Australian Occupational Therapy Journal (2015) 62, 219–222
doi: 10.1111/1440-1630.12186
Viewpoint
Contemporary occupational therapy: Our occupational therapy models are essential to occupation centred practice Annette V. Joosten School of Occupational Therapy and Social Work, Curtin University, Bentley, Western Australia, Australia
KEY WORDS evidence, occupation based, occupational therapy models, paradigm.
Our “Contemporary Paradigm” (Kielhofner, 2009) provides the profession with a shared view about occupational therapy practice. Three conceptual foundations form the basis for our Contemporary Paradigm (i) the importance of occupation to health and wellbeing; (ii) recognition of occupational problems/challenges as the focus of occupational therapy; and (iii) the defining feature and core of occupational therapy practice is the use of occupation to improve health status (Kielhofner, p. 49). Gustafsson, Molineux and Bennett (2014) in Contemporary occupational therapy practice: The challenges of being evidence based and philosophically congruent, proposed that occupational therapy intervention must be occupation and unique to occupational therapy, to be congruent with our Contemporary Paradigm. They further suggested that occupational therapists use of many evidence-based, but not occupational therapy specific, practices risked taking us back closer to biomedical approaches adopted in the middle of the 20th century. In response, it is proposed that we can, and need to, use evidence that is not unique to occupational therapy. It is, however, through the use of our occupational therapy conceptual models, and ensuring that our intervention and documentation reflect our occupation focus that we can wisely use related knowledge to inform practice. As Kielhofner (2009) reminded us, our Contemporary Paradigm is only part of the conceptual foundation of the profession of occupational therapy. Our paradigm defines occupational therapy and enables us to share a common identity about our service. To know how to
Annette V. Joosten PhD, M Dis Studies, BAppsSc (OT); Senior Lecturer. Correspondence: Annette Joosten, School of Occupational Therapy and Social Work, Curtin University, Kent Street, Bentley, WA 6102, Australia. Email:
[email protected] Accepted for publication 23 December 2014. © 2015 Occupational Therapy Australia
practise, we also generate and use two other types of knowledge: conceptual practice knowledge, and related knowledge. Kielhofner described the order as our identity knowledge (paradigm) being at the centre, surrounded by an inner ring consisting of our occupational therapy conceptual models, and an outer ring of related knowledge. When Gustafsson et al. (2014) urged occupational therapists to use an occupational perspective as the key lens through which to view evidence, they also needed to advocate the focusing of this lens on all our layers of knowledge, not just the paradigm, in order to be true to all our conceptual foundations. Occupational therapy conceptual models were developed from the 1980s to support a move away from an impairment focus to an occupational focus, with a goal of understanding what our clients want, need and are expected, to do. While the person-environment-occupation interaction is an essential occupational therapy consideration, without structure it does not provide a process for action. Evidence based conceptual models provide an organisational structure to reduce personal bias and provide occupational therapists with the appropriate language to communicate, document and act on the complex evidence and professional process of conceptual problems solving, and planning (Turpin & Iwama, 2011). Several conceptual models for example, the Occupational Performance Model (OPM) (Pedretti, 1996; Pedretti & Early, 2001); the Model of Human Occupation (Kielhofner, 1985, 1995, 2002; Kielhofner, 2008); PersonEnvironment-Occupation-Performance (PEOP) (Christiansen & Baum, 1991, 1997; Baum & Christiansen, 2005); Occupational Performance Model (Australia) (OPM(A)) (Chapparo & Ranka, 1997; Ranka & Chapparo, 2011); Canadian Model of Occupational Performance (CMOP) (Canadian Association of Occupational Therapy, 1997, 2002); the Canadian Model of Occupational Performance and Engagement (CMOP-E) (Polatajko, Townsend & Craik, 2007); and the KAWA model (Iwama, 2006) have been developed to meet diverse individual and cultural needs and contexts. Each model has unique characteristics and concepts but they share a common focus on occupation, occupational performance and the relationship of person to environment as a dynamic process (Brown, 2014).
220 In addition to our conceptual models we have used knowledge which is unique to our profession with related knowledge to develop frames of reference. These are customised and they categorise theoretical information to occupational therapy practice by developing assumptions, principles and actions that guide occupational therapy assessment and intervention (Craik, Davis & Polatajko, 2013). A number of frames of reference may be used throughout the occupational therapy process and it is essential to consider the compatibility of theories (Craik et al.). To implement practice that is based on our models, to develop frames of reference, to research and fulfil other activities of the profession, we are dependent on the use of related knowledge. Related knowledge is the theory and techniques that exist outside occupational therapy which is not unique to occupational therapy. Examples include learning and behaviour theories, motor learning and control theory, attachment theory, and techniques such as counselling, therapeutic handling, electrical stimulation and memory training. Ours is not the only profession to use ‘therapeutic use of self’, scaffolding and prompting, and client or person centred practice as key terms in our work. Gustafsson et al. (2014) urged therapists not to use knowledge which is not unique to occupational therapy just because it has supporting evidence. A more realistic call would be that occupational therapists do use evidenced based theory and techniques, but when they are not unique to occupational therapy we need to do so with two conditions. We need to ensure (i) this knowledge, be it theory or technique, is congruent with our occupational therapy paradigm and with all our conceptual foundations, and (ii) that it does not become the focus of our intervention or the measure of our clients’ intervention outcomes. In agreement with Gustafsson et al. (2014) it is not sufficient to claim we have occupation at the centre simply by saying that what we are doing will lead to a return to occupation. As they highlight, we risk losing our professional identity when we just do what others could do without demonstrating application of our own conceptual models. Problems arise when we do not know what the person wants, needs, or is expected, to do and, when the technique becomes ‘what we offer’ rather than a technique used within out broader occupational therapy approach. This applies as readily to all areas of practice, for example counselling, mindfulness and therapeutic handling, as is does to other more targeted techniques such as electrical stimulation which was the example used by Gustafsson et al.. The solution does not rely in taking a narrow view of being occupation based – it lies in adopting an approach that is inclusive of our three layers of knowledge so that we truly works towards enabling the person to engage in occupation in their desired environments. Occupational science has helped create a better understanding of occupation and what it is to be an © 2015 Occupational Therapy Australia
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occupational being (Wilcock, 2003). However, it may also have led to a significant narrowing of our interpretation of the conceptual foundation that engagement is the basic dynamic and core of occupational therapy. A broader view of being occupation based is that occupational performance or engagement is enabled by a mutifaceted approach including the need to reduce impairment, compensate or adapt, make social change, develop new skills, to advocate and focus on health and wellbeing (Polatakjo & Davis, 2012). Understanding and addressing why a person has difficulty performing given tasks in an occupation, and knowing the person’s learning style and capacity, enables more realistic goal setting and the development of intervention strategies that best scaffold optimal performance (Wilby, 2007). Rather than the concern being with occupational therapists using techniques not unique to occupational therapy or providing intervention that does not to meet a very narrow interpretation of being occupation based, the real challenge for contemporary occupational therapy practice is for occupational therapists to adopt and adhere to the principles of our occupational therapy conceptual models. Four problems arise when we practice without using our conceptual models. We are at risk of (i) not knowing what our clients want, need or are expected to do; (ii) not choosing outcome measures with clients; (iii) not choosing outcomes which are occupation based and (iv) not documenting in a way that reflects change in a clients’ participation in meaningful activity, and in ways that highlight the unique contribution of our profession. What does it mean to practise using our conceptual models? Our engagement in the occupational therapy process needs to begin with interviews, ideally structured with outcome measures such as the Canadian Occupational Performance Measure (Law et al., 2005) or other occupation and interest assessments. The aim is to understand the person as an occupational being in context, and the result is a set of information that is primarily the perception of the client. Our occupational therapy model of choice is then used to gain an understanding of the person’s abilities, the environments and contexts in which the occupations occur (and in which the client wishes to participate), and the demands of the occupation. At this point we then decide whether we need assessment that is performance/person component focussed to understand body structure and function that may be contributing to performance difficulties. The selection of performance assessment tools at this stage is very important. As Gillen (2013) highlights, occupational therapists have developed and tested the psychometric properties of performance based assessments using real life activities, but we continue to use assessments which assess person abilities in isolation and have little connection to everyday activity. With a better knowledge of performance component capacities, added to the information already in our conceptual model, we can better
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understand activity limitations (parts of the activity that the person is unable to complete) (WHO, 2001) and then make decisions about the interventions and techniques that will best ensure increased participation in meaningful occupation in desired environments. Using a model elevates clinical practice from the application of techniques to a professional process of conceptual problem solving, planning and action (Kielhofner, 2009). Occupational therapy is a dynamic profession so models need to be responsive to changes in our occupation knowledge. This can, and should happen without needing to change our central contemporary paradigm. Early occupational therapy models were influenced by a biopsychosocial, individualised understanding of humans and health (Turpin & Iwama, 2011). More recent developments, for example the CMOP-E (Polatajko et al., 2007) have begun to reflect our professions shift to a more socio-ecological focus with an emphasis on population and community opportunity for health and participation, and a focus on non-western cultures (Turpin & Iwama, 2011). Christiansen, Baum and Bass (2012) also propose using the PEOP model to conduct situational analyses when it is more appropriate to address the occupational issues of a population or community rather than the individual. Our implementation of practice based on models is also influenced by changes in related knowledge, for example, the development of new techniques that emerge with advances in technology, and increased knowledge about neuroplasticity and the brain’s ability to change and restore and take over function. The advancement in related knowledge means we need to reconsider, adapt, research and build evidence for our decision-making and clinical reasoning. This will support our application of restorative and compensatory measures aimed at increasing client engagement in occupation. In a similar manner, as we expand our roles to focus on a community level of engagement, equity and justice using related knowledge, we need to build the evidence for practice. We need to renew and strengthen our focus on clinical and research partnerships so that not only does research inform practice but practice shapes research. Our requirement for continuing professional development, our graduating competency requirements and mentoring programs offer further means of ensuring that we undertake the actions required to develop evidenced-based practices (EBPs) and adopt practices congruent with our conceptual foundations. Occupational therapists report the structure of the health-care system, prescriptive care pathways and treatment guidelines, requirements to use particular assessments and outcome measures, and the recency of client diagnosis, as reasons for it being difficult to retain an occupation based focus (Gustafsson, Nugent & Biros, 2012). While such factors have influenced practice, with an increased focus on inter-professional teams and with
221 other professions taking a more active interest in, and adoption of the way we have best engaged in activity within therapy, we need to stop, reflect and be more proactive in restoring our position as the enablers of engagement in occupation. This way we will ensure that what we do has occupation at its centre and looks and sounds like occupation. Several studies reporting on our face-to-face time with clients suggest that most time is spent on component (body structure and function) level intervention but the same studies have raised the issue of whether this truly represents our practice, or whether it is what we document and the way we document it, that gives the impression that it is not in a context of occupation (Gustafsson et al., 2012; Maitra et al., 2010; Smallfield & Karges, 2009). The practice context might require standardised component focussed assessment measures, however, we do have the means, and a responsibility to identify and document our occupation focus. The inclusion of client determined measurable goals demonstrating increased participation in meaningful activity and client measurement of satisfaction with performance are two important ways this can be achieved. In doing so we also contribute to EBP using both standardised and occupation based measures. In the time it takes to set and write a goal with a client about increasing hand strength or range of movement we can equally write a goal about being able to grasp a spoon and eat dinner or hold a hand of cards (knowing that we can have a conversation with our client about what we might need to do in therapy) to achieve this goal. To document that someone showered safely and independently while standing for 10 minutes, presents a very different picture of our intervention, and our unique contribution, than reporting improved balance or ‘now able to stand for 10 minutes’. Reporting that a client was discharged and had returned to work with a wheelchair that enabled independent mobility, rather than documenting ‘she was discharged with wheelchair’, reflects a knowing of our clients and a focus on their return to desired occupational roles and contexts. Our Contemporary Paradigm is the most stable component of our conceptual foundations and importantly, it ensures that we maintain a common and shared view of the profession while we develop, adopt and modify our conceptual models and apply the theories and techniques of our unique and related knowledge. The changing scope of our practice and the evidence provided by research, demand that we continually reflect on our practice to ensure that is true to our paradigm, with occupation at the centre, and contemporary to our times. Keeping occupation at the centre is about the knowledge we use, and clinical reasoning we apply to the evidence, the goals we set with our clients and the accurate reporting of the occupation that emerges through our practice.
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