Evidence for your Practice: Learning from Adversity

Learning from adversity: Occupational therapy staff experiences of coping during Covid-19

Article: Ingham, L., Jackson, E., & Purcell, C. (2022). Learning from adversity: Occupational therapy staff experiences of coping during Covid-19. British Journal of Occupational Therapy, 03080226211064490.

Rationale: During the COVID-19 pandemic, health care staff experience increased workload demands, reallocation of duties, adapting to protocols such as use of PPE and concerns about the risk of infecting their family. Health care workers are at a higher risk of burnout in “normal” times and this may be increasingly the case during a crisis situation such as a global pandemic

Occupational therapists have roles including direct client care, educating clients, families and caregivers, in-direct client care through management and leadership positions, academic and research related responsibilities among others. Therefore there is a broad range of ways in which occupational therapists can be and are impacted by the pandemic.

Purpose: To explore how OTs felt and coped during the first wave of the COVID-19 pandemic.  

Methods: A questionnaire was created with open-ended questions asked to 75 participants, 69 of whom were female. The sample included 49 participants who were in a full-time position. Data collection took place during the first wave of the COVID-19 pandemic. Participants answered questions about their coping techniques, what they found most challenging or helpful, and whether anything could have been done differently to enable effective coping.

Findings: 

• Participants reflected on protective factors such as their ability to adapt and remain flexible. With frequently changing processes and protocols, being adaptable eased stressors for some participants. 
• Supportive family members, friends and colleagues were found to be a source of reflection for how well participants felt they were coping. Some participants reported an increased reliance on their social network for emotional support, including talking about their experiences and feelings with others to help process them. 
• Engaging in their own meaningful occupations was an important means of coping with the pandemic, combined with limiting the amount of time they spent reading or watching COVID related news/media.  
• Barriers to coping included organizational, personal and professional challenges. Some occupations that were previously a way to relieve stress such as going to the gym after work were no longer an option during pandemic restrictions. This led to decreased feelings of effective coping and presented challenges for participants who had to find other ways to cope.
• Professional challenges included uncertainty of their role with the rapidly changing processes and procedures at the work place, feeling isolated from the profession, and concern for patients.
• Organizational challenges included mixed messages about work processes and protocols, as well as PPE availability and requirements. 

Conclusion & Implications for OT:

• Consistent and concise communication with clinicians, clients and leadership is important to prevent unnecessary stressors and spread of misinformation.
• Providing channels of communication for clinicians to remain connected to the profession and to their sources of support both within and external to their workplace. 
• Providing and sharing information about effective coping strategies that are realistic and attainable for use at home or in the workplace.
• Seeking opportunities to connect with counseling or other mental health services to assist with emotional and psychological processing of challenging emotions and situations. 

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Evidence for your Practice: Sleep habits and routines

 

 Sleep Habits and Routines of Individuals Diagnosed with Mental and/or Substance-Use Disorder

Article:  Gardner, J., Swarbrick, M., Dennis, S., Franklin, M., Pricken, M., & Palmer, K. (2021). Sleep Habits and Routines of Individuals Diagnosed with Mental and/or Substance-Use Disorders. Occupational Therapy in Mental Health, 37(2), 158-177.

Rationale: Sleep challenges such as insomnia affect approximately 10% of the general population and the challenges are perhaps further problematic for those experiencing mental illness and substance use disorders. Sleep is one of the most frequently reported occupations that individuals with mental health challenges tend to have problems with, particularly sleep preparation and management.

Method: A sleep quality index was used with 52 participants who self-reported as having a mental illness and/or substance use disorder. 13 of the 52 participants completed individual interviews with a focus on exploring sleep routines and habits.

Results: 

• 78.6% of participants reported having poor sleep
• Nearly 50% of participants reported taking medications such as antidepressants, antipsychotics and mood stabilizers
• 52.4% reported sleeping 7 or more hours per night, while 19% of participants reported sleeping 5 or less hours per night; suggesting duration of sleep does not necessarily mean feeling rested the next day. 
• Habits and routines that participants identified as positively impacting their sleep included taking a bath/shower, turning off the lights, listening to music, praying, taking medication, and snacking. 
• Habits and routines that participants reported as negatively impacting their sleep included napping, smoking, consuming caffeine, texting and talking on the phone. 
• Noise was reported as both a facilitator (e.g., listening to relaxing music) and a barrier (e.g., loud cars, animals) to sleep. 
• Toileting during the night was reported to disrupt sleep quality. 

Implications for OT: 

• Occupational therapists are experts in analyzing occupational performance issues and the potential causes of the occupational disruption. Assessing the sleep habits and routines of individuals is an important part of identifying the facilitators and barriers to sleep for clients with mental illness and/or substance use disorder. 
• Sleep may be influenced by personal factors (e.g., health status) and environmental factors (e.g., temperature, noise level, ambient light) and therefore requires a thorough investigation to determine the most appropriate recommendations. 
• Encouraging positive behaviors such as decreased use of technology before bed, turning off the lights, listening to relaxing music, taking medications as prescribed and creating a consistent sleep routine are important. 

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Evidence for your practice: Change agency

Article: Carrier, A., Éthier, A., Beaudoin, M., Hudon, A., Bédard, D., Jasmin, E., & Verville, F. (2021). Acting as change agents: Insight into Québec occupational therapists’ current practice. Canadian Journal of Occupational Therapy, 0008417421994367.

Rationale: Previous research in the area of exploring occupational therapists' roles as change agents has not focused on the actions occupational therapists take in their everyday practice. The aim of this study was to identify the change agent actions occupational therapists take in their day-to-day work.   

Method: In partnership with the CAOT-Quebec chapter, a one-day change agent workshop was provided to Quebec occupational therapists followed by an evaluation. 103 occupational therapists participated in the study and answered questions about their involvement in change agent work. 

Results: 

• The most commonly reported change agent actions in the workplace included communicating, informing and collaborating, while participants reported rarely engaging in social actions related to mass media and public speaking.

• Targeted audiences for change agent actions included patients' families, colleagues, managers, and political bodies. 

• Occupational therapists who had taken change agent training in the past were more likely to engage in network creation, creating partnerships, giving a speech and planning an event compared to those who had no previous training. 

• Those who participated in the training most commonly worked in rehabilitation, community care or in-patient hospital settings. 

Conclusion: Occupational therapists play an important role as change agents, and appear to take a wider range of clinical and social actions when change agency training has been provided. There are a range of intended audiences who occupational therapists can target with their efforts, which will each lead to different types of changes taking place. 

Implications for OT: 

• Clinical efforts to be an agent of change commonly include communication, informing others, and collaboration. 
• Participating in higher education and change agent training can increase the variety of actions one will take and the comfort in different sociopolitical contexts. 
• Occupational therapists are well positioned to enact change agency work within their clinical work as well as other settings such as education and political engagements. 

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Evidence for your Practice: Occupational Therapy Interventions in the Transition from Homelessness

Article:  Marshall, C. A., Boland, L., Westover, L., Isard, R. & Gutman, S. (2021). A systematic review of occupational therapy interventions in the transition from homelessness. Scandinavian Journal of Occupational Therapy, 28(3), 171-187.

Rationale: Occupational therapy has a growing role in working with populations experiencing homelessness. While research exists around occupational experiences and occupation-based interventions for homeless persons, few studies have explored these same experiences and interventions during the transition from homelessness to being housed. This study aimed to evaluate the quality of current evidence around occupational therapy interventions that support the transition to housing following homelessness.

Method: Researchers conducted a systematic review of existing literature evaluating occupational therapy interventions that support the transition from homelessness to being housed. Eleven studies were included in the review, all of which were conducted in the United States between 2004 and 2018. 

Results: 

• Life skills are important to address when supporting homeless populations to transition to housing. Many people experiencing homelessness expressed concern about their ability to return to activities associated with being housed, as many had never learned these skills or needed more support around them due to mental illness or cognitive challenges. Positive outcomes of life skills interventions included improved knowledge and confidence in independent living skills; reduced trauma symptoms; and improvements in goal attainment, activity performance and satisfaction, social skills, quality of life, and housing and community functioning 

• A persistent challenge for many is a lack of opportunity to engage in meaningful occupations, resulting in boredom and negatively impacting mental wellness. As such, interventions that address barriers to engaging in meaningful activities and support the same are equally as important as interventions teaching life skills. These interventions may positively impact tenancy sustainment, goal attainment, mental health, substance use, and a perceived sense of belonging, which are key outcomes for OT interventions with people experiencing homelessness.

• Few interventions reviewed targeted increasing access to employment for individuals leaving homelessness. Employment is an important activity for most adults, and has the potential to improve community and social inclusion and reduce poverty, which is important for prevention of homelessness. Existing employment interventions for people experiencing homelessness have been explored and have been found to be effective in interdisciplinary literature. 

Conclusion: OTs play an important role in supporting individuals in the transition from homeless to housed. Existing interventions from other disciplines working with individuals transitioning from homelessness to housing focus largely on tenancy sustainment. However, interventions which address function and performance of life skills as well as barriers to engagement in meaningful activities have potential support this population to truly thrive. Study authors recommend that occupational therapists working with this population continue to develop and evaluate interventions that target both the development of life skills and engagement in meaningful occupation.

Implications for OT: 

• OTs working with people transitioning from homelessness to housing should consider using interventions that address and enable engagement in meaningful occupations, and using standardized measures of meaningful activity engagement to evaluate the effectiveness of interventions. 

• Interventions targeting engagement in meaningful activities should be used in conjunction with interventions targeting function life-skill development in order to support formerly homeless individuals to thrive in the transition to housing

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Evidence for your practice: Gardening as a Meaningful Occupation in Initial Stroke Rehabilitation

 

Gardening as a Meaningful Occupation in Initial Stroke Rehabilitation

Article: Madsen, L. S., Nielsen, C. V., Oliffe, J. L., & Handberg, C. (2021). Navigating a Middle Ground-Exploring Health Professionals’ Experiences and Perceptions of Providing Rehabilitation in Outdoor Community Settings. Qualitative Health Research, 31(1), 41-53.

Rationale: Following a stroke, individuals may experience feelings of uncertainty about their health and future life. It is important for participants to engage in meaningful occupations that promote health and improve quality of life during this time. Garden-related activities have been used for therapeutic purposes for many population groups in the field of occupational therapy. Garden-related activities have shown to promote mental healing, learning new recreational occupations, social integration, sensory enrichment and integration, cognitive reorganization, sensory motor training, assessment and training of prevocational skills, and assessment and training of ergonomic bodily positions.

Methods: This qualitative study analyzed notes written by occupational therapists who worked in stroke rehabilitation during a 6 month-period. The notes reflected their observations and descriptions after sessions with a gardening group. The therapists were trained in stroke rehabilitation and offered two sessions with gardening groups per week. The patients participated in horticultural activities, such as propagating plants from seeds or cuttings, potting, planting, watering, composting, harvesting plant material, and preserving the material for tea or decorative purposes. They also made food or handicraft items using materials obtained from outdoors.

Results:

Six themes were revealed through qualitative thematic analysis:

1. Possibilities for skills training:

Occupational therapists commented on how the patients worked on the functioning of their hands and feet to perform the tasks and meet the rehabilitation goals. The notes described how the patients’ capacities, such as strength, balance and coordination, gross and fine motor skills, and cognitive and sensory skills, were challenged.

2. Engagement in the occupation

Engaging in garden-related activities and surrounding themselves with the smell and taste of plants and garden products made the patients aware of their sensory capacity. For instance, one patient used lavender to explore whether their sense of smell was still intact. Furthermore, gardening as an occupation led to enjoyment and satisfaction from making a specific product, and through this, the gardening contributed to the patients’ increased sense of wellbeing and self-esteem.

3. Mastery of the activity

Occupational therapists described the patients’ experience of mastery when participating in the gardening group. Patients expressed satisfaction when doing an occupation that was adapted to their functional level, and their satisfaction was particularly enhanced when they managed tasks that were of interest to them. The occupational therapists considered the use of gardening in stroke rehabilitation as both a context and an occupation in which the patients themselves could recognize their own progress, experience mastery in functioning, and look for new ways to challenge themselves.

4. Finding mental rest

Many of the gardening sessions introduced occupations that helped patients to become calmer and to gain mental rest. The therapists also described how seeing plants grow and develop over time could help patients to unwind and be less impatient concerning the rate of their rehabilitation progress:

5. Connection to past experiences

In some circumstances, patients related gardening to past experiences and experienced gardening as a familiar and preferred context and occupation. They observed that the patients could thus experience gardening as personally meaningful and as a reflection of their identity and preferences.

6. Shared experiences and hope

The occupational therapists described the gardening group as an opportunity for patients to meet and work together. They considered the social environment as supportive and noted that the patients shared their experiences and own stories about gardening, their health challenges and worries, and their views and hopes for the future.

Conclusions and Implications for OT:

Occupational therapists found that gardening provided clinical opportunities for skills training and health resources. As a group-based, common occupation, gardening may provide a complementary approach in stroke rehabilitation. In addition, the findings indicate that therapists saw possibilities for individual patient’s adaptation through everyday, common gardening activities, which also led to engagement, mastery, mental rest, connection to past experiences, and connection with others.

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Evidence for your practice: Improving Reading Performance in Older Adults with Low Vision

Photo retrieved from: BBH Singapore on Unsplash

Article: Smallfield, S., Kaldenberg, J. (2020). Occupational therapy interventions to improve reading performance of older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 74(1), 7401185030p1- 7401185030p18. 

Rationale: Experiencing low vision can impact many aspects of a person’s day-to-day life, including reading, a skill required for participation in numerous occupations. This study sought to determine the effectiveness of occupational therapy interventions targeting improvement of reading abilities required for older adults with low vision to participate in their occupations. 

Method: Researchers conducted a systematic review of sixteen articles addressing occupational therapy interventions targeting reading performance. Evidence for the interventions presented in this article was labeled either as strong (consistent results from high-quality studies, usually RCTs); moderate (sufficient evidence, some limitations present); or low (evidence from low-level studies and is insufficient for conclusively assessing impact on health and occupational outcomes).

Results: Three intervention themes were identified from the reviewed literature: 

(1) Technology – There is moderate evidence supporting the use of stand-based electronic magnification (e.g. closed circuit television [CCTV]) to enhance reading abilities compared to other low vision devices. Participants using CCTV experienced increase reading speed and acuity and decreased reading errors.

There is low evidence supporting the use of low vision devices (e.g. handheld magnifiers, high-add spectacles, etc.), vision-specific assistive technology (e.g. OrCam), and mainstream technology (e.g. reading on a tablet or e-reader). 

(2) Visual Skills Training – There is moderate evidence for the use of eccentric viewing training with controlled eye movements for clients with central visual field impairments. This intervention was found to result in increased reading speed, duration, and comprehension.

There is low evidence for the effectiveness of visual skills training in improving reading performance in older adults with hemianopsia.

(3) Multicomponent Interventions – There is strong evidence supporting interprofessional low vision programs that include occupational therapy. Occupational therapists can run groups; support problem-solving; modify environments; educate clients about their condition, adjustment to vision loss, available resources, and adaptive strategies; and train clients to use low vision devices and perform daily occupations.

There is strong evidence supporting multicomponent interventions including vision therapy, environmental modification, low vision device prescription and training, and homework to improve reading required for occupational performance in older adults with low vision.

Conclusion & Implications for OT: 

- Low vision that affects reading abilities can limit participation in a wide variety of occupations. Reading skills should be addressed by occupational therapists who are working with older adults with low vision in order to support occupational participation.

- Evidence-based OT interventions to support reading for older adults with low vision include comprehensive low vision rehabilitation, stand-based electronic magnification, eccentric viewing training using the steady eye technique, and multicomponent low vision interventions. The evidence behind other interventions targeting this goal and population varies, and should be considered prior to use. 

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Evidence for your practice: Occupational therapy and sports

 

Occupational therapists’ experiences of enabling people to participate in sport

Article: Bullen, D., & Clarke, C. (2020). Occupational therapists’ experiences of enabling people to participate in sport. British Journal of Occupational Therapy, 0308022620973944.

Rationale: In response to growing demands on health and social care services there is an emphasis on communities addressing the needs of local populations to improve lives and reduce inequalities. Occupational therapists are responding to these demands by expanding their scope of practice into innovative settings, such as working with refugees, the homeless and residents of nursing homes, and within sport and leisure environments. The benefits of sport are widely acknowledged, and this paper argues that occupational therapists could play a pivotal role in enabling people to participate

Method: Semi-structured interviews were used to explore the experiences of enabling people to participate in sport from the perspective of five occupational therapists from the UK.

Findings: Two overarching themes and multiple sub-themes emerged in this study including:

1) “Practicing through an occupational therapy lens” demonstrated how occupational therapists viewed their clients through an OT lens while using a holistic approach to understanding and addressing their clients needs. Interventions that include sport and leisure activities were reported to be approaches OTs used to help clients nurture new social relationships and enable them to gain and transfer self-confidence to other aspects of their life.

The unique skills OTs bring – this subtheme described how sport was used therapeutically while adapting and modifying the environment and activities to fit a clients abilities.

2) “Challenges and opportunities for occupational therapists” emphasized how working outside traditional settings meant that some clients had barriers to inclusion. For instance, some therapists felt labeling something as a disability sport deterred clients from wanting to participate because they didn’t necessarily have a diagnosis or identify as having a disability. Further, sports tend to recruit individuals who are “sporty, who think sport’s brilliant and who think everyone should be doing more,” which can discourage less experienced people from feeling safe and confident enough to participate in sports.

Opportunities for the profession – this subtheme captured the perspective from participants that OTs working outside traditional settings have the opportunity to reach wider communities and those who weren’t previously accessing services because they didn’t meet the criteria for diagnosis.

Conclusion: Findings from this study support the understanding that occupational therapists are exploring new territory, pushing boundaries of traditional practice settings, and making a difference for clients who previously had sport and leisure occupations that were unexplored.

Implications for OT:

- Empowering clients by offering choice and control over the occupations they engage in can promote increased self-confidence and transference of this confidence to other occupations in their life

- Supporting clients without a diagnosis or who do not identify as having a disability can create new opportunities for physical and social activities

- OTs can use a holistic approach by using sport as a therapeutic means to address occupational transitions, new or different roles after an injury or disability, and promotion of the health benefits of engaging in physical activity

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Evidence for your Practice: Outdoor contexts and empowerment

  

Retrieved from https://unsplash.com/photos/TO_RcfcfdMg

The potential of outdoor contexts within community-based rehabilitation 

Article: Madsen, L. S., Jakubec, S. L., V. Nielsen, C., & Handberg, C. (2021). The potential of outdoor contexts within community-based rehabilitation to empower people with disabilities in their rehabilitation. Disability and Rehabilitation, 1-12.

Rationale: For people with disabilities, outdoor contexts can sometimes be difficult to navigate. However, visiting outdoor spaces can be therapeutic and offer many opportunities to engage in new or different ways. Outdoor spaces are also contexts that typically invite community, gathering and social engagement. The aim of this study was to examine how the potential of outdoor contexts within community-based rehabilitation to empower people with disabilities in their rehabilitation

Method: This study was a 5 month ethnographic fieldwork study including 115 people with disabilities. Participant observation and walking interviews were conducted.

Results: Four overlapping themes were revealed:

1) Revisiting the outdoors – This overarching theme encompassed how outdoor spaces facilitate the constructs in the following three themes.

2) Building autonomy – Participants were empowered to take a more active role in their rehabilitation by participating in and navigating outdoor spaces.

3) Connecting with Community – Unique opportunities came about for participants and led to increased connections with the community spaces and its members.

4) Embodied learning – The learning that the participants acquired throughout the study was identified as transferrable to other settings including contexts of everyday life and their own home environment.

Conclusion: Outdoor contexts within community-based rehabilitation appeared to hold potential for connecting people with disabilities to communities. Despite there being barriers at times, it is suggested that revisiting the outdoors supports collective awareness and action with the potential to influence community attitudes more broadly.

Implications for OT:

- Outdoor contexts within community-based rehabilitation for folks with disabilities can capitalize on the features of both indoor and outdoor environments to meet shifting individual priorities and needs

- Outdoor spaces offer people with disabilities empowering experiences that are part of the landscape for everyday life and transfer well to other contexts (eg home environments)

- Outdoor contexts and related skills provide a bridge from individual rehabilitation to community belonging  

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