Is it really all good?

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..)

I have finally had five minutes to make live the OT Courses list of USA Courses. It has been a nightmare to be honest - If you are from the US and can spare some time to help improve the data please step forward - Im hoping this will be a useful resource but it will only be if the data is accurate!

See here for the BIG list http://www.metaot.com/ot-courses-usa

Please feel free to comment but once again note that the list will be moderated!

Assessing patients is part of the rubric of everyday life for most occupational therapists (OT’s). OT’s are trained to gather information from multiple sources and formulate complete, competent and accurate appraisals of the patient’s occupational status, often in the face of time restraints and limited quality contact with the individual. The result of this process is a valuable document reflecting the OT’s unique perspective on the patient’s level of functioning and arguably the closest representation of the patient’s own preferences for treatment. The lifespan of this document, however, does not necessarily end after it has been completed and filed away. Exploration of its uses should justify the rigors of its acquisition. A large and immovable aspect of this exploration is to what extent assessment results can be shared with the subjects themselves.

OT’s legal obligation

The law states that we, as OT’s, have a legal obligation to share assessment results with all patients, regardless of the setting. The Access to Health Records Act (Department of Health (DoH), 1990) was the first Bill to specifically address the responsibility of occupational therapists to disclose any information; ”˜relating to the physical or mental health of an individual who can be identified from that information, or from that and other information in the possession of the holder of the record’ (section 2.1 (f) DoH, 1990). Since this benchmark legislation both the Data Protection Act 1998, European Union Data Directive (1998) and the Freedom of Information Act (FOI) (2000) have refined and reinforced this policy. Significantly for health-care professionals the FOI was designed to promote and highlight patients rights to publicly held information, after the Audit Commission in 1995 found that many health professionals were reticent in permitting patients free access to their records. In light of this legislation, omitting results of a MOHOST assessment, for example, is of equal offence to omitting medical records (section 2.1 (f) DoH, 1990).

The Code of Ethics and Professional Conduct for Occupational Therapy (COT 2005) echoes government directives for information access by stating ”˜access to records shall be granted in accordance with current statutory requirements’ (2.3.5, COT, 2005). The Code also refers to a clause in the Data Protection Act (1998) that exempts information that is ”˜likely to cause substantial damage or substantial distress to him or to another’ (Data Protection Act 1998 section 10A). The closest statement within the code of ethics relating specifically to the process of assessment feedback itself is that ”˜reasonable steps shall be taken to ensure that the client understands”¦the proposed intervention(s) (2.1.4, COT, 2005).

The Evidence”

Over the last three decades piecemeal research on this subject has been produced, often contrasting psychiatric notes with medical notes to gain insights. A study by Critchon, Douzenis, Leggatt and Hughes (1992), titled ”˜Are psychiatric case notes offensive’, found that acute in-patients found the formulation “chronic schizophrenic” to be offensive but not the formulation “chronic diabetic”, in those patients with a duel diagnosis. Other studies have attempted to measure anxiety levels in patients who were exposed to candid reports about themselves in clinical records, revealing contrasts between physical and psychiatric patients. In one randomized trial, 11% of medical outpatients reported they had “upsetting feelings” as a result of reading their records (Golodetz, Ruess, Milhous, 1976). In a non-randomised controlled trial, 23% of obstetic patients reported that records were “worrying” (Elbourne, Richardson, Chalmers, Waterhouse, Holt, 1987). In three separate studies of psychiatric patients’ anxiety levels, using varied research methods, however, results range from 12% to 50% of patients reporting discontent after reading their clinical reports (Beradt, Gunning, Quenstedt, 1991; Miller, Morrow, Kaye, Maier, 1987; Stein, Furedy, Simonton, Neuffer, 1979).

Within OT itself very little has been written about the way patients interface with assessment results. Kielhofner (2005) admits that although it is common-place to discuss assessment results with patients in both mental and physical health within the MOHO tradition, there is no explicit guidance for practitioners in this area or adequate evidence-base (personal correspondence, 2005). The few examples that exist show the positive effect of sharing feedback between patient and OT, and the scope for creativity in this field.

In a case study by Auzmendia, Gloria de las Heras, Kielhofner and Miranda (2002) the results of a Volitional Questionnaire, an observational assessment ascertaining the level of volition of the individual, were shared with a community outpatient who has a bipolar disorder. At first the OT refrained from sharing the assessment results and instead used it to learn more about the individual. As the goal setting process became more concrete the OT began sharing the results with him and eventually taught him to use the measure himself as a self-assessment.

Kirsty Forsyth, author of the MOHOST, sounds a cautionary note on whether or not a there should be a blanket feeding back of assessment results to patients by stating that sharing is not always appropriate and needs to be flexible (personal correspondence, 2005). A good example of this flexibility is illustrated by Kielhofner, Brenneman Baron, Mentrup, Schulte and Shepard (2002) who describe how an Assessment of Communication and Interaction Skills (ACIS), another observational assessment, was used to help an acute patient with depression self analyze whilst watching a videotape of his social interaction. This empowered the patient to be the main definer of his problems rather than have them defined for him by a health-care professional. An important footnote in this example is that the client had volunteered to be assessed by this method, so would have been more conducive to such a candid process.

If communicated effectively, therefore, the feeding back of assessment results can provide a foundation to mutual and therapeutic goal setting. If communicated bluntly, on the other hand, it can serve to offend the patient (Starke, Andrews, Griffin, Rebeiro, 2001). It is essential for more evidence-based research in the field to be generated because of the unique nature of the OT assessment and partnership between OT and patient. For this reason conclusions from other professions cannot be borrowed. More needs to be learnt about what factors influence the feedback process and how patients and practitioners feel about it. Acute mental health is the ideal platform on which to stimulate debate on this subject.

References

Bernadt, M., Gunning, L., Quenstedt, M. (1991) Patients’ access to their own psychiatric records. British Medical Journal, 303: 967

Department for Constitutional Affairs (2000) Freedom of Information Act. London. HMSO.

Department of Health (1990) Access to Health Records Act in Mental Health. London. HMSO.

Elbourne, D., Richardson, M., Chalmers, I,. Waterhouse, I., Holt, E. (1987) The Newbury Maternity Care Study: a randomized controlled trial to assess a policy of women holding their own obstetric records. British Journal of Obstetrics and Gynecology; 94: 612—619

Crichton, P., Douzenis, A., Leggatt, C., Hughes, T., Lewis, S. (1992) Are psychiatric case-notes offensive? Psychiatric Bulletin Review. Nov; 16(11): 675-7

Forsyth, K. (2005) Personal correspondence via e-mail (29/08/2005)

Golodetz, A., Ruess, J., Milhous, R. L. (1976) The right to know: giving the patient his medical record. Archive of Physical Medical Rehabilitation; 57: 78—81

Kielhofner, G., Brenneman, B., Baron, K., Mentrup, C., Schulte, D., Sheppard, J. (2002) Enabling clients to reconstruct their occupational lives in long-term rehabilitation in Kielhofner, G. (2002) Model Of Human Occupation (3rd Edition), Philadelphia, Lippincott Williams and Wilkins

Kielhofner, G. (2005) Personal correspondence via e-mail (28/08/2005 and 31/08/2005)

Miller, R. D., Morrow, B., Kaye, M., Maier, G. J. (1987) Patient access to medical records in a forensic center: A controlled study. Hospital and Community Psychiatry; 38:1081—1085

Stein, E. J., Furedy, R. L., Simonton, M. J., Neuffer, C. H. (1979) Patient access to medical records on a psychiatric inpatient unit. American Journal of Psychiatry; 136: 327—329

Starke, L. Andrews, P., Griffin, C., Rebeiro, K. (2001) Being on the other side: OT’s who have been recipients of OT. OT Now. May/June 2001 p25-27

“Well at least she’s prettier
than the last OT I had”

Around 12,000 years ago in a stone aged settlement in central Europe, a tribal elder made a decision that would change the course of civilization forever, and eek mankind one notch further on the evolutionary scale. This man decided to unleash the family goat from the nearby tree, and guide it to the warmth and protection of the hut. From that moment on, the history of animal domestication began. 10,500 years later, on the battle fields of the Crimea, Florence Nightingale reflected on this giant leap for mankind, and its potential benefits to the disabled; “a small pet is often an excellent companion for the sick, for long chronic cases especially”. For maximum pleasure Ms. Nightingale suggested a small “caged bird”. Decades earlier the Moral Managers of the York retreat in England envisioned that animals could become an important part of psychiatric treatment, helping lessen the need for medication and restraint. Since then animals have consistently been used in health care from guide dogs to helper monkeys. Can animals continue to play a role in the 21st century healthcare system, or should they be consigned to the history books? ”¦And what’s it all got to do with OT anyway?

Over the last decade, a wealth of studies have emerged to support the widely held anecdotal views that animals can be ”˜therapeutic’. A large proportion of these have looked at the benefits of animal assisted therapy (AAT) or therapy involving a trained (furry) animal and its owner, as opposed to a ”˜service animal’ such as a guide dog. A common finding between the studies is that animals have an intrinsically therapeutic effect on patients. Studying the benefits of a companion dog for patients with schizophrenia, for example, Barker, and Dawson (1998) found that the caring human-canine relationship helped ground the patient in reality. In another study Arnold discovered that for patients with dissociative disorders, a dog was a calming influence, which not only relaxed the patient but also gave the patient confidence to interact more with the healthcare professionals. Similarly, Holcomb and Meacham (1989) found that AAT was most effective in engaging patients who were most isolated on the ward. The conclusion made by Arnold (1995) is that interacting with the dog posed fewer demands than other traditional therapy groups that may have otherwise caused states of increased anxiety.

Although this evidence clearly expounds the comforting qualities of AAT, some critics have suggested that there needs to be more task-focused research in order to make it more clinically relevant for professions such as OT’s.

A study by Oakley and Bardin (1998) highlights the measurable effects of AAT on children recovering from traumatic brain injury. In treatment sessions at St Mary’s hospital for children in New York, the OT’s incorporate a dog into therapy sessions in order to satisfy specified goals. If, for example, a child has difficulty dressing and grooming due to decreased function on one arm, the therapist will get the child to reach out with the affected arm and stroke the dog. The child then becomes motivated and excited to participate in the task, and eventually attains the goals quicker than anticipated without the dog. According to Davies (1998) this is not only a fun activity for the child on a psychological level, but one that operates on a biological level too. Tests show that when stroking dogs, the blood pressure of children, and adults, decreases, even when performing an unpleasant task simultaneously.

The potential benefits of AAT to peoples physical health has more resonant implications for older adults. Recent studies have confirmed that pet owners experience greater longevity than their non-pet owning counterparts. A recent Australian study, for example, involving 5,741 participants found that pet owners had significantly lower blood pressure and triglyceride levels compared with non-pet owners (Anderson, Reed, Jennings, 1992). These findings could not be explained by other influencing factors such as smoking, alcohol consumption and social status. The exact causal link between animals and good health however is still unclear, ranging from the intrinsic anxiety reducing qualities of animals to, simply, the benefits of dog walking.

How can these findings relate to OT practice? For a start many OT clients are pet owners, and each has or could have a responsibility of care for that animal. The demands of looking after that animal such as feeding, cleaning andexercising the animal all rely on complex co-ordinated movements, exercise tolerance and even social interaction. This will help embed a structured routine into the client’s day. So, next time you are on a home visit, don’t just step over the dog or pat it on the head, think how the animal can be incorporated into an achievable and measurable goal for the client in his or her rehabilitation. Dr Albert Schweitzer, a leading expert of animal therapy, believes that animals have an important role to play in the future of health care “as we except animals as potential healers and major contributors to our health, wellness and vitality”¦we need a new wiser concept of animals’. In order for this vision to be fully realised, however, more evidence is needed that looks at specific, task related, AAT interventions and outcomes.

If OT’s fail to keep on top of the developments in the world of AAT then we are potentially leaving the door wide open for helper monkeys to take over our jobs. This monkey (above) is already working as a Senior I in Basingstoke ICT.

References

Anderson WP, Reid CM, Jennings GL: Pet ownership and risk factors for cardiovascular disease. Medical Journal of Australia 157:298-301, 1992 [Medline]

Arnold JC: Therapy dogs and the dissociative patient: preliminary observations. Dissociation 8:247-252, 1995

Barker S, Dawson K: The effects of animal assisted therapy on anxiety ratings of hospitalized psychiatric patients Psychiatric Services 49:797-801, June 1998

Beck A, Katcher A: A new look at animal-assisted therapy. Journal of the American Veterinary Medical Association 184:414-421, 1984 [Medline]

Davis JH: Animal-facilitated therapy in stress mediation. Holistic Nursing Practice 2:75-83, 1988

Holcomb R, Meacham M: Effectiveness of an animal-assisted therapy program in an inpatient psychiatric unit. Anthrozoös 2:259-264, 1989

Oakley D, Bardin G: The potential benefits of animal assisted therapy for children with special needs, 1998 (www.kidneeds.com)

The good thing about OT is that its actually quite a small world. The bad thing is its actually quite a small and hard-to-find-any-information world. Really as a test for future, much more useful and intresting "things"that I have planned, I have created a database of all OT Courses from around the world. Currently data is viewable for the UK only but USA and Australia are just around the corner (If you are from the USA, Australia or New Zealand please contact me to help me out!!). Here are the UK courses:

http://metaot.com/ot-courses-uk

I am keen for students to write comments on courses from their institution - but please note the comments are moderated so be nice! Also please be aware that courses are constantly changing so take anything that may be written with a pinch of salt. I remember when I was fist looking into the world of OT and it was quite frankly a nightmare to find any information about the courses apart from the universities own literature and the QAA site*. I hope this may be useful to you if you wonder which courses to go for.

Any problems with the data then drop me a line.

*Only useful for UK courses.

10 minute guide to Activity Analysis
Activity Analysis: What is it?
The ability to analyse activity in minute detail is one of the unique skills of an OT (Hagedorn 1992). Activity analysis or "the exploration of the typical contexts, demands and potential meanings that could be ascribed to activity" (Crepau 2003 p191) has two main purposes - to identify difficulties and problems experienced by the individual in activities and provide specific interventions that are meaningful and purposeful to the individual.

How?
The content of the activity must be analysed and evaluated. Note that there is no one set way to achieve activity analysis - different authors vary in their approach and terminology. The first stage in any method however is to understand what is required of an individual to perform the activity competently. Items to consider should include (Hagedorn 1992):

• Performance components required (e.g. cognitive, motor, interpersonal - the headings for each may depend on the model being used)
• Degree of complexity
• Positive or negative social or cultural aspects
• Structured or Unstructured activity?
• Familiar to a person?
• Tools and environment required to perform the activity
• Safety and risk concerns
• Potential for engagement of patient interest and participation
• The tasks that make up the activity:
• sequence and flexibility of order
• task components (some define this as "task analysis")

Remember this first stage is to investigate activity - which remember is context-free (See box). Think of it as how someone would 'normally' perform the task*.

The next stage is to investigate the activity in context and discover how the person in question performs the required elements. Although often innately achieved by a therapist, there are a number of formats to achieve this. Lamport, Coffey and Hersch (2001) give some suggested forms to discover expected performance and for therapeutic intervention. The AOTA (in Crepau 2003) suggest one format that breaks down performance components into motor skills, process skills and communication/interaction skills (Crepau 2003 p193). A form that investigates expected and actual performance for a activity can be downloaded to use for your own use here (word, pdf). This is largely based on the Lamport et al text and you will need to refer to descriptions of the performance components to understand this form although its relatively straightforward. Note that some elements are missing from the form; these are mainly the performance contexts and should be taken into account within any activity analysis.

What now?
With the understanding of normal function and ability and being able to highlight those areas of difficulty seen by the individual it is possible to combine the two and formulate meaningful treatment plans. This will typically involve the use of graded activity - sequentially increasing the demands of an activity on a person to stimulate improvement in their functional ability (Crepau 2003). This will differ depending on the nature of the identified problems and theoretical approaches being taken (including Model, Approaches and Frames of Reference). Adapting the activity may also be required. Both adaption and grading requires modification and planning of not only the activities steps but also the context (e.g. environment).

* Im not keen on the word 'normal' but for clarity it is used here.

References
Lamport N.K., Coffey M.S, Hersch G.I (2001) Activity Analysis & Application, 4th Edition, NJ: Slack
- A nice text. Its slightly unrealistic to expect a practitioner to carry out all 5 forms suggested in the book but note that it has been designed to facilitate learning rather than for practice. What is useful is that the authors have gone to some effort to create steps to perform activity analysis and use terminology that is common - making full use of the AOTA Uniform Terminology; repeated for reference in the appendix of the book. If you buy it you also get access to the forms for downloading (once only).

Crepau E.R. (2003) Analyzing occupation and activity: A way of thinking about occupational performance in Willard & Spackman's Occupational Therapy pp 189-198

Hagedorn R (1992) Occupational Therapy: Foundations for Practice, Edinburgh UK: Chuchill Livingstone

Trombly, C.A (1995) Occupation, purposefulness and meaningfulness as therapeutic mechanisms (Eleanor Clarke Slagle Lecture), American Journal of Occupational Therapy 47, 960-972