CONTENTS Editorial 3
Monitoring the progress of young people’s occupational performance in an inpatient mental health setting. Glenda Schnell 4
The nature of occupational therapy practice in acute physical care settings. Luciana Blaga & Linda Robertson 11
Occupational participation at 85 plus: A review of the literature. Laura Haslam 19
Occupational therapy student’s fieldwork placement: Institutional and community based rehabilitation models in the Solomon Islands. Ana Burggraaf & Helen Bourke-Taylor 25
Tools of practice: A view of changes in occupational therapy in Aotearoa New Zealand. Linda H Wilson & Kaye Cheetham 32
Cover photograph courtesy of photographer, John Nelson: Ponga Tree - tree fern. Ferns are an unofficial symbol of New Zealand’s national identity. Their dominance in native bush, and their importance as food and medicine, led to their common use as design elements in traditional Ma-ori carving. The ponga has been commemorated in the Christmas song by Kingi Ihaka (1981) which includes the lines:
... On the twelfth day of Christmas My true love gave to me Twelve piupius swinging Eleven haka lessons Ten juicy fish heads Nine sacks of pipis Eight plants of puha Seven eels a swimming Six pois a twirling Five - big - fat - pigs ! Four huhu grubs Three flax kits Two kumera And a pukeko in a ponga tree!
Volume 55 No 2 New Zealand Journal of Occupational Therapy New Zealand Journal of Occupational Therapy Advertising enquiries is an official publication of the New Zealand Association of All matters relating to advertisement bookings should be Occupational Therapists Inc. You may visit our web site at addressed to: www.nzaot.com Pam Chin Aims and scope Tasman Image Ltd The New Zealand Journal of Occupational Therapy is dedicated to PO Box 51014 the publication of high quality national and international articles Tawa that are grounded in practice. We invite practitioners, researchers, Wellington 5249 teachers, students and users of services to submit manuscripts Phone: +64 4 232 3128 that provide a forum to discuss or debate issues relevant to Fax: +64 4 232 3129 occupational therapy. These will be reviewed promptly by the Email: [email protected] Editorial Review Board, and, if accepted, will be published in a timely manner. Disclaimer The Association or the Editor cannot be held responsible for Editorial correspondence errors or any consequences arising from the use of information Papers and other material for publication should be sent to the published in this Journal. Opinions expressed in articles and letters do not necessarily represent those of the Association or of Editor: Grace O’Sullivan the Editor. Publication of advertisements does not constitute any New Zealand Journal of Occupational Therapy endorsement by the Association or the Editor. PO Box 12506 Thorndon Editorial committee Wellington 6144 New Zealand Editor Phone: +64 9 410 9541 Grace O’Sullivan Private Practice, Auckland Email: [email protected] Assistant editors For details related to the submission of manuscripts please re- Nancy Wright fer to the Guidelines for Authors, available in this publication or Rowena Scaletti Child & Family Counselling Ltd from the Association web site. Retired, Auckland Abstracting and indexing Editorial review board The Journal is now indexed in the CINAHL, the OT SEARCH Ann Christie Community Child, Adolescent, and database and the OTDBASE. Family Service, Auckland Subscription enquiries Gretchen Thomas Counties Manukau DHB, Auckland The Journal is published twice a year and the prices for 2008 are Lyn Dancer Community Health Services, as follows: (nee Leadley) Retired, Al Khobar, Saudi Arabia ■ For NZAOT members - NZ$40 in New Zealand, NZ$47 in Mary Butler Otago Polytechnic, Dunedin Australia and the Pacific, and NZ$52 for the rest of the world. Merrolee Penman Otago Polytechnic, Dunedin n For non NZAOT members and institutions - NZ$70 in New Zealand, NZ$80 in Australia and the Pacific, and NZ$88 for Robert Bull Funding & Planning, Hawkes Bay DHB the rest of the world. Trisha Egan Private Practice, Christchurch & Dunedin Subscription enquiries should be directed to: Executive Director New Zealand Association of Occupational Therapy PO Box 12506 Thorndon Wellington 6144 New Zealand Phone: +64 473 6510 Fax: +64 473 6513 Email: [email protected]
New Zealand Journal of Occupational Therapy Volume 55 No 2 EDITORIAL
Editorial
elcome to the September 2008 issue of The New Zealand Haslam’s review of literature pertaining to the occupations of WJournal of Occupational Therapy. Many topics relevant people aged 85 plus, found links to theories of aging. Wilson and to the advancement of occupational therapy have been covered Cheetham’s article looked at the history of occupational therapy in NZJOT in recent editions, including Occupational Therapy’s in New Zealand. This review of literature revealed how the tools place and purpose in aging New Zealand, Embracing diversity: of occupational therapy practice outlined by Anne Mosey, over 25 Explaining the cultural dimensions of our occupational therapeutic years ago, are basically the same even though practice has grown selves, and Autonomy, accountability, and professional practice: and diversified in that time. On a different track, Anna Burggraaf Contemporary issues and challenges, to name a few. However, and Helen Burke-Taylor write about a student’s experience of perhaps the greatest stride forward has been the increase in the helping to develop occupational therapy services within existing number of research articles ‘grounded in practice’ that have been institutional and community based rehabilitation models while submitted for publication. on student placement in the Solomon Islands. Enjoy!
Developing evidence which underscores the role of occupation Acknowledgement to health and well-being, and thereby the profession’s place in the In this the second, and final, edition of the Journal for the year provision of health services, has helped to promote our unique I would like to acknowledge and thank colleagues who have knowledge while at the same time focusing on advances in clinical given their time, and made the effort to review one or more practice. The importance of providing evidence which enhances manuscripts submitted for publication to the New Zealand taken-for-granted knowledge cannot be overstated. Ultimately it Journal of Occupational Therapy during 2007-8. In many may be used to improve quality of life for the many people we instances, these are people I have never met so I want them to strive to serve. Keeping readers informed and up to date with know that I appreciate their support, especially since the number new knowledge is the purpose of the Journal. If you have made a of articles being submitted for review has increased. difference in your practice, via innovative practice, or if you have a story to tell, please share your knowledge and let others know. Once again I thank Clare Hocking who is always willing to share her knowledge and experience as an editor. Next, to Ann Paddy, This issue of the Journal is supported by an interesting selection Beth Gordon, Clare Miller, Dale Rook, Daniel Sutton, Diane of articles. The topics look back, forward, and broad side, at the Henare, Gale Cull, Gretchen Thomas, Heleen Blijlevens, Helen diversity of occupational therapy in New Zealand. Glenda Schnell Byrne, Jean Dominy, Jo-Anne Gilsenan, Kaye Buchanan, Mary leads the way with a retrospective analysis of data. This research Butler, Mathijs Lucassen, Nancy Wright, Rowena Scaletti, Sarah article looked at the effectiveness of occupational therapy services Haskell, Tamzin Brott, and Valerie Wright-St Clair – many thanks, for young people in an inpatient mental health setting. Similarly, without your support... Luciana Blaga and Linda Robertson’s research explored the challenges faced by occupational therapists working in acute care Grace O’Sullivan settings. Other articles focus on literature. For instance, Laura Editor
Volume 55 No 2 New Zealand Journal of Occupational Therapy RESEARCH ARTICLE Glenda Schnell
Monitoring the progress of young people’s occupational performance in an inpatient mental health setting Glenda Schnell
Abstract Objective: This retrospective analysis of existing data was undertaken to determine the extent to which young people in an inpatient mental health setting improve in the area of occupational and social functioning. Method: Components of occupational performance were observed, and tracked over time. The revised version of the Occupational Therapy Task Observation Scale (OTTOS) was used to gather data during group work within the unit. The data was analysed retrospectively. Results: A strong positive linear relationship with recovery was indicated, although individual variance was evident. Clusters of OTTOS subscores were also analysed, and results indicated the rate of change in cognition was quicker than conation (motivation), affect or behaviour. Conclusion: The use of the OTTOS provided a means to effective communication and useful clinical application within the team. Further prospective research is recommended. Key words Retrospective analysis; adolescent; inpatient mental health; occupational performance. Reference Schnell, G. (2008). Monitoring the progress of young people’s occupational performance in an inpatient mental health setting. New Zealand Journal of Occupational Therapy, 55(2), 4-10.
hen adolescents face serious mental health issues, their families who experience serious mental health disorders which Wperformance of daily activities can be disrupted. Similarly, result in disrupted occupational performance. Young people who when these issues are evident for extended periods of time they use the service, usually stay in the unit between one week and nine may impact on normal development (Henry & Coster, 1996). months (see Table 1). They have a range of psychiatric disorders, It has been reported that up to 36.6% of young people in New including mood and anxiety disorders, psychotic disorders and Zealand aged between 11 and 18 years (see Fig. 1) have mental eating disorders (see Table 2). The unit serves to assess and treat health disorders (Fergusson, Horwood & Lynsky, 1997; Ministry these complex conditions. of Health 1998). The Child and Family Unit (CFU), is a regional Changes in young people’s performance or presentation over inpatient facility, set up to support children, adolescents, and time had not previously been captured within the unit. There were no outcome measures being used and valuable information about the success of interventions within the unit was being lost. This information could provide evidence of the mental state generally observed by members of the clinical team or symptoms reported by the adolescents (Margolis, Harrison, Robinson & Jayram, 1996; Schnell, 2004).
Glenda Schnell (NZROT) MHSc PGDipHSc B.OT Professional leader - Occupational Therapy Mental Health Services Middlemore Hospital, CMDHB [email protected]
New Zealand Journal of Occupational Therapy Volume 55 No 2 Monitoring the progress of young people’s occupational performance RESEARCH ARTICLE
Table 1: Demographic data and length of stay over a two year psychiatrists and a kaiatawhai (Maori cultural worker), are period: involved in setting goals towards wellness and recovery with the young people and their families. Occupational therapists play a n % leading role towards improving function and re-entry into the Gender community. It is their job to address young people’s occupational Female 125 48.4 performance issues using group work as a therapeutic medium. Male 133 51.6 The aim of intervention is not only to return adolescents to their Total inpatients 258 100 pre-morbid level of ability, but also to help them to proceed with Ethnicity age appropriate developmental tasks (Zaff, Calkins, Bridges & Maori 69 26.8 Margie, 2002). Group work interventions are an interdisciplinary NZ European 162 62.7 initiative in the unit and all disciplines are involved to some Pacific Island 14 5.4 degree. The groups are combined with the school programme Asian 10 4.0 and given the name ‘The Unit Programme’. Middle Eastern 2 0.7 African 1 0.4 The unit programme Length of Stay Group programmes are fundamental to the unit’s inpatient 1 week 71 27.5 services as they provide an opportunity for learning, engaging 2 weeks 30 11.6 with others, and development of occupational performance skills 3 weeks 39 15.1 to support graded re-entry into the community. Group activities 4 weeks 28 10.5 also offer a release from ward monotony (Parahoo, McGurn & >4 weeks 89 34.4 McDonnell, 1995). Types of group work made available to people 7 weeks 11 4.3 in the unit include recreational, physical, and craft orientated 8 weeks 11 4.3 groups. In addition, discussion groups centre on coping strategies, goal setting and life skills as well as those which facilitate self- awareness and self-reflection. Some groups are specifically To ascertain what trends occur for young people in their recovery designed to role play normal social behaviour in the community. and return to daily life, a retrospective analysis of existing data was undertaken for the purpose of practice evaluation. It was These group sessions are used as stepping stones to recovery, hypothesised by occupational therapists in the unit that young in that they inherently offer choice, opportunity and hope. This people would slowly recover over time, and that a pattern of in turn gives adolescents opportunities for self-determination improvements and setbacks would be evident. This hypothesis is (Deegan, 2001; Howe & Schwartzberg, 2001). Group programmes at the root of two questions: are an important method of occupational therapy assessment in inpatient settings and while success cannot be claimed by any 1. To what extent do young people in an inpatient mental health one intervention, the unit programme is designed to monitor setting improve in the area of occupational performance? change. 2. Does a pattern emerge over time? When young people are admitted to the service, only limited An interdisciplinary team, which included three occupational information provided by referring agencies is available on their therapists, psychologists, registered nurses, social workers, occupational and social functioning. Consequently, group work is a useful means of gathering additional information through Table 2: Primary diagnosis over a two year period: observation (Schnell, 2004), because it can provide an excellent source of critical information about an individual’s occupational n % ability (Reed & Sanderson, 1992). For this reason, groups are semi- Schizophrenia 48 18.5 structured and structured within varied situations, environments, Psychosis NOS 42 16.2 demands and experiences. Bipolar 35 13.6 Depression/ dysthymia 35 13.6 Ethics Adjustment disorder 26 10.1 Ethical approval was granted by the Northern X Regional Ethics Borderline PD traits 19 7.4 Committee for a retrospective analysis of data to be undertaken Anxiety disorder 14 5.3 as a component of a Master’s degree programme. Because a Schizoaffective 12 4.4 non-identifiable set of numerical data was being used, there was Conduct disorder 10 3.7 a proviso that raw data be destroyed on completion. Since the Anorexia 7 2.6 data was not originally intended for use in a research project, Dissociative disorder 4 1.6 no demographic or identifying information was included. This PTSD 3 1.5 meant consent could not be sought from participants because the OCD 3 1.5 data was collected over a two year period and the young people Total Inpatients 258 10 whose information was being reviewed had been discharged from the unit.
Volume 55 No 2 New Zealand Journal of Occupational Therapy RESEARCH ARTICLE Glenda Schnell
Literature review can make a difference. Although the literature included recovery and resilience, it did not address the challenges related to young To access more current information on the occupational people with severe mental illness. performance of young people receiving inpatient mental health services, a literature review of relevant databases was undertaken. Evans (2002) suggested that a clinical evaluation of young people’s These included Medline, CINAHL, PsychINFO, and PROQUEST. occupational performance would enable health professionals to Key words used in the search were: occupational performance, monitor care delivery, take action when deficits are identified, and group work, audit, evaluation, monitoring, inpatient mental that this would ultimately serve to ascertain outcomes. To this health, occupational therapy and young people. Functional end, many occupational therapists use the Health of the Nation deficits were found to be a significant feature of the diagnostic Outcomes Scale for Children and Adolescents (HoNOSCA) criteria (DSM IV, 1994) yet there was limited information (Gowers, 1999), a population outcome indicator which considers with respect to adolescents and how they recover in the area of a broad range of aspects from social and occupational factors. occupational performance. Information pertaining to young As a clinical tool the HoNOSCA is useful in determining long people’s occupational performance seemed to be concentrated on term outcomes in the community but because it is a population the relationship to specific disorders (Henry & Coster, 1996). There measure it is not sensitive enough for inpatient services. It has were a number of correlations drawn between the elements of a role in national outcome measurement with specific relevance psychiatric disability and occupational performance components. to this age group and although it has been used extensively For instance, cognition, occupational and social performance within New Zealand Child and Adolescent Services, the data is (Reeder, Newton, Frangou & Wykes, 2004), and chronic mental yet to be analysed. According to Tse, Lloyd, Penman, King and illness in adulthood (American Academy of Child and Adolescent Bassett (2004), data collected while working towards prevention Psychiatry Official Action., 1997; Clark & Lewis, 1998; Haglund, and promotion of mental health could be reproduced and used Thorell, & Walinder, 1998; Mairs & Bradshaw, 2004; Schretlen, towards improved evidence based learning and practice. This Jayaram, Maki, Park & Abebe, 2000). Adult literature has found concept is consistent with the goal of this retrospective analysis that people displaying affective symptoms are shown to display of existing data which was undertaken to bridge the knowledge better occupational and social functioning than those who do not gap related to the recovery of young people with mental health whereas those with first episode psychosis have a better outcome problems. than those who have experienced increased relapses (Haglund, Thorell & Walinder, 1998). Early onset is correlated with poorer Methods functional outcomes over time (Clark & Lewis, 1998). Those The methods used to collate the required information will now with a positive symptoms such as hallucinations are often seen as be outlined. having better functional outcomes than those displaying negative symptoms such as lack of motivation (American Academy of Description of data base Child and Adolescent Psychiatry Official Action, 1997). Mairs and The original Occupational Therapy Task Observation Scale Bradshaw, (2004) noted that some individuals with schizophrenia (OTTOS) is a 15 item rating scale incorporating occupational have developmental delays pre-onset which may explain added performance components. The measure is based on the Model functional deficits observed in practise. of Human Occupation (Keilhofner, 1995) and was designed to audit improvements in adults with significant performance Cognitive functioning has a direct relationship to functional issues. The scale was shown to be sensitive to changes in competence however, the functional consequences of cognitive functional performance during task groups. According to Jones, impairment among various disorders remains poorly understood Jayaram, Samuels and Robinson (1998) OTTOS has good inter- (Schretlen, Jayaram, & Maki, et al., 2000). Schretlen, Jayaram, and rater reliability and the validity has been tested against three Maki, et al. suggested that attention difficulties, verbal learning established rating instruments (Margolis, Hamson, Robinson & and memory skills might be particularly relevant to everyday Jayram, 1996); functioning, as cognitive functioning is more closely aligned to occupational functioning than any other identifying factor such 1. The Bay Area Functional Performance Evaluation as age, diagnosis, sex, race, education or psychotic symptoms. (Mann, Klyczek, & Fiedler, 1989). The literature pertaining to adolescent mental health strongly 2. The Comprehensive Occupational Therapy Evaluation emphasises health promotion and recovery philosophies Scale (Brayman, Kirby, Misenheimer, & Short, 1976). related to positive experience in school. For example, positive 3. The Milwaukee Evaluation of Daily Living Skills relationships with teachers were associated with better mental (Leonardelli, 1988). health and higher motivation (Ministry of Youth Affairs, 2002). Similarly, personal characteristics such as verbal communication OTTOS was trialled in its basic form for a two month period, skills, a cool, calm and collected temperament, problem-solving before being modified to ‘fit’ the population under investigation capacities, humour, empathy, and the ability to be circumspect at the time. Permission to further revise the OTTOS was given were said to be critical elements towards resiliency (Resnick, by the original OTTOS designers who were consulted before 2000). The Ministry of Youth Affairs suggested adolescence ‘just the six new criteria were added. Although useful in task groups, happens’ but it is how the resulting challenges are dealt with that the original OTTOS did not capture the degree of information
New Zealand Journal of Occupational Therapy Volume 55 No 2 Monitoring the progress of young people’s occupational performance RESEARCH ARTICLE required for analysis. Nor did it address the goals of the n Outside factors that may affect performance e.g. stressful population being studied. Therefore a process of revision was family meetings, or plans for discharge undertaken and additional themes, comments, and/or goals n Alternate interventions being used at the same time e.g. were incorporated. Although the psychometric properties were psychology, family therapy, medications. changed, the added criteria had no impact on the original items, and the new criterion, which were closely monitored, were found These variables were managed by: to be clinically useful. Data gathered using the revised version of n Using issues brought into the groups for learning. the OTTOS was analysed for this study. n Moderating all data collected by other facilitators involved with the young people. Appraising the data Only adolescents who had scores recorded over three weeks were n Excluding alternative interventions other than groups from included from all possible sources. Length of stay was not directly the study. relevant to inclusion in the data collection as many young people were initially too unwell to engage in any activity at all. The goal Assumptions was to include as many as possible and allow patterns to evolve. A number of assumptions precluded this study. These need to be Data had been collected for all the young people who engaged exposed for the purpose of statistical analysis. in group work at the CFU over a two year period (January 2003 n Admission occurred at a time when participants were unable - December 2004). Of those, 78 from a total number of 158 were to cope with their mental health issues. deemed suitable. Adolescents who engaged for a minimum of seven and eight weeks were further reviewed. For the purpose n Individual young people experience recovery progress at of this study additional information such as mood, insight, different rates, and this is reflected in varied lengths of stay. responsibility, frustration, tolerance and socialisation was sought. n Discharge occurred when young people were in a position The criterion was discussed by those facilitating groups and to manage their mental health issues within a supportive agreed by the interdisciplinary team as appropriate and necessary community. for the analysis. The process of naming and defining the terms and definitions against which to check observable behaviour was n Recovery continues after discharge into the community. also critiqued by the team. The nature and quality of performance was discussed by Table 3: OTTOS scores by duration of involvement in group staff involved in group work to facilitate an outcome whereby programme concerns around levels of concentration and mood variances Duration (weeks) n mean score std dev could be managed. Following the successful trial of the revised 3 7 137 8.5 OTTOS in the unit programme, its use was expanded to include 4 6 128.8 4.4 adolescents from the time they engaged in planned activity 5 8 133 6.2 groups. This allowed occupational performance to be monitored 6 10 134.7 6.8 from admission to discharge. The structure and process used in 7 11 138.8 5.7 execution of the measure during group work was unchanged. 8 11 150.4 9.6 9 5 154.0 8.0 Each group had 11 participants. Group facilitators and school 10 6 121.9 20.6 teachers met weekly to discuss the scores of each young person. 11 2 138.4 21.0 Direct observable behaviour was managed within a numerical, 12 5 128.9 5.9 statistical framework. This process enabled discussion regarding 13 3 114.7 6.6 needs and intervention, as well as moderation of scores. The 15 3 141.8 10.7 occupational therapists scoring young people on OTTOS were 18 1 86.6 32.9 of the opinion that the percentage scores had face value because 28 1 108.8 17.4 they represented therapists’ independent views on percentages of normal functioning. The scores and salient observations were discussed with the interdisciplinary team. Progress scores Statistical analysis were filed in individual progress notes together with written Since young people admitted to the unit are involved in group interpretive information. When clinical relevance was no longer work for varied lengths of time, each week’s entry of score was needed, the information was destroyed. viewed as a proportion of the total time within CFU, to investigate the pattern of change from first to last period of involvement (See Variables Table 3). Weeks 7 and 8 are bolded as they correspond to figures 2 Extraneous or confounding variables relate to aspects which may and 3 under the results section. affect the results, by causing alternative outcomes. Variables in To further investigate the pattern of change in score over time this analysis were identified as: within the CFU, the cubic, quadratic and linear effects were n Interpersonal issues occurring in the unit being brought into tested. The SAS MIXED procedure software (SAS Institute the group situation
Volume 55 No 2 New Zealand Journal of Occupational Therapy RESEARCH ARTICLE Glenda Schnell
Inc.) was used to calculate the ‘linear mixed model’. In order to Fig. 2 represents all subjects participating in the programme for maximize the data, subgroups were established to ascertain which 7 weeks. components showed most improvement and whether any pattern Within Figure 3, the representative data for all those admitted for existed within these subgroups. These contained like variables, to 8 weeks, the pattern concurs with a linear relationship between be used for further analysis. the admission and discharge points, with minimal occupational Results performance increase over time. The graphic representation of the data shows some similar internal patterning for each person, The results showed the extent to which young people in although there were distinct differences in how individual an inpatient mental health setting improved in the area of recovery was made. occupational performance and the subgroup of components of performance. No pattern, other than a linear recovery, emerged. Table 4: Subscore trends from admission to discharge
Composite OTTOS results: OTTOS subscore Represented Rate of change: There was a strong indication of a linear relationship (p<.0001) variables: n = 78 Admission to with an estimated average of 27.9 increased score out of 100, discharge (~ score over time. On the contrary, there was no evidence of a cubic increase) relationship of total score change in group involvement (p = 0.62), Cognitive Attention, nor of a quadratic fit (p = 0.13). This indicates that the progress concentration, insight, and setbacks observed in young people do not follow a distinct judgment, planning, 5.4 pattern. Nonetheless, for the purposes of demonstration the processing and variation of individual recovery over time was further examined. problem solving Conative Engagement, Graphic representation 4.4 initiative, activity level Representative data for individual patterns of OTTOS scores were analysed further, to clearly identify the nature of individual Affective Frustration tolerance, 4.4 recovery patterns within the sample. Individual composite expression, mood OTTOS scores are portrayed for those participating over 7 and 8 Behaviour Independence, weeks (Fig. ii & iii) respectively and as bolded in Table iii. These co-operation, 3.7 weeks were chosen for the high numbers involved. The data in responsibility
Subscore changes over time: Subscores presented in Table 4 were chosen to represent the varied types of components. These subscores were further analysed to investigate whether any pattern existed within certain aspects of recovery. To investigate whether there was a difference in how the subscores changed following admission, a linear mixed model using the SAS MIXED procedure software (SAS Institute Inc.) was used to fit a random coefficients model for the individual change over time. As a repeated measure, a subscore ascertained which components showed most improvement and what, if any, pattern existed within the subgroups. There was strong evidence of difference in the rate of change in the subscores (p<.0001) with a significant linear increase over the time spent in the CFU. Cognitive factors which include attention, concentration, insight, judgment, planning, processing and problem solving increased at a greater rate (see Table 4) than the other 3 subscores, conative, affective and behavioural. Behaviour recorded the least improvement. Indeed the analysis results indicated that OTTOS scores increase as adolescents improve in their occupational and social functioning during the time spent in the unit. There was little evidence of any pattern other than linear. Conversely, a number of patterns revealing individual variation in how people improve were evident.
New Zealand Journal of Occupational Therapy Volume 55 No 2 Monitoring the progress of young people’s occupational performance RESEARCH ARTICLE
Previous studies point to a strong correlation between cognitive Limitations functioning and social and occupational performance, with A three week cut off for inclusion into the analysis may not have cognitive ability used to guide and influence improvement in been the most appropriate time frame since the three week pattern other components (Reeder, Newton, Frangou & Wykes, 2004; produced a straight line. Although this only applies to the data for Schretlen, Jayaram, Maki, Park & Abebe, 2000). Given the seven participants, it is not known how many weeks would be often severe cognitive symptoms and the high prevalence of required for an alternative pattern to be produced. Similarly, the psychotic disorders within the CFU population, the results could availability of clinical information such as changes in medication, reflect the extent to which these symptoms were manifested movement between wards or physical illness may have provided a and resolved. Affective components which include frustration, rationale for observed changes, adding to further knowledge. tolerance, expression and mood were found to improve equally Henry and Coster (1996) have stated that prospective studies are over time along with conative components such as, engagement, superior to retrospective studies because base line information initiative and activity levels. These components are most often is collected systematically during hospitalisation. This viewpoint affected by each other. On the contrary and as previously stated, was found to have merit as in this case data analysis was limited behavioural aspects which include independence, co-operation, because non-identifiable data was used. Prospective demographic and responsibility were the last to change. information such as age, ethnicity and diagnosis may have enabled Discussion a more in-depth analysis of a variety of variables. Similarly, the hypothesised variability of patterns may have been revealed. This analysis endorses the belief that cognitive functioning has a direct relationship to functional competence (Schretlen, The revised OTTOS was limited to use at the CFU, therefore Jayaram, & Maki, et al., 2000). In addition, cognitive abilities scores of function following discharge are unavailable. Although were found to return first with improvement in affect, behaviour measured in a variety of situations including the community, it is and occupational performance following. Alternatively, there was acknowledged that the context is contrived under the auspices of no evidence to support findings which indicated that cognitive the unit programme. functioning is more closely aligned to occupational functioning than other identifying factors such as age, diagnosis, sex, race, Recommendations education or the presence of psychotic symptoms (Schretlen, It may be useful to report a study in which OTTOS (a sensitive Jayaram, & Maki, et al.). measure for an inpatient setting) is followed by the HoNOSCA (a population measure, more conducive to community settings). From a clinical perspective, the revised OTTOS was extremely In this way ongoing progress would be monitored. Likewise, useful as it provided baseline information on specific performance having identified that components of cognition re-emerge before components. That information was then passed on when the affect or behavioural components further prospective research is young person was deemed to be ready for discharge from the unit recommended to determine the steps to young people’s recovery with a view to ongoing recovery in the community. The progress from acute mental illness. made in the clinical setting informed clinical decisions about the young person’s readiness for discharge. Equally, it highlighted the Conclusion need for further intervention by the team. Margolis, Harrison, Using the revised OTTOS to monitor occupational performance Robinson and Jayram (1996), suggested that the revised OTTOS over time between admission to, and discharge from a CFU improved communication between clinicians. Anecdotally, this had useful clinical applications, in that individual progress was was found to be correct within the CFU, as all clinicians were able highlighted. Group interventions used by occupational therapists to understand the young person’s level of ability as indicated by to monitor the occupational and social performance skills and the grading system. abilities of young people in an inpatient mental health service are successful in achieving the goals of the unit. Components of Strengths occupational performance tracked over time using the revised A particular strength of this analysis pertains to the systematic OTTOS helped to determine how young people with mental care taken to record OTTOS scores with observations noted and illness recover and what, if any, patterns emerge in the process. applied in a consistent fashion. Additional measures taken to The findings revealed that although young people improved their ensure validity of the analysis included having the data entries occupational performance from admission to discharge, only reviewed by at least one other occupational therapist with a linear pattern was statistically significant within the analysed knowledge and understanding of adolescent mental health and data. normal adolescent functioning. The therapist was also familiar with the unit programme and was therefore able to challenge Key messages unsubstantiated or inaccurate interpretation of behaviours. n Communication within a multidisciplinary team can be Scores were modified as required. In keeping with the practice enhanced by using a clinical tool such as OTTOS to monitor advocated by Prouteau, Verdoux, Brians, and Lesage, et al., (2004) change. during groupwork the young people were asked to account for any unusual aspects of their performance within the group. n Improvements in cognition may be followed by conative and affective components throughout admission.
Volume 55 No 2 New Zealand Journal of Occupational Therapy RESEARCH ARTICLE Glenda Schnell n Behaviour showed the lowest rate of change. Mairs, H., Bradshaw, T. (2004). Life skills training in schizophrenia. British n Literature on the occupational performance of adolescent’s Journal of Occupational Therapy, 67(5), 217-224. within a mental health setting is scarce. Mann, W. C., Klyczek, J. P., Fiedler, R. C. (1989). Bay Area Functional Evaluation (BaFPE): Standard Scores. Occupational Therapy in Mental References Health, 9(3), 1-7. American Academy of Child and Adolescent Psychiatry Official Action. Margolis, R., Hamson, S., Robinson, H., & Jayram, G. (1996). Occupational (1997). Practice parameters for the assessment and treatment of child therapy task observation scale (OTTOS): A rapid rating task group and adolescents with schizophrenia. Journal of the American Academy function of psychiatric patients. The American Journal of Occupational Child, Adolescent Psychiatry, 36(10), 117S-193S. Therapy, 50(5), 380-385. Alsop, A. (1997). Evidence-based practice and continuing professional Ministry of Health. (1998). New futures: A strategic framework for specialist development. British Journal of Occupational Therapy, 60(11), 503- mental health services for children and young people in New Zealand. 508. Wellington: Author. Brayman, S. J., Kirby, T. F., Misenheimer, A. M., Short, M. J. (1976). Ministry of Youth Affairs. (2002). Youth development strategy Aoteroa. Comprehensive occupational therapy evaluation scale. The American Wellington: Author. Journal of Occupational Therapy, 30(2), 94-100. Parahoo, K., McGurn, A., & McDonnell, R. (1995). Using research to Clark, A. F., & Lewis, S. W. (1998). Practitioner review: Treatment of implement change: The introduction of group activities on a psychiatric schizophrenia in childhood and adolescence. Journal of Child Psychiatry, unit. Journal of Nursing, 4(3), 195-202. 39(8), 1071-1081. Prouteau, A., Verdoux, H., Brians, C., Lesage, A., Lalonde, P., Nicole, L., Deegan, P. (2001). Recovery as a self-directed process of healing and Reinharz, D., & Stip, E. (2004). Self-assessed cognitive dysfunction and transformation. Occupational Therapy in Mental Health, 17(3-4), 5-21. objective performance in outputs with schizophrenia participating in a rehabilitation programme. Schizophrenia Research, 69, 85-91. Evans, B. (2002). Auditing clinical practice. Primary Health Care, 12(6), 32- 33. Reed, K., & Sanderson, S. (1992). Concepts of occupational therapy. Baltimore: Williams & Williams. Fergusson, D., Horwood, J., & Lynsky, M. (1997). Child and adolescence: In P. M. Ellis & S. C. D. Collins (Eds.). Public Health Report no. 3: Mental Reeder, C., Newton, E., Frangou, S., & Wykes, T. (2004). Which executive health in New Zealand from a public health perspective. 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10 New Zealand Journal of Occupational Therapy Volume 55 No 2 The nature of occupational therapy practice in acute physical care settings RESEARCH
The nature of occupational therapy practice
in acute physical care settings
Luciana Blaga & Linda Robertson
Abstract Acute care practice in New Zealand is delivered in environments where there are many challenges to occupational therapy practice. In order to identify ways in which therapists make sense of this area of practice we developed and distributed a questionnaire containing closed and open questions. The findings suggest that occupational therapists have positive views of their work and are able to clearly articulate their practice. Relating views of practice to theoretical models lacks clarity with therapists using broad professional frameworks and/or the notion of holism to provide a conceptual lens. Key words Acute physical care; occupational therapy; holism. Reference Blaga, L., & Robertson, L. (2008). The nature of occupational therapy practice in acute physical care settings. New Zealand Journal of Occupational Therapy, 55(2), 11-18.
he acute care service is delivered in an environment where either of these studies, we developed a questionnaire that targeted Tthere are a range of challenges for occupational therapists all occupational therapists working in acute care practice in New (Griffin, 1993) particularly the dominance of the medical model. Zealand (Blaga, 2006). Its focus on curing illness does not sit easily with the professional focus of occupational therapy (Wilding & Whiteford, 2007). A Literature review second issue arises from discharging patients following a very A literature search of the Cumulated Index of Nursing and Allied short hospital stay because it creates pressures for fast decision Health (CINAHL), ProQuest databases and occupational therapy making (Moats, 2006). More recently, negative opinions of the textbooks was undertaken, using the key words: acute physical acute care service from within the profession itself (Whiteford, occupational therapy, and professional identity. A major feature of 2006) have provided further stimulus for occupational therapists the acute setting identified in the literature is the pressure on fast to provide greater clarity of their role and to confidently rationalise discharge driven by economic constraints (Griffin & McConnell, their contribution to patient care. To understand how best to 2001; Robertson & Finlay, 2007; Sutton, 1998). This particular justify this area of work, the authors felt it was important to learn pressure has an impact on the way health practitioners work. from those who work in this area about how they perceive their Griffin (1993) suggested that as a result of this, the occupational contribution to patients’ care. Therefore the aim of this study therapist’s role is limited to assessing and planning for discharge, was to ask the question: how is occupational therapy practiced with little emphasis on treatment. in acute physical care settings in New Zealand? The study also Further studies reinforced this point of view. For instance, Griffin sought to identify the ways in which therapists made sense of their and McConnell (2001) used a self-administered questionnaire practice, including their use of professional frameworks. What with a sample of 226 therapists who worked in acute care in theoretical justification can be used as a basis for occupational Australia (response rate 64.7 %). They discovered that the most therapy practice in acute care services? There is limited research on occupational therapy in the acute care settings and even less that is specific to the New Zealand Luciana Blaga (B.OT, Hons) environment. Only two studies were found to have been carried Dunedin Hospital - Otago DHB out and published about New Zealand occupational therapy Email: [email protected] in an acute physical context: one was a pilot study which Linda Robertson investigated the nature of acute physical occupational therapy Otago Polytechnic practice using a questionnaire (Craig, Robertson & Milligan, School of Occupational Therapy 2004) and the other one used a focus group method to look at Forth St., Private Bag 1910 Dunedin job satisfaction of therapists working in the same setting (Shiri, Email: [email protected] 2006). To gain information from a broader perspective than
Volume 55 No 2 New Zealand Journal of Occupational Therapy 11 RESEARCH Luciana Blaga, Linda Robertson
the studies regarding the nature of the practice in acute physical frequently used assessments were initial interview and self- care little detail is given about the professional frameworks that care and that intervention focused on safe discharge. A further guide practice. In Craig et al. (2004) the participants reported Australian study using the Delphi technique (Griffin, 2002) using mainly the compensatory and biomechanical approaches, looked at occupational therapy practice specifically in acute care but other models were also identified. These were the Model orthopaedics and neurology. Again the consensus was that the of Human Occupation (MOHO), neurodevelopmental, primary aim of occupational therapy intervention in this setting cognitive behavioural and the Canadian Model of Occupational was preparation for discharge and when discharge was not likely, Performance (CMOP). Griffin (2002) indicated that therapists referral for further rehabilitation. working in acute orthopaedic and neurological practice did Only one study was done in New Zealand (Craig et al., 2004) not use specific occupational therapy models, but more general describing the nature of occupational therapy practice in acute models related to intervention such as the rehabilitative or the care. It employed a self-administered questionnaire with open remedial approaches. She noted that there was a trade off between and closed questions that was sent to therapists in three District using the terminology of the more generic models (such as the Health Boards (DHB). The authors made the point that there biomechanical) which could be readily understood by other was confusion among respondents over the difference between health professionals and the need to have occupational therapy assessment and treatment because they are closely intertwined. It practice models to provide specific guidance. The literature search is interesting to note the similarities identified in the Australian reinforced the need to explore a New Zealand perspective of how and New Zealand studies: the most common assessment tool used occupational therapy is practiced in acute physical care settings. by practitioners was the initial interview and the most common We sought our answer through an exploration of specific issues interventions were individual education and issuing of aids/ such as type of assessment and interventions, nature of discharge equipment (Craig et al., 2004; Griffin and McConnell, 2001). planning, theoretical and personal paradigms that underpin practice as well as occupational therapists perceptions of their The above studies focused on the therapists’ reported contribution contribution. to the acute care service and did not target the relationship between therapists and clients. In physical rehabilitation practice Methodology occupational therapy aims to promote self-efficacy and self-esteem, The methodology chosen for this research was descriptive through a holistic approach (Trombly, 2002). The intervention mixed quantitative and qualitative (DePoy & Gitlin, 1998). A is directed to performance in all aspects of daily life, through a cross-sectional survey was used (Forsyth & Kviz, 2006), and a collaborative process between the therapist and the client, based mailed self-administered questionnaire was developed based on respect for client’s choices, beliefs and values (Christiansen & on the literature review and themes found in previous studies. Baum, 1997). These sentiments about the profession are echoed It included both closed and open-ended questions. Face validity by therapists describing their practice in acute care (Wilding & was checked by a panel (Litwin, 1995) comprised of individuals Whiteford, 2007). However, in acute hospital settings according with expertise in occupational therapy and questionnaire design. to Hanschu and McFadden (1981, cited in Griffin, 1993), After consultation with the panel small changes in wording and “the primary orientation is to relieve pathology, which may questions were implemented. The questionnaire was then piloted preclude the occupational therapy perspective of occupational (Creswell, 2003; Forsyth & Kviz, 2006) by seven occupational performance” (p. 2). This is consistent with Feinberg (1988) who therapists working in the acute care service at a metropolitan argued that “the approach of the occupational therapist in this hospital. Based on their feedback some minor changes in wording setting differs from that elsewhere because of the nature of the were made. medical problems seen in the acute stages of disease” (p. 419). This medical orientation to treatment combined with economical Participant recruitment constraints pushing for fast discharge has resulted in the The participants were occupational therapists working in rehabilitation approach no longer being appropriate or possible acute physical care, inpatient wards (i.e. orthopaedic, medical, in acute care settings (Griffin, 1993; Shiri, 2006). As reported neurological, paediatric) in New Zealand. The term ‘acute’ was in these studies, this reality leaves some practitioners feeling used here to mean short-term stay as opposed to rehabilitation or unhappy about their contribution to the patients’ care. Two community services. As some participants had a mixed case load published studies emphasised the importance of occupational (i.e. acute care and community) they were asked to refer only to therapy input in decreasing the length of hospitalisation and their inpatient case load when answering the questions. ensuring safe discharge (Griffin, 1993; Sutton, 1998). However, The participants could not be randomly selected due to a how therapists perceived their role and whether or not they lack of current data about therapists in acute care. Therefore thought they were doing a worthwhile job was not identified. the Managers’ Special Interest Group of the New Zealand One method of gaining role clarity is through the use of Association of Occupational Therapists was approached to assist conceptual models. Kielhofner, (1997) explains that a conceptual in the location of occupational therapists that met the criteria. practice model “presents and organizes a number of theoretical The coordinator of this group identified a contact person in concepts used by the therapists in their work” (p. 22) and provides each of 20 DHBs. The DHB used for the pilot survey was not a structure and a common language to explain their practice. In used in the main survey. We approached the identified contact
12 New Zealand Journal of Occupational Therapy Volume 55 No 2 The nature of occupational therapy practice in acute physical care settings RESEARCH people by email. Those who agreed to act as a Table 1: Years of experience as an occupational therapist and as an occupational therapist liaison person between the researcher and the working in acute care potential participants were asked to identify the Not < 1 1 - 3 4 – 6 7 – 10 > 10 number of staff working in their department, and stated to distribute the questionnaires. Occupational Years of experience therapists in 18 of the DHBs contacted completed as an 30% 19% 17% 14% 19% 1% the questionnaire. occupational therapist Data collection One hundred and fifty two questionnaires and Years of experience working in acute 39% 27% 16% 13% 6% information sheets were mailed to the liaison care managers for distribution. The decision to complete the questionnaire was made independently by each therapist and once completed the questionnaires headings: the practice and the role of occupational therapy in were returned directly to the researcher in reply pre-paid envelopes acute care. by individual respondents. By completing the questionnaire the 1. Occupational therapy practice participants were consenting to the information being used in Of the 70 participants, 12 (17%) were male and 58 (83%) were the data analysis. To ensure confidentiality participants were female. 30% of practitioners had less than one year of practice in assured that identifying information would not be used in any the profession (see Table 1). Therapists who had more than one publications and the completed questionnaires were only able to year of practice represented 9% of the total group. be accessed by the researchers. Ethical approval was sought and obtained from Otago Polytechnic ethics committee. Areas of clinical work: Out of the 152 questionnaires, 72 were completed and returned, We asked participants to identify all the clinical area(s) that they generating a 47% response rate. However, it should be noted worked in, from the following list: medical (including oncology, that the researcher was not directly involved in the distribution cardio-respiratory, rheumatology, renal), neurology and process, so it was difficult to determine the non-response bias. neurosurgery, orthopaedics, surgical (including amputations) Out of the completed questionnaires, two were excluded as the and paediatrics. Only 27% (19) indicated that they worked in respondents were working in non-acute settings. one area while 73% (51) indicated that they worked in more than one area. Data analysis The questionnaire contained two types of data: quantitative Informal assessments: and qualitative (narrative). The quantitative data was analysed A list of tasks was given to participants to mark how often they numerically in Excel worksheets using descriptive statistics. The narrative data Table 2: Areas that were informally assessed was analysed by grouping the responses for each question and identifying the Always main themes (DePoy & Gitlin, 1998). (with every Frequently Occasionally Rarely Never patient) For the questions which contained both quantitative and qualitative data Home environment 78% 16% 3% 3% 0% a further analysis was made to identify Transfers and functional 69% 28% 1% 0% 1% whether or not the narrative description mobility supported the quantitative response. Self care (including shower, Preliminary statistical information and dressing, 62% 28% 7% 3% 0% themes in narratives emerged from personal hygiene, toilet) this initial data analysis process. The Meal preparation/cooking 35% 31% 24% 9% 1% questionnaires and the first phase of the analysis were checked for accuracy by the Cognitive functioning 31% 41% 19% 6% 3% second author who reviewed 50% of the questionnaires. The emerging findings Leisure 16% 25% 33% 15% 10% were supported and some differences Upper extremity 9% 41% 26% 22% 1% in emphasis were noted and discussed. functioning Minor changes were then made to reflect Employment 6% 18% 24% 32% 20% the agreed differences in findings. Wheelchairs and seating 4% 16% 39% 34% 6% Results The findings are reported using two School work 3% 6% 8% 32% 52%
Volume 55 No 2 New Zealand Journal of Occupational Therapy 13 RESEARCH Luciana Blaga, Linda Robertson informally assessed these in their encounter with the patient. It choice on the fact that observation of alertness, awareness of can be seen in Table 2 that self-care (including shower, dressing), therapists’ arrival, body movements, body position and use of the home environment and transfers/functional abilities are the areas environment provided them with information. Most respondents most frequently assessed. felt that although the assessment is started “when the therapist walks in the door” that Table 3: Frequency of use of Standardised/Formal assessments observation alone is not enough to give the full Always (with every Frequently Occasionally Rarely Never No response picture of the patient: patient) As one respondent said: “While it is very important Cognitive assessments 6% 56% 29% 1% 7% 0% to be observant as one walks Westmead Post Traumatic to the bed and can pick up 0% 18% 35% 7% 34% 6% Amnesia a lot of clues, one cannot Canadian Occupational see everything e.g. transfers, 1% 9% 6% 22% 57% 4% Performance Measure mobility, comprehension”. Functional assessments Barthel ADL Index 0% 9% 22% 4% 60% 4% were considered to Functional Independence 0% 4% 4% 9% 78% 4% involve cognitive problem Measure solving to provide a Assessment of Motor and 0% 1% 3% 6% 85% 4% broader understanding Process Skills of functioning: “First Australian Therapy 0% 0% 0% 1% 94% 4% impressions can be Outcomes Measure deceiving. Cognition Occupational involved in functional Circumstances Assessment 0% 0% 0% 1% 94% 4% tasks may not be seen until Interview and Rating Scale functional assessments are completed”. Participants felt very strongly that Formal assessments: they do not make assumptions about the patients’ ability and We asked participants to indicate how often they used consider functional assessments to be an essential part of a standardised/formal assessments from a list provided (Table complete evaluation. Three participants (4%) did not answer this 3). The most commonly used are the cognitive assessments question. (e.g. Cognistat, Rivermead, Loewenstein Occupational Therapy Cognitive Assessment, Mini Mental State Evaluation); only four Intervention: respondents (5.7%) used them with every patient. However, the Participants were asked to indicate how often they employed overall response was that formal assessments are rarely or never interventions from a pre-determined list. The most used used. Twenty-nine respondents (41.4%) also added other formal interventions were provision and training in use of equipment, assessments to the list with Allen’s cognitive level assessment being most frequently mentioned (9/13%). Table 4: Frequency of interventions employed Always Functional assessment: Intervention (every Frequently Occasionally Rarely Never Not stated Participants were asked to patient) rate their level of agreement Issue equipment 13% 79% 6% 1% 0% 0% with the following Training in use of statement and explain their 32% 57% 9% 1% 0% 0% equipment answers: “From the minute you walk in the door till Individual education 10% 62% 22% 3% 0% 3% you get beside the bed you Self-care training 6% 53% 35% 3% 0% 3% have already done your techniques functional assessments” (Griffin, 1993, p.1088). Functional mobility 19% 60% 12% 4% 3% 1% - Forty seven participants Family/whanau education 10% 50% 32% 4% 1% 1% (68%) disagreed with this statement. Those who Upper extremity exercises 1% 28% 25% 34% 12% 0% agreed with the statement Home alteration 1% 9% 34% 24% 32% 0% (20/29%) based their (permanent)
14 New Zealand Journal of Occupational Therapy Volume 55 No 2 The nature of occupational therapy practice in acute physical care settings RESEARCH followed by individual education, self-care training, functional with the statement saying that their role was not limited to these mobility and family/whanau education (Table 4). two components claiming that “The role of OT in physical acute care is about understanding a person’s occupational performance Discharge planning: and addressing any dysfunction”. Participants were asked if they differentiated between intervention Participants were asked to give their opinion of the statement: and discharge planning. The responses were split equally between “Occupational therapy will always have a place in acute care ‘yes’ and ‘no’ with two (3%) not responding. no matter how much acute care stays are reduced” (Joe, 1996, When explaining their responses, those who answered p. 12). Sixty five participants (96%) agreed with this statement negatively felt that intervention was directed towards discharge, indicating that the reason for this was related to the specific roles and that discharge planning was part of occupational therapy that occupational therapists play in the health care team: ensuring intervention in acute wards. Justification for this explanation safety on discharge, provision of equipment, looking at function was that the fast paced and speedy discharge required in acute in the context of the home, advocating for the patients and their settings, resulted in only seeing “patients once, so it is all in one”. families, always looking at the wider picture of the patients’ care However, one respondent who circled “yes” commented, “In acute and trying to ensure that patients do not return to hospital. For you end up doing both [intervention and discharge planning] all these reasons the participants argued there would always be a simultaneously”. place for occupational therapy in acute care, especially when the current trend is for the length of stay to be constantly reduced, Those who saw intervention as different to discharge planning for instance with the introduction of an “acute assessment unit argued that discharge planning is a team activity. One participant for 36 hours stays”. However, three participants (4%) noted that even stated that “Discharge is separate to intervention. I do not although there is a definite place for occupational therapists in use the word discharge planning”. Twelve participants (17%), who acute settings, the time pressure will have an impact on their circled “yes”, noted that ultimately intervention leads to discharge practice, as the “accurate and appropriate interventions will be planning, with intervention being a continuum starting at sacrificed for speed”. Only two participants (2%) disagreed with admission and carrying on to discharge. the statement. One argued that there was a “Diminishing role - 2. Occupational therapy role in acute physical settings people’s function is limited by being medically unwell”. Participants were asked if they agreed or disagreed with Griffin (1993) that: “The role of occupational therapists in physical acute Theoretical frameworks: care setting is to assess and plan for discharge” (p. 1091). Participants were asked if they felt that a theoretical framework guided their practice. Fifty five participants (79%) responded Those who agreed with the statement (Table 5) based this on ‘yes’, 14 (20%) responded ‘no’ and 1 (1%) answered ‘sometimes’. the reality of the acute settings where time factors and funding play a major role. One participant wrote: “As hospital stays become shorter this is what the organisation is wanting from our service, Table 6: Theoretical frameworks/models identified by therapists in and [what] there is often time for”. Another participant said that acute care Participants Theoretical Framework or Model Table 5: Participants’ opinions regarding the statement about the n=70 role of occupational therapy being to assess and plan for discharge Canadian Model of Occupational Performance (CMOP) 36 Strongly Strongly Agree Disagree Biomechanical compensatory or rehabilitation 27 Agree Disagree Model of Human Occupation (MOHO) 20 Percentage 14% 49% 29% 7% Motor-learning approach 2 Neuro-developmental 2 Bio-psycho-social 2 because of the profession’s focus on “the whole scenario of the Humanistic approach 1 client” a good job was accomplished even in the limited time they have with the client. Also, occupational therapists are able Sensory motor approach 1 to identify when discharge home is inappropriate and therefore International Classification of Function (ICF) 1 recommend rehabilitation. Cognitive behaviour approach 1 Those who did not strongly agree or disagree felt that they did Strength model 1 more than assess and plan for discharge, participants stating: “I feel we have much more to offer, however, unfortunately this Client centred approach 1 is the reality as time does not allow us to do any more than plan for discharge” and “Our role is to facilitate/promote participation. Participants had the option to write down their preferred Discharge is certainly a component with our intervention. We do theoretical framework (Table 6). The majority of the participants not only look at discharge”. Some participants strongly disagreed (54/77%) identified more than one, but not all the participants
Volume 55 No 2 New Zealand Journal of Occupational Therapy 15 RESEARCH Luciana Blaga, Linda Robertson who circled ‘yes’, wrote a specific framework. Some participants trained to do and the reality of acute practice was emphasised in (4/6%) who used a theoretical framework explained that they used previous studies of acute care (Craig et al., 2004; Griffin, 1993). it in an informal way, when reflecting back on their practice. Although restricted in their input, the therapists felt that their contribution was valuable because they provided expertise to Unique contribution: ensure safety on discharge. Participants were asked to describe what they considered to be One question that arises is whether or not the holistic approach their unique contribution to the patient’s care as occupational claimed by the therapists is appropriate and relevant in acute therapists. The following themes were gathered: care. Therapists perceived their contribution to patients’ care as Approach to clients’ care: being their unique skill to look at the patients’ “wider picture” Twenty-six therapists (37%) made the point that they are the and to consider the implications for the patients when returning only professional (in the team) that takes the time to listen to the home. Therapists explained that this ‘holistic approach’ was patients’ or families’ concerns. By doing this they allow patients evident in their ability to assess current function, i.e. all the to set their own goals and help them to “achieve what is important performance components, and to predict possible difficulties at to the person”. Collaboration with the patients, the individualistic home. Consistent with Finlay’s (2001) study, holism was noted by approach to treatment and the emphasis on abilities rather than participants as a feature of occupational therapy that defined and disabilities are seen as unique contributions to the patients’ care. set the profession apart from other disciplines. However, one participant suggested that this could be merely an However, several authors note that there is considerable confusion ideal they want to achieve. in the profession about what is meant by holism. Barnitt and Occupation as the final outcome of occupational therapy Mayers (1993), and McColl (1994) concluded that an environment input: that has a primarily reductionistic biomedical focus is at odds Twenty-four participants (34%) saw their unique input as helping with the idea of holism. On the other hand Finlay (2001) says that people to return to their previous occupations. Participants it is possible to have different types of practice within a broader believed they had “specific knowledge of activities/occupations”and social context. Her study demonstrated that some therapists how current health concerns have impacted in patients’ ability to working in biomedical contexts embraced reductionistic ways carry out their activities of daily living in their own environment. of working while at the same time celebrated their holistic One participant wrote: “OCCUPATION. No other profession has a practice. The ambivalence felt by occupational therapists about focus on occupation and this is what makes our profession so unique proving credibility within a biomedical environment, while and valuable. Occupation is more than what a person does, but also simultaneously being concerned with treating the whole person, considers the environment, values and beliefs”. was also noted by Fleming and Mattingly (1994). They referred to this as “unease at the heart of their practice” (p. 296). Finlay’s Holistic approach: (2001) assertion is that it is not always necessary to take a holistic Twenty one participants (30%) mentioned using a holistic approach and that “we need to understand that holism means approach which was explained by them as their ability to see the different things, at different times, to different people (and wider picture of the patient’s care. One respondent stated: “Often professions)” (p. 275). Making an effort to understand the factors other members of the multidisciplinary team are concerned with that push for reductionistic practice and those that enable holism only one part of the patient. We relate all the things that are going would be important in acute care practice so that the personal on with them to how they are going to manage in relation to all and professional meanings of holism are identified. This is an the performance components”. They indicated that occupational area for further research. therapists address all the areas of function that other professions might not think about, making the connection between Another dichotomy noted in the results was that some therapists medical problem, current functional abilities and the patient’s based assessment on referral information while others always environment. included observation of function. One characteristic of problem solvers is that they quickly develop hypotheses in an attempt Skills to assist people to return to previous occupations: to define the problem even on the basis of relatively little Eighteen participants (25%) identified skills such as functional information (Robertson, 1996). This is supported by Griffith’s assessments, education, equipment provision, adaptive techniques, (1993) statement about the therapist having completed an environment modifications, as well as the ability “to do cognitive assessment by the time s/he reaches the patient. Consistent testing and determine patient’s safety when used in conjunction with problem solving processes, the therapist is likely to have with functional assessment”. developed a number of hypotheses at this point. The time spent Discussion with the client allows these hunches to be evaluated resulting in the identification of the problem which will be used as the The therapists in this study agreed that their main role was to basis of intervention and recommendations. As many therapists assess and plan for safe discharge, or make an appropriate referral noted, their ideas about the problems they should address need when discharge was not possible, as suggested by Griffin (1993). to be checked out by observation and interview thus confirming However, they felt that they were trained to do more, but that or disputing the original hypotheses. However, consistent with time constraints and big caseloads limited their intervention. The Rogers and Masagatani’s (1982) study, other therapists used the ambivalence and contradiction between what the therapists are
16 New Zealand Journal of Occupational Therapy Volume 55 No 2 The nature of occupational therapy practice in acute physical care settings RESEARCH medical problem as the primary defining factor for decision elicit further details and clarify ambiguities due to the anonymity making. This again illustrates two approaches to working in acute of the participants. care - one taking a ‘standard’ approach to the likely problems based on pathology and the other being concerned to identify Conclusions any factors that are specific to the individual. It is evident from this study that occupational therapists in acute physical settings are able to clearly articulate their practice A surprising result of the current study was the use of CMOP and their contribution to the patients’ care. Their expertise is in and MOHO conceptual frameworks which Griffin (1993) assessing the current functional status of the patient and relating indicates are not compatible with the acute physical setting. this to discharge planning and their focus is on maximising Griffin indicated that conceptual models which address a more independence and safety post discharge. To achieve this, therapists comprehensive view of the patient were not appropriate for the must make fast clinical judgments in relation to very diverse acute setting. However, in this study, several participants explained pathologies on a daily basis. Conceptualising practice remains that these frameworks are not used in a formal way, but more an issue with therapists using broad professional frameworks to guide their reflection and help them keep the focus of their and/or the notion of holism to provide a conceptual lens for input on the core values of the profession. This is evidenced by this specialised field of practice. Finding satisfactory ways to the fact that although the majority of participants mentioned the articulate practice is an issue that could be further explored so use of CMOP and MOHO in their practice, they did not use the that occupational therapists to feel more confident their work is standardised assessments specific to these models. As Kielhofner recognised within the broad parameters of occupational therapy (1997) suggests, the models that therapists employ to guide their practice. practice may help them conceptualise their unique contribution, and at the same time support them to cope in a medical world. Key messages They act as a starting point for more intuitive reasoning which n In acute care, conceptual occupational therapy models provide is characteristically used when there is limited time and the task a wide lens to view professional practice rather than a guide to is familiar (Hamm, 1988). It is possible that the combination of decision-making. more (generic) conceptual occupational therapy models, such as CMOP and MOHO, with specific (models) approaches, such as n The implications of using both reductionistic and holistic biomechanical/compensatory or neurodevelopmental is a good approaches in acute care practice should be explored more match, keeping the occupational focus while addressing physical fully. impairments as expected in this setting. However this integration of models was not evident in most responses and could be further References explored to get greater clarity. Barnitt, R. & Mayers, C. (1993). Can occupational therapists be both humanists and Christians? A study of two conflicting frames of An alternative approach would be to assist therapists to voice reference. British Journal of Occupational Therapy, 56(3), 84-88. their ‘theories in use’ (Lester, 1995; Ostermand & Kottkamp, Blaga, L. (2006). New Zealand occupational therapy practice in acute physical care settings. Unpublished honours dissertation, Otago Polytechnic, 1993) as a way of explaining what they know they do. Therapists Dunedin, New Zealand. were articulate regarding their practice so this seems a reasonable Christiansen, C. & Baum C. (1997). Occupational therapy: Enabling function approach rather than to impose practice models that do not and well-being. Thorofare, NJ: Slack. necessarily fit their area of work. In the current climate where Craig, G., Robertson, L. & Milligan, S. (2004). Occupational therapy practice in acute physical health care settings: A pilot study. New Zealand nothing is certain, the ability to generate knowledge from practice Journal of Occupational Therapy, 51(1), 5-13. is regarded as one of the hallmarks of the effective practitioner Creswell, J. W. (2003). Research design: Qualitative, quantitative and mixed (Higgs & Titchen, 2001; Lester, 1995). Theories of any kind methods approaches (2nd ed.). London: Sage. quickly become outdated as practice evolves. Understanding DePoy, E. & Gitlin, L. N. (2005). Introduction to research: Understanding and applying multiple strategies (3rd ed.). St. Louis, MO: Elsevier Mosby. how knowledge is derived from experience is essential (Higgs Feinberg, J. (1988). Acute care. In H. L. Hopkins & H. L. Smith (Eds.), & Titchen, 2001; Lester, 1995) and articulating this confidently Willard and Spackman’s occupational therapy (7th ed.), (pp. 419-434). rather than seeking more knowledge about formal models may Philadelphia, PA: Lippincott. be a better way forward for therapists in acute care. Finlay, L. (2001). Holism in occupational therapy: Elusive fiction and ambivalent struggle. The American Journal of Occupational Therapy, 55(3), 268-274. Study limitations Fleming, M. & Mattingly, C. (1994). The underground practice. In C. The participants were able to clearly articulate their practice and Mattingly & M. Fleming (Eds.), Clinical reasoning: Forms of inquiry in most of them enjoyed this area of work, however, we acknowledge a therapeutic practice, (pp. 295-315). Philadelphia: Davis the possibility that the sample was biased. Therapists who received Forsyth, K. & Kviz, F. J. (2006). Survey research design. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for the questionnaire but were not satisfied with their practice may enhancing practice, (pp. 91-109). Philadelphia, PA: Davis. have chosen not to participate in the study. The statistics for the Griffin, S. D. (1993). Short bed stays: Their effect on occupational therapy number of occupational therapists working in acute care practice services in teaching hospitals. Archives of Physical Medicine & are not available thus the percentage who responded cannot be Rehabilitation, 74(10), 1087-90. Griffin, S. D. (2002). Occupational therapy practice in acute care neurology verified. The method was restricted from the point of view that and orthopaedics. Journal of Allied Health, 31(1), 35-42. once the questionnaires have been received it is impossible to
Volume 55 No 2 New Zealand Journal of Occupational Therapy 17 RESEARCH Luciana Blaga, Linda Robertson
Griffin, S. D. & McConnell, D. (2001). Australian occupational therapy Robertson, L. (1996). Clinical reasoning, Part 1: The nature of problem practice in acute care setting. Occupational Therapy International, 8(3), solving, a literature review. British Journal of Occupational Therapy, 184-197. 59(4), 178-182. Hamm, R. M. (1988). Clinical intuition and clinical analysis: Expertise and Rogers, J.C. & Masagatani, G (1982). Clinical reasoning of occupational the cognitive continuum. In J. Downie & A. Elskin (Eds.), Professional therapists during the initial assessment of physically disabled patients. judgement, (pp. 78-103). Cambridge: University Press. The Occupational Therapy Journal of Research, 2, 195-219. Higgs, J. & Titchen, A. (2001). Rethinking the practice-knowledge interface Shiri, S. (2006). Job satisfaction, physical acute care and occupational in an uncertain world: A model for practice development. British therapists. New Zealand Journal of Occupational Therapy, 53(2), 5-11. Journal of Occupational Therapy, 64(11), 526-533. Sutton, S. (1998). An acute medical admission unit: Is there a place for an Joe, B. E. (1996). Is there an OT role in acute care? OT Week, 10(6), 12-13. occupational therapist? British Journal of Occupational Therapy, 61(1), Kielhofner, G. (1997). Conceptual foundations of occupational therapy. 2-6. Philadelphia, PA: Davis. Trombly, C. A. (2002). Conceptual foundation for practice. In C. A. Trombly Lester, S. (1995). Beyond knowledge and competence: Towards a framework & M. V. Radomski, Occupational therapy for physical dysfunction (5th for professional education. Higher Education for Capability, 1(3), 44- ed.), pp. 1-15. Baltimore, MA: Lippincott Williams & Wilkins. 52. Wilding, C. & Whiteford, G., (2007). Occupation and occupational therapy: Litwin, M. S. (1995). How to measure survey reliability and validity. In A. Knowledge paradigms and everyday practice. Australian Occupational Fink (Series Ed.), The survey kit (7). Thousand Oaks, CA: Sage. Therapy Journal, 54(3), 185-193. McColl, M. A. (1994). Holistic occupational therapy: Historical meaning Whiteford, G. (2006). Diversity in occupational therapy: Myth or reality? and contemporary implications. Canadian Journal of Occupational OT Insight, 27(6), 1-4. Therapy, 61(2), 72-77. Moats, G. (2006). Discharge decision-making with older people: The Acknowledgements influence of the institutional environment. Australian Occupational The authors would like to thank Carolyn Simmons Carlsson who Therapy Journal, 53(2), 107-116. provided the impetus for this project as well as ongoing support. Ostermand, K., & Kottkamp, R. (1993). Developing a reflective perspective. In addition, the managers who supported it, the occupational California: Corwin. Robertson, C. & Finlay, L. (2007). Making a difference, teamwork and therapists who participated, and Dr. Annemarie Jutel who coping: The meaning of practice in acute physical settings. British provided critical feedback on drafts of the article. Journal of Occupational Therapy, 70(2), 73-80.
18 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupations at 85 plus THEORETICAL ARTICLE
Occupational participation at 85 plus: A review of the literature
Laura Haslam
Abstract Relevant international and New Zealand literature regarding the occupations of people 85 plus is reviewed in this paper, and related to theories on ageing and the effect of personal factors and the environment on occupational participation. Substantial variety in the occupations of people 85 plus was found. The theories of ageing discussed were reflected in the literature and found to complement each other. The most important personal factors affecting participation were personal interests, health, disability, physical and cognitive functioning. All aspects of the environment were significant. Due to the small amount of NZ literature on this topic, further research is needed. Keywords Elderly; older people; occupations; health. Reference Haslam, L. (2008). Occupational participation at 85 plus: A review of the literature. New Zealand Journal of Occupational Therapy, 55(2), 19-24.
n affluent societies worldwide, the populations of older people the Government’s commitment to promote the value and Iare increasing and older people are living longer than at any participation of older people in communities. The Health of Older previous time in human history. Compared to the Organisation People Strategy (Ministry of Health, NZ, 2002) has identified for Economic Co-operation and Development (OECD) countries, the need for research into the development and evaluation of New Zealand has a young population, with 11.5 percent of people interventions to promote the health and well-being of older aged 65 plus. However, this percentage is projected to grow steadily people as a priority area. Occupational science has demonstrated to around 13 percent by 2010 and then much more rapidly to that engagement in occupation is based on a biological need 22 percent by 2031 and 25 percent by 2051 (Ministry of Health, and contributes to health and survival throughout the life span 2002). In effect, this means that over this period, the number of (Wilcock, 1995; Wood, 1998). In order to promote the health and people 65 and over will double, while the number of people aged well-being of people 85 plus through occupational participation, 85 plus is expected to increase six fold, reaching over a quarter of occupational therapists need to be aware of current theories of a million by 2051. At this time, people over 85 will make up 22 ageing which relate to occupation, know what the occupations percent of all New Zealanders aged 65 years and over, compared of this age group are, and understand the factors which shape with 9 percent in 1996 (Ministry of Statistics, 2000). occupational participation.
This paper focuses on the occupations of people over 85 for Theories of occupation and ageing two reasons. Firstly, as shown above, this age group will have Broad understandings of the occupations of older people are the highest growth rate. Secondly, it is important to differentiate contained in theories of ageing. Cummings and Henry (1961) within the population aged 65 and over. This population covers argued for a theory of disengagement in which the main task at least two generations - the oldest people alive today were born of old age was defined as letting go and withdrawal from work in the first decade of the 20th century, whereas those in their 60s and strenuous recreation. Since then results from a ten year were born in the 1940s, and could well be the children of the programme of interdisciplinary research which began in the USA oldest. It is generally assumed that from around the age of 85, in the late 1960s, led to a paradigm shift away from disengagement health and capacity for independent living will decline, and that disability and the need for care will increase. If this is the case, then the occupations of this age group will be different to those Laura Haslam, B.Sc. (Hons.) Psychology, of people aged 65 to 85. Due to variable use of age bands in the B.Sc. (Hons.), OT, NZROT literature, articles were included in this review which referred to Senior Occupational Therapist people younger than 85 if they also dealt with people 85 plus. Psychiatric Service for the Elderly Current policy as outlined in the New Zealand Positive Canterbury District Health Board Ageing Strategy (Minister for Senior Citizens, 2001) reinforces Email: [email protected]
Volume 55 No 2 New Zealand Journal of Occupational Therapy 19 LITERATURE REVIEW Laura Haslam theory to “successful ageing” (Rowe & Kahn, 1998). Rowe and The above theories were selected from many theories of ageing Kahn defined the task of successful ageing as discovering or due to their relevance to occupational participation. It is evident rediscovering relationships and activities that provide closeness that no single theory of ageing is sufficient to fully address its and meaningfulness for the older person. They identified three complexities. Apart from disengagement theory, which has characteristics of successful ageing: low risk of disease and disease been discredited as arbitrary, partial, and potentially oppressive related disability; high mental and physical functioning; and (Hugman, 1999, p. 1), the theories discussed complement each active engagement with life. other to describe the opportunities and challenges facing people 85 plus, ways to adapt to declining function, and the effect of Closely related to successful ageing is “productive ageing” which contextual influences on their experience of occupation. refers to “behaviours that are inner-directed, personally meaningful and satisfying to the older person, whether or not they can be Occupations of people 85 plus categorised as paid or volunteer service and regardless of whether In this review, three major international quantitative studies were others benefit directly from them” (Kaye, Butler, & Webster, 2003, found which describe what older people do. Horgas, Wilms and p. 203). This perspective includes concrete contributions made Baltes (1998), as part of the Berlin Ageing Study investigated the to society by older people as well as older people engaging in everyday activities of 516 people aged 70-105 years. In a secondary activities that can be self-actualising, meaningful and personally analysis of data from 1,439 Canadians aged 67 to 95, Menec satisfying. This theory attempts to debunk the myth that older (2003) investigated the activities participated in within the past people are less productive than younger people and in contrast week using a 21 item activity checklist. In Sweden, Häggblom- highlights assets, resources, capacities and skills rather than Kronlöf and Sonn (2005) interviewed 86 year old persons (n = problems, deficiencies and needs. 205) at home about their interests. The only New Zealand studies While the theories of successful and productive ageing highlight identified were the 1998-99 Time Use Survey, a population based positive aspects of older age, they do not address how older survey which involved a crude analysis of time use patterns for people deal with losses experienced or how their environment people of different ages (Statistics New Zealand & Ministry of may support or constrain their occupations. The theory of Women’s Affairs, 2001), and a statistical review of data on people “selective optimisation with compensation” (Lang, Ricckmann, 85 plus derived from national data bases carried out by Davey & Baltes, 2002) developed during the 1990s suggests older people and Gee (2002). can adapt to functional decline in three ways: The findings in common from these three studies were that the 1. By reducing participation in the number of activities, most frequent activities of older people were leisure, instrumental goals or domains of activity they participate in to focus on activities of daily living and personal maintenance activities. Paid those that are most important to them; work was the least frequent activity that older people engage in, closely followed by education. When leisure interests were 2. By maximising their resources in a selected domain of investigated, the most frequently reported activities were watching functioning where no ageing losses have occurred; and TV, reading and social activities (Häggblom-Kronlöf et al., 2005; 3. By using new or alternative means to reach a goal or Horgas et al., 1998; Menec, 2003). maintain a desired state once losses have occurred (Lang, There was substantial variety in the way older people spent Ricckmann, & Baltes, 2002). their time. This supports a heterogeneous view of ageing and The ecological model of ageing and adaptation developed by reflects life-long activity patterns as well as personal preferences Lawton and colleagues (as cited in Wood, 2005) expands on the (Häggblom-Kronlöf & Sonn, 2005; Horgas et al., 1998). This previous theories by considering the contextual influences on the heterogeneity was also evident in the qualitative literature. Carlson, occupations of older people. This model suggests that as older Clark and Young, (1998) listed a number of exemplary elders who people grow less competent, they become more environmentally showed very high levels of competence and achievements which vulnerable. Within this model the concept of environmental press surpass those of average people in their prime. Ichijirou Araya is proposed as “immediate environments press for, encourage or who successfully climbed Mt. Fuji at 100 years of age, and Thelma demand, the expression of some behaviours while discouraging Pitt-Turner, a New Zealander, who finished a marathon at age 82 others” (Wood, 2005, p. 123). The fit between the environmental years are examples. In a qualitative study of 80 people aged 80- press and the older person’s level of functioning is of great 90, living in Sweden and the UK, participants talked about their importance. If the environmental presses slightly exceed the participation in golf, attending a gym, sculpting, bread-making, older person’s competency level, new learning and pleasurable surfing the internet, other computer related activities (including experiences are likely to occur. If, however, the environmental emailing, and playing games) and looking after grandchildren presses significantly exceed competency levels, extreme distress (Green, Sixsmith, Dahlin Ivanoff, & Sixsmith, 2005). can occur. Conversely, if the environmental presses are slightly In alignment with the models of successful ageing and productive beneath competency levels, relaxation and maintenance of skills ageing, a number of studies investigated the engagement of older can occur, and if the environmental presses fall significantly people in productive activities. Davey and Gee (2002) report that beneath competency levels, the result is likely to be boredom and in New Zealand, only 5.6% of men and 2.3% of women aged 85 atrophy of skills. and over participate in paid work, most of them part-time. Horgas
20 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupations at 85 plus THEORETICAL ARTICLE et al. (1998) found that participation in paid work decreased activities than being in poor health and/or experiencing disability with age. Similarly, the 1998-99 Time Use Survey (Statistics (Glass, Mendes de Leon, Marattoli, & Berkman, 1999; Green et al., New Zealand & Ministry of Women’s Affairs, 2001) showed that 2005; Häggblom-Kronlöf & Sonn, 2005; Menec, 2003). Similarly participation in unpaid work (i.e. household work, caregiving lower levels of physical functioning and decreased cognitive for household members, purchasing goods or services for one’s functioning were also linked to decreased levels of activity own household, and unpaid work for people outside the home) participation (Christensen et al., 1996; Menec, 2003). decreased over the age of 85. Older people aged 74-85 carry out around 4.5 hours unpaid work on average per day, but for those Gender aged 85 plus, this figure drops to around 3.6 hours per day on For many occupations, there were no significant differences in average. While the literature reviewed indicated a decrease in paid engagement between men and women. Older people conformed and unpaid work, the evidence above of continued participation to traditional gender stereotypes in certain occupations, for in meaningful and satisfying activities suggests that the models example, women aged 80 plus were more likely to participate in of successful and productive ageing are still relevant for people cooking, baking, housework and art/craft activities than male 85 and over. counterparts (Häggblom-Kronlöf & Sonn, 2005; Horgas et al., 1998). In a study with a mean age of 76 years, men were more As well as active occupations, some of the literature raised the likely to participate in other domestic activities such as gardening, importance of more passive occupations such as reflecting, sitting lawn care, and home maintenance (Stanley, 1995). Another study and watching, or connecting with nature (Dahlin-Ivanoff, Haak, involving people age 65 plus found that while older men were Fãnge, & Iwarsson, 2007; Rowles, 1991). These occupations were more likely to engage in fitness activities, older women were more closely linked with the environment of the older person. Rowles likely to engage in productive activities, which they defined as a (1991) carried out an intensive 3 year ethnographic study of combination of instrumental activities of daily living and paid or 15 residents aged from 62 to 91 in a small community in the unpaid work (Glass et al., 1999). Appalachians (USA). One of his findings concerned what he named the ‘surveillance zone’, or the space immediately beyond Marital status the threshold, which assumed increasing importance in many Few of the studies considered marital status. Horgas et al., (1999), older people’s lives as they grew older. For older people who were however, found that unmarried persons spent more time engaged housebound, this space became the “arena of their lives” (Rowles, in instrumental activities of daily living, and less time watching 1991, p. 268) and comprised of the space they could see from television than others. As a large proportion of unmarried people their window or porch. Many of these people spent long periods are widowed women, this finding reflects the gender stereotyping of time sitting and watching the outside world from this vantage noted above. Davey and Gee (2002) reported that in the 85 plus point, and occasionally interacting with others with a wave or a age group, partnered women recorded more necessary time (self conversation. care and sleep), more unpaid work inside and outside the home, Personal factors pertaining to and less free time, than both partnered men and unpartnered participation in occupation men and women. What individuals 85 plus do, depends on a number of personal Finances factors including, interests, health, disability, physical and Hugman (1999) suggested that while many older people are cognitive functioning, gender, marital status and finances. increasingly well-off and able to enjoy leisure activities, travel and community life, others remain limited by financial circumstances Interests so that old age is increasingly a divided stage of the life-course. Nilsson, Löfgren, Fisher, and Bernspång (2006) investigated The research was inconclusive on the effect of finances. Two factors underlying participation in activities of Swedish people studies found no relationship between finances and occupational 85 plus. They found that the leisure activities people in that age participation (Glass et al., 1999; Horgas et al., 1998), while group were most likely to participate in (social activities, cultural another study found that lack of money was one of seven reasons activities and TV/video/movies) were also activities of interest. reported for giving up interests and was linked to fewer interests Therefore they were motivated to participate and thus achieved a outside of the home (Häggblom-Kronlöf & Sonn, 2005). sense of well-being. These results suggest that people 85 and over, select meaningful activities related to their interests and ability, Environment and participation in occupation and this supports both the theory of selective optimisation with The environment is the context in which occupational compensation (Lang, Ricckmann, & Baltes, 2002) and the model performance takes place and can be defined as having cultural, of successful ageing (Carlson, Clark & Young, 1998). institutional, physical and social elements (Townsend, 1997). Health, disability, physical and cognitive functioning Culture Health, disability, physical and cognitive function are closely Currently in New Zealand, Maori, Pacific and Asian people related to age. Research did not always separate these factors together make up only 3% of the population aged 85 years and and their effect on activity participation. Being in good health, over (Davey & Gee, 2002). Nonetheless, these population groups however, is associated with participation in a wider range of are also ageing. By 2051, it is projected that Maori will make
Volume 55 No 2 New Zealand Journal of Occupational Therapy 21 LITERATURE REVIEW Laura Haslam up 13% of the population aged 65 and over (Cunningham et home reported, “I sit and think, and listen to my tapes, talk to my al., 2002). No research was found related to the occupations of carers and friends, and then I go to the day centre to talk to other older Pacific and Asian people in New Zealand, but limited data people who never see anyone” (Hearle et al., 2005, p. 29). was available on the occupations of older Maori. The 1998-99 Hearle et al’s. (2005) finding was consistent with an Australian Time Use Survey (Statistics New Zealand & Ministry of Women’s study by French (2002) which used an ethnographic approach to Affairs, 2001) reported that Maori aged 65 plus undertook more investigate the impact of the organisational culture of a care facility unpaid work outside the home than non-Maori, and more on the residents’ participation in occupations. French found that specifically, that Maori spent significantly more time on religious, the key task of the facility was “to provide a transitional space cultural and civic participation than non-Maori. Waldon (2004) for residents to pass from social death to physical death” (French, interviewed 400 older Maori (45% of the sample were aged 2002, p. 30) and that residents seemed to be “processed through 70 years plus) recruited through iwi and Maori community a series of procedures administered by various staff including networks. Eighty five percent of respondents indicated they were toileting, bathing and medication” (French, 2002, p. 32). In order seen as kaumatua, and 68% were involved in marae activities. to prevent falls, residents were often risk deprived, which seemed Whanau relationships were typically close. Respondents reported to reduce their potential to participate in satisfying occupations. reciprocal involvement where older Maori could count on their French found that compared to the range of occupations reported wider whanau for assistance including financial aid, transport in the literature for people 85 plus living in the community, and help when unwell, but that much more often, older Maori people in a residential facility participated in a restricted range offered assistance to their whanau by caring for children, disabled of occupations. or older whanau members. In contrast to the findings of French (2002) and Hearle et al. Political (2005), Van’T Leven and Jonsson (2002) found that for some What people choose to do at any age is influenced by the socio- frail older people in long term care, watching others engaged in historical context that they live in. The social policy of compulsory activities provided a degree of occupational satisfaction, and they retirement at age 60 or 65 was closely related to belief in the suggested that “being in the atmosphere of doing” was experienced disengagement model of ageing. In recent decades, attitudes have as having the same or very similar quality to the actual doing. shifted away from disengagement theory towards successful and Paradoxically, their participants felt that “they did a lot and at productive ageing, and socially acceptable options available to the same time they did nothing” (Van’T Leven & Jonsson, 2002, older people are now more varied. For example, as stated in the p. 152). New Zealand Positive Ageing Strategy: While the studies by French (2002) and Hearle et al. (2005) Retirement from the paid workforce does not mean cannot be generalised due to the limited number of facilities they that people cease to contribute to society - it provides included, both raised the issue of the potential for occupational opportunities for participation in different ways and in a deprivation in long term care settings. Hearle et al. (2005) suggested range of roles: as employees, volunteers, family members, that institutions press on residents in their rigid adherence to neighbours, caregivers, committee and trust members, routines, and through the lack of opportunity to pursue interests kaumatua, business mentors and advisors, and members of and hobbies. In line with the ecological model of ageing and communities (Minister for Senior Citizens, 2001, p. 10). adaptation, it seems that in some long term care environments, In New Zealand, this has been accompanied by structural changes the environmental presses fall significantly beneath competency such as abolishing mandatory retirement, and increasing the age levels, leading to apathy, high levels of inactivity, and excess of eligibility for public pensions. Another shift has been towards disability, where a resident becomes more functionally disabled reducing dependence on public pensions and fostering privatised due to staff performing more care than is actually needed (Aller saving for retirement. Over time, these changes are likely to result & Van Ess Coeling, 1995). As Hearle et al. suggested, where this is in an increase in the numbers of older people (including those 85 the case, the ecology of residential homes needs to be examined plus) in paid employment. and changed to empower residents with the acknowledgement of personal choice and to meet their occupational needs. Institutional Facilities that empowered residents and where organisational In this section, the effects of the organisational structure of living culture supported residents’ participation in occupations were in a long term care institution on the occupations of people 85 described by Green and Acheson Cooper (2000) in the UK. Green plus are discussed. A qualitative study from the UK on people and Acheson Cooper found this depended on management with a mean age of 90 underlined the difference in participation taking a lead in promoting participation. Due to the difficulties of in occupations for residents living in residential care compared engaging frail residents in activities, the use of informal and non- to people living at home (Hearle, Prince & Rees, 2005). The traditional activities and flexible use of the environment were narratives of the people living in residential care indicated sterility found to be essential, for example: impromptu dancing, helping in their lives when compared to the narratives given by those in the home, gardening, and fish & chip lunches. living in the community: one of the residents in a care setting stated “We just go from one meal to another. I don’t do anything, The literature also provided examples of long term care using I can’t...” (Hearle et al., 2005, p. 29), whereas a person living at alternative models to traditional institutional care which were
22 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupations at 85 plus THEORETICAL ARTICLE successful in promoting increased levels of participation in related to occupational participation, although limited literature occupations of their elderly residents. Bundgaard (2005), and was found which discussed the effects of the social and physical Reimer, Slaughter, Donaldson, Currie, and Eliasziw (2004), environment. reported on small living units in Denmark and Canada Given the lack of detailed research related to the occupations of respectively, where if residents choose to, and are capable, they people 85 plus in New Zealand, there is a need for more New are involved in the everyday activities of the unit and eat together Zealand based research which examines this topic. In particular, with staff. Bundgaard (2005) found that this way of organising it is proposed that occupational participation of people 85 plus meals influenced most of the everyday life in the unit by “shaping a living in a range of environments, and how these environments homely place” (p. 94) and provided a place for valued occupations support or constrain their participation, should be investigated. for the residents. Reimer et al. (2004) found that these residents Both quantitative and qualitative research is needed to describe demonstrated fewer declines in their activities of daily living than the occupations of people over 85 and to explore the complex residents in traditional facilities. relationship between personal factors, environment, and participation. Physical The physical environment includes natural and built Key points surroundings such as buildings, roads, gardens, vehicles for n There is a large degree of heterogeneity in the occupations of transportation, technology, and weather. Minimal literature was people 85 plus. found relating to occupations of people 85 plus and aspects of their physical environment. In the previous discussion on passive n The theories of successful and productive ageing, selective occupations, both Rowles (1991) and Dahlin-Ivanoff et al. optimisation with compensation, and the ecological model of (2007) mentioned the importance of a window, porch or balcony ageing and adaptation were upheld by the literature and found overlooking a scene of interest for housebound people. Green to complement each other. and Acheson Cooper (2005) identified the nearby location of n A person’s interests, health, disability, physical and cognitive friendly neighbours, accessible shops, and a “not-too-big-garden” functioning are key factors affecting participation in as important for personal wellbeing for people aged 80-89 years. occupations when aged 85 plus. Nilsson, Löfgren, Fisher and Bernspång, (2006) found that people aged 85 plus living in an urban/suburban area were more likely n There is a lack of New Zealand research into the occupations to report participation in cultural activities and hobbies, while of this age group. those living in rural areas were more likely to report pets, music, watching sport, and fishing, hunting, and shooting. References Social Aller, L. J., & Van Ess Coeling, H. (1995). Quality of life: Its meaning to The social environment refers to patterns of relationships, the long-term care resident. Journal of Gerontological Nursing, Feb., community, and social groupings (Townsend, 1997). As noted 20-25. previously, social activities are one of the most frequently Bundgaard, K. M. (2005). The meaning of everyday meals in living units for older people. Journal of Occupational Science, 12(2), 91-101. reported occupations internationally for people aged 85 plus. Carlson, M., Clark, F., & Young, B. (1998). Practical contributions of In New Zealand, Davey and Gee (2002) found a high frequency occupational science to the art of successful ageing: How to sculpt a of contact with family and close friends (49% had contact every meaningful life in older adulthood. Journal of Occupational Science, day and 41% once a week). No studies were identified which 5(3), 107-118. Christensen, H., Korten A., Jorm, A. F., Henderson, A. S., Scott, R., & specifically discussed the effect of the social environment on the Mackinnon, A. J. (1996). Activity levels and cognitive functioning in an occupations of people aged 85 plus. elderly community sample. Age and Ageing, 25, 72-80. Cumming, E., & Henry, W. (1961). Growing old: The process of disengagement. Conclusion New York: Basic Books. Cunningham, C., Durie, M., Fergusson, D., Fitzgerald E., Hong, B., Horwood, This paper set out to investigate the occupations of people J., Jensen, J., Rochford, M., & Stevenson, B. (2002). Living standards of 85 plus and the effect of personal factors and environmental older Maori. Wellington: Ministry of Social Development. context on their participation in occupations. A significant Dahlin-Ivanoff, S., Haak, M., Fãnge, A., & Iwarsson, S. (2007). The multiple body of international research was discussed but data pertinent meanings of home as experienced by very old Swedish people. Scandinavian Journal of Occupational Therapy, 14, 25-32. to New Zealand appears insufficient. The literature reviews Davey, J., & Gee, S. (2002). Life at 85 plus: A statistical review. Wellington: indicated a substantial variety in the way people 85 plus spend New Zealand Institute for Research on Ageing. their time, and the range of occupations carried out. While the French, G. (2002). Occupational disfranchisement in the dependency culture proportion of people 85 plus in paid work is small, they continue of a nursing home. Journal of Occupational Science, 9(1), 28-37. to participate in a significant amount of unpaid work, especially Glass, T. A., Mendes de Leon, C., Marattoli, R., & Berkman, L. F. (1999). Population based study of social and productive activities as predictors in the case of Maori. As well as active occupations, for some of survival among elderly Americans. British Medical Journal, 319, 478- people in this age group, passive occupations are important. 483. The most significant personal factors affecting occupational Green, S., & Acheson Cooper, B. (2000). Occupation as a quality of life participation were a person’s interests, health, disability, physical constituent: A nursing home perspective. British Journal of Occupational Therapy, 63(1), 17-24. and cognitive functioning. All aspects of the environment were
Volume 55 No 2 New Zealand Journal of Occupational Therapy 23 LITERATURE REVIEW Laura Haslam
Green, S., Sixsmith, J., Dahlin Ivanoff, S. D., & Sixsmith, A. (2005). Influence Nilsson, I., Löfgren, B., Fisher, A. G., & Bernspång, B. (2006). Focus on of occupation and home environment on the well-being of European leisure repertoire in the oldest old persons: The Ume 85+ study. The elders. International Journal of Therapy and Rehabilitation, 12(11), 505- Journal of Applied Gerontology, 25(5), 391-405. 509. Reimer, M. A., Slaughter, S., Donaldson, C., Currie, G., & Eliasziw, M. Häggblom-Kronlöf, G., & Sonn, U. (2006). Interests that occupy 86-year-old (2004). Special care facility compared with traditional environments persons living at home: Associations with functional ability, self-rated for dementia care: A longitudinal study of quality of life. Journal of the health and sociodemographic characteristics. Australian Occupational American Geriatric Society, 52, 1085-1092. Therapy Journal, 53(3), 196-204. Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Random Hearle, D., Prince, J. & Rees, V. (2005). An exploration of the relationship House Inc. between place of residence, balance of occupation and self-concept in Rowles, G. D. (1991). Beyond performance: Being in place as a component older adults as reflected in life narratives. Quality in Ageing, 6(4), 24- of occupational therapy. The American Journal of Occupational 33. Therapy, 43(3), 265-271. Horgas, A. L., Wilms, H., & Baltes, M. M. (1998). Daily life in very old age: Stanley, M. (1995). An investigation into the relationship between Everyday activites as expression of successful living. The Gerontologist, engagement in valued occupations and life satisfaction for elderly 38(5), 556-568. South Australians. Journal of Occupational Science, 2(3), 100-114. Hugman, R. (1999). Ageing, occupation and social engagement: Towards a Statistics New Zealand & Ministry of Women’s Affairs. (2001). Around the lively later life. Journal of Occupational Science, 6(2), 1-7. clock: Findings from the time use survey 1998-99. Wellington: Statistics Kaye, L. W., Butler, S. S., & Webster, N. M. (2003). Towards a productive New Zealand. ageing paradigm for geriatric practice. Ageing International, 28(2), 200- Townsend, E. (Ed.). (1997). Enabling occupation: An occupational therapy 213. perspective. Ottawa: CAOT Publications ACE. Lang, F. R., Ricckmann, N., & Baltes, M. M. (2002). Adapting to aging Van’T Leven, N., & Jonsson, H. (2002). Doing and being in the atmosphere losses: Do resources facilitate strategies of selection, compensation and of doing: Environmental influences on occupational performance in a optimisation in everyday functioning? The Journals of Gerontology, nursing home. Scandinavian Journal of Occupational Therapy, 9, 148- 57B(6), 501-509. 155. Menec, V. H. (2003). The relation between everyday activities and successful Waldon, J. (2004). Oranga kaumatua: Perspectives of health in older Maori aging: A 6-year longitudinal study. Journals of Gerontology, 58B(2), 74- people. Social Policy Journal of New Zealand, 23, 167-180. 82. Wilcock, A. (1995). The occupational brain: A theory of human nature. Ministry of Health. (2002). Health of older people strategy. Dunedin: Journal of Occupational Science, 2(1), 68-73. Ministry of Health Publications. Wood, W. (1998). Biological requirements for occupation in primates: An Minister for Senior Citizens. (2001). The New Zealand positive ageing exploratory study and theoretical analysis. Journal of Occupational strategy: Towards a society of all ages. Wellington: Senior Citizens Unit, Science, 5(2), 66-81. Ministry of Social Policy. Wood, W. (2005). Toward developing new occupational science measures: Ministry of Statistics. (2000). Population ageing in New Zealand. Retrieved An example from dementia care research. Journal of Occupational January 19, 2008 from http://www.stats.govt.nz/NR/rdonlyres/02677883- Science, 12(3), 121-129. A742-4000-AA80-59D264E774F6/0/PopAgeNZ.pdf
Funded study in 2009
The Postgraduate Certificate in Health (Allied Mental Health) is a programme for occupational therapists and social workers.
This national programme funded by Te Pou is offered to those with less than 2 years experience in mental health practice. The For more information please contact: programme is delivered online through the web-based teaching platform Blackboard Chris Fox and students also attend two Schools during Graduate School of Nursing, the year. Midwifery & Health
Applications for 2009 intake are now being Freephone: 0800-108 005 Ph: +64 4 463 6647 accepted. Email: [email protected]
24 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupational therapy service in Solomon Islands FEATURE ARTICLE Occupational therapy student’s fieldwork placement: Institutional and community based rehabilitation models in the Solomon Islands.
Ana Burggraaf & Helen Bourke-Taylor
Abstract Prior to the first permanent indigenous occupational therapist in the Solomon Islands setting up practice, two Australian students on a fieldwork placement were involved in helping to develop occupational therapy services. Services were delivered within existing institutional and community based rehabilitation models. This article describes the student’s experiences and reflections on programme development and delivery. The reflections may assist occupational therapists and other students involved in similar ventures to address this large and varied area of practice. The project has significance for the professions intention to advance community based rehabilitation services to people living under adverse conditions in poorly resourced communities. Key words Occupational therapy; community based rehabilitation; student fieldwork. Reference Burggraaf, A., & Bourke-Taylor, H. (2008). Occupational therapy student’s fieldwork placement: Institutional and community based rehabilitation models in the Solomon Islands. New Zealand Journal of Occupational Therapy, 55(2), 25-31.
ccupational therapists are concerned with the health and placement was the final fieldwork requirement of the four year Owell being of people challenged by adversity within any Bachelors in Health Science in Occupational Therapy, at La Trobe community. Adversity can take many forms such as: disease, University, Melbourne Australia. At the time of this placement, disability, societal rejection due to religion, poverty, adversive physiotherapy was well established within the local hospital in governments, war, natural disasters, persistent and unyielding Honiora, and provided on site supervision for the occupational weather conditions and many others. Occupational therapists therapy students. Supervision by an occupational therapist was work with disadvantaged communities in wealthy developed not an option because although the first indigenous occupational nations as well as in poorly developed countries around the world therapist had completed her training in New Zealand and (World Federation of Occupational Therapists, 2004). returned to the region, she had to wait for an official start date from the Government before commencing paid employment. The Thibeault (2006) introduced the profession to the term ‘majority occupational therapist started work six weeks into the student’s world’ referring to the nations of the world that are unable, or placement following official confirmation of employment. unwilling to adequately sustain a healthy lifestyle for all people living therein. The majority world lives with inequity and a lack A faculty member at La Trobe Univeristy (second author) of services in the field of health, education, human services and provided distance supervision via email. Because it was the basic infrastructure. Thibeault highlighted social justice, equity final year of study, the student was expected to extend her of resources and individualized meaning within occupations, as core values within the profession. Such values serve occupational therapists well as they expand service provision to non- Ana Burggraaf, B. Occ. Thy. traditional settings, marginalized populations and communities Barwon Health, McKellar Centre in the majority world. Communication about cross cultural work Geelong, 3220. Victoria, Australia experiences in disaster regions, developing and marginalized [email protected] communities where people experience occupational apartheid, Helen Bourke-Taylor (corresponding author) injustice and deprivation is growing (Kronenberg, Salvador, & B. App. Sc. O.T., M.S. O.T., PhD candidate Pollard, 2005). Lecturer, La Trobe University This paper describes the first hand experience of an occupational School of Occupational Therapy therapy student who, with another student, completed a 10 Bundoora, 3083. Victoria, Australia. week fieldwork placement in Honiara, Solomon Islands. The [email protected]
Volume 55 No 2 New Zealand Journal of Occupational Therapy 25 FEATURE ARTICLE Ana Burggraaf, Helen Bourke-Taylor knowledge and skills through preset, self directed goals in a the Solomon Islands since 1988, when an Australian led group of contractual agreement with her supervisor. A description of allied health workers, including an occupational therapist and a both institutional and community based rehabilitation (IBR physiotherapist, were invited to give a workshop by the national and CBR respectively) is given because the student contributed Disabled Persons Association. Subsequently, the CBR unit was to provision of occupational therapy service within these two established in the early 1990s and a physiotherapist was appointed models. An overview of the differences between Australia and national coordinator. The CBR unit recruited local people to be Solomon Islands will also be presented to contextualize the cross CBR aides, and to undertake a one year course in CBR. Further cultural exchange between the student and local people involved workshops to train CBR aides occurred on an ad hoc basis. The in the project. aides were mainly supervised by nurses.
Majority world: Health and The CBR unit is managed by the Ministry of Health and rehabilitation strategies coordinates all services for the disabled in the community. It provides community based rehabilitation aides to work in the The World Health Organization (WHO) estimates that less than provinces to enable people with disabilities to have access to 5% of the world’s 480 million people living with a disability have rehabilitation services. Staff from the CBR unit also undertakes access to medical and rehabilitation services (WHO, 2005b). community development work in their local area to improve Consequently, the WHO promotes the right to equal opportunity quality of life for people with disabilities. In 2005, the national and the active participation of people with disabilities within co-ordinator of CBR contacted the occupational therapist who their communities, and acknowledges the relationships between assisted with the introduction of CBR, seeking a consultancy to health, disability and poverty (WHO, 2004). Community based design a 2 year occupational therapy programme accredited by rehabilitation (CBR) is a WHO community development the Solomon Island College of Higher Education for CBR aides. strategy that seeks to equalize opportunities for people living Part of the consultancy was the recruitment of occupational with a disability. The goals and philosophy of CBR are compatible therapists to teach the accreditation course which began in 2006. with the values, goals and philosophy of the occupational therapy profession (Fransen, 2005; WFOT, 2004). Another model of service provision utilized in developing communities is institutional based rehabilitation (IBR). This CBR seeks to provide access to community benefits such as work model more closely resembles western ideas of rehabilitation. and education, increase availability of rehabilitation and health Physiotherapy is an established department in a hospital within services, and improve the overall social inclusion of people with the IBR model. The likely absence of specialized personnel such disabilities (WHO, 2004). The objective is to facilitate change as occupational therapists however means that “special efforts at an organizational level; community level, (including altering are needed to train local health personnel and family members physical and attitudinal barriers); and to improve or make to perform some of the tasks of the various rehabilitation available, rehabilitation services and services that facilitate the professionals” (WHO, 2005a, p. 2). One drawback of IBR is that full community participation of all people. CBR workers are the western model on which it is based may be incompatible with locals who directly work with their community members to local culture. Establishing occupational therapy services with an facilitate the goals of CBR. Health professionals both work with, IBR model alone can be particularly challenging, even when a and train, CBR workers and have an important role in facilitating physiotherapy department already exists (Bourke-Taylor, 2006; achievement of CBR objectives (WHO, 2004). Bourke-Taylor & Hudson, 2005). The impact of CBR programmes on the quality of life for service recipients has been researched using a qualitative methodology (WHO, Table 1: Brief comparison: Solomon Islands and Australia (National Geographical Society, 2008) 2002). This research found that CBR positively impacts on the recipient’s Items of comparison Solomon Islands Australia self-esteem; feelings of empowerment and influence; self reliance; and social Population 472,000 20,351,000 inclusion. Further, the initiatives Official languages identified as being of the highest Melanesian pidgin, 120 English, Indigenous languages, priority and most useful for persons indigenous languages, English various immigrant languages with disabilities were firstly, “social counselling” and secondly, “training Rate of unemployment More than 80% of Solomon in mobility and daily living skills” islanders live outside the cash 4.8% economy (WHO, 2002, p.8). Such findings demonstrate that the occupational Literacy percent (estimated) 62 99 therapy profession has much to contribute to the development of Life expectancy (yrs) 71 80 CBR programmes. Gross domestic product per US$1,700 US$26,900 CBR and IBR had been operating in capita
26 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupational therapy service in Solomon Islands FEATURE ARTICLE
The Solomon Islands: Description of the setting issues affecting service implementation; and resource needs. Our The Solomon Islands have existed under considerable political needs assessment only took shape in a realistic sense once we turmoil, including violent conflicts for some time. Australian actually started work. In relation to the therapeutic programme and New Zealand peace keeping forces have been present in the we wanted to implement we had planned to become familiar with Islands since 2003. Violent conflicts in 1998, and again in 2005 the culture, language and occupations by spending time with local severely disturbed the economy and community infrastructure. people before starting our placement. Many customs and habits Many people lost personal property, homes, businesses, and were new to us and we had to adapt to those. Examples included, opportunities for paid employment. In April, 2007 an earthquake men holding hands while walking down the road, greetings and and tsunami struck the Solomons some 90 miles from the capital directions given via eyebrow communication, signalling a bus to Honiara. Fifty-two people were killed and hundreds displaced. stop by hissing and bright crimson smiles because teeth, gums Subsequently, relief agencies have had an ongoing presence in and lips were stained red from chewing the local, mildly narcotic the region to address issues such as the provision of shelter and beetle nut. Many daily occupations, that were also new to us, were education. performed in novel ways or valued in an unexpected manner. Examples of the differences are included in Table 2. Even prior to the tsunami, the Solomon Islands were considered the poorest Pacific island nation as a result of social and political Honiara, the city where we were situated was approached by unrest (Gordon, 2006). Accurate facts about disease, mortality a tarmacked road dotted with potholes. Building regulations and disability are limited. Infectious disease such as malaria, for universal access including use of ramps or hand rails was tuberculosis and meningitis are common. The mortality rate nonexistent. Most of the buildings were one or two storied and for children under 5 years is 9 times higher than Australian accommodation varied, with large extended families living in children (WHO, 2006b). The ratio of physicians to the rest of the western style houses, tin shacks or picturesque huts on poles. population is approximately 1:769 in the Solomons and 1:404 People reacted to us with curiosity and friendship. Many would in Australia (WHO, 2006a). Table 1 compares statistics from stop us and ask to ‘story’ (tell about ourselves). In rural areas the the Solomon Islands and Australia using global benchmarks to sight of a white young woman was rare, and often people would provide the reader with an idea of the contrast between the lives of call out a greeting waving furiously with their machete. The the student and the recipients of service. The reader is reminded stifling heat made physical activity strenuous. that the selected source for this information was deemed reliable, although the potential for minor inaccuracies is acknowledged. Table 2: Examples of Solomon Island occupations, customs, and performance.
Student placement Occupation Examples Customs / performance / tools and tool use experience The following account is by the first Gardening Machetes as multipurpose tools. author of this paper. Fishing Traditional dug out canoes with paddles. In 2004, my classmate and I decided Produce marketing Open air markets, small subsistence produces. to pursue our final fieldwork Productive placement in a hospital and CBR department in the Solomon Islands. Craft Different provinces have specific craft expertise. Prior to leaving for the islands we Caring for ‘stacka pikini’ Shared by all family members. A child chosen by prepared ourselves by researching (many children) the family may become the ‘maidservant’. dress codes, indigenous customs, health considerations including Toileting Long drops, the sea or the bush. what inoculations were required and the local pidgin dialect. In addition, Personal ADL’s Locations included: the sea, rivers, the pump or we established guidelines for ethical ‘swim swim’ public taps with buckets. Self care considerations, distance supervision Cooking by open fire, underground ‘motus’ or and safety issues. Although we Cooking ‘kaikai’ and eating ovens made from barrels. attempted to complete a needs Food often eaten outside. analysis of the clients we would Toe nails Toe nails are cut with a machete work with, there was a paucity of up Hold hands while conversing. People invited and to date information available. ‘Storying’ or conversation thanked for ‘storying’. Socio-cultural differences Most villages have their own soccer fields and On arrival in the Solomon’s we were Leisure Soccer and volley ball volleyball areas. challenged by common morbidities People with disabilities often excluded from active and mortalities; the local perception Music and dance sport. of medical conditions; organisational Style of dance and music varied between tribes.
Volume 55 No 2 New Zealand Journal of Occupational Therapy 27 FEATURE ARTICLE Ana Burggraaf, Helen Bourke-Taylor
Service provision Within the hospital, Our first impression of the hospital was daunting. Located by sports and garden the beach, it comprised of single storey buildings connected groups were organised by walkways. Equipment was limited and the facilities often for clients with various overcrowded. Relatives who came to visit people who had no impairments, such as ‘wantok’ (family) in the city, stayed in the hospital room. The upper or lower limb beach was used as a dump for hospital refuse. amputation; acquired brain injury; burns; and Our physiotherapy colleagues had limited knowledge of the musculoskeletal injuries skills occupational therapy students could offer but they were mainly related to excited to have ‘splint makers’. Some of the physiotherapists had machete cuts. Self care been trained in Australia and some in Fiji, others were trained and domestic activities on the job. As previously mentioned, the country’s first paid of daily living groups occupational therapist started work six weeks into the placement. were also facilitated. She was an indigenous Solomon Islander, who had trained in In the community, New Zealand. Her education had been financed by the Solomon developmental groups Island Government. On completion of her degree she had to wait were run for children 10 months for them to decide her future employment. with CP within the local Aside from the health professionals already mentioned, staffing Red Cross facility. We Figure 1 was limited to the CBR aides. These local workers were not visited clients in their trained in any specific allied health discipline. Accountability in home to address issues such as pressure care; inclusion of children terms of time management, professional protocols, gathering and with disabilities in family routines; incorporating appropriate documenting client information was limited in both CBR and play ideas for children with developmental delay into daily IBR workplaces. For instance, documentation and accountability routines; and assisting adults with hemiplegia, or other physical for a CBR aide could consist solely of a letter written to their disabilities to learn ways to dress and care for themselves. These department head explaining what they had done the past CBR home visits introduced us to various levels of poverty and a month. range of living conditions. The terrain covered, the local housing conditions of more affluent clients, and the appropriate dress for Service needs the region is illustrated in Figure 1. People with disabilities faced poverty, discrimination and physical environmental barriers limiting their participation in occupations. Reflections A lack of general health knowledge and limited schooling caused Formal evaluation of the student led occupational therapy minor problems to develop into major impairments. Many programmes was not undertaken. Nonetheless the student’s islands had no immediate access to health professionals. People reflections are described in this section. came to the hospital sometimes one year post injury. As a result, Several factors that might have improved our performance and conditions such as a dislocated hip required lengthy admissions. university supervision of this placement became apparent only Strong family ties in the ‘wantok’ system ensured family members after the project had begun. Prior to leaving for the Solomon with a disability were cared for. Tailored services were limited or Islands research into the health needs of the people living there, unavailable and so often people with a disability did little for revealed little information about the types of conditions and themself. For example, children with cerebral palsy (CP) could be left Table 3: Occupation focused interventions lying on their back, on a mat, all day as family fed and cleaned them but Obstacles Strategies Outcomes provided few activities. Thus, family ‘Wantok’ cared for clients Endeavoured to educate Mixed responses. Interest in interdependence inadvertently when client capable and clients and ‘wantok’ on the learning to be independent promoted pressure sores, deformity, interested in self care. relationship between health limited to young or newly contractures and underdeveloped and participation in daily disabled persons. cognitive and emotional skills. activities. Negative attitudes limited Sports and gardening groups Clients enjoyed participating Student’s occupational therapy client participation in initiated to facilitate client and began to ignore negative programme occupations. empowerment. comments from onlookers. After considering the above People with disabilities Sports group offering Clients more motivated to join needs we set about developing a hidden/laughed at, or avoided. modified games, such as sit in leisure occupations. programme. A week consisted of down volley ball, table soccer, two days in the hospital (IBR) and and paired cricket (person A 3 days in the community with the running, person B batting). local CBR aides visiting local homes.
28 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupational therapy service in Solomon Islands FEATURE ARTICLE disabilities that we would need to address. Moreover, we found few autonomy and self sufficiency for the programme and workers guidelines to direct the preparation process within occupational in the Solomon Islands, and we did achieve this to some extent therapy literature. The successful preparation strategies included by modifying local items. Nonetheless, other items manufactured attending meetings over the course of one week prior to our and easily available in Australia made an enormous difference. departure. We wanted to learn what we could about culturally Some people with amputations for example, were given specially appropriate dress, communication style, family customs, roles modified wheelchairs from Australia that had big tyres enabling of men and women, taboo customs/beliefs/habits of the local them to navigate rough terrain. Overall the question of providing people and attitudes to white people, from people familiar with materials from Australia was a dilemma because it is contrary the Solomon Islands. This also provided opportunity to practice to the principles of CBR. Ultimately, we were guided by the the pidgin dialect, and come to understand the many differences philosophy of CBR which promotes self sufficiency for, and by, between us and the local people. Cultural competency was further the local community. See Table 4. enhanced by preliminary tutorials and key readings provided by Once the paucity of supplies and local funding options was our supervisor and others, to facilitate reflection on our personal revealed several aid agencies were approached for donations and beliefs, attitudes, and values. In addition, on our arrival CBR the money was used for supplies. The indigenous occupational workers and hospital based colleagues provided crucial insight therapist collaborated and expanded our findings and efforts into many aspects of the Solomon Island culture that might have after she joined the team. Various organizational issues were taken us months to understand. also addressed. These included establishing a system for documentation, client transport, funding options, and staff Interventions accountability. See Table 5. Internet communications with experienced occupational therapists in Australia occurred regularly during the placement. Discussion As a result, our supervisor was able to suggest, direct, and provide This paper has described the experience of two Australian feedback that led to the implementation of a group programme occupational therapy students on fieldwork placement in the for children with cerebral palsy, as well as ideas for facilitating Solomon Islands. The students planned interventions and function for the child in the home. This advice usually came coped with difficulties as they arose and thus achieved positive within a day of asking. Alternatively, other conditions presented outcomes during their learning experience. Not having an a need for different expertise and locating a suitable clinician occupational therapy supervisor at hand meant the students willing and able to offer appropriate advice often led to crucial faced many challenges in trying to practice efficiently. Their delays. For example, burns and machete cuts were common local IBR physiotherapy supervisor provided valuable assistance due to the methods being used in the performance of daily by introducing contacts, interpreting, explaining cultural issues occupations. In one instance, a girl required a splint for a burn to as they pertained to therapy, and setting up opportunities for her hand. Finding a suitable advisor caused a two week delay in practical experience. However, he had limited knowledge of the treatment inasmuch as the splint we made was unsuitable and the specifics of occupational therapy practice. Although the students prescription of range of motion exercises was delayed. Things like were able to contact their Australian supervisor daily, they also this may have been avoided if we had more information about the type of conditions likely to require Table 4: Resources intervention prior to leaving. Our physical presence in the Obstacles Strategies Outcomes hospital and in the communities Limited access to technology. Laptop computer taken to the Reproducible outlines, gave us a realistic picture of what Solomon Islands. handouts, application letters, we could possibly achieve. Informal and Occupational Therapy evaluation of the types, number, and PowerPoint presentations. adequacy of current programmes Communication Other staff interpreted, More effective communication. was addressed by talking with local directions repeated, picture handouts created. people. After we discovered the cultural tendency to hide people with Overwhelming need, Debriefed with fellow student; Self management - disabilities away from public view disabilities, poverty, and recorded personal feelings in contained feelings of being unsanitary conditions. a diary. overwhelmed / ineffective. we investigated, and identified, the population groups missing out on Absence of therapy tools. Smooth sticks used to build Adaptive equipment and service delivery. See Table 3. up handles, bottles filled with therapy items organised with stones to make a rattle. little expense. Similarly, equipment could possibly have been organized and shipped in Other disciplines unaware of In-service for IBR and CBR Staff more aware of occupational therapy scope of staff. occupational therapy preparation. For instance, the local practice. Lecture to final year nursing knowledge base. mobility aids (especially wheelchairs) students. CBR worker applied to study and splinting materials were basic. occupational therapy. Overall, we wanted to promote
Volume 55 No 2 New Zealand Journal of Occupational Therapy 29 FEATURE ARTICLE Ana Burggraaf, Helen Bourke-Taylor relied on each other for support. Coming from similar cultural output had different levels of success. For instance, a small gift backgrounds helped them to relate to each others needs. of a watch made a difference to time management but it was disappointing when documentation was not completed because Fransen (2005) identified important strategies to advance there was no accountability. Training groups were always well occupational therapy services within CBR. These included attended, perhaps because the group dynamics were so powerful. collecting and sharing examples of the work occupational For example, members of the sports group would encourage each other to ignore negative comments Table 5: Improving work management skills from onlookers. Mentorship between old and new group members was a Obstacles Strategies Outcomes useful strategy to ensure ongoing Time management = group participation. ‘bush time’. CBR aides given watches. Staff arrived on time. Given the local tendency to rely on Appointments missed due to Multiple clients scheduled am, the wantok system, a disabled person ‘bush time’. noon, or pm only. Attendance improved. may assume it is family’s duty to Walking as a means of 4 wheel-drive borrowed from More clients seen and assist them with activities of daily transport. hosts. equipment transported. living. Thus, relevant occupation based interventions met with mixed Large clientele, limited Various group programmes Improved client contact. Group responses. Alternatively, engaging professional staff. initiated. work enhanced therapy. clients with disabilities in leisure Poor writing skills to apply Hard copy and electronic Timber off-cuts to make occupations had much more impact for financial and resource outline for letter writing to aid equipment; petrol and the on the Solomon Island locals. assistance. agencies provided. use of a school bus, and This may be because the singular equipment for the visually sedentary activities found in Western impaired donated. cultures, such as TV and radio, are Developmental group for Group advertised via IBR and 12 children regularly not available in the islands and so children with cerebral palsy CBR programme, local radio, attended the group. poorly attended. word of mouth. leisure occupations are commonly shared with others. Poor group work skills to run A step-by-step guide written CBR aides facilitated a developmental group for in simple English. Observation sessions independently and The lack of accurate information children with cerebral palsy. and mentoring of CBR aides. competently. about the needs of clients with Lack of detail in New client and family centred Staff not interested in the disabilities in the Solomon Islands documentation. forms created. extra work involved. prior to departure meant the students did not feel they were appropriately prepared. Those needs only became therapists are doing in CBR; mentorship from those working evident when the students were faced with assessing client’s within CBR; development of process models that bridge the gap needs. In addition, the students struggled to cope with the local between occupational therapy theory and the realities of CBR attitude towards people with disabilities as the general community practice; dissemination of information through publication; and commonly responded by shunning or laughing at them. research to improve occupational therapy’s agency in CBR. Nonetheless, placements like this are worthwhile to both students, and the facilities that host them. They are a valuable opportunity Outcomes for Western students to gain experiences they would unlikely The students skill development initiatives were mainly aimed be exposed to otherwise. Facilities that host student placements at the CBR aides. Although the effect of the students input benefit from the students knowledge, skill, and enthusiasm, was not formally reviewed, the students themselves thought which are valuable commodities in the majority world. Working documentation and group skills improved. The aides’ ability in collaboration with local people promotes self-esteem and to maintain the developed programmes was facilitated by determination, encourages ownership of programmes initiated, providing them with resources, increased autonomy, and by and thus the continuation of worthwhile projects. inclusion in the latter stages of service development. Had they been involved in all stages of the programme development they Key messages: may have gained more understanding and confidence. In the end, n Occupational therapy services in the Pacific region benefit the new occupational therapist was provided with programme people with disabilities. information for continued maintenance. In hindsight, it would have been more effective to include the occupational therapist n Sharing knowledge of strategies used to meet the needs of from the beginning. In that way, she would have had increased people with disabilities living in adverse and under resourced ownership of the programme as it developed. communities as well as positive and negative outcomes is important. Strategies used to improve time management and thus work
30 New Zealand Journal of Occupational Therapy Volume 55 No 2 Occupational therapy service in Solomon Islands FEATURE ARTICLE
Kronenberg, F., Salvador, S. A., & Pollard, N. (2005). Occupational therapy n Collaboration with local people is essential for ongoing without borders: Learning from the spirit of survivors. London, UK: development of occupational therapy services in CBR. Elsevier. National Geographic Society. (2008). People and places? Map machine: n Professional communities in New Zealand and Australia Country profiles. Retrieved April 07, 2008, from http://plasma. could assist occupational therapy service development in nationalgeographic.com/places/directory.html under privileged communities by educating and supporting Thibeault, R. (2006). Globalizations, universities and the future of occupational therapy: Dispatches for the majority world. Australian indigenous people through student placements. Occupational Therapy Journal, 53(3), 159-165. Townsend, E., & Wilcock, A. (2004). Occupational justice and client centred n The WHO’s CBR and IBR strategies require support and practice: A dialogue in progress. Canadian Journal of Occupational assistance from the worldwide occupational therapy profession Therapy, 71(2), 75-87. to sustain health professionals, students and CBR workers. World Federation of Occupational Therapists. (2004). Position paper on Community Based Rehabilitation Retrieved April 4, 2008 from Footnote: http://www.wfot.org/office_files/CBRposition%20Final%20CM2004% 281%29 At the completion of the placement, the CBR manager advertised World Health Organization. (2002). Community-based rehabilitation as we three generic positions within the field of disability in Solomon have experienced it: Voices of persons with disabilities, part 1. Retrieved Islands, in an Australia-wide Occupational Therapy newsletter. April 4, 2008 from http://whoqlibdoc.who.int/publications/9241590432 One of the CBR aides working at the time of this placement has World Health Organization. (2004). CBR: A strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of now graduated from the local occupational therapy course. people with disabilities. Retrieved April 3, 2008 from http://whoqlibdoc. who.int/publications/2004/9241592389.pdf References World Health Organization. (2005a). Disaster, disability and rehabilitation. Bourke-Taylor, H. M., & Hudson, D. (2005). Cultural differences: The Retrieved April 4, 2008, from http://www.who.int/violence_injury_ experience of establishing an occupational therapy service in a prevention/other_injury/disaster_disability2.pdf developing community. Australian Occupational Therapy Journal, World Health Organization. (2005b). United Nations Commission on 52(3), 188-198. Human Rights, (61st session). Retrieved March 30, 2008 from http:// Bourke-Taylor, H. M. (July, 2006). Overcoming obstacles to occupational www.who.int/hhr/information/en/Written%20submission%202005_ therapy service delivery in developing communities: Cultural 61st%20session considerations and case examples. Presentation at the World Federation World Health Organisation. (2006a). Global atlas of the health work of Occupational Therapists 14th Congress, Sydney, Australia. force. Retrieved April 1, 2008, from http://www.who.int/globalatlas/ Fransen, H. (2005). Challenges for occupational therapy in community- DataQuery/default based rehabilitation. In F. Kronenberg, S. A. Salvador, & N. Pollard World Health Organisation. (2006b). World Health Report. Retrieved April (Eds.). Occupational therapy without borders: Learning from the spirit 3rd, 2008, from http://www.who.int/whr/2006/annex/06_annex1_en.pdf of survivors (pp. 166-182). London, UK: Elsevier. Gordon, M. (Saturday July 5th, 2006). Pacific politicians turn a blind eye: Poor governance and corruption threatens to sweep island nations down the drain. The Age, p.15.
Volume 55 No 2 New Zealand Journal of Occupational Therapy 31 THEORETICAL ARTICLE Linda H Wilson, Kaye Cheetham Tools of practice: A view of changes in occupational therapy in Aotearoa New Zealand.
Linda H. Wilson & Kaye Cheetham
Abstract This historical review of literature relevant to occupational therapy practice in Aotearoa/New Zealand identified three eras, each with a distinct focus. We argue that knowledge of practices used in the past can usefully inform present and future practice. To this end product advertisements, book reviews and therapists’ writings in publications of the New Zealand Association of Occupational Therapists have been used as sources of information about the past. The three eras identified included, focus on activity, problem solving, and management of clinical practices, services and knowledge. The practices in each era are still evident today and each focus remains legitimate. Key words History; occupational therapy tools of practice; practice changes. Reference Wilson, H. W., & Cheetham, K. (2008). Tools of practice: A view of changes in occupational therapy in Aotearoa New Zealand. New Zealand Journal of Occupational Therapy, 55(2), 32-39.
he expression ‘tools of practice’ has had a particular meaning and community attitudes, diversified occupational therapy. Tin occupational therapy since Anne Cronin Mosey first From early practice in mental and public hospitals, occupational articulated them in 1981 (Mosey, 1981). Mosey defined the therapists now work in schools, voluntary organisations, and occupational therapy tools of practice as: the teaching learning in independent practice, with people who have a wide range of process, human, and non-human environments, conscious use of health conditions, and/or circumstances that affect their ability self, activity groups, activity analysis, and activity synthesis. The to engage in occupations. publication of her book ‘Configuration of a profession’ (1981) Historical analyses of literature may help to develop more provided many therapists with an exciting way to see the diverse understanding of past practices and thus can usefully be used knowledge and skills used by the profession that were previously to inform the future. The findings of this literature review are unnamed and uncodified. Her vision was a significant contributor presented as three eras that are not mutually exclusive; rather they to the ideas underpinning the profession and clinicians, educators, overlap and flow into one another. Ultimately, each era remains and students were advised they “should recognise in this book the evident in the profession today and deserves to be acknowledged basis for re-examination of the foundations and ever changing and respected. The emergence of new practices does not negate structural components of the profession” (Gillette, 1982, p.678). the need for established practices and so we argue that all practice Mosey’s (1981) use of the word tool is conceptual, contrasting domains remain legitimate. with the customary use of ‘tool’ which refers to an artefact, an implement or simple machine (Sykes, 1980) used in an Reviewing the literature occupation or pursuit. Mosey used the term as an idiom and The New Zealand Association of Occupational Therapists included all those things needed to perform the specific tasks of occupational therapy practice. Throughout this article, the term Linda H. Wilson PhD, MSc, DHA, NZROT, NZCAET tools of practice is used in both ways, referring to Mosey’s tools Principal Lecturer and to actual equipment. School of Occupational Therapy Despite people being employed in a range of occupation related Otago Polytechnic roles, in various settings, since the 1914-18 war it was not Kaye Cheetham Dip O.T., PGDip Occ Ther Pract. NZROT until 1940 that a formal training programme for occupational Senior Lecturer therapists was started, leading to the profession we now know School of Occupational Therapy (Skilton, 1981). A professional association began in 1948 and Otago Polytechnic one year later registration was instituted by an Act of Parliament. There are some 1700 therapists currently practising and over Private Bag 1910 5000 have been registered since then. Growth in the number of Dunedin therapists, along with changes in health and disability services Email: [email protected]
32 New Zealand Journal of Occupational Therapy Volume 55 No 2 Tools of practice THEORETICAL ARTICLE
(NZAOT), and its antecedents, has had a Table 1: Selection of activities named in first newsletter publication of various names and formats, basketry hand quilted cushion covers powder bowl since 1948. Both Levine (1986) and Schwartz (1988) have written about the value of historical bath mats handicrafts scarves ( woven) research to the profession of occupational book ends in laid wood work shadow work (embroidery) therapy so in keeping with their advice a bookbinding knitting skirt length (woven) systematic examination of NZAOT newsletters and journals was undertaken. Tortenstahl (1990) braille reading knotting smocking supported this approach when he stated, “A bread flowers leatherwork spinning proper way to study professional groups is then, carpentry letter cases supper cloths ( embroidery) often, to examine their history and prehistory” (p .45). Professional publications have a range of coir mats making scarf looms tapestry pictures/stool tops information that can help to reveal the evolution crochet moccasins tatting of practice. We located descriptions of practice, felt animals necklaces ties (woven) product advertisements, and book reviews to extract an understanding of practice from 1948 fine sewing/hemstitching paper crumpling toy making to today. Articles were examined to identify data floristry paper flower making travelling rugs (woven) about the authors, practice settings, tools and gardening pikloom weaving approaches to practice in the form suggested by gloves poker work woolly sheepskins toys Cusick (1995). There are caveats to using this type of data as a window to the past. For instance, product advertising can only be an indicator of practice because they used in practice. Table 1 lists, in alphabetical order, the range suppliers only advertise where they perceive potential purchasers. of products and processes identified by nine therapists in the 11 Similarly items termed ‘book reviews’ change in depth, referencing cyclostyled pages of the newsletter. Few therapists provided details and amount of critique. However, these all relate to the practices of the activities; perhaps because there was an assumption that of the time, and can be used to examine and illustrate changes in colleagues would know them, as many were part of the formal occupational therapy practice. training programmes of the time (Wilson, 2004). In this case, the data builds on the history of the NZAOT Over the next two decades therapists recorded diverse activities publications previously reported, (see Wilson, 2002). Information including creative, social, and work, all of which required the use was gathered from 98 out of 119 possible editions of the association’s of tools. The tools and machinery used in occupational therapy variously named journals, though some editions prior to 1972 were departments within hospitals were those associated with the untraceable. Information about the early 1940s was found in Hazel production of practical items such as, looms, scissors, spinning Skilton’s memoirs (Skilton, 1981). Time lines and spreadsheets were wheels, crochet hooks, pliers, and so forth. Parties, outings, and developed from these sources, and thus we were able to construct a plays were also considered therapy, not only in the large psychiatric clear image of changes in practice over time. To explore and present hospitals (Skilton, 1981) but also for example, in association with the practice across the different eras we adopted the notion of tools of Dunedin Spastic Fellowship (Walker, 1959). Because hospital stays practice. could be lengthy, there was time for people to develop skills, and to undertake large projects. First era: Focus on activity: 1940-1965 Getting people involved, Cottage crafts are most obvious in the first era when activity is being busy, leading to a the focus of therapy. In newsletters of the time therapists named good time was deemed to be the activities they used, as well as describing ideas, techniques and therapeutic. resources. In their writings the therapists emphasised the crafts and Advertisements from this products made by clients (then patients), rather than their therapeutic era were usually for craft effects. Ideas on how activities could be graded or modified, to materials and construction enable the person to complete it within their competence were supplies. For instance, shared, but the primary emphasis was on activity participation and leathers and suede split for completion. leather work (Sutherland, S/he has done most of the light crafts allowed TB patients and 1953), wools and needlecraft ...has made beautiful articles for her home - a tea shower in supplies (Art Needlework shadow work, hand quilted cushion covers, tapestry pictures, Industries, 1953), marquetry tapestry stool top, and fire screen to match, pokered plaques, kitsets for toy making bookends and powder bowl (Timms, 1948, p.7). (Martin, 1957), and weaving supplies including, 12 and The first New Zealand Occupational Therapy Newsletter (1948) 15 inch rigid heddle looms included pieces from local therapists who described the activities Figure 1: (Sutherland, 1959) were Sample advertisements from 1959
Volume 55 No 2 New Zealand Journal of Occupational Therapy 33 THEORETICAL ARTICLE Linda H Wilson, Kaye Cheetham all advertised. These advertisements were predominately text and full participation possible. Hazel Skilton described one returned followed a standard style. One exception was a reproduction from soldier: a hobby magazine (Martin, 1957). Figure 1 gives an example of He was...convinced life was finished for him. After seeing advertising in 1959. the fruit bowl made by another one armed man he was finally encouraged to try and with the help of a similar Books were also named as resources or tools of practice, with pouch to hold the chisel he made a very creditable bowl of authors recorded but not the publisher. Focusing on activity, inlaid wood (Skilton, 1981, p. 44). the majority offered specific techniques for toy making, floral art, or block printing. These books were rarely reviewed as we Mosey’s tools, and the articles produced, were known to understand the process today, rather titles were merely listed. constitute successful therapy, in terms of therapists goals. As For example, volume 7 of what was then called the Newsletter Skilton stated: “When he showed it to us we found it difficult to Journal carried a list of “books you may like to read” (p. 2) with speak for the lumps in our throats. ...(A)s he held that bowl for seven titles which included ‘Glovemaking’ and ‘Modern trends in inspection there was a look on his face that would be impossible psychological medicine’. In 1956, a short paragraph “Have you to describe” (p. 44). read these?” carried two recommended titles on ‘Psychiatric art’ and ‘An introduction to embroidery’ which were accompanied Fields of practice by the comment “Both these books are very interesting and well Using occupation as a tool to address other health problems illustrated, the latter in colour” (NZROTA (Inc), 1956, p.11). became increasingly visible in the late 1950s. For instance, in 1958 There were few profession specific titles. Joyce Sutherland talked about a residential service for people with physical disabilities in which she described the range of activities Mosey’s tools the residents participated in. These included quiz sessions with These snapshots of practice affirm that all of Mosey’s seven tools local Jaycees, a stamp club, darkroom, films, and the production existed in this era, before she actually defined them. For instance, of a newspaper. She also identified the main functions of the her ideas on teaching and learning were implicit in that if people occupational therapy department as being: are taught new activities then teaching and learning takes place. To maintain the movement residents already have; develop Sometimes this was explicit, such as when Mollie Sheriff described and improve muscular power where possible; try to develop the new knitwear unit for the organisation now known as NZCCS. co-ordination and maintain it when developed; learn hand She reported “Two of them [the children] had never used a sewing skills that can be applied to some form of useful occupation machine before so they were taught right from the beginning” with an end of sheltered employment; and assist with any (Sheriff, 1953, p. 5). It would seem the early therapists knew how daily living problems that may make them more independent to deliberately motivate people into participation in activities, and relieve the nursing staff (Sutherland, 1958, p.13). the forerunner to what Mosey would have called conscious use of To summarise this era, we presumed that the purpose of activities self. Likewise, Hazel Skilton (1981) told of the student who “used in those days was to offer people something useful to do. It was her personality to gain the woman’s attention” (p. 67). the ‘being occupied’ that was therapeutic. Activity motivated Similarly, the environment, non human and human, was evident people and helped them to restore function or to make possible through descriptions of different centres. The occupational paid employment, benefits that were welcomed by-products of therapy department at the Auckland mental hospital was described making and doing. In that era it would seem the primary tool of in detail and included comment on the “large airy workroom”, practice was to create opportunities for people to be occupied. which is “pale duck-egg blue” with “plenty of large windows to let When two types of practice became evident in the same article in the light and plenty of louvres to let in the air” (NZOTA, 1953, it established the shift from an occupational focus to one which p.8). Appropriate space helped to create the context for therapy addressed specific problems. As the focus shifted so did the type as therapists often worked with large numbers of clients together. of equipment and materials used. Nonetheless, Mosey’s tools of “We have two classes of women numbering around 16 to 18 a practice remained evident. class and 42 men on our roll...” (Renner, 1948, p. 8). Interaction between the activity groups’ was deemed important, and whether Second era: Focus on problem it was deliberate or spontaneous it was acknowledged. solving: 1960-1980 The last few weeks it has been such a pleasure for they During the second era the focal point became problem based seemed so very happy in their work, and it was such a thrill in that the goal of therapy was to enable the person to do the when the whole class broke forth into song, softly at first, tasks important to them, and thus to improve specific skills or then part singing and ending in rounds (Renner, 1948. p. 8). functions. As articulated later in the literature of the 1990s, the goal of activities became purposeful as opposed to just participatory Careful activity analysis was evident when the suitability of a (Gray, 1998). Letting go of the notion of involvement in leisure specific activity was considered say for example, regarding the activities as therapeutic, was especially noticeable in areas effects of tuberculosis. Gladys Timms wrote: “He is a haemorrhagic concerned with physical illness and disabilities. For instance, case frequently staining for days so needlework and the plait of Bassett (1973) described a threading game used to improve his brother’s cane trays are his limit” (p. 7). Activity synthesis was perception, which seemed to have had the elements of ‘game’ evident in the techniques used to adapt and modify tasks to make removed.
34 New Zealand Journal of Occupational Therapy Volume 55 No 2 Tools of practice THEORETICAL ARTICLE
As a consequence, the tools of practice changed and equipment suggestions for that measured and resolved the problems faced by people with rehabilitation disabilities or other health conditions were introduced. These practices and included tools such as grip meters, which recorded grip strength devices. Sample in relation to hand function, (Anonymous, 1968), bicycle fretsaws, titles from this (Haliburton, 1976), upright looms (Sutherland, 1966) which were period which Figure 3: sample advertisement from 1979 used to improve physical function and reduce disability. Other captured the equipment used to eliminate or reduce the effects of disability diversity of practice included, ‘Rehabilitation following fracture included raised toilet seats (Anonymous, 1969) and adjustable of femoral neck’, ‘The sociology & social psychology of disability bath boards (Ford, 1974). The tools were described along with & rehabilitation’, and ‘The garden and the handicapped child’. The construction details, and advertised as purchasable items in the reviewer of a cookery book offered the following opinion “ideal journal. for those requiring rehabilitation in their kitchens” (Emery, 1976, p. 6) while another publication on managing life with arthritis It is easy to understand why occupational therapists were focused on “alternate ways of doing things as well as simple aids” drawn to this newer aspect of practice. The profession had (Marshall, 1974, p. 24). It would seem the primary tools of the experience in modifying activities to enable people to participate. profession had moved from those associated with creating and Whereas activities were modified to be beneficial in specific making an object, to tools that would enable independence. ways likewise equipment was modified for the same reason. This problem solving approach was congruent with the medical Groupwork model whereby diagnosing and treating a problem is the basis Returning to Mosey’s (1973) tools of practice, the conceptual of practice (Mattingly & Fleming, 1994). For example, similar framework for this article, leisure activity based therapy was problem solving tactics were evident in descriptions of modified congruent with occupational therapy practice in New Zealand. nappies for a hemiplegic mother (Climo, 1976), or a design for When groups of clients came together, therapists used components a toy trolley for a child with a disability (Buchanan, 1976) and of activities to influence physical, social or psychological splints, both lower to aid mobility (Wilson, 1972) and upper limb functioning (Haddon, 1976). Reported groups included to reduce contractures (Brown & Taimana, 1966). supporting people with rheumatoid arthritis (Clinch, 1975; The changes were a gradual process. In 1966 therapists were Dey, 1979), and cardiac assessment groups (Macdonald, 1975). still using basketry, weaving, and stool seating (the seat of a stool The activity group at one unit “employs leisure time activities to was woven using sea grass or rattan cane) as functional activity encourage social skills” (Nell, 1975, p. 22) furthermore, teaching options more frequently than creating assistive devices (Tillson, and learning strategies were clearly evident in these activity 1966). groups (Liew, 1979, p. 32). Modifications to the non human environment were visible in equipment prescription, but the human environment was less evident. Conscious use of self was not described but it was evident in the description of services for “thirteen-going-on-thirty, adolescents” (Wheeler & Banga, 1979, p. 31). The nature of articles and contributions to the journal began to change towards the end of this era, from reporting and describing practice, to service evaluation and conceptual approaches to practice. In an editorial at the end of the 1970s Cameron (1979), reflected on the changes in practice. She expressed concern that “only a few therapists are willing to use occupational therapy activities for patient treatment” and argued for the retention of “purposeful, real tasks” in rehabilitation (Cameron, p. 32). Figure 2: Tillson’s survey of activities used in practice (1966). However, purposeful activities became less visible over the next This was reflected in the advertisements for activity materials twenty five years. carried in the journal throughout the era. Nevertheless, awareness of equipment to aid problem solving in daily living activities Third era: Focus on management: increased as the journal contained information on equipment 1980 - present and costs, which were neither indexed as articles nor positioned as A focus on management was very evident in the third era. This advertisements. Figure 3 shows a copy of a typical advertisement became obvious from three different aspects: clinical management, from 1979. service management, and professional knowledge management. As the theoretical tools that aided understanding, articulation, The focus on activity appeared to diminish as more books were and justification of practice became more apparent, rehabilitative reviewed, an overview of the content provided, and a range of equipment, the problem solving process, and Mosey’s tools of therapeutic interventions reported (Anonymous, 1981). The practice remained. reviews advised therapists on texts that provided helpful hints and
Volume 55 No 2 New Zealand Journal of Occupational Therapy 35 THEORETICAL ARTICLE Linda H Wilson, Kaye Cheetham
According to Stewart (1979), the purpose of management is “deciding what should be done and getting it done” (p. 71) while the functions of management include planning, organising, directing (or coordinating) and controlling (Shortell & Kaluzny, 1988). The place of management is very clear in this era and supports our assertion that management is another tool of practice. Within the occupational therapy journal the term clinical management was used in relation to many areas of practice. For instance, pain management, (Milne, 1983), anger management (Hocking, 1990), anxiety management (Halford, 1985), and equipment management services (Gooder, 1995) are the focus of specific articles. Problems were not solved with these processes but could be organised and controlled with appropriate planning. So, just as the problem solving process became a conceptual tool in the previous era, management became a new tool of practice. When the health sector adopted management theory, and as the number of people in the work force increased, service management became an important topic. Articles on the subject Figure 4: sample advertisement from 1981 included staffing (Polkinghorne, 1983), reorganisation (Kendall, titles such as, Crafts in therapy and rehabilitation (Drake, 1992), 1994), filing (Glenday, 1988) quality assurance processes (Cowan, Activities with developmentally disabled elderly and older adults 1986), and change management (Dever, 1991). Evidence of (Keller, 1991), and Occupational therapy protocol management the profession’s interest in understanding and managing its in adult physical dysfunction (Daniel & Strickland, 1992). One unique knowledge became apparent when the emphasis turned 1996 edition of the Journal contained eleven book reviews, which to articulating occupational therapy practice (Leary, 1986, ranged from hand assessment and treatment (Nettlingham, 1996), Cameron, Managh, Moffit, & Sirrett, 1988). With the renaissance leadership for group activities (Kokich, 1996), and therapeutic of occupation as a core concept of health, occupation specific activities for people with Alzheimer’s (Preston-Jones, 1996). knowledge was important (Gooder, 1992). In 2002, Otago Polytechnic School of Occupational Therapy Around this time, the rationale for specific treatment approaches investigated current trends in practice associated with a (Cull, 1990), was aligned to occupational therapy theory curriculum review. (Ferguson, 1982), and the theory applied to specific practice settings (Thompson, 1987). Commercially produced equipment The overall top 10 therapeutic interventions can be seen in Table for daily living came to the fore along with an awareness of the 3. Ranked by practice area, a mixture of locations, processes need for housing and workplace modifications to support people and techniques are identified using therapists’ own language. with disability in their daily activities. Structured assessments and The emphasis on problem solving and practice management in frames of reference were developed and used to guide therapists’ comparison to activities is overwhelming. judgment and decision making with reference to competence Here again Mosey’s tools of practice are evident, the teaching in daily tasks. Articles which focused on occupational therapy learning inherent in ADL retraining, the human and non human interventions with specific clients, in specific settings, using environment is considered in wheelchair prescription, activity specified technical approaches were published. Examples included community support groups (Whyatt, 1986), groups Table 2: Top 10 daily activities in geriatric services (Thompson, 1987), autism rating scales (Christie & Robertson, 1991) and computers (Christie & Marsh, Top 10 activities Number reporting Percentage reporting 1989; Simmons, 1988). Home visits 59 50% By the early 1990s advertisements in the journal were primarily Team meetings 58 49% about equipment to manage physical disabilities. Products were Documentation 54 45% increasingly manufactured commercially rather than produced by therapists. The mass produced items were based on similar Group work 49 41% Equipment principles as those used by the early occupational therapists, 48 40% prescription improved by technology and marketed professionally. Initial interviews 39 33% Books on occupational therapy became increasingly conceptual, ADL assessments 33 28% and activity as a therapeutic process remerged. For example, Mosey’s (1981) Configuration of a profession, Kielhofner’s (1985) Goal setting 23 19% Cognitive Model of human occupation, and Young and Quinn’s (1992) 22 18% Theories and principles of occupational therapy. Increasingly assessments the books reflected the diversity of practice across all eras with Education 19 16%
36 New Zealand Journal of Occupational Therapy Volume 55 No 2 Tools of practice THEORETICAL ARTICLE analysis and synthesis appears in the evaluation of equipment. The emerging role of consultant requires tools of practice which There are also tantalising glimpses of activity groups, although include: relationship building to enable collaborative practice whether the focus is on activities, skill development, or self (Simmons Carlsson, 2006), evidence based decision making management is unclear. It would seem that from the time specific (Dunn, 2000), teaching/learning and supervision accompanied activities were used with clients through to the development of by an understanding of organisational and political power conceptual and process tools, Mosey’s tool are visible, albeit with (Hasselbusch, 2006) and process skills. In terms of Mosey’s tools different emphases. these are strongly about the human environment, conscious use of self, teaching and learning, activity Table 3: Overall top 10 interventions by group rank analysis, and group synthesis, Acute albeit in a different context to AT & Community Children / inpatient Mental Health activity groups. Rehabilitation (physical) (Physical) young person N= 12 30 16 36 21 Occupation The second trend we identify is Home visits 2 1 1 3 7 around the services needed by Group work 7 1 3 people with significant impairment especially people with intellectual Equipment prescriptions 2 2 1 or physical disabilities, the elderly Issue and evaluation of and those with continuing mental 1 3 equipment use health problems. Many day care Goal setting 3 6 centres exist to ensure people with disabilities have ‘Something Liaison in community 7 4 to do and somewhere to go’ Wheelchair prescription 5 6 (Dickson, 2003). These centres Education 3 8 and agencies primarily provide an opportunity for people to engage ADL retraining 4 8 in occupations because people with Vocational retraining/support 9 9 an ongoing condition usually need ongoing assistance to that end. From reflections to projections The sustainable services create the environment of community; By looking to the past we can understand the present, and the place to go, to be with others, to find something meaningful prepare for the future. All the eras of occupational therapy that and purposeful to do. These settings usually understand the have been described in this article have equivalents in current importance of offering a range of occupations that occur in practice. The focus on enabling people to carry out their daily daily life. Thus they provide an environment whereby a sense activities competently is well established however, there seems to of community can be facilitated through domestic, creative, or be less emphasis on remediation. We did not find a reason for work opportunities. So the tools encompass a busy environment, this documented in the reviewed literature, so it is difficult to with equipment for cooking and other domestic housekeeping, ascertain whether this conclusion is appropriate. resources for making items and producing small goods. All of Mosey’s tools are apparent here, from the human and non Professional literature from overseas, as well as health and human environment (with an accessible, accepting situation), disability sector priorities, indicates three emerging trends for the deliberate use of self (to enable people to participate at future development. Given our review of the past, we would now the level of their ability), the careful analysis of activities (to like to explore the nature of these new directions which we believe encourage active participation and successful outcomes) the include: consultation, occupation, and primary health. teaching learning strategies (to make it possible for each task to be perceived as valuable) resulting in activity groups with a Consultation cohesiveness reminiscent of Renner’s experience. To ensure the The pattern of service through consultation is increasing, most people attending these day care centres staff need knowledge and especially in work involving children and older people. According skills, similar to those of the early occupational therapists. The to Schein (1981), consultation as a process comes initially from taken for granted knowledge and awareness used by occupational management literature and is a “set of activities ...that help the therapists in the early days, is now being rekindled and claimed client to perceive, understand and act upon the process events...to by others, such as diversional therapists, job coaches and activity improve the situation, as defined by the client” (p. 11). It involves workers. This is a clear indicator that the need is still there educating and working with others to carry out the intervention. and the knowledge is still required. We believe that all people The term ‘others’ may relate to a work colleague, family member with occupational needs should have access to the specialised or care staff. This way of working requires different skills; a knowledge of an occupational therapist. By ignoring the situation greater emphasis on programme planning and evaluation, staff we ignore diverse client groups with occupational needs and a supervision and education, and networking across agencies. legitimate call for our knowledge.
Volume 55 No 2 New Zealand Journal of Occupational Therapy 37 THEORETICAL ARTICLE Linda H Wilson, Kaye Cheetham
Primary health n The profession of occupational therapy has evolved through a The third area of current practice about which there is increasing focus on activity, problem solving, and management. professional literature is primary health. It is well recognized n New fields of practice may emerge but the old core skills that this is an area for development, whether because most New remain relevant. Zealand occupational therapists already work outside large acute hospitals (New Zealand Health Information Service, 2003) or References because we know that engagement in occupation promotes health Anonymous. (1968). Grip meter. New Zealand Journal of Occupational (Wilcock, 2005). Some of the possible professional contributions Therapy, 21(3), 26-27. previously discussed include, activity demonstrations, risk Anonymous. (1969). Raised toilet seat. The New Zealand Journal of management of the environment, and occupational patterns Occupational Therapy, 22(2), 5. Anonymous. (1981). Published elsewhere. New Zealand Journal of Occupational (Finlayson & Edwards, 1997), environmental modifications Therapy, 32(1), 19. (Devereaux & Walker, 1995) and networking with community Art Needlework Industries. (1953). Advertisement. Journal New Zealand activity groups (Scriven & Atwal, 2004). Like the developments Occupational Therapy Association, 7(July), 12. referred to earlier with reference to consulting, the process has Bassett, F. (1973). Threading game. New Zealand Journal of Occupational an organisational focus as opposed to an individual focus. Here Therapy, 24(1), 26. Bridson, L. (1983). Book review: Occupational therapy - configuration of again the tools of practice include, teaching and learning, activity a profession. Journal of the New Zealand Association of Occupational groups, group facilitation (including information, resources, Therapists, 33(2), 21. and community development), conscious use of self, and the Brown, M., & Taimana, C. (1966). A trip into orthotics. New Zealand Journal of human and non human environment. Addressing the needs of Occupational Therapy, 19(2), 8-12. Buchanan, C. (1976). Combined effort in toy trolley design. New Zealand any population will also require the use of activity analysis and Journal of Occupational Therapy, 27(2), 14. synthesis. We conclude that Mosey’s (1981) articulation of the Cameron, J. (1979). Editorial: Purposeful activity for the “total person”. New profession’s tools of practice remains a useful a way to view our Zealand Journal of Occupational Therapy, 30(2), 2. skills into the future as well as in the past. Cameron, R., Managh, M., Moffit, K., & Sirrett, R. (1988). Basket weaving and beyond. Journal of the New Zealand Association of Occupational While we acknowledge such developments we also want to Therapists, 39(1), 15-18. advocate for people who have needs similar to those met by Caulton, R., & Dickson, R. (2007). What’s going on? Finding an explanation for what we do. In J. Creek & A. Lawson-Porter (Eds.), Contemporary Issues occupational therapy practice in the past. We call on occupational in Occupational Therapy (pp. 87-114). Chichester: John Wiley & Sons. therapists to remain alert to, and aware of, people’s diverse needs. Christie, A., & Marsh, S. (1989). Computers: A therapeutic tool. Journal of the Rather than expecting the new practices to replace the old New Zealand Association of Occupational Therapists, 40(1), 10-12. practices, all are required. Seeking to work only in emerging areas Christie, A., & Robertson, S. (1991). The use of the childhood autism rating or areas that are deemed to have some sort of status would deny the scale in an occupational therapy programme. Journal of the New Zealand Association of Occupational Therapists, 42(2), 13-16. profession’s social responsibility to those with occupational needs Climo, E. (1976). Nappies for a hemiplegic mother’s baby. New Zealand Journal who would benefit from professional knowledge. As we plan our of Occupational Therapy, 27(1), 26. future curricula, journals, and other professional activities (such Clinch, V. (1975). Group therapy for rheumatoid arthritis patients. New Zealand as conferences and workshops) we need to include all areas of Journal of Occupational Therapy 26(1), 14-18. Cowan, J. (1986). Setting up a quality assurance programme. Journal of the New practice. Our professional tools of practice are our strength and Zealand Association of Occupational Therapists 37(1), 10-11. as in the past, they are intended to enable people to live the life Cull, G. (1990). Anorexia nervosa: A review of theory and approaches to they want, regardless of disability. treatment. Journal of the New Zealand Association of Occupational Therapists, 40(2), 3-6. Conclusion Cusick, A. (1995). Australian occupational therapy research: A review of publications 1987-91. Australian Occupational Therapy Journal, 42(2), 67- This article is based on a review of three historical eras related 75. to the tools of occupational therapy practice as they evolved Daniel, M. & Strickland, L. R. (1992). Occupational therapy protocol in Aotearoa/New Zealand. An examination of the current era management in adult physical dysfunction. Gaithersburg, Md.: Aspen considered the way in which practice is developing, as health Dever, N. (1991). Managing change in the health services: What can occupational therapists contribute? Journal of the New Zealand Association of needs and service delivery systems change. The needs addressed Occupational Therapists, 42(1), 14 -16. by the profession in each era have not disappeared, rather the Devereaux, E. B., & Walker, R. B. (1995). Nationally speaking - The role of practice aspects of occupational therapy have merely diversified. occupational therapy in primary health care. The American Journal of The focus of each era has current legitimacy and we believe that Occupational Therapy, 49(5), 391-396. Dey, J. (1979). Rheumatoid arthritis - a group programme for outpatients. New the special skills required in each should be acknowledged and Zealand Journal of Occupational Therapy, 30(2), 19. respected within the profession. Dickson, R. (2003). Somewhere to go and something to do. Unpublished Masters thesis. University of Otago, Dunedin Key points Drake, M. (1992). Crafts in therapy and rehabilitation. Thorofare, NJ: slack. Dunn, W. (2000). Best practice occupational therapy in community services with n Mosey’s tools of practice can be used to track professional children and families Thorofare, NJ: Slack. development over time. Emery, S. (1976). Book review: New life cookery. New Zealand Journal of Occupational Therapy, 27(1), 6. n Three distinct eras are evident in the history of occupational Ferguson, J. (1982). Occupational therapy is activity. Journal of the New Zealand therapy within Aotearoa/New Zealand and the tools from each Association of Occupational Therapists, 33(1), 19-20. era of practice remain legitimate today.
38 New Zealand Journal of Occupational Therapy Volume 55 No 2 Tools of practice THEORETICAL ARTICLE
Finlayson, M., & Edwards, J. (1997). Evolving health environments and Polkinghorne, P. (1983). Establishing occupational therapy staffing priorities. occupational therapy: definitions, descriptions, and opportunities. British Journal of the New Zealand Association of Occupational Therapists, 82(1), Journal of Occupational Therapy, 60(10), 456-460. 14-15. Ford, M. (1974). Adjustable bath board. New Zealand Journal of Occupational Preston-Jones, R. (1996). Book review: Therapeutic activities with persons Therapy, 25(1), 22. disabled by alzheimers disease and related disorders. Journal of the New Gillette, N. (1982). Book review - Configuration of a profession. The American Zealand Association of Occupational Therapists, 47(1), 24. Journal of Occupational Therapy, 36(10), 677-678. Renner, Y. (1948). News from Hamner Springs. New Zealand Occupational Glenday, H. (1988). Filing systems. Journal of the New Zealand Association of Therapy Newsletter 1(September), 2. Occupational Therapists, 38(2), 14. Schein, E. H. (1981). Process consultation: It’s role in organisation development Gooder, J. (1992). Resource management. Journal of the New Zealand (2nd ed. Vol. 1). Reading, Mass: Addison-Wesley. Association of Occupational Therapists, 43(2), 4-9. Schwartz, K., & Colman, W. (1988). Historical research methods in occupational Gooder, J. (1995). Editorial: The official transfer has happened! Journal of the therapy. The American Journal of Occupational Therapy, 42(4), 239-244. New Zealand Association of Occupational Therapists, 46(1), 3-4. Scriven, A., & Atwal, A. (2004). Occupational therapists as primary health Gray, J. M. (1998). Putting occupation into practice: Occupation as ends, promoters: Opportunities and barriers. British Journal of Occupational occupation as means. The American Journal of Occupational Therapy, Therapy, 67(10), 424-429. 52(5), 354-364. Sheriff, M. (1953). Occupational Therapy for crippled children. Newsletter Haddon, J. (1976). Body image and the psychiatric patient. New Zealand Journal New Zealand Occupational Therapy Association, 7(July), 5. Journal of Occupational Therapy, 27(2), 24. Shortell, S., & Kaluzny, A. (1988). Health care management (2nd ed.). New Halford, M. R. (1985). Anxiety management: Application in acute psychiatry York: John Wiley & Sons. and within the community. Journal of the New Zealand Association of Simmons, C. (1988). Computer software: Selecting for cognitive rehabilitation. Occupational Therapists, 36(1), 16-18. Journal of the New Zealand Association of Occupational Therapists, 39(1), Haliburton, M. (1976). Adaptations used to strengthen quadriceps muscles - in 3-5. particular - vastus medialis. New Zealand Journal of Occupational Therapy, Simmons Carlsson, C. (2006). The “culture of practice” of Ministry of Education, 27(2), 22-23. special education occupational therapists and physiotherapists. Unpublished Hasselbusch, A. (2006). Working together: Exploring the occupational therapy Masters thesis. Auckland University of Technology: Auckland. consultation process related to students with ASD attending a regular Skilton, H. (1981). Work for your life - the story of the beginning and early years classroom. Unpublished Masters thesis. Otago Polytechnic, Dunedin of occupational therapy in New Zealand. Hamilton: Hudlo Printers. Hocking, C. (1990). Anger management. Journal of the New Zealand Association Stewart, R. (1979). The reality of management. London: Pan of Occupational Therapists, 40(2), 12-17. Sutherland, J. (1958). Pukeora. Journal of the New Zealand Registered Keller, M. J. (1991), (Ed) Activities with developmentally disabled elderly and Occupational Therapy Association, 13(1), 7-10. older adults. New York: Harworth. Sutherland, W. (1966). Advertisement New Zealand Journal of Occupational Kendall, S. (1994). The New Zealand health reforms: impacts on one Therapy, 19(2), 22. occupational therapy service. Journal of the New Zealand Association of Sutherland, W. (1953). Advertisement. Newsletter Journal of the New Zealand Occupational Therapists, 45(1), 8-11. Occupational Therapy Association, 7(July), 11. Kielhofner, G. (1985). Model of human occupation: Theory and application. Sutherland, W. (1959). Advertisement. Occupational Therapy, 14(1), 13. Baltimore, Md Williams & Wilkins. Sykes, J. B. (1980). The Concise Oxford Dictionary. Oxford: Oxford University Kokich, D. (1996). Book review: Group activities for personal development. Press. Journal of the New Zealand Association of Occupational Therapists, 47(1), Thompson, B. (1987). Groups in geriatrics Journal of the New Zealand 22. Association of Occupational Therapists, 37(2), 3-6. Leary, S. (1986). Explaining the tools of occupational therapy. Journal of the Tillson, M. (1966). Letter to the Editor. New Zealand Journal of Occupational New Zealand Association of Occupational Therapists, 37(1), 14-15. Therapy, 19(3), 17. Levine, R. E. (1986). Historical research: Ordering the past to chart our future. Timms, G. (1948). Work at Wakari Chest Hospital and Pleasant Valley The Occupational Therapy Journal of Research, 6(5), 259-269. Sanatorium. New Zealand Occupational Therapy Newsletter, 1(September), Liew, C. (1979). Developing a social skills programme. New Zealand Journal of 7. Occupational Therapy, 30(1), 31-32. Tortenstahl, R. (1990). Essential properties, static aims and historical Macdonald, E. (1975). Cardiac assessment group. New Zealand Journal of development: three approaches to theories of professionalism. In M. Occupational Therapy, 26(1), 20-21. Burrage & R. Tortenstahl (Eds.), Professions and their history - Rethinking Marshall, Y. (1974). Book review: How can I/do others manage with rheumatoid the study of the professions (44-61). London: Sage. arthritis. New Zealand Journal of Occupational Therapy, 25(2), 24. Walker, J. (1959). Spastic concert party. Journal of the New Zealand Registered Martin, A. M. (1957). Advertisement. Occupational Therapy, 12(1), inside Occupational Therapy Association, 14(4), 10. cover. Wheeler, S., & Banga, F. (1979). The adolescent unit, Department of Mattingly, C., & Fleming, M. H. (1994). Clinical reasoning: Forms of inquiry in Psychological Medicine, Wakari Hospital. New Zealand Journal of a therapeutic practice. Philadelphia P.A: F. A. Davis. Occupational Therapy, 30(2), 31-32. Milne, J. (1983). The biopsychosocial model as applied to a multidisciplinary Whyatt, J. (1986). The development of a community support group for CORD pain management programme. Journal of the New Zealand Association of sufferers. Journal of the New Zealand Association of Occupational Occupational Therapists, 34(1), 19-21 Therapists, 36(2), 8-9. Mosey, A. (1973). Activities therapy. New York: Raven Press. Wilcock, A. A. (2005). 2004 CAOT Conference keynote address. Occupational Mosey, A. (1981). Configuration of a profession. New York: Raven Press. science: bridging occupation and health. Canadian Journal of Occupational Nell, J., Runciman, L., & Light, A. (1975). Occupational therapy at Manawaroa, Therapy, 72(1), 5-12. centre for psychological medicine. New Zealand Journal of Occupational Wilson, D. (1972). Temporary foot drop splint. New Zealand Journal of Therapy, 26(1), 21-23. Occupational Therapy, 23(1), 24. Nettlingham, V. (1996). Book review: Developmental hand dysfunction. Journal Wilson, L. (2002). A review of the journals of the New Zealand Association of of the New Zealand Association of Occupational Therapists, 47(2), 21. Occupational Therapists, 1949-2002. New Zealand Journal of Occupational New Zealand Health Information Service. (2003). Selected health professional Therapy, 49(2), 5-13. workforce 2002. Wellington Ministry of Health Wilson, L. (2004). Role differentiation in a professionalising occupation: The NZOTA. (1953). Auckland Mental Hospital. Journal New Zealand Occupational case of occupational therapy, New Zealand. Unpublished PhD thesis. Therapy Association, 7(July), 8. University of Otago, Dunedin. NZROTA. (Inc). (1956). Have you read these? Occupational Therapy, Young, M. E. & Quinn, E. (1992). Theories and principles of occupational 11(1), 12. therapy. Edinburgh: Churchill Livingstone.
Volume 55 No 2 New Zealand Journal of Occupational Therapy 39 New Zealand Journal Of Occupational Therapy: Guidelines For Authors
ZJOT is a refereed journal dedicated to the publication of title (less than 40 characters including spaces) should also be Nhigh quality national and international articles that are provided. grounded in practice and provide practical, hands-on information Title page for theses abstracts should include the title of the thesis representing all fields of occupational therapy. We invite or coursework, the name of the author, the name of the degree practitioners, researchers, teachers, students and users of services conferred the name and address of the institution that conferred to submit manuscripts that provide a forum to discuss or debate the degree. issues relevant to occupational therapy. The journal informs you of developments in occupational therapy practice and research, To allow the blind review process to take place, except for the title theoretical inquiry, professional and resources issues, policy page, manuscript should contain no identifying names of specific development and ethical questions. persons or places. The journal publishes feature articles (should not exceed Abstract and key words: 4000 words), research articles (should not exceed 5000 words), All articles (except annotated bibliographies, reviews and letters annotated bibliographies and reviews (should not exceed 2000 to editor) must include a brief but informative abstract of no words), viewpoint articles (should not exceed 2000 words and more than 100 words. The abstract should describe the purpose, have no more than 10 references), letters to editor (should not basic procedures, major findings and conclusions of the work. exceed 500 words) and abstracts for doctoral thesis (should not The abstract should not contain abbreviations or references. Up exceed 500 words and there should be no references). If there are to five key words should be provided to assist with indexing of any difficulties keeping to the specifications of the article, please the article. discuss the matter with the Editor. These guidelines aim to help authors write acceptable articles. Should you have any queries Text: please do not hesitate to contact the Editor, Grace O’Sullivan, Authors should consider the use of appropriate subheadings to email: [email protected] label sections of their manuscripts. For example: Preparation of manuscripts Feature article - report on a therapeutic programme: suggested Please read the guidelines carefully. It is important that all papers sub-headings include- Introduction, Description of the setting, are published in the same format. Manuscripts should conform Therapeutic Programme, Reflection on outcomes, Discussion to the style detailed in the Publication Manual of the American and future research directions. Psychological Association (APA), 5th edition (2001). Spelling Research article: Suggested sub-headings include - Introduction, should follow the Concise Oxford Dictionary of Current English Method, Results and Discussion. Usage. Submissions not complying with these guidelines will be returned to the authors without consideration. Key messages (for feature and research articles): Submissions should be typed in standard Times New Roman To help readers, authors are requested to provide a short 12 point, double-spaced, on one side only of A4 paper. The top, statement or series of points encapsulating the main message(s) bottom and side margins should be 3cm. Laser or quality print is or implication(s) to occupational therapists arising from the required. All pages should be numbered consecutively in the top article. They should be limited to 50 words and 2-5 points. right-hand corner, beginning with the title page. Acknowledgments: All manuscripts should be presented in the following order: The source of financial grants and the contribution of colleagues title page, abstract and key words, text, key messages (relevant or institutions should be acknowledged. to feature and research articles), acknowledgements, references, tables, figure legends and figures. References: Title page: For format and reference style, consult the APA style manual. In The title page should contain the (i) category of article, (ii) the text, references should be made by giving the author’s name, the title of the article, (iii) the name(s) of the author(s), (iv) with the year of publication in parentheses. If there are two authors, academic qualification(s), (v) professional titles, (vi) complete within the text use ‘and’ but, within parentheses use the ampersand correspondence address and an e-mail address. (&). For works that have more than two but less than six authors, cite all authors the first time and in subsequent citations include The title should be short and informative. A short running only the name of the first author followed by et al. For works by
40 New Zealand Journal of Occupational Therapy Volume 55 No 2