4. Skills and processes in occupational therapy
Edward A.S. Duncan
Overview
This chapter focuses on theoretical foundations of what occupational therapists ‘do’. As the preceding chapter concluded, humans and the systems and environments in which they exist are complex processes. Describing occupational therapy, which focuses on individuals within the context of their physical and social environments, is not, therefore, quite as simple as it may at first appear. This chapter commences with a brief summary of occupational therapy definitions. Over the years, there has been considerable interest within occupational therapy literature regarding the nature of practice and the skills of an occupational therapist. In order to address this, the chapter will examine the various skills (core, shared and specialist) of an occupational therapist. The chapter then concludes by examining the occupational therapy process.
This chapter:
• highlights the core skills and processes of occupational therapy
• separates skills into those that are core, shared or specialist for practice
• outlines the occupational therapy process and its cyclical nature
• examines issues arising in assessment, goal-setting and evaluation.
Defining occupational therapy
Definitions are important. To define something is to clarify a topic and provide a vision of its function. Definitions also set boundaries and limitations. Therefore, definitions should be a useful tool in the description of occupational therapy. However, as previously acknowledged, defining occupational therapy can be complex. Despite or perhaps because of this, a multiplicity of occupational therapy definitions exist. The College of Occupational Therapists (COT) provides the following brief description of occupational therapy,
Occupational Therapy enables people to achieve health, well being and life satisfaction through participation in occupation. (College of Occupational Therapists 2004a)
The World Federation of Occupational Therapists (WFOT) describes occupational therapy as:
a health discipline which is concerned with people who are physically and/or mentally impaired, disabled and/or handicapped, either temporarily or permanently. The professional qualified occupational therapist involves the patients in activities designed to promote the restoration and maximum use of function with the aim of helping such people meet the demands of their working, social, personal and domestic environment, and to participate in life in its fullest sense. (World Federation of Occupational Therapists 2003)
This definition is significant, as it considers the role of the occupational therapist in relation to the environment, an area of increasing relevance in contemporary practice.
The WFOT (2003) provides a further 37 definitions of occupational therapy that have been developed by its national member associations. Reviewing comparative definitions of occupational therapy, it is apparent that there is substantial consensus of opinion regarding the definition of occupational therapy. National differences appear more reflective of the differing layers of complexity considered rather than significant differences of opinion.
Defining the skills of an occupational therapist
The skills of an occupational therapist are many and varied, and are often presented in seemingly simple ways. This is both the profession’s strength and greatest challenge. A key skill of an occupational therapist is their ability to bring an occupational perspective, in terms of both a person’s ability and their identity, to the therapeutic context. Within this context, occupational therapists work with client’s strengths and address areas of occupational dysfunction. To achieve this, occupational therapists use a range of skills: core, shared (sometimes referred to as ‘generic’) and specialist.
Core skills in occupational therapy
The ‘core’ of an object is it most important part. From there everything else develops. (Schwartz 1994)
If an uninformed observer were to witness the work of occupational therapists from different specialties, their initial impression might be, at least on a superficial level, that they have little in common. Therapists working in social services, mental health and physical rehabiliation often appear, at first glance, to be doing different things. In all honesty, it must be admitted that at times they are — practice in some areas has lost its focus. This, however, is not how it should be.
Defining practice and developing a shared understanding of a profession’s key competencies and processes are vital to its development. Mosey was perhaps the first theorist to tackle the concept of core skills in occupational therapy rigorously (Mosey 1986). Within the UK, the 1990s witnessed considerable interest and effort invested in further identifying and describing occupational therapy’s core skills (Thorner, 1991, Renton, 1992, Hollis, 1993a, Hollis, 1993b, Hollis and Clark, 1993 and Phillips and Renton, 1995). The reason that such discussion was stimulated is reflective of the complexity of occupational therapy and the multi-layered components of each skill.
The COT outlined seven core skills (College of Occupational Therapists 2004a):
• collaboration with the client
• assessment
• enablement
• problem-solving
• using activity as a therapeutic tool
• group work
• environmental adaptation (Creek 2003).
Hagedorn recognized the complexity of occupational therapy and the difficulties that are faced when attempting to define the core skills of the profession, stating that:
Our core competencies and processes must somehow encompass the nebulous aspects of professional judgment and reasoning, problem solving and research as well as the ‘hands on’ forms of therapeutic knowledge and skill … This exercise will probably demonstrate that it is far from easy to untangle the things which are only done by occupational therapists from those which many other professions may do. (Hagedorn 2001, p.34)
Analysis and adaptation of occupations
The analysis of occupations and their use in therapy has also been recognized as a core skill of the occupational therapist (Hagedorn 2001). The analysis and prescription of occupations have two purposes:
• to deal with problems experienced by the client in all aspects of their everyday life — frequently classified as work, leisure and self-care
• the use of occupations as specific therapeutic interventions to address occupational perfomance difficulties and assist in the development of a positive occupational identity.
Activity analysis involves dissection of an occupational form into its component parts (tasks) and sequence, looking at its stable and situational components and evaluating its therapeutic potential. In doing so, it finds or adjusts an occupation for therapeutic benefit and enables a person to engage or re-engage in some form of occupation (Kielhofner & Forsyth 2009). Occupational therapists carry out activity analysis in order to consider:
• the kind(s) of performance needed to achieve the occupational form, e.g. cognitive, motor, physical, interpersonal (the headings used for detailed analysis will depend on the selected conceptual model or frame of reference)
• the degree of complexity of the activity
• the social or cultural associations
• defining the component tasks of which the occupational form is composed
• analysing the sequence of task performance and whether this is fixed or flexible
• defining the tools, furniture, materials and environment required for completion of the occupational form
• defining and taking account of safety precautions or risk factors.
Environmental analysis and adaptation
This is another skill used in a way that is core to occupational therapy practice. Occupational therapists recognize that the physical and social environments can have an important beneficial or detrimental effect on the individual. Environmental analysis may provide information on the causes of problems for the individual, explanations for behaviour or ideas or suggestions for therapeutic adaptation.
As conceptual models of practice have developed within occupational therapy, core skills have become increasingly linked to theory. Conceptual models can provide assessment(s) and taxonomies that assist in the detailed and structured analysis of occupations (see Kielhofner & Forsyth 2009 and Chapter 6 for an example of this). Frames of reference provide theoretical frameworks to support the therapeutic use of self (read Chapter 6, Chapter 7 and Chapter 8 for further information).
Shared skills
It is acknowledged that, as well as their core skills, each occupational therapist has a variety of shared skills. Whilst shared, these skills are no less essential to practice. Occupational therapists draw on the wealth of assessments and interventions that have not been developed by occupational therapists but facilitate the development of occupational performance and assist in the creation of a greater occupational self-identity.
The use of interventions that are not occupational therapy-specific is a contentious topic, as the profession becomes ever more deeply occupation-focused. Do non-occupational therapy-specific interventions have a place in the profession today? Several of the chapters in this book address this issue, either directly or indirectly.
Occupational therapists have a range of shared skills. Some of the most central are described below.
Leadership and management
Often placed together, leadership and management are two important but distinct skills.
Management
Occupational therapists have to manage services, a case load, an academic department or research team resources, and, importantly, themselves. The therapist needs to set standards, monitor quality and audit performance. These findings need to be communicated within the profession and to others. The therapist must be critically aware of their performance, seeking regular supervision and evaluating and updating personal knowledge. Management is not, therefore, a skill that is the remit of the head of a service, but the responsibility of all staff, albeit in differing ways. Furthermore, as well as managing others, therapists must also be able to manage themselves. Self-management consists of the actions and strategies we use to direct our own activity and ensure that we remain fit for purpose at work and at home. Bannigan (2009) describes the importance of self-management and the development of professional resilience in the face of the many challenges that arise in the workplace.
Leadership
Leadership is different from management. Whilst management has been defined as the ‘bottom line … how can I best accomplish things’, leadership has been defined as knowing ‘what are the things I want to accomplish’ (Covey 1989, p.101). Leaders in occupational therapy develop innovative approaches to intervention, work with clients in new ways, spot opportunities and develop services. The historical view of management and leadership as components of the same role is increasingly recognized as ineffectual. Indeed, the developing roles of consultant and clinical specialist occupational therapists (within the UK) appears to recognize that certain career pathways offer and require particular leadership qualities. Managing a service is an alternative professional pathway. Therefore, the leader of an occupational therapy team is not necessarily the manager, but may be a senior clinician with the vision and skills to move the service forward. Developing as a leader, however, is more than merely a professional skill; it is a personal and professional quality.
An awareness of one’s need for continuous self-improvement and openness to others’ perspectives of our own leadership qualities is essential. Whilst everyone will have their own leadership style, lots can be learned from other people. Often the best way to start devloping this quality is to observe leaders you admire (both within and outside the profession), taking a bird’s-eye view of their practice/life. What do they do that makes you admire them? How do they deal with other people? How do they deal with themselves? What is their vision? How do they maintain their integrity in difficult situations? Conversly, the same exercise can be carried out with individuals whose practice you may not like to emulate! Reflect on these observations and consider any lessons that can be learnt. What would you wish to integrate into your practice/life?
As well as observation, a lot can be learnt from the wealth of literature that is available on this subject (e.g. Covey, 1989 and Goleman et al., 2002). Christiansen (2009) writes on leadership with direct reference to leadership in occupational therapy. Ultimately, however, leadership qualities are lived, developed and refined over a lifetime.
Therapeutic use of self
The therapeutic use of self is arguably one of the most important skills a therapist has. Mosey (1986) describes an occupational therapist’s use of self as a concsious therapeutic tool and suggests that there is a difference between a spontaneous interaction that is unplanned and a planned interaction that, whilst appearing spontaneous, is guided and informed. Yarwood and Johnstone (2002) suggest four issues that essentially relate to the therapeutic use of self and the development of a therapeutic relationship:
• ‘Establish rapport;
• Respect the wishes of the client;
• Use honesty and strive to develop a collaborative approach; and
• Adapt to communicate effectively with all kinds of people’ (p.327).
Occupational therapists have adopted various theoretical frameworks that assist in the development of the therapeutic use of self in differing ways. These include the client-centred, the cognitive behavioural and the psychodynamic frames of reference (see Chapter 11, Chapter 12 and Chapter 13 for further information).
Research
Research is a central component of occupational therapy practice (Ilott & White 2001) and the emphasis on research is arguably the single most significant development that has occurred in occupational therapy in the last 20 years (Duncan 2009). Every occupational therapist is required to use skills in research. This does not mean that every occupational therapist must carry out independent research, but at the very least everyone should be effective and critical consumers of research (Ilott & White 2001). The skills required to do this include:
• information and communication technology skills, to search and locate the literature
• critical appraisal skills, to evaluate research
• development of a personal evaluative perspective, to challenge custom and practice
• ability to integrate research into practice, in order to deliver consistently the highest quality of service available.
Specialist skills
Specialist skills are skills that cannot be expected of a competent clinician without further training, supervision and expertise (Duncan 1999). Occupational therapists can develop specialist skills that are either an extension of their core skills, such as specialist assessments (e.g. the Assessment of Motor and Process Skills (AMPS); Fisher 1997), or an extension of their shared skills, such as undertaking advanced splinting or psychotherapy training (Duncan 1999).
Defining the occupational therapy process
The occupational therapy process is the name given to the series of actions a therapist initiates in order to provide services to their client. This process is clearly not unique to occupational therapy. It is a form of problem analysis and solution that has been used by various healthcare professionals. There have been several representations of the process in occupational therapy, each differing a little from the others in accordance with each author’s personal concept of the sequence. Generally, there is close agreement on the basic format. This involves gathering information concerning the client, their situation and challenges, carrying out assessments, identifying and formulating the problem or need, setting goals, setting consequent priorities for action, deciding on how to achieve these, implementing action and evaluating the outcome. Creek (2003) illustrates this process in a linear model (Fig. 4.1). Hagedorn (2001) uses similar points but illustrates the process’s cyclical nature (Fig. 4.2). In practice, the occupational therapy process is often not linear (Creek 2003) or even cyclical. Frequently, these activities occur in synchrony and are repeated at various stages of therapy. The process is therefore circuitous, with overlapping and interwoven aspects of the process occurring throughout.
Related posts:
Theoretical foundations of occupational therapy
An introduction to the psychodynamic frame of reference
An introduction to conceptual models of practice and frames of reference
The Functional Information-processing Model
The Person–Environment–Occupational Performance (PEOP) Model
The cognitive behavioural frame of reference
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