My occupational therapy studies are now in their third year and I feel, this year, more than any other year that I am beginning to understand and appreciate the core values of the profession. These values include client-centeredness, use of evidence, cultural competence and occupation-based practices. All of these values embody the fundamental principles of occupational therapy practice (Law, 2004). Although I struggled to understand the values of occupational therapy in the beginning and was unsure of the true benefits of the profession I can now see that our profession is one which should be truly valued and respected. However I feel that our profession can only be viewed in this way when its core values are upheld. Unfortunately I feel that this is not often the case due to a number of different barriers which I will discuss further later in the assignment. I feel that unless these values are practiced by occupational therapists our profession will continue to struggle with its definition and its identity with the professional medical world. This year I completed a ten week placement within an acute physical setting. I feel that within this setting occupational therapists conformed more to the medical model at times and although they upheld many of the core values, I think that it can be difficult to address occupation based practice within this setting, which is really the key element of our profession. I also feel that therapists found it difficult to use evidence based practice due to time constraints but also as there are very few occupational therapy related articles. Therefore I feel there is a large gap of literature within our profession. This was evident when researching for this assignment.
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I chose the above title for this paper, as I will reflect on the core concepts of the occupational therapy profession but also the barriers to applying them in practice. I will review the literature and I will also draw on my own learning to date. I will than consider how effectively I applied these core skills in my recent practice experience by reflecting on some key experiences. I will identify gaps in my own learning and also any challenges I experienced in applying these skills in practice. To conclude my paper, I will reflect on the implications that exist in applying these core skills in current practice settings and I will explore strategies to overcome these implications in future practice.
Client Centred Practice
Before discussing client centred practice it is important that I have a clear definition of the approach. On review of the literature, it appears that there has been much debate in establishing a definition for client-centred occupational therapy practice and I was unable to find one clear-cut definition of the term. The extent of the research in this area is largely based on the difficulty in defining the concept and applying the approach in practice. However I did realise that there are a number of key elements underpinning the definitions. These are choice, partnership, empowerment, respect, joint goal setting and decision-making and autonomy (Sumsion, 2000, Law & Baptiste, 2002, Sumsion & Law, 2006,). The overall goal of this practice approach is to "create a caring, dignified and empowering environment in which clients truly direct the course of their care and call upon their inner resources to speed up the healing process" (Law & Baptiste, 2002).
Client centred practice has been proven to be effective however there appear to be a number of issues relating to its implementation in practice. For example as Nelligan et al (2002) discussed - often it appears the budget, the current approach to management or staff shortages prevail and dictate how work is performed. There can also be conflicts arising between the client's decision making and the values of the professional and the patient. For example, often on placement there were times when I, as the OT student would recommend something that would be in the best interest of the client but still they might prefer not to accept it. Clients may also not be able to be effective partners in the client centred collaboration due to barriers to communication, for example, or they may have cognitive deficits (Rosa, 2008). On discussion with others it would appear that this can often be a regular occurrence for professionals. I have identified two gaps throughout my research and that is that there is a lack of recommendations in existence to assist occupational therapists in overcoming the barriers to client-centred practice. Also there is little research evidence to support how current occupational therapy practitioners are applying this approach in practice.
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In an effort to address the diversity of the healthcare system, the drive for healthcare professionals to attain cultural competence has become important (Black & Wells, 2007). This has been noted within occupational therapy where the terms culture and cultural competency are broadly discussed. Cultural competence has been defined as "having an awareness of, sensitivity to and knowledge of the meaning of culture" (Dillard et al., as cited in Guiral, 2002 & Awaad, 2003). The AOTA, 1995 refer cultural competency to the process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different persons. Why is cultural competence of importance? As occupational therapists our client group is often composed of individuals with dissimilar cultural backgrounds but I realise now that this may not necessarily mean that the client is of a different racial group. For example, the interaction of clients and practitioners can embody a form of multiculturalism in which several cultures- the health care profession, institution, family, community, traditional culture, etc.-are all merged (Genao et al., 2003). Therefore, from my research I realise that every therapeutic interaction can be considered a cross-cultural interaction. This overlap and interaction of cultures and dialects can create ethical conflicts and dilemmas in providing occupational therapy services. Therefore, I feel, cultural competency is important within our profession. In order to uphold the core values of our profession and apply interventions that are occupation-based, client-centred and supported by evidence, we need to consider the client's culture. Otherwise our cultural incompetence will result in compromised quality of care, noncompliance by the client, inability to recognize differences, fear of the new or unknown, denial, and inability to look in-depth at the individual needs of the client and their family (Wells & Black, 2000).
On reviewing the literature it appears that there is an abundance of information on what it means to be culturally competent. However, a number of individuals have commented on how attaining cultural competence in our practice has been referred to as one of the least developed areas of occupational therapy (Awaad, 2003, Guiral, 2002, Odawara, 2005). This, I feel, is due to the lack of clear guidelines or an evidence base on how to achieve cultural competence and apply it in practice with different cultural groups. This presents practicing therapists with a challenge.
Occupation Based Practice (OBP)
Occupation-based practice has been documented in the occupational therapy literature since the foundation of our profession. During my literature review I noticed that the main focus was in defining occupation and what it means to be occupation-based in our practice. Gray (1998) stated that occupation is meaningful and goal-directed, and that "occupation, when it is applied as activity with wholeness, purpose, and meaning to the person, can also affect him or her psychologically, emotionally, and socially in ways that purposeful activity unrelated to the person cannot" (p. 356). I feel that it is precisely because occupation as intervention has the ability to create change throughout the individual's multiple systems that occupation-based practice is worth exploring. According to the AOTA (2005), the therapist's activity analysis and environmental/activity modification skills are critical to the linkage process described above and are key factors in using occupation in an integrated approach to intervention and I too feel that this is what makes us unique as OT's. However within the literature the barriers to implementing occupation-based practice are also discussed. These barriers can be internal or external.
According to the AOTA (2005), the barriers to implementing OBP are related to factors internal to the therapist and profession as well as to issues in our external environments. Internally, two of the most noteworthy barriers relate to the interrelationship of the therapist's value system and habit structure. I have seen on both placements how easy it can to stick to a habit and not explore other intervention possibilities that may hold more meaning for a client. Externally, there are numerous setting and system issues that hinder OBP. These include factors such as reimbursement, limited time and resources, productivity expectations, population specifics such as length of stay or acuity and treatment environments that promote reductionism and are impoverished occupationally. Limited resources and time have been the most significant external factors I have witnessed. These points are important to consider as they most often affect every therapist and their ability to carry out occupation based practice.
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On review of the literature, it was evident that there was no current research evidence into how many current practitioners such barriers affect and how many practitioners are conducting interventions that are occupation-based. The majority of the literature in this area appears to be based on the theories of OPB and the benefits, rather than solid research evidence on how practitioners are applying this concept in practice.
Evidence Based Practice
Evidence-based practice has been defined as 'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients' (Sackett, Rosenberg, Gray, Haynes & Richardson, 1996; p. 7). On review the literature appears to be concerned with defining evidence-based practice and acknowledging it's importance. The aim of evidence-based practice is to ensure that the interventions being provided to clients are the most effective. External evidence such as journal articles and research studies is only one aspect of the process and it must be combined with the clinical reasoning of the occupational therapist and the client's decision (Taylor, 2007). The Canadian Association of Occupational Therapy et al. (as cited in Taylor, 2007) support this by defining evidence-based occupational therapy as "client-centred enablement of occupation, based on client information and a critical review of relevant research, expert consensus and past experience". Having an evidence base is essential in our practice as occupational therapists. It supports and clearly articulates our clinical decision making to clients and also justifies our practice methods to authority figures (Taylor, 2007). The literature on evidence-based practice appears to draw on the role of the occupational therapist in reflecting on their practice methods to enhance their evidence-base (Stube & Jedlicka, 2007, Taylor, 2007, Bailey et al., 2007). While we can acknowledge the sheer importance of having an evidence-base to our practice, the literature suggests that there is insufficient research being carried out to determine the effectiveness of particular interventions in all areas of practice. Melton et al. (2003) identified insufficient resources, time constraints and lack of skills as the main challenges impacting on occupational therapists acquisition of evidence-based practice. Without a sound evidence-base to our practice it is difficult to justify our interventions and apply interventions that are client-centred, occupation-based and culturally competent.
Discussion and Findings /My Own Personal Experience
I believe that being able to effectively find and critically appraise research is an essential skill which all occupational therapist should be competent in. As a relatively young profession, with limited research, occupational therapy does not have a particularly persuasive evidence base compared with that of other health professions. When I was on placement the speech therapist or physiotherapist or consultant would, regularly in multi disciplinary meetings (MDT), bring up research articles they had read regarding to their profession. It demonstrated the knowledge they had but also the evidence base for their interventions. It helps to advocate for their profession. With this in mind I feel it is important that all practicing occupational therapists are able to validate their practice through evidence based practice. With more occupational therapists able to provide treatment, which is evidence based, occupational therapy will have more credibility as a profession with both clients and other health professionals (Taylor, 2007).
However one barrier I noticed was that when on placement it can be very difficult to find the time to research, yet this is perhaps the time it is most valuable as ideas are fresh and can be applied to practice. On placement I had many patients who had acquired brain injuries (ABI) either from stroke or seizures and who required regular intervention. With little time to research before intervention I began to carry out intervention using a bottom up approach. However when I finally managed to have the time to research I discovered that a top down approach is more effective with people with ABI. This incident made me realise how important it is to make time for research, as it may be more beneficial in the long term. I also realise that other professionals are just as busy but still they find time to research. In the future I hope to be more skilful in managing my time effectively so that I can carry out the research necessary to support my work.
Prior to my literature review I always considered cultural competence as a skill to apply with clients from other ethnic groups. During my practice experience the majority of the client group I worked with were of Irish culture. Knowledge of my own culture was essential in order to be culturally competent in my interventions. I also needed to have a positive attitude to embracing different lifestyles and values as occasionally I was presented with clients whose values and lifestyles deviated from my own. According to Rosa (2008) occupational therapists need to be more open to exploring differences regarding therapy goals. On one occasion I met a gentleman who had just undergone bilateral knee replacement and had a transient ischemic attack. I felt he would benefit from a long handled reacher and sock aid due to his poor ability to bend. However he admitted that he was not a materialistic gentleman, enjoying a simple life, and would often even go without wearing socks and shoes in the house and would make do with any slip on shoes he had at home instead for when going outdoors. It was difficult for me to understand at first so explained the benefits of the equipment but I also knew I had to accept his own beliefs even though they were different to my own. Although, I managed this challenge well, I am unsure if I would define myself as culturally competent. Especially as I have limited experience and knowledge of working with other ethnic groups. I hope to develop my knowledge in this area through future learning and practice opportunities.
Maitra and Erway (2006) state that the success of client centred practice can also often depend on the client's ability and desire to engage in decision-making processes. For example one of my clients had moderate mixed aphasia and a moderate cognitive impairment. Therefore it was a challenge to maintain a collaborative client centred partnership. But according to Rosa (2008, p. 288) "practitioners are called on to overcome the barriers that are present to the extent possible in an effort to understand the clients as fully as they can and share the power and responsibility of decision making." However I could find no guidelines that would of helped me achieve this and in hindsight I believe these would of been useful as I found it difficult to be client centred and instead of creating joint goals I established my own goals for the client. I do not feel that I ever provided the opportunity for this client to direct the course of his therapy. I know that in the future I will have many clients who have cognitive or communication impairments and therefore I need to improve my communication and personal interaction skills which are required to deal with such barriers according to Rosa (2008). I also need to be knowledgeable as to what methods are being used by other occupational therapists to provide client centred care with such clients as well as having a more positive attitude to thinking more creatively about methods of communicating with my clients. It is important that I explore many areas with them so that I can gather a sense of the direction they would like therapy to take.
Being occupation based was something I really struggled with on placement which left me disheartened as I feel it is important that all OT's are occupation based as the fundamental principle of our profession and hallmark of our practice (Hersch et al, 2005). I was in an acute physical setting and often the main intervention was concerned with providing equipment or making a community OT referral. However on one occasion I felt I was occupation based and the outcome was successful. An important skill to be occupation based it to know what people like to do in their daily life and to be aware of what motivates them (Chisholm et al, 2004). I had a client who enjoyed drawing and colouring on a daily basis. As she had fine motor difficulties and visual perception difficulties I thought that using her drawing and art skills would have been a nice intervention plan as it was a meaningful activity for the client. It proved to be very successful and she looked forward to our sessions together. I think another skill to have when being occupation based is to be creative and I personally struggled to think of ideas to keep the sessions fun and interesting. I overcame this by researching other activities to do in my spare time but I know that if I had had a larger caseload I would not have managed as well as I did. Only on a rare occurrence did I witness OT's engaging clients in meaningful occupations although it was evident each of them knew the importance of meaningful occupation for clients they just never had the time to carry it out. I think that in order to be true to our profession OT's need to try and use meaningful occupations more in practice. I think research on how other OT's are managing to carry out occupation-based practice in acute physical settings would be very useful to guiding our practice.
Implications for Practice, Summary and Conclusions
Translating theory into practice is a challenge faced by all occupational therapy practitioners. We endeavour to uphold the core values of our profession while simultaneously we are impacted upon by a number of barriers in our practice setting. I experienced such barriers in my setting. Reflecting on the year and my practice education I realise that it is our professional responsibility to enter a therapy situation with the aim of applying all four of these concepts. When we are faced with a challenge, we need to draw on our own evidence-base in order to make sound clinical judgements. The literature provides us with an abundance of information on what it means to be client-centred, occupation-based, culturally competent and evidence-based. I am aware of the meaning of all of these concepts, as are the majority of practicing therapists. However, what the literature fails to convey, is how occupational therapists can effectively uphold these core concepts when presented with a challenging situation in real practice. We can draw on our own personal and clinical judgement, but where is the evidence-base to support our actions and define what is right?
Based on my practice experience, I recommend that we remain up to date with the current literature to guide our daily practice and reflect on our own interventions and performance regularly. I am aware that this is a skill I need to improve on and I need to begin regularly researching databases, journals and books to remain up to date but also to increase my knowledge as a young professional. I also suggest that we take the opportunity to participate in or carry out research studies that will guide our practice. This will allow us to set goals for our own development and modify our approaches so that we can engage in best practice. My practice experience provided me with a thorough insight into the realities of occupational therapy practice. I am aware of the challenges that exist in being client-centred, occupation-based, culturally competent and evidence based in real practice. However, more importantly I am aware of what I can do to be effective in practice. By striving to be the occupational therapist at the core of these four concepts, I hope to fulfil my journey in becoming a competent occupational therapist.