Strategically-minded fighters required

1. Introduction: This blog entry is my reflection on how we as occupational therapists undermine our own profession by failing to reflect deeply on and analyse the global repercussions of some of the mundane decisions we make. The example used for this reflection is conflict with social workers, but it could just as easily have been any one of several other situations that occur routinely during my working day. One of my seniors expressed to me on several occasions that she did not feel able to deal with global issues, and those are the responsibilities of managers and the College of Occupational Therapists. This argument could only stand if we were actually applying the standards set by the College of Occupational Therapists to our work. Some of us would like to think we are, but are we really? When was the last time you studied them with a view to scrutinising your own work? If we do not apply the standards set by the College of Occupational Therapists, how can we expect the British Association to protect us?

2. Context: Conflict between occupational therapists and social workers is a recurring theme I have seen in three hospitals throughout my short career. A common focal point has been social workers’ dependency on us and their ability or lack thereof to act autonomously as professionals. I have worked with social workers who did not believe they could assess patients without first having occupational therapy reports, or even worse, could not set up care packages unless the occupational therapy reports specifically stated how many times a day care was needed. In one post I found myself being asked why a patient had no shopping when she was discharged home, to which I replied: “Why are you asking me? I am an occupational therapist; not a social worker.” On the other end of the spectrum I have worked with social workers that resented being told how many times a day occupational therapists thought service-users would need care, as telling them so showed a lack of respect for their professional autonomy.

3. Specifics: In one particular meeting of occupational therapy staff, we were told that social work managers from one borough were demanding care package specifications on occupational therapy reports before they would authorise care, whereas social workers from another borough specifically demanded that occupational therapists should not specify care package requirements. The team then discussed methods to deal with this situation. Superficially it seems that a simple practical solution to this would be to ‘suggest’ care package requirements without actually ‘specifying’ what we felt was needed. Looking at the wider picture, is this really a good idea though? I argued that we are a self-defining autonomous profession and should not alter the way we work to suit the whims of social work managers if by doing so we would encourage their inappropriate dependency on us, thus generating more non-occupational therapy work demands on ourselves in the future. Care packages are not our responsibility after all; we cannot negotiate directly with care agencies and authorise funding can we? Unfortunately I was the most junior occupational therapist present, and none of the seniors displayed any wish to deeply consider my thoughts. I was told this was an ongoing issue that could not be resolved by us, and this was a case of choosing which battles to fight.

4. The wider repercussions: These events remind me of several themes I believe are currently undermining the occupational therapy profession in England:

4.1. Role blurring leading to an ambiguous professional image and dilution of the occupational therapy ethos: In my opinion, care packages are on the social workers’ remit, not ours. By bending to social work managers’ demands we are re-enforcing the false image of occupational therapy as the profession of hospital discharge management, or a profession that mops up the jobs that others cannot manage or would like to disregard. The same applies to arranging for shopping (social work), tissue viability management such as pressure cushions (except for on wheelchairs) and mattresses (nursing) or splinting of limbs that will never be used occupationally (orthotics or physiotherapy) and incontinence management (nursing and physiotherapy). Why do people expect us to deal with these things? I suspect it is because the occupational therapists who laid the ground for us in the past took on these roles without reflecting on whether they were actually occupational therapy or not, and we have become so busy with these non-occupational therapy tasks that we no longer have the time or resources to practise holistic occupational therapy.

The problem with loss of professional definition is it reduces our ability to market ourselves effectively and other professions will start eating into our role. The other day I faxed referrals to social services occupational therapy and a primary care mental health team requesting community occupational therapy. A social services occupational therapy team leader phoned me and told me that community occupational therapists only provide equipment and adaptations, and a senior nurse from the primary care mental health team told me that the primary care service no longer had any occupational therapists, and even when they used to, they did not supply occupational therapy, but worked generically. She actually said “we provide mental health-care; not occupational therapy”. I wonder if she has any idea what occupational therapy actually is. Meanwhile, physiotherapists are using cognitive behavioural therapy, lifestyle and activity advice, psychosocial interventions and even techniques such mindfulness! The usefulness of life coaches was recently mentioned on television news in England. I doubt these people realise they are actually practising occupational therapy, because most of them have no idea what occupational therapy is. That is simply because we are not projecting a clear professional image. These developments are threats to our profession (and are probably putting occupational therapists out of jobs), but we can choose to ignore them (at our peril).

Some may argue that even though individual services are not providing holistic occupational therapy, over all we are doing so as a team. Acute occupational therapists may simply facilitate hospital discharge and refer on to community services for rehabilitation for example. How do you think this line of thinking would apply to other professions? If a long line of doctors approached a patient, the first cleaned the skin, the second made an incision, the third cut down to the bone, the forth did a bit of drilling, the fifth put in metal work, and so on, do you think any of these people could really call themselves orthopaedic surgeons? Could any of them as individuals not be replaced by technicians? Imagine if there were waiting lists between metal work and skin closure. What would this do for the quality of care and the professional image of orthopaedic surgery? This is metaphorically how the occupational therapy profession appears to be working in England.

4.2. Lacking professional pride or passion: Several of my recently qualified friends expressed dissatisfaction to me because they feel they are not practising occupational therapy though ‘occupational therapist’ is their job title. Ironically, the only newly qualified occupational therapist I know that has expressed job satisfaction is working for a private company as an employment adviser. None of my friends that expressed dissatisfaction had time to read or apply occupational therapy literature (everybody has time, what they choose to do with it is a matter of priority) to their work. None of them thought the College of Occupational Therapists’ Professional Standards for Occupational Therapy Practice [1] are realistic or worth fighting for, and none of them were motivated to do anything about their job dissatisfaction. They have accepted this as the lot of the profession and they are not alone in their apathy.

Perhaps this apathy is due to occupational therapists’ lack of respect for their own profession. An anonymous member of the British Association of Occupational Therapists once wrote “OT is based on a pretty basic idea that any half good mother (have thought about putting father in here but haven't convinced myself to put it in) could invent; but applied well, when it works”[2]. If this is our estimation of the value of our own profession, is it any wonder we are not prepared to fight for it?

4.3. Self-defeating attitude (low personal causation, low professional causation): Several experienced occupational therapists have expressed the belief that our professional ideals are not realistically achievable in public sector employment, in various threads of the British Association of Occupational Therapists’ internet discussion forum: http://www.cot.org.uk/members/phpBB2/ In a previous entry to this blog [3] I mentioned how senior staff I worked with had been directly discouraging about professional standards. Section 3 of this blog entry describes senior occupational therapists believing we are unable to mark our own professional boundaries with respect to a very specific part of our role and inter-professional communication. It is my personal belief that people in positions of leadership undermine our profession by making these pessimistic expressions when they are not accurate. One would be naive to believe that in a competitive environment any battle can be fought, won and then forgotten about. Boundaries will continually be tested and therefore must be continually fought for. This is not an indication for giving up; it is an indication for persistent assertiveness.

4.4. Lack of attention to detail: Section 3 of this blog entry describes senior occupational therapists choosing to simply solve a working problem instead of dealing with the professional role and image issues underlying it. I was told this was a case of choosing ‘which battles to fight’. Most wars are won or lost by the summation of results from numerous battles. The strategic value of ground is often very different to its superficial value due to tactical or symbolic significance. Many occupational therapists in my opinion, have overlooked this when making mundane decisions about the way they work within the multidisciplinary team. They are therefore choosing not to fight battles that are in fact key to the empowerment of our profession, and then not realising that they (through their actions or lack thereof) are responsible for the de-valuing of occupational therapy. The way we communicate with social workers, and generic working in mental health (as mentioned in section 4.1.) are just two examples I have reflected on. A previous example I have used was the timing of home or access visits [4], but there are many others.

4.5. Disparate, non-cohesive efforts: In one of my jobs the clinical lead for occupational therapy told me that she had told all of the occupational therapists not to fax their assessments to the hospital social workers because the social workers should come to the wards to assess the patients themselves (as autonomous professionals), and they can look at the occupational therapy reports while they are there. Superficially this idea may look like bad team working, but reflecting on it more deeply I thought it was a great idea for the following reasons:

a) What do you think would happen if occupational therapists started asking for medical and nursing notes to be faxed down to the occupational therapy office so that we could do our subjective assessments without visiting the ward? Do you think this request would be taken seriously? Why should there be one standard of convenience for social workers and another for occupational therapists?

b) Before the clinical lead had instructed me on this issue I had been faxing my reports to the social workers. The problem was, even when I had done so, they often denied having them and used this as an excuse for delayed discharge. This was despite the fact I had been phoning to confirm receipt of the faxes and had documented the names of the people who confirmed receipt in the medical notes. In other words, there was not much point faxing my reports, because the social work department was losing them anyway and then saying I had not faxed them as an excuse for delayed discharge.

c) Faxing our reports to the social work department just reinforced the over-dependency of the social workers on the occupational therapists and reinforced our false image as discharge facilitators. This kind of behaviour was more likely to encourage them to ask us questions like “how many times a day does X need care” than to come to the ward and do their own professional assessments.

The problem with the clinical lead’s idea was some of the occupational therapists were not following it. She told me she could only tell them so many times, and there was nothing more she could do to get them to follow her lead.

Once the clinical lead had spoken to me I stopped faxing my reports to the social workers. When they asked me for reports I told them they were in the medical notes and could be accessed there when the social workers were on the ward doing their assessments. I also told this to the nursing staff when they told me social workers had told them they were waiting for occupational therapy assessments. Then, one day I was on a ward and a nurse asked me to fax a Section-2 form to the social worker. Section-2 forms were normally filled out and sent by nursing staff and had nothing to do with the occupational therapists. I asked her why she wanted me to send it instead of faxing it herself and she told me I could just fax it of along with my occupational therapy report when I faxed that. I then told her that I was not faxing occupational therapy reports to social workers because they could look at them when they came to the wards to assess the patients themselves. She then told me my senior (band 7) had sent off a section-2 for her, so she thought I would do it too! Later, I asked my band 7 why she did this, and she told me it was to save time. When I told her what the clinical lead told me, my band 7 told me she was an autonomous professional just like me, and that while I sometimes do things differently to how she does, she just lets me get on with it. This to her, was just an example of how different occupational therapists work differently.

When it comes to protecting the profession there are wider repercussions from individual occupational therapists working differently from each other. The above occurrence is a good example of how taking on non-occupational therapy tasks alters people’s expectations of us and therefore alters the image of our profession. Just one occupational therapist’s act of sending a section-2 led to the expectation that we would all do it. It may be through a gradual process of sequential slippages such as this that in-patient occupational therapists devolved into discharge facilitators. Before I was an occupational therapist I tried the reserve forces All Arms Commando Course. During recruit training I could not help but notice that I was robbed of my individuality. Everything about me had to be the same as my colleagues, down to my toothbrush and three-piece razor being blacked out with tape and the way my kit was marked with my identity. At first, in my immaturity, I resented this, but soon I realised that this was what it meant to be part of something much larger than myself, and that sameness was a source of great strength. The same applies to an occupational therapy department. If all of the occupational therapists sing off exactly the same song sheet they can draw strength from and shield each other. It only takes one occupational therapist to drop his or her shield for the whole defensive line to fall though. Can a team that is under threat afford to be divided within itself? In a competitive environment with decreasing financial resources what chance does a team plagued by the above attributes stand of survival? It was no surprise to me that the department described in section 3 above had been downsized yet still had a recruitment and retention problem and was failing to survive. Most of the occupational therapists I spoke to individually knew it, but they all had somebody else to blame.

The same applies to British occupational therapists as a whole. If every single one of us stuck rigidly to our core standards we would be in a much stronger position than we are in now. It seems though, that there are too many people in the profession who believe our ideals are impossible to achieve. Individuals and individual teams are picking which core standards they would like to follow and which they would like to ignore. So many shields have been dropped, it seems there is little hope of our profession achieving its potential without a profound change of attitude.

5. Solutions?
5.1. Recruitment and training: The heterogeneous nature of occupational therapists gives strength to our profession, but I frequently wonder whether we have enough deep thinkers and assertive personalities to compete in today’s statutory healthcare environment. As a physiotherapist I found myself surrounded by type-A personalities. I once saw a physiotherapist walk up to a patient sitting in a wheelchair being adjusted by an occupational therapy assistant, ignore the occupational therapy assistant entirely and walk away with the patient in the half-adjusted wheelchair leaving the occupational therapy assistant kneeling with a spanner on the floor. There is even a Facebook group called ‘Why do physio's think they are god's gift (applies to vast majority)’[5]. I have worked with some great physiotherapists, and therefore do not feel that the generalisations made in this group are accurate. Physiotherapy courses are notably hard to get onto and through though. Perhaps this is where their professional pride comes from. In contrast, while I was at University I met two occupational therapy students who could not write a sentence in English. Another managed to graduate despite getting stoned at night and sleeping during the day while her friends signed the lecture registers for her. What about my friends who do not even care about occupational therapy enough to pick up our journal and read it? How did these people get onto the occupational therapy course in the first place?

The toughest thing I had to deal with during my undergraduate training was boredom. During my third year of undergraduate training I surveyed my colleagues for an assignment and found that only three out of thirty students (10%) could remember Ann Wilcock’s description of occupational risk factors (which she had lectured us on)! When asked how psychosocial factors can damage physical health, two students (7%) said they did not know and one (3%) was unable to think of anything other than hypochondria. Only fourteen out of thirty (47%) third year students believed in psychosomatic disease mechanisms. Of these fourteen, ten (33% of the sample) said they could offer no physiological explanations for psychosomatic disease. How can occupational therapists defend our profession with such limited knowledge of the scientific theories and evidence that can underpin it? I suspect the messenger is going to get shot, but the fact there are 162 members in the Bored of Fluffy Occupational Therapy Facebook group suggests to me that I am not the only person with this opinion. I think we need more rigorous training proceedures to ensure that all student occupational therapists are knowledgable, assertive, deep, critical thinkers by the time they graduate. A tougher course might also inspire greater pride in our profession; enough to make us want to stand up and fight for it.

5.2. Continuing education: Knowing the potential of occupational therapy, and how well it could fill so many of the demands of various national service frameworks and government policies [6] how can occupational therapists stand by and watch the essential corners of their work being cut away while life coaches, reverse therapists and even physiotherapists take over, without becoming enraged by the demise of our profession? Why are we content to busy ourselves only with care-package selection, raised toilet seats and architectural adaptations, while other professions practise the components of occupational therapy that we need to be truly holistic? Is it possible that the students I trained with are representative of how many of my seniors were when they were students? Perhaps regular training to remind qualified occupational therapists of our potential, and inspire professional pride is necessary to remind us that our profession is currently nowhere near achieving all that it realistically could, even in the competitive public-sector healthcare environment. Self-belief and dissatisfaction are the precursors of revolution. I have seen plenty of evidence of dissatisfaction. Perhaps we collectively just need training to increase our professional self-belief.

6. Before you shoot the messenger: This blog entry is far from politically correct, and I expect to take a lot of heat for suggesting profound weaknesses within our profession. I make no apologies for this, as I believe that anybody that thinks the occupational therapy profession is thriving in England has his or her head buried in the sand like an ostridge. When occupational therapy is held in the same esteem as medicine or pharmacy it will be thriving. At least if it was held in the same esteem as physiotherapy I would consider that we were getting by. I see no evidence of this when I am at work though.

My use of the word ‘fighters’ is open to misinterpretation. Fighting to maintain our professional identity in no way implies fighting against other members of the multidisciplinary team; it simply means fighting against a lack of resources and falling standards. I have used the word the same way I would to describe a patient fighting for survival in intensive care. This has nothing to do with conflict or aggression.

7. Conclusion: Perhaps occupational therapists are by nature caring, helpful and flexible workers. This can make us great healthcare providers and team members. If left completely unchecked these qualities could prove the undoing of our profession; occupational therapy is in danger of devolving into the multidisciplinary doormat. Good teamwork does not depend on individuals doing other people’s jobs (generic working); it depends on congruency of the efforts and purposes of each of the team members working within their own specialities (what they are best at). Before we make mundane decisions about changing the ways we work, perhaps we should reflect deeply on how these changes may affect the image and future prospects of our profession.

8. References:
1. College of Occupational Therapists (2007) Professional Standards for Occupational Therapy Practice London: British Association of Occupational Therapists
2. Guest666 (2007) occupational apartheid http://www.cot.org.uk/members/phpBB2/viewtopic.php?t=1848&postdays=0&pos...
3. Venth (2007) Application of the Ayurvedic Model of Human Occupation – A case study.http://metaot.com/blogs/%5Buser%5D-3
4. Venth (2007) Early access visit v later home visit? http://www.metaot.com/blogs/%5Buser%5D-4
5. Rogers L. (undated) Why do physio's think they are god's gift (applies to vast majority) http://www.facebook.com/group.php?gid=2246701539
6. Venth (2007) Occupational Therapy First - It is time for our profession to lead; not follow. http://www.metaot.com/blogs/%5Buser%5D-6