioning or affect. Instruction sessions were simulated in the OT department rather than reproducing the patients’ real-life situations, and patients received on average 1 session lasting 9 minutes for bathing demonstration. They also highlight that patients were issued with an average of 5 devices but were discharged with scant information on their use and precautions, and recommend greater involvement of family caregivers.

Guidetti & Tham (2002), attempted to understand the therapeutic strategies used during self-care training by analysing descriptions given by 12 therapists. 8 clearly defined strategies emerged, including relationship building, motivation and support, varying as the therapist/patient relationship developed. A study by Larsson Lund, Tamm & Branholm, (2001), divided healthcare staff into ”˜information providers’ and ”˜rehabilitation practitioners’, (p151) following analysis of semi-structured interviews according to their stated degree of patient interaction, with nurses predominating in the first category and therapists in the second, showing that staff worked according to their traditional professional strategies.

Patients’ perspectives on ADL interventions
Few studies into patients’ perspectives regarding ADL intervention were found. Larsson Lund, Tamm and Branholm (2001) analysed semi-structured interviews with 57 hospitalised patients, 39 nurses and 11 therapists and found that patients could be categorised as ”˜relinquishers’, ”˜participants’ or ”˜occasional participants’, (p151) according to their stated participation in rehabilitation planning. ”˜Relinquishers’ had a mean age of 80 compared to 72 for the other 2 categories, and their wish to relinquish responsibility remained unchanged even if the professional strategy was varied. This study shows staff need more awareness of the patient’s own wishes when designing rehabilitation, that should be tailored to their individual preference for participation, which may vary with age.

Palmadottir, (2003), took a grounded theory approach to discover more about clients’ perspectives on rehabilitation outcomes. Open unstructured interviews with 20 adults recently discharged from 3 rehabilitation institutions, revealed perceptions categorised under balance and enjoyment, enabling everyday life and building a new future. The results support McKinnon’s (2000) findings that patients perceive their quality of OT service as dependent on their therapists’ interests, professional competence and the quality of their interpersonal relationship and the context of service can hinder client-centred actions because of restrictions caused by the institutional setting.

Lilja, Bergh, Johansson & Nygard, (2003) studied 53 randomly-selected, elderly adults identified as having unmet rehabilitation needs, who were living in ordinary housing with public home help provision. Analysis of structured interviews lasting approximately 2 hours, revealed differing characteristics between those who accepted the offer of rehabilitation and those who declined. Attitudes to social engagement and change had a greater influence than their disability and ability to carry out ADL’s, and surprisingly, the participants who declined rehabilitation were apparently more disabled (using reliable ADL measures) than those accepting it, and expressed contentment with the existing situation. Those who accepted rehabilitation were more able in ADL’s, had more assistive devices and less personal support from carers, and had specific rehabilitation goals. Reasons for declining rehabilitation included valuing an undisturbed home life and fear of losing existing assistance, with some participants explaining that their attitude and situation would have been different had they been offered rehabilitation when they felt it was needed. This demonstrates the importance of occupational therapy services being offered with optimal timing, as the patient may not wish to expend energy and resources once they have become accustomed to a changed life situation.

A qualitative study of 7 individuals over 65 who had been hospitalised and discharged with residual disabilities was carried out by Satterly, Grizzle, Fortener & Brayman, (2000). Patients’ perspectives on their ability to carry out self-care were found to be linked to a change in lifestyle following hospitalisation with a loss of routine and meaningful occupation. A secondary theme was the lack of opportunity to practice self-care routines in hospital which could have decreased fear of falling whilst bathing on discharge. The authors suggest that actual practice of bathing rather than just practising bath transfers, highlighted by Schemm & Gitlin, (1998), would have helped decrease anxiety and risk, supporting the concept that training in a natural context will increase effective performance, (Hui-ing, Trombly, Robinson-Podolski, 1999). This is supported by the patients who actually practiced dressing whilst hospitalised having few difficulties on discharge.

Most of these studies have involved small samples meeting specific criteria and linked to specific contexts and so would be difficult to generalise to the larger population, (Robson, 1993). Surveys such as these are subject to memory decay, variations in patient motivation to answer truthfully and to bias related to the questions and the researcher, (ibid) although researchers have employed techniques to improve trustworthiness, (Krefting, 1991). The range of valuable insights gained, concerning issues such as patients’ values and participation style, can be used for reflection and for evaluation of client-centred, evidence-based OT services and also provide a rich source of hypotheses for testing in future research.

The profession is committed to client-centred care, (COT, 2005), at a time when standards of care for older people are being raised, (DOH, 2001). Help the Aged (2004) describe going into hospital as distressing for older people, with the possibility of problems at all stages of their stay, and a lack of responsiveness to their needs. Older people in acute medical settings following unplanned admission can be seen to form a large patient group who will be experiencing an upsetting occupational disruption. They may not have had previous contact with OT services and will, if referred, experience limited interventions focussed on a safe discharge, (Welch & Forster, 2003). Currently it is difficult to ensure that OT services to these patients are evidence-based due to the lack of research into this topic, (McIntyre & Atwal, 2005).

Older people form the largest user group of the NHS. They have particular needs and viewpoints which this review has suggested are not being considered. A better understanding would assist OT’s in planning more effective interventions and services that more efficiently meet these patients’ needs. This may be more cost-effective, as patient and practitioner would work together more effectively towards shared goals and a greater understanding of older patients’ perspectives would enhance their experience of interaction with OT services.

References
College of Occupational Therapists. (2005) Code of Ethics and Professional Conduct for Occupational Therapists. London: COT.

Clarke, J. and Rugg, S. (2005) The Importance of Independence in Toileting: The Views of Stroke Survivors and their Occupational Therapists, British Journal of Occupational Therapy, 68(4), 165-171.

Corring, D., Cook, J. (1999) Client-centred care means that I am a valued human being, Canadian Journal of Occupational Therapy, 66(2), 71-82.

Department of Health (2001) The National Service Framework for Older People. London: HMSO

Fricke, J. & Unsworth, C. (2001) Time use and importance of instrumental activities of daily living, Australian Occupational Therapy Journal, 48, 118-131

Guidetti, S., Tham, K. (2002) Therapeutic strategies used by occupational therapists in self-care training: A qualitative study, Occupational Therapy International, 9(4), 257

Help the Aged (2004) Hospital and Intermediate Care. Help the Aged Policy Statement 2004. [online].UK: Help the Aged. Available from: http://press.helptheaged.org.uk/_press/KeyIssues/default.htm [Accessed 9/8/05]

Hui-ing, M., Trombly, C.A., Robinson-Podolski, C. (1999) The Effect of Context on Skill Acquisition and Transfer, American Journal of Occupational Therapy, 53(2), 138-144.
Krefting, L.M. (1991) Rigor in qualitative research: the assessment of trustworthiness, American Journal of Occupational Therapy, 45(3), 214-22
Larsson Lund, M., Tamm, M., & Branholm, I.B. (2001 Patients’ perceptions of their participation in rehabilitation planning and professionals’ view of their strategies to encourage it, Occupational Therapy International, 8(3), 151-167.

Lilja, M., Bergh, A., Johansson, L., Nygard, L. (2003) Attitudes towards rehabilitation needs and support from assistive technology and the social environment among elderly people with disability, Occupational Therapy International, 10(1), 75-93.

McIntyre, A., Atwal, A. (2005)’ Introduction’, In: McIntyre, A., Atwal, A. (eds) Occupational Therapy and Older People. U.K.: Blackwell Publishing. 1-13.

McKinnon, A.L., (2000) Client Values and Satisfaction with Occupational Therapy, Scandinavian Journal of Occupational Therapy, 7(3), 99-106.

Palmadottir, G., (2003) Client Perspectives on Occupational Therapy in Rehabilitation Services, Scandinavian Journal of Occupational Therapy, 10, 157-166

Robson, C. (1993) Real World Research. Oxford: Blackwell Publishers.

Satterly, L., Grizzle, M., Fortener, L., Brayman, S. (2000) Individuals’ Perspectives Regarding Hospital Based Self-Care Instruction and Its Effect on Ability to Perform Self-Care at Home, Physical & Occupational Therapy in Geriatrics, 17(3), 23-36.

Schemm, R.L., Gitlin, L.N. (1998) How Occupational Therapists teach Older Patients to Use Bathing and Dressing Devices in Rehabilitation, American Journal of Occupational Therapy, 52(4), 276-282.

Welch A., Forster S. (2003) A clinical audit of the outcome of occupational therapy assessment and negotiated patient goals in the acute setting, British Journal of Occupational Therapy, 66(8), 363-68.

Picture courtesy of Queensland Home and Community Care