Having worked for the army I see access visits as a form of reconnaissance to inform my goal setting and treatment planning in physical rehabilitation settings. I therefore like to do them as early as possible if my initial assessments indicate that the home environment may present specific rehabilitation or adaptation needs. I have however worked with other occupational therapists that prefer to wait until a patient is fit for a home visit instead. I have only worked as an occupational therapist for 2 months so far, so I am reluctant to disagree with more experienced therapists. I am therefore posting this blog entry in the hope that you will share your experiences and opinions on the issue. Assuming whichever occupational therapy department I work for lacks the human-resources to undertake both access visits and home visits and therefore must choose between the two, this is my current perception of the choice:

Advantages home visits when a patient is fit enough:
1. This is the most valid test of a service-user’s function in his or her home environment. It may reveal unpredicted behavioural risks.

2. This method avoids wasted time for patients who end up never going home (e.g. due to placement or death).

Disadvantages of waiting until a patient is fit for a home visit:
1. This significantly increases the risk of discharges being delayed by occupational therapy, and therefore has an impact on the entire patient journey from A&E admissions or elective waiting lists onwards (the functioning of the whole NHS is adversely affected).

2. This allows less time for equipment orders. Urgent equipment orders cost more, as does an OT or OTA going out to fit equipment (considering rates of pay, transport etc). This impacts on PCT budgets.

3. Urgency of referrals for unforeseen problems is then offloaded onto social-workers and other agencies giving them less time to react.

4. Specific environmental factors are not used to inform the rehabilitation process and it may therefore not be as service-user centred as it could be.

5. We risk being seen as a profession of discharge facilitators that follows the directions of the rest of the multi-disciplinary team (e.g. doctors, nurses and physiotherapists tell us it is time for us to facilitate a person’s discharge).

6. If you have not done an access visit first, you may find yourself taking a patient into a dangerous home environment.

Advantages of early access visits:
1. Reconnaissance informs goal setting for the rehabilitation process. We tell the rest of the multi-disciplinary team the level of function required for a person to go home, and they set their goals based on the information we provide (e.g. telling the physiotherapists a person needs to be able to mobilise distance-x with a walking aid no more than y-wide and sit-to-stand from surfaces z-high).

2. We can replicate the service-user’s home environment for hospital treatments, thus making them more client-centred, realistic and valid.

3. We can order equipment early at the cheapest delivery rates, thus making the best use of our budgets and minimising the risks of delayed discharge.

4. We can provide social-workers and external agencies with a heads-up on likely needs, giving them a reasonable time to prepare for discharge (e.g. identifying a patient with crush fractures of the vertebrae will not be able to reach her oven, freezer or washing machine and may therefore need help for cooking and laundry on discharge).

5. This way we will be viewed as rehabilitation directors instead of discharge facilitators.

6. An access visit involves less clinical risk than a home visit.

Disadvantages of early access visits:
1. Access visits will not reveal unpredictable behaviours a service-user may exhibit in his or her home environment.

2. If the patient never gets home, the access visit may have been a wasted exercise.

The text above is a generalisation. In specific circumstances one option would be indicated as opposed to the other, but overall which option do you think is preferable?

V

I believe Will Wade recently mentioned BOFOT (Bored of Fluffy Occupational Therapy) in his blog entry regarding www.facebook.com What is BOFOT? It is a networking group for occupational therapy staff and students who are fed up with the profession's fluffy image and would like to change it.

BOFOT ethos (slightly stolen from the SAS):

1. The unrelenting pursuit of clinical excellence: Every individual has a responsibility to advance the occupational therapy profession and its image; we cannot afford to leave this to some obscure researchers in some obscure laboratories that we hope exist.

2. The highest standards of discipline: without which we will never achieve point 1 or be taken seriously.

3. No sense of class: Every member’s views (regardless of job-title or years of experience) should be given serious consideration for the advancement of the profession. A profession ruled by dinosaurs alone is a profession in danger of extinction.

4. Humility and humour: Let us try not to get our heads stuck up our own bums or we might get a reputation like certain other professions have: http://www.facebook.com/group.php?gid=2246701539

Join us, and together we can bring balance to the fluff!

If you would like to join us, just follow one or both of these links:
http://www.bebo.com/BOFOT
http://www.facebook.com/group.php?gid=2242527728

I hope to have you on-board soon ;0)

V

**Update:** Please read this in relation to the comments attached!!

OK lets cut the crap, this article isn’t going to help you make you a better OT student, its not going to give you constructive advice on how to best use your limited practice time and its not going to be pretty. It is, however, going to give you the powers to bullshit your way to the best grade possible and have hypnotic control over your educator. After only a few weeks you will see results. By the end of your placement your practice educator will be waiting patiently by your desk, on all fours, drooling from the mouth and asking for ‘another MOHO biscuit’.

**Always carry a black pen** – When everything is going well and there are no significant flaws in your work practice educators tend to regress to Freud’s anal stage, in which the smallest details are highlighted to you, ostensibly returning the educator to the position of authority.

**Go for a drink with them** – As Oscar Wilde recognizes it is not what one does in work that makes one successful but what one does outside of work. Quite

**Feign ignorance** – Of course you know what a functional split is or errorless learning or CBT or solution focused therapy. You know because you are aware of current evidence base and NICE guidelines. Thing is your practice educator graduated from a Women’s Institute craft school in the 1930’s and have held on to the one or two stands of knowledge that dementia has not whittled away. Just say, “oh how interesting, I really did not know that…well done”.

**Furnish their Ego’s** – Don’t be fooled into thinking the Educator is an altruistic in nature. The educator resents being legally obliged to have a student and will moan about the inconvenience at every opportunity. Instead the educator wants to be both admired and loved. Love them and admire them.

**Ask them to be an accomplice** - At your midway interview say how you are aiming for the best possible grade and would like their assistance in pushing you that bit harder. Demand criticism! (Reverse psychology works every time)

**The anti COPM** – Don’t be fooled into thinking that it is a student-centred relationship - The educator is the main problem definer.

**Flirt** – If you fail to win them over with your clinical reasoning skills try blinding them with more primitive influences (please refer to Maslow’s hierarchy of needs). This will subvert the balance of power and make it more equal (only in a smutty way, not in a professional capacity).

**Threaten** – If your final review didn’t go quite as planned the ‘final solution’ is the good old-fashioned ultra violence. You can employ many techniques including verbal and non-verbal behaviour. Borrowing lines from famous films is recommended if your mind goes blank from the anticipated sadism that you are about to create – “I’m gonna make you an offer you can’t refuse” is a good one. Counting backwards with a threat at the end is always intimidating too. The last tip is to slowly walk over to the door and lock it, then walk behind the educators back laughing nervously, like a James Bond baddy.

**Quote Kielhofner** - If all else fails just spout some Kielhofner rubbish. Showing your practice educator MOHO is like showing a monkey an ipod: It doesn’t understand it yet it will look puzzlingly at it for hours on end.

**Go forth and succeed!**

(Image Courtesy of [epc @ flickr](http://flickr.com/photos/epc/407862586/) - Licensed under [Creative Commons](http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en_GB))

This is a somewhat old post that I had been taking my time to finally post it so here goes..it is based around two letters that were submitted to the [Telegraph](http://telegraph.co.uk) way back about a year ago:

> "Tea test
>
> SIR - Office juniors are not the only people who have no idea how to make real tea (Letters, July 15). My mother was assessed last year by an occupational therapist as to whether she was fit to return home after a stroke. The OT considered she was not fully compos mentis. Why? She warmed the teapot with hot water, then poured it away before putting leaf tea in the pot and adding boiling water.
>
> I was not believed when I pointed out that this method was correct and she had not been making the tea twice over.
>
> N. Beale
> London, SE3"
>
> [Telegraph 18 July, 2006](http://www.telegraph.co.uk/opinion/main.jhtml?xml=/opinion/2006/07/18/no...)

I can't of course speak on behalf of the OT in question but I *know* this complaint, if not directly the same, is not unheard of (from both patients and staff). The therapist in question has not been able to reply to these letters but there could of well been a reasonable reason for saying these patients in question were not "compos mentis". Or of course they never actually said those things but hinted towards it. Whatever the case its simply not on.

So why is it that this sometimes occurs? Well the problem lies with that little thing called [activity analysis](http://metaot.com/quick-notes-activity-analysis) which OT's are supposedly fantastic at. The problem in particular is that we all have our preconceived idea of how a person *should* do something. Tea making is a classic example used by OT's as a every day activity and as [James suggests](http://www.housingot.co.uk/page9.htm#2387) it is a somewhat subjective measure:
> "One of the main criticisms of kitchen assessments in hospital - usually in the hospital OT kitchen, is that it isn't actually the same as in the person's own home, where they will probably be returning to. Someone might quite happily manage to do all sorts of things in their own kitchen, but appear to be confused and unable to the OT kitchen"

With much regret to my workmates I regularly provide an example of getting this activity "wrong" and that's simply because I don't make tea. Actually scrap that - I don't drink tea. Infact my friends and family ban me from trying to make tea because I'm so lousy*. Yes, I am a total social outcast! God forbid the day if I have a brain injury and someone asks me to make a cup of tea - I would invariably fail with the above example.

Here's a little side story which will let you into a little about me. I spoke to an old computer programming friend the other month and completely unprompted (regarding my current role as an OT) he said the following:
> "I had to write a program for a job interview to simulate making a cup of tea. do you know it had about 200 steps?! a cup of tea is hard you know! ... the worst bit was working out which order to put it all in - I'm a milk before tea man myself but realise its not the common method"

Aye, I certainly do.. there are more coincidences between computer programming and OT but that is for another post. The point is that OT's sometimes forget the complexity of the task and more importantly the route in which it is taken. There is also another thing to remember we all have cultural differences between the way we do things. George Orwell recognises this issue when he talks about the "Russian style" of tea drinking in his essay ["A Nice cup of tea"](http://www.netcharles.com/orwell/essays/nicecupoftea.htm):

>"Lastly, tea—unless one is drinking it in the Russian style—should be drunk without sugar. I know very well that I am in a minority here. But still, how can you call yourself a true tea-lover if you destroy the flavour of your tea by putting sugar in it? It would be equally reasonable to put in pepper or salt"

Unlike George we need to be understanding of these cultural differences, and some would argue this means learning about them. If you aren't aware, the strange technique of warming the teapot is not unusual and infact it has been declared as the scientifically best way of making tea:

>"Yesterday, he said the keys to producing the perfect cup were using soft water, warming the pot before filling and allowing the tea to brew for three minutes. It was also essential to use loose-leaf Assam tea rather than tea bags - "they slow down the infusion"." From the [Guide to the perfect cuppa starts a storm in a teacup](http://www.telegraph.co.uk/connected/main.jhtml?xml=/connected/2003/06/2...)

And now for the second letter in this posting.

> "World Cup Revision
>
> SIR - I was interested to read Neville Beale's letter (July 18) about his mother who failed her stroke recovery test because medical staff did not understand the old-fashioned way she made tea. It does not Surprise me.
>
> Eight years ago, during the World Cup, I had a stroke. The nurses were going to write me off because I could not answer their questions on football. They would not believe my wife when she told them I had no interest in the subject. "All men know about football" the said.
>
> It took a visit to the hospital by my boss, to converse with me about nuclear engineering, to convince them I was actually compos mentis.
>
> Since then, the joke every World Cup has been that I have to do my revision in case I have another stroke.
>
> Richard Chester-Browne.
> Warrington, Cheshire."
>
> [Telegraph 25 July, 2006](http://www.telegraph.co.uk/opinion/main.jhtml?xml=/opinion/2006/07/25/no...)

So what about the second letter writers experience? What can be the excuse for that? Lets imagine for a moment that the writer meant "OT's" rather than "nurses" which could well have been the case\**. Well, if that's the case then I have to say there isn't really any excuse - and even if they were nurses that's still no excuse. OT's *should* be skilled in being client-centred and at the heart of this, working out what it is that engages & motivates individuals. We realise that no-one individual is the same and we are all different. Or at least we should.

In certain environments mistakes do happen and the reasons are often so numerous and complex that no one person is to blame. The football one is a classic mistake that I have kind of witnessed when you run a group five times a week, every week and your mind goes blank when trying to think of a current affairs topic to discuss and the general group seems to like football - but on a one-to-one basis? The mistake is perhaps borne out of routine and to a certain degree the human trait of stereotyping people. It can be difficult to assess a persons interests if they cannot easily communicate or their friends & relatives are not around. You could argue that if you take the average OT, their understanding of nuclear engineering would be quite limited (or perhaps "we were never taught that at college!" would be the response) - but now I'm stereotyping right?! So if you have been in this situation buck this worrying stereotype; What trouble would it take to google "nuclear engineering" and spend 5 minutes over lunch discovering that the man may be interested in that MRI scan you have recently taken of his brain! (if you haven't worked it out, "nuclear engineering" covers a whole range of topics - one of which is nuclear medicine/physics read [wikipedia](http://en.wikipedia.org/wiki/Nuclear_engineering) for more info). What, do I hear you say "We don't have time to look on wikipedia what nuclear engineering is!"?? Im afraid that I would equally say "this isn't a luxury - its part of your job!"

\* My Brother believes that there is a more sinister reason for me not being able to make tea: that it gets me out of making the tea. A clever approach that can get you out of doing all sorts of things but I have to say in this example its simply not true.

\** I admit I hold onto this line of thought for quite sometime. If they were nurses then it could be more of an argument for OT's on that ward which turns the argument into something entirely different..!

I'm sitting at my computer trying to write a presentation for a conference later this week but struggling to keep focused. Why? Its because I've been introduced to another social-networking site - this time its [facebook](http://facebook.com). I figured that instead of wasting work time on it I would turn it into a reflective piece for meta-ot - so enjoy!

Now I had heard of it for ages - but largely I thought that the majority of contributors were students and I simply figured it was another myspace - full of unending tedious messages from friend to friend and random media that would have no interest in anyone other than the intended audience*. But recently I was introduced by an old school friend and on a bored Saturday afternoon I signed up. For about a week I became obsessed - I have had the amazing pleasure of "bumping" into old friends and stalking old workmates. Put simply its what [friends reunited](http://friendsreunited.co.uk) was meant to be. So then why am I writing about it on this site? Well typing in "occupational therapy" brings up a staggering 83 groups - some not actively written on but that's beside the point. And the most interesting thing is this: they aren't all (so it seems) students using them. But what are the discussions? Lets take a quick look at a few:

* "Bored Of Fluffy Occupational Therapy" (55 members)
* "Collaborating & Sharing Ideas With Other Occupational Therapists" (71 members)
* "I'm tired of having to explain what Occupational Therapy is!" (2108 members)
* "I wish i didn't choose Occupational Therapy as a career" (20 members) (has the amusing address of 77 Kielhofner way)
This one has, somewhat ironically, the BAOT logo as the groups logo.
* "Yes, I am a Occupational Therapist and no we don't wipe bums!!" (366 members)
* "British OT's" (83 members)
* "LOOKING FOR A MAJOR? NOT SURE WHAT TO DO? O.T. is the way to go!!" (15 members)
* "My OT professor wants me to do what....?!?" (57 members)
* "Booze Drinking Occupational Therapy Students (B-DOTS)" (89 members)
* "OTs are hot" (260 members)
* "Why do physio's think they are god's gift (applies to vast majority)" (126 members)

And a whole load of "OT's [some-college] [some-year]" which are usually specific to a particular college/university and graduation year.

Now some thoughts.
If I was a recruiter I could just as easily use it for work reasons as well as social reasons and look up a potential candidate. Would a candidate who has joined "I wish i didn't choose OT as a career" be a potentially wise choice for a post? This potential danger is [not unheard of](http://news.com.com/From+googling+to+firing/2010-1022_3-6187344.html) - anyone can google your name and come up with a posting from 5 years ago where you may have belittled a previous boss - but facebook makes the whole process a little easier - and, by its nature of being one of the largest social networking social sites - entirely likely that your candidate is on the site.

It is this general concern that someone I recently spoke to stated as to why they didn't want to contribute to putting things online in such a public way. I would argue this fact shouldn't scare OTs away from joining in with discussion. Lets put it another way, in comparison to my above recruitment problem: would someone who has posted to "Bored of fluffy Occupational Therapy" and trying to change the profession actually strengthen their position for a post?

Purely because your view may not be the same as others is not a reason to not join in with debate. For example, reflection - in whatever form you decide to use it, may involve discussing difficulties of working with colleagues, or dare I say it - clients. But in the same way that you were trying to talk to your boss about a potential working-relationship problem you would (I hope) try to be professional. Its in your own interest, and ultimately the professions (remember these groups are public! Imagine you are a potential client and find out that your OT doesn't believe in what they are doing? what kind of image does that give?). Although I realise, more than anyone, that there are times that you just want to go "aarrgh I hate this!" doing it so publicly may be a tad dangerous. Just be careful - that's all.

Conversley, facebook - along with blogging etc, is a easy way of getting to know your online peers. Facebook is, by its very nature, good at finding others who have your same interests and background. It can be a little stalkerish in a way - but I would be interested to see how it develops as a social-networking cum-working tool.

\* myspace suffers somewhat from multiple-design-failure which doesn't help my hatred for the service.

Wowsers. So the OT blogosphere has really taken off over the past few months. Without a doubt this is pretty much down to Merrolee's group in New Zealand but also to student's and of course a few bods like James Lamport Housing-OT Blog and Chris' ABC Therapeutics Blog in the States.

Merrolee and I were talking on GTalk just the other night and discussing ways on broadening the blogosphere / getting methods on us all talking to each other. Then something struck me. In a lot of other communities on the net these various bloggers and community members get together once in a while - yes, actually get away from a computer! Call it a meetup, blogmeet - whatever. I can't accommodate the world (although hey, your all invited!) so I have setup a upcoming group for anyone to join titled "OT's On The Net - UK" and in the upcoming future (like it?) I will organise a suitable venue/date to have a beverage and a chat. So, if your in the UK and reading this.. thinking of starting a Blog, contributing to the net in someway and your an OT (or student OT) then add yourself to the group to be informed of when/where!

Update I stupidly forgot to post the URL in the first revision of this post. To add yourself go to : http://upcoming.yahoo.com/group/3203/ (It's a yahoo application so you will need to join yahoo )

(Thanks Merrolee)

UPDATE (2) See the forum on the meetup page for some inital thoughts of this meeting and please give me your feedback! http://upcoming.yahoo.com/group/topic/1716/