discussion

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. 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 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 - 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.

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..)

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