The role of an Occupational Therapist
The following essay will give a critical evaluation of the role of an Occupational Therapist (O.T) within vocational rehabilitation in the private mental health setting. Firstly the essay will describe a critical analysis of vocational rehabilitation and the added value of an O.T within this setting. Secondly it will analyse the trends within vocational rehabilitation and how these relate to O.T philosophy and core tenets, thirdly an examination of concepts of management that relate to vocational rehabilitation and finally a justification of the identification of a model relevant to vocational rehabilitation.
Work can be seen as being an important part of health and wellbeing and also social inclusion. Waddell & Burton (2006) suggest that work is therapeutic, helps promote recovery and rehabilitation. Leads to better health outcomes, minimises physical mental and social effects of long term sickness absence and worklessness, decrease the chances of chronic disability, long term incapacity from work and social exclusion. Also promotes full participation in society, independence and human rights, reduces poverty and improves quality of life and wellbeing. Work can be divided into four different areas: paid (contract, material reward), unpaid (housework, caring, volunteering), hidden (illegal, morally questionable) and substitute (sheltered workshop, work projects, day centres) (Ross 2007).
The demand for work is extremely high due to the amount of people that are living. Compared to other countries, the United Kingdom employment figures are high with people being employed with a health related condition increasing (Department of Health 2008).
It has been estimated that 175 million days were lost in 2008 due to illness with 600,00 people turning to incapacity benefit. (Department of Health 2008)
It has been shown that 40% of medical certificates issued have been related to mental ill health with the average time off working being 15 weeks. (Department of Health 2008)
Work has been shown to be good for your health and employers who adopt a good approach to health, by protecting and promoting it, are important in stopping illness from occurring. This is an area in which O.T's can provide a key role in supporting and maintaining people back into work or who are already in work to stay there.
Vocational rehabilitation is important. This has been shown in the government's new mental health strategy 'No Health Without Mental Health' (Department of Health 2011). One of the aims is working to help people with mental health problems to enter, return to employment and stay in it.
The application of O.T within this area is important as our core philosophy is to enable individuals to engage in meaningful occupations, therefore there is a key role for O.T's to play within vocational rehabilitation. The following quote demonstrates that meaningful engagement in occupation can be important, which reflects O.T's core ethics and philosophies. 'Not everyone wants to be employed but almost all want to work, that is to be engaged in some kind of valued activity that uses their skills and facilitates social inclusion' (College of Occupational Therapist 2007 p9).
Currently within vocational rehabilitation, employment specialists are trained in advice and guidance and REC level 3 advanced certificate in recruitment practice. Employment specialities tend not to be mental health professional but have skills in vocational rehabilitation or industry experience (Waghorn 2009). O.T's already have these skills and also can add a holistic client centred approach from an occupational perspective. O.T's can also add an educative approach, combine medical and occupational models and use activity analysis. They can assess occupational function/performance, build therapeutic relationships, carry out psychosocial assessments and interventions, cognitive evaluation and training, help with work life balance for the client and work with client's strengths. (Waghorn et al 2009, Devline et al 2006 & Joss 2001, cited in College of Occupational Therapist 2007 p15)
An O.T can bring seven core skills to vocational rehabilitation: collaboration with the client e.g. building therapeutic relationships, assessment e.g. Model of Human Occupation Screening Tool, enablement, problem solving, using activity as a therapeutic tool, group work and environmental adaptations e.g. graded return to work (Duncan 2006 p45)
Current themes and drivers within mental health are social inclusion, return to work agenda, recovery. Social exclusion happens when people are 'unemployed have poor skills, low incomes, poor housing, high crime, bad health and family breakdown' (social inclusion and co-production 2011)
A report called 'Mental Health and Social Exclusion' was published in June 2004 by the Office of the deputy Prime Minister. It aimed to improve the live's of people with mental health problems by getting rid of obstacles to employment and social participation. There are five main reasons why social exclusion occurs for people with mental health problems. Firstly stigma and discrimination, in which an O.T can help by activity speaking to employers about mental health and how reasonable adjustments, could be made. An O.T can help by increasing low expectations, help promote vocational and social outcomes, help provide ongoing support whilst in employment by regular outreach appointments and help access basic services e.g. dry runs on transport, membership to sports centres (Office of the deputy Prime Minister 2004). Overall an O.T can help people remain in their jobs longer and return to employment faster and manage the work environment better by grading work, breaking down activities and rebuilding them step by step and making adaptations to the work environment for example.
Another trend is recovery. Recovery is 'building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems' (Slade et al 2008). Recovery encourages people to develop relationships which give their life meaning. There are five stages of recovery: moratorium (withdrawal, loss, hopelessness), awareness (realisation), preparation (strengths and weakness regarding recovery), rebuilding (positive identity, goal and taking control), growth (living a meaningful life, self management of illness, resilience, positive sense of self) (Andresen, Caputi & Oades, cited in Slade et al 2008). Satisfying work supports recovery and as such O.T's can have a great impact here by ensuring clients are in jobs they really enjoy and able to cope with the work demands. By working in a client centred way, listening, help identify and prioritise personal goals for recovery; identify examples of own lived experience. Also pay attention to goals which will enable the service user to get back into work, suggest non-mental health resources (friends, contacts, organisations), encourage self management of problems, discuss what the service user needs in terms of psychological treatment, convey an attitude of respect and continue to support, an O.T can help a service user to achieve their ideal job.
The return to work agenda is about helping people in and/or return to work. O.T's can aid this by grading work activities e.g. working hours to start with 16 hours per week and gradually increase by 5 hours per week until full time hours are achieved for example. Also by providing support whilst in job by light touch support, setting up group work activities and training the service user. A practice called 'place then train' helps increase motivation and confidence by placing someone in work and then training them instead of the other way around. It improves employment outcomes and peoples mental and physical health over a long period of time (Centre for Mental Health 2011). Its philosophy emphases rapid job searching, individualised job placement in work followed by on-the-job training and ongoing support (Twamley et al 2008).
Currently the concepts of management in vocational rehabilitation within the private mental health sector follows the following structure:
Employment specialists Volunteers
With the introduction of an O.T manager the following structure will be placed:
Band 5/6 O.T
Employment specialist/ Volunteers
Referrals will either come from people themselves or via the community e.g. mental health teams, doctor surgery's, job centres. With new referrals the degree of risk, impact of O.T on service user, consequences of service user not receiving treatment, length of waiting time and the appropriateness of skills and abilities will be considered.
To get people on board for the change in management, people will be listened to for their points of views, concern will be shown, the manager must be approachable e.g. leaving door open and using positive body language, change will be promoting in a positive manner e.g. it will benefit the patients and questions will be encouraged, integrity and charisma will be shown, also have a good ability to communicate, set direction and unify and manage change.
The Lewins stages of change (Mullins 2007) will be adopted where first unfreezing will take place followed by moving and then refreezing. Unfreezing is about getting ready to change by understanding that change is necessary and moving out of comfort zones. It's about weighing up benefits and negatives of the change.
Moving or change is when people are unfrozen and decide to move toward a new way of working. This is often the hardest for people and support is needed.
Refreezing is stability once the changes have been completed. These changes have been accepted and become the norm. People create new relationships and become comfortable with the new routines.
The O.T manager will provide supervision to the band 5/6 O.T and have supervision from a paid outside O.T at that equivalent level. The Band 5/6 O.T will have supervision from the O.T manager and the Occupational therapy assistant (OTA) / employment specialist and volunteers will be supervised by the band 5/6 O.T. Volunteers will be looked after by the OTA.
Management will be in a democratic style by listen to people opinions and having staff work with the manager, not against. Make sure that management set examples by dressing correctly, not being late for work; develop an image, project self confidence, influence others and establish personal authority (Martin et al 2010). Also address self management by managing time, self and case load e.g. size up task, knowing themselves (need for breaks, strengths and weakness), prioritising and planning control(keeping a dairy, decreasing interruptions). Bad management will be discouraged such as not resolving problems, criticising staff, poor decision making, disorganisation, failing to deal with staff issues, done give recognition, inflexibility, and have an uncaring attitude and poor communication skills (Moore et al 2006)
Management will consider professional duties and responsibilities such as the code of ethics, continues professional development (competence), health and safety (risk assessments) and deal with the present.
A number of factors may influence management style: confidence in staff e.g. their abilities, need for certainty (risks of handing over control), personal contribution and stress (overload, worry, pressure) (Martin et al 2010).
The justification of a model relevant to vocational rehabilitation is the Model of Human Occupation (M.O.H.O). M.O.H.O looks at people's motivation (volition), routine planning (Habituation) and the influence of environment on occupation (performance capacity). Some of these areas will be affected by the service user.
Volition is the thought and feelings we adopt whilst doing things. This involved three areas: personal causation, value and interest. To change motivation these areas will need to be addressed. By looking at the service users present and potential abilities relating to work and how able they are to bring about work (what is good, right and important) e.g. security, accomplishment and interests, having positive feelings associated with working. Habituation looks at reoccurring patterns of behaviour that make up our daily routines. A service user can change their habits by learning new ways of doing occupations and by changing their perceived role to one of a worker/bread winner. Performance capacity is how the musculoskeletal, neurological, cardiopulmonary and other body systems are used during performance. If there is a problem in performance capacity, the environment must be addressed.
Work is an increasing important aspect in our lifes. Some of us live and breath work spending the majority of our waking hours working. Work gives us a sense of identity, an occupation, money to spend. It also provides us with a role in the community helping others with our knowledge in a particular area.
Work provides us with a purpose, includes us within society preventing social exclusion, increases self esteem and gives us a role/meaning within society.
Work can be seen as the idea of doing, either mental or physical, giving an economic reward, social interaction, the structuring and organisation of time, opportunity for social interaction, contribution to society and self identity (Baker & Jacobs 2003)
What can Occupational Therapy offer that is different?
Occupational Therapy can offer an approach which looks at the whole of a person by putting the client at the centre of their treatment from an occupational perspective. Occupational therapists can also educate people, focusing on independence and ensuring participation in meaningful activities.
Occupational Therapists are able to combine medical and occupations models. This means they can look at the impact that physical, social and cultural environments have on everyday activities.
The following patch will give a critical evaluation and analysis of social policy, legislation and ethical issues impacting on vocational rehabilitation in a report style.
No Health without Mental Health (Department of Health 2011)
The government is helping people with mental health problems to enter, stay in, and return to employment. This can by achieved by using light touch support, increase confidence in returning to and remaining in work, help manage conditions and help the interaction between appropriate work and well being. It consists of six main objectives:
'more people will have good mental health, more people with mental health problems will recover, more people with mental health problems will have good physical health, more people will have a positive experience of care and support, fewer people will suffer avoidable harm and fewer people will experience stigma and discrimination' (Department of Health 2011 p6).
Its outcome strategies is to focus on how people can be best empowered to lead the life they want to lead, to keep themselves and their families healthy, to learn and be able to work in safe and resilient communities and how practitioners can be supported to deliver what matters to service user.
Occupational Therapists can provide high quality employment support which will include building confidence in returning to and retaining work, changing employers and service user's beliefs, that they can perform the job and their condition is manageable. Support Interaction between appropriate work and wellbeing and help employees to make appropriate recruitment decisions and manage workplace health.
New Horizons (Department of Health 2009)
This mentions that work can be good for mental health and wellbeing and support recovery. Those who are unemployed are at an increased risk of developing mental illness and benefit from early support.
Employment should be seen as an important outcome to the treatment of mental illness in health care settings.
O.T's can help change attitudes to mental health, can improve health and wellbeing in work, provide swift intervention when things go wrong, coordinate help tailored to individuals needs and build resilience from the early years and thought working lives.
Health, Work and Wellbeing - Caring for Our Future (Department of Health 2005)
Suggests that work is recognised by all as important and barriers to starting, returning to or remaining in work are removed. For people to remain in and return to work, that healthcare services meet the needs of people of working age. That health is not affected by work and good quality advice and support is available. Ensure work offers opportunities to promote health and wellbeing and access to the retention of work promotes and improves population, people with health conditions and disabilities are able to optimise work opportunities and people make the right lifestyle choices from an early age.
O.T's already recognise the importance of work for their patients wellbeing and can provide the assistance necessary to fulfil their key roles in helping patients to remain in and return to work.
O.T's can help people return to work following and absence by employment advice and helping to find a suitable job by adapting the work place environment e.g. time flexibilities.
National Skills Framework - 5 years on (Department of Health 2004)
Help to prevent social exclusion in people with mental health problems, improving their employment prospects and opposing stigma and discrimination. O.T's can help prevent social exclusion by building confidence, motivation and skills, speak to employers about mental health and how reasonable adjustments could be made, help provide ongoing support whilst in employment and help reduce stigma and discrimination by educating people.
Working for a healthier tomorrow (Department of Health 2008)
Is concerned with the health of people of working age (females 16 to 59 and males 16 to 64). Identifies factors that prevent good health and changes in attitudes, behaviours and practices.
Three main principal objectives:
prevention of illness and promotion of health and wellbeing
improvement in health of those out of work
O.T's can prevent illness and promote health and wellbeing by using activity as a therapeutic tool, ensuring early intervention and help those out of work by doing group work to build confidence, motivation and reduce anxieties.
There are at least five potential ethical issues which may be encountered within vocational rehabilitation in a private mental health charity organisation. These are confidentiality, consent, autonomy and welfare, human rights, issues of power and control (College of Occupational Therapists 2005):
Safeguarding of confidential information relating to clients, only disclose information when client has given consent, there is a legal justification or it is in public interest to prevent harm. Only disclose to third parties if there is a valid consent or legal justification to do so. Keep all records locked away securely and only make available to those who have a legitimate right or need to see them. Clients can see their records and prior to producing material, issues of confidentiality will be addressed.
Use the confidentiality model: Protect (look after information), inform (ensure service user is aware), provide choice (allow service user to decide if information will be disclosed and improve (look for better ways to protect, inform and provide choice) (Department of health 2003)
Making sure the client has the capacity to consent. The 2005 Mental Capacity Act makes provision for people who are thought to lack capacity to make their own decisions. It has five key areas: 'a presumption of capacity' - every adult has the right to make choices and must be assumed to have capacity to do so unless it is proved otherwise; 'the right for individuals to be supported to make their own decisions' - appropriate help must be provided before anyone suggests that they cannot make their own decisions; 'that individuals must retain the right to make what might be seen as eccentric or unwise decisions'; 'Best interests' - anything done must be in the best interest for the service user and 'Least restrictive intervention' - anything done should be the least restrictive of service users basic rights and freedoms. (Department of health 2007)
Autonomy and welfare
Respect client's autonomy and promote dignity, privacy and safety of client. Give patients the right to make choices and decisions about their own healthcare and independence. Provide sufficient information to enable them to give informed consent and in a language that can be understood. Make sure client understands the nature, purpose and likely effect of intervention and acknowledge refusal.
A right not to be discriminated against regardless of person's religion, sex, race, colour or mental health
A right to respect for private and family life e.g. medical record keeping, parental involvement, collection of data
A right not to impact on the individual's freedom of thought, expression or conscience e.g. spoken language and access to interpreters
Issues of power and control
Respect individuals, enable client to take power and promote partnership
Management of Quality Issues
The service provided will ensure that it meets the needs and expectations of clients and communities, that there is an understanding of service delivery systems and its key services, that data is analysed, problems are identified, performance is measured and that a team approach to problem solving and quality improvement is used.
Make sure service users, carers and public are involved within the service by holding focus groups, open days, suggestion boxes, questionnaires, panels e.g. to find out opinions on waiting times, attitudes of staff and the physical environment
Establish what could go wrong and rank this. Think how probable it is likely to occur, what can be done about it and what action should be taken if incident happens again (Health & Safety executive 2006). E.g. service users deliberately harming herself in occupational therapy session or a spillage on the floor. The Healthy and Safety at Work Act (1974) states that it is the duty of the employer 'to ensure so far as is reasonable practical, the health, safety and welfare at work of all his employees (section 2 (1) Health and safety at work act 1974). Although it is the duty of the employee to take reasonable care for the health and safety of him/her and others who may be affected by his/her acts of omission and to co-operate with their employer in regard to any duty or requirements imposed (section7 Health and Safety at Work Act 1974)
Identify topics relevant to vocational rehabilitation e.g. referral response times, set standard (3 days), collect data (computer package), analyse data (if standard not met then why) and implement change. Other examples may be how the service compares with standards set by other clinical governance activity.
Ensure that all treatment is up to date and based on evidence based practice, National Institute of Clinical Excellence and National Service Framework guidelines.
Staffing and staff management
All staff recruited have the skills and qualifications needed to do the job e.g. that they are Health Professional Council (HPC) registered, induct them, give supervision and appraisal and deal with poor performance. Also supervision on a regular basis and appraisal once a year. Use an indirect approach which is more centred around the person, talk less and listen more, provide a supportive relationship, ask questions, accept and use ideas, reflect and summaries ideas (Enthwistle 2000)
Education, training and Continues Professional Development (CPD)
Ensure mandatory training is given e.g. fire training, child protection, health and safety. Complete CPD portfolios and HPC audits; provide training and opportunities to enhance CPD such as visits to another vocational rehabilitation service. The HPC (2011) states five standards for the CPD. A registrant must maintain:
'an up-to-date and accurate record of their CPD activities'
'demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice'
' make sure that their CPD has contributed to the quality of their practice and service delivery'
'ensure that their CPD benefits the service user'
'present a written profile containing evidence of their CPD on request'
Use of information systems
Use information systems to record treatment sessions that service users attend, time spent preparing treatment sessions, time spent on phone calls to service user and time spent in case discussions. Also handling patient identifiable information by applying the data protection act and locking information away. The data protection act implies that anyone collecting personal information must 'fairly and lawfully process it, process it for limited, specifically stated purposes, use the information in an adequate relevant and not excessive way, use information accurately, keep information on file no logger than necessary, process information in accordance with legal rights, keep information secure and never transfer information outside U.K without adequate protection' (Direct Gov 2009)
The following patch will provide a reflective narrative of the learning experienced throughout the module utilising the Gibbs reflective cycle. This has been developed from Kolb's ideas and develops the features of the
experience-reflection-action cycle (Jasper 2003):
Action plan Feelings
The Gibbs cycle consists of six stages and asks a series of questions about the experience. Description stage is what happened, feelings stage is what where you thinking and feeling, evaluation stage summarises what is good and bad about the experience, description stage involves making sense of the situation, conclusion stage is what else could have been done and the action plan stage asks if the situation arose again, what would you do.
To begin with the whole assignment seemed extremely daunting as I had never participated within a role emerging placement/role before. I had also never completed a patch work text and knew very little of both. As part of the assignment we were asked to discuss ideas with peers. I felt it was a good idea to share information with others and thought that this would be an ideal opportunity to reflect on things I was not sure about and where to go for more information. Whilst discussing ideas with my peers I was thinking how what we had discussed would fit into my assignment and in what patch. It made me feel a little more comfortable sharing with other as we could bounce ideas and thoughts off each other. I feel other peers also felt that group discussions were useful and helpful. From start to finish I felt good about discussing information and still feel that this was of great benefit to all of us.
Exchanging views helped put things in some kind of order and others could help in areas where I had difficulties. I do not feel there was anything negative about this experience in general. Sharing ideas with others went well as we all had views to share. To contribute, I helped others to see what went in each patch and gave ideas about the assignment.
Overall there is not much I would have done differently with this peer review work. The aim was to share and discuss information and this was done successfully. If I were to do peer review work again I would do the same by sharing ideas and information with others.
During my visit to a vocational rehabilitation setting I got to see how the service was run, where referrals come from, meet staff and service users and view leaflets. Upon arrival I felt overwhelmed by information and was intrigued about the service. I was thinking how I could relate this to my assignment and what role an occupational therapist would play within such a service. The service manager, who showed me around, knew about occupational therapy as previously they had worked as an assistant in such a role. This made me feel happier as I could share some ideas with them. I felt the visit went extremely well and it was a positive learning experience. From the start I felt comfortable about visiting the service and knew I would collect lots of relevant information from it. Access to information and ideas was the most significant factor for me.
Actually seeing a vocational rehabilitation service running was a great inspiration and thought provoking for me, as I could see where parts of my assignment would fit in. I feel the whole visit went well and managed to collect a lot of relevant information.
To complete patch work two we were asked to produce a leaflet aimed at our intended service users. I found this patch difficult because selecting relevant information was not easy e.g. font, colours, headings, content, pictures. When I first started the leaflet I had previous knowledge from another module, so had an idea how to construct the framework. I was thinking what type of content would go into the framework of the leaflet and how. Others mentioned that the leaflet should be easy to read and with bullet points, pictures and a calming background. I felt this would be a good idea, by aiming the leaflet at my service user group in particular. I thought that the leaflet was starting to take shape and it was aimed at who it was intended for. To start with I felt a little lost as to what to so but with help from my peer review group I eventual found a way. The most significant thing to me was being able to reflect ideas with other people about the leaflet.
I feel that putting the leaflet together was a good experience as it has taught me how to present information to a targeted audience by using easy to understand phrases rather than jargon. Also working in peer review groups was a good experience as we were able to share ideas with each other and share information. The only thing that didn't go so well was working out how to transfer the leaflet from publisher to a word document, also slimming down the content without vital information being lost.
I feel the leaflet went well and managed to collect and produce the correct information. Others did help by offering encouragement and ideas which aided me in producing the leaflet.
I realise now that I should have consulted my peer group earlier to starting the leaflet as their ideas helped and guided me.
To complete patch three we were asked to critically evaluate and analyse social policy, legislation and ethical issues impacting vocational rehabilitation. I found writing this patch extremely difficult as I had no idea of legislation, ethical issues and quality issues relating to this subject.
When I started this patch I felt very nervous and worried as to how I would find such information. I was wondering how I would go about doing this patch and what was involved. When I was looking for information I found a vast array. I had to sieve through relevant legislation and apply it to vocational rehabilitation. This was difficult as the legislations consisted of hundreds of pages in which I had to pick out relevant information from this.
When I started the patch work I had no idea where to look and what to do. I was feeling overwhelmed by all the different types of information I found. Again other people helped me to pick out relevant information and gave me some focus. When I eventually finished the patch I felt a sense of achievement. From start to finish I felt anxious about starting the patch and finding relevant information. Towards the end I felt a sense of achievement that I had completed it.
The experience was positive as it taught me how to pick out relevant information from large publications. It taught me about quality and ethical issues and how theses related to vocational rehabilitation. I feel I choose this information very well.
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