Sandra Colyer

Paper presented as, “Application of a model of occupational therapy practice in a rehabilitation setting” at the 18th Federal and Inaugural Pacific Rim Conference of OT Australia, Hobart, Tasmania (1995, July).

SandraColyer is currently employed as the NSW Home Healthcare Consultant,Faulding Home Healthcare, Pty Ltd. At the time of writing this papershe was the Director of Occupational Therapy Services at the RoyalRehabilitation Centre Sydney.

PUBLISHEDABSTRACT:

This paper outlines the application of a Model of O.T. Practice in a rehabilitation setting. The royal Rehabilitation Centre Sydney is a large rehabilitation centre in Sydney that has several specialised units including spinal, neurological, brain injury and orthopaedics. As a response to organisational changes in the management structure at the centre and changes in Government policy in relation to the delivery and accountability of health care service, the Occupational Therapy Service decided to adopt a Model of O.T. practice. The aim of this was to assist in uniting the Occupational Therapy staff through this changing time and to help define the Occupational Therapy Service for the future. This paper, therefore, outlines the practical implementation of a Model in a rehabilitation setting and its impact on the attitudes of both the Occupational Therapy staff and centre staff towards Occupational Therapy practice. This paper looks at the benefits of having one Model as a guide to which language and report writing are based.As we move to the future and the needs to be more accountable it is important that the Occupational Therapy profession has a more united front with a special confidence in what we can offer. This paper may hold some of the answers to this.

PAPERPRESENTED:

PURPOSE

The aim of this paper is to describe how the model of Occupational Performance (Chapparo, & Ranka, 1992) was used to unite services in a large occupational therapy department which has a devolved unit structure and diverse areas of practice.

BACKGROUND

The Royal Rehabilitation Centre Sydney provides services to clients requiring rehabilitation. It is predominantly funded by the State Government but has a number of other sources of government and private funding. The Centre consists of several specialised units which include Brain Injury, Spinal Cord Injury, Orthopaedics, Neurology, Aged Care and Residential Care.

The structure of the Centre has recently moved towards business units and a matrix system where staff are responsible and accountable to both a Unit Manager and Service Director, or professional head. The aim of the unit structure is to provide specialised customer-focused services to specific groups of clients within a defined budget. These changes have come about in response to the ‘shrinking’ health care dollar and, therefore, the need to rationalise client services.

I commenced my position as Director of Occupational Therapy Services at the Centre 20 months ago when the new matrix management structure was being implemented. The occupational therapy staff consist of 18 occupational therapists and 12 support staff including diversional therapists, recreational staff and occupational therapy assistants. All these staff are allocated to the specialised units and there is little opportunity for rotation.

Soon after my appointment, all professional groups at the Centre were being asked to define the service they were providing and to predict the future direction of services in light of this changing climate. As a manager, I assessed that this time of change was difficult for staff of both the Occupational Therapy Service and the Centre.

I saw two significant factors which were impacting on both occupational therapy service provision and development of the Service. These were 1) the structural changes occurring throughout the Centre, and 2) the apparent diversity of training and skills within the occupational therapy staff. I decided my main role as a new manager was to assist the occupational therapy staff through this change, and that this could occur by two primary means:

First,there needed to be mechanisms put in place that would unite theservice and assist staff in maintaining professional cohesion.

I believed that establishing professional cohesion would ensure a support network that appeared to be threatened by the unit structure. This was also important because, apart from the new unit structure, I observed difficulties in communication between the occupational therapy staff.

We assume as occupational therapists that our language is the same. Experience indicates that when occupational therapists communicated, they actually alienated each other by using unfamiliar language and interpreting the same language in different ways. For example, try asking the person next to you what ADL or Activities of Daily Living means. I am sure it varies from your definition! This could be due to a variety of factors such as those experienced at the Centre. The occupational therapists I work with are from various educational backgrounds which have shaped their individual language. For example, some have degrees, others have diplomas; some trained in Australia, others overseas; some trained recently and others years ago; some trained in programs which are structured around a specific theoretical model and others had a more general training; some have backgrounds in acute care, some rehabilitation and others community, etc. The support staff are also an integral part of the Occupational Therapy service and their backgrounds are even more varied. Overall, this diversity in backgrounds significantly impacted on communication styles and led to misunderstandings amongst the occupational therapy staff, which in turn impacted on interaction with other health professionals. The physical separation created by the unit structure compounded the situation.

Second,staff needed to be given ownership of the present and any futurechanges.

I was concerned that staff felt in control of the process and that changes taking place in the Centre and the Department were not imposed on them. To achieve unity, they needed to be involved in shaping the change.

The major question I was faced with was, “What mechanisms would enable us to achieve unity as an occupational therapy service?” I believed this required a clear and common sense of identity. Occupational therapy however has had a long history of difficulty defining its role. Occupational therapists know instinctively what their role is but how effectively is this role communicated to others? If the profession has difficulty explaining itself now, how is it going to educate others about where it wants to be in the future? How were we to explain where we wanted to be as a Service in the future?

USINGTHE MODEL OF OCCUPATIONAL PERFORMANCE TO ESTABLISH DEPARTMENTAL UNITY

One solution to developing a sense of unity and identity and to providing structure to occupational therapy services is to find a

common language. The model of Occupational Performance (Chapparo, & Ranka, 1992) appeared to have a language and structure that could be easily adapted to meet our needs.

Barriersto implementation

The process of deciding how to utilise the model had several barriers that needed consideration

First, the impact of educational training of occupational therapy staff as previously outlined.

Second, the impact of diversity of personalities and learning styles; for example, it seemed that those who prefer structure embraced the model with fewer reservations.

Third, the differing perceptions of service provision; for example, some occupational therapists viewed the service provided to spinal clients as being very different to the service given to aged care clients. Some staff had conceptual difficulties in regarding these as fundamentally similar.

Fourth, there were expectations of occupational therapy practice held by other health professionals which impacted on the process; for example, some staff in other departments had expectations of what occupational therapy service delivery should be based on historical practises within the Centre.

Implementation:

The occupational therapists could see a need for unity and some structure, and were willing to challenge themselves and their work habits. They eventually reached consensus that the model of Occupational Performance (Chapparo, & Ranka, 1992) is both adaptable and comprehensive and could be used to explain occupational therapy practice in each of the specialised services. It also was congruent with the views of different therapists and their different styles of practice.

The time frame for the introduction of the Model was approximately 12 months although it is recognised that this will be an ongoing process

as new staff enter the Service and continual changes occur within the health care area. At the time of this presentation we are nearing the end of this 12 month period.

BENEFITSOF USING OCCUPATIONAL PERFORMANCE:

The Service has recently seen the benefits of utilising the Model as evident in the following examples:

Definingthe Service

First, the Model provided a clinical framework in which occupational therapists defined their services. These definitions all focused on addressing the occupational need of clients and enhancing occupational performance. The Model provided a structure that was easily conceptualised and, consequently, clearly illustrated the existing Occupational Therapy Service. With this knowledge the occupational therapy staff were able to identify both a rationale for existing services and could easily identify future changes in service delivery. For example, previously, occupational therapists working in Neurology focused specific intervention sessions on component operations such as biomechanical components and cognitive components. However, now there is a need for us to look more clearly at how component- focused interventions (eg., neurodevelopmental therapy) contribute to or enhance a client’s ability to function in their own environment (occupational role performance).

From a manager’s perspective the constructs and structure of the Model provided a framework from which policies and procedures for occupational therapy services in each of the Units in the Centre could be established and still reflect a common view of what occupational therapy is (eg. addresses clients occupational needs). From these we were also able to develop an outline for standards of clinical performance.

StrategicPlanning:

As a result of being clearer about our present role, we were able to devise a strategic plan which clearly identifies future directions of the Service. In order to achieve the marketing goal in our strategic plan, we recently utilised the Model to identify photographs that depicted the roles of occupational therapy within the Centre. This process only took half an hour because we didn’t have to spend time discussing what the focus of service is in the various Units.

ReportWriting:

Report writing has always been a difficult area for occupational therapists to reach consensus on what headings should be included and what should be documented under these headings. Previously, staff had adapted old formats to suit their service area according to how they had conceptualised the occupational therapy role. This was time consuming, lacked accuracy and was inconsistent in content across the Occupational Therapy Service.

Currently, the Occupational Therapy Service is using the Model to develop a series of report writing formats which cover the performance areas identified in the model (Occupational Roles, Occupational Areas, Components of Occupational Performance, Core Elements, Environment, Space & Time) and therefore report writing is becoming standardised over all Units.

Otherareas:

Other areas in which the Model has been utilised are reporting at case conferences, student education and formats for case presentations and job descriptions. I am happy to discuss these at the end of this paper.

SUMMARY:

In conclusion, the general consensus from staff is that although the Model doesn’t convey any new information, it provides a framework for their practice. From a management perspective it has provided consistency and standards to occupational therapy work practices throughout the Centre. At a time when outcome measures are increasingly important it is anticipated that the Model will be invaluable for this purpose.

Utilising the Model has without a doubt given the Occupational Therapy Service a sense of unity and the staff are now more confident in the services they are providing — primarily because they can articulate the rationale for their actions. This has been an important process for our service, and I believe has a message for our profession worldwide. Can we articulate a consistent message locally and internationally about what we do as occupational therapists and why?

Acknowledgments:

The Occupational Therapy Service Staff at Royal Rehabilitation Centre Sydney

Judy Ranka, Lecturer, School of Occupational Therapy, The University of Sydney

REFERENCES

Chapparo, C., & Ranka, J. (1992).Occupational performance, Draftmanuscript. (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW, Australia 2141)