(OT) Program SYMPOSIUM 2006 - BlueWire Computer Services

McMASTER UNIVERSITY
Master of Science (OT) Program
SYMPOSIUM 2006
Wednesday, June 14, 9:30 to 4:00
9:30 to 11:15 ~ Concurrent Podium Presentations:
CIBC Hall, Room #308
Time
Title
9:30 –
9:50
The Effects of Compensatory Aids on Children with
Disabilities and their Families
10:00 –
10:30
ICF
10:40 –
11:00
OT in Home Care
CIBC Hall, Room #315
Presenter(s)
Stacey Henderson
Heather Skelton
Time
9:30 –
9:50
Title
Presenter(s)
Development of a Handwriting Protocol for Primary
School Aged Children
Sarah Brunetti
Jeannette Bradley
Denise Amirault
Alison Bentham
Michele Hampton
Stacy Schincariol
Stacey Anutooshkin
Kim Hewitt
Jennifer Farrell
Stacey Anderson
10:00 –
10:30
Factors Contributing to Quality of Life in Individuals
with Mental Illness Re-integrating into the Community
Laura Bradley
Kathryn Schnarr
10:40 –
11:00
OT Perceptions of Obesity
Deanna Garraway
Jay MacDonald
11:25 to 1:00 ~ Concurrent Podium Presentations:
CIBC Hall, Room #308
CIBC Hall, Room #315
Time
Title
Presenter(s)
11:25 –
11:55
Informational Needs of Grandparents of Children with
Disabilities – CP and DCD
Cynthia Perry
Heather McCallum
Lisa McCrea
Shannon Grant
Jennifer Joss
12:05 –
12:20
Evaluation Process of Productivity Consultations
12:30 –
12:50
Inclusive OT Education
Heather Rutherford
Elizabeth Buhler
Magda Mouneimne
Time
11:25 –
11:40
11:50 12:05
12:15 –
12:35
12:45 1:05
Title
Presenter(s)
Profile of Aging Clients at Community Living Hamilton
Sandra Rodrigue
The Experiences of Occupational Therapists Practicing
in Rural and Remote Communities of Northern British
Columbia
Kathryn Fields
More than Words: Community Living and Mental
Illness
Comprehensive Management of CRPS in the Upper
Extremity
Jennifer Neill
Allison Henderson
Lauren Sloan
Adam Burke
2:00 to 4:00 ~ Concurrent Poster Defences, CIBC Hall Room 319:
Title:
Presenters:
Student Attitudes and Perceptions Towards Interprofessional Education
Samantha Yeung
Title:
Presenters:
Environmental Design and Dementia Care: Creating a Link Between Research and Implementation
Laura Motherwell, Catherine Smith
Title:
Presenters:
Catholic Family Counselling Centre: Can Local Providers Meet the Needs of the EAP Clients?
Natasha Annett-Lawrence, Andrea Oattes
Title:
Presenters:
The Family Doctor’s Role in Timely Return to Work: A Survey of the Key Issues
Jennifer Appelton, Kevin Campbell
Title:
Presenters:
Recommendation for Measuring Support at Sheena’s Place
Amy Morrison, Kaleigh Starritt
Title:
Presenters:
Recovery Outcome Measures
Astrid Scholte, Alisson White, Susie Gregg
2:00 to 4:00 ~ Concurrent Poster Defences, CIBC Hall Room 319:
Title:
Presenters:
“What’s Next?” A Goal Setting Group for Teens
Julie Roberts, Cynthia Lennon
Title:
Presenters:
Development of Modified Work Program (MWP) and Procedure
Sarah Sidney, Jeff Perrier
Title:
Presenters:
Disability Management Program Development
Nicole Johnson
Title:
Presenters:
Task Analysis as an ADL Measure Compared to the FIM & Klein-Bell in ABI Populations
Rhodine Thomas, Angela Rose
Factors Contributing to Quality of Life in
Individuals with Mental Illness Re-integrating into the
Community
Students: Denise Amirault, Stacey Anutooshkin, Alison
Bentham-Rudge, Michele Hampton & Stacy Schincariol
Supervisors: Ivy Morton & Muriel Westmorland
Introduction:
For individuals with mental illness, leaving the hospital and
re-integrating into the community can pose a significant
challenge. Currently, mental health consumers are reintegrating
into the community after hospitalization and utilizing formal and
informal support systems, however their quality of life is not
being formally acknowledged within the health care system.
Therefore, the purpose of this pilot study was to a) examine what
people with mental illness felt they needed to improve their
quality of life when re-integrating into the community following
hospitalization in Hamilton, Ontario, and b) how this compared
to the perceptions of their families and friends as well as mental
health service providers.
Literature Review:
The researchers conducted an extensive search of the
literature pertaining to barriers to community integration, quality
of life for consumers, and the different perspectives between
service providers and consumers. Examples of barriers to
community integration are finances, lack of employment (Mallik,
Reeves, & Dellario, 1998), social isolation, and lack of structured
activities (Kelly, McKenna, Parahoo, & Dusoir, 2001). Quality
of life can be defined as one’s subjective physical, mental, and
social well-being and is suggested to be the most relevant
outcome measure when evaluating community based services
(Prince & Prince, 2001). It has been identified in the literature
that perceptions of factors influencing quality of life differ
between consumers and service providers (Shoen Lamaire &
Mallick, 2005), providing further evidence for the importance of
exploring all perspectives. No literature was found comparing
the perspectives of family members, service providers and
mental health consumers.
Methods:
Design: A phenomenological qualitative research design was
utilized to better understand the lived experiences of the study
participants. This study used focus groups and individual
interviews as a means of obtaining the data.
Sample: Ethics approval was obtained from the McMaster
University Research Ethics Board. Informed consent was
obtained from each participant. Three stakeholder groups were
recruited: 1) individuals 18 years of age or older, diagnosed with
a mental illness who had been hospitalized within the last two
years and were now living in the community; 2) service
providers working with people with mental illness; and 3) family
and friends of people with mental illness. Eight of the 11 study
participants were women. There were 5 consumers, 2 family
members and 4 service providers. The average age of study
participants was 42.5.
Data Collection: Focus groups and interviews were used to
gather data. All focus groups and interviews were audio-taped.
Focus groups were transcribed verbatim. Focus group and
interview questions can be found in Table 1.
Table 1: Focus Group and Interview Questions
1. In order that we can help to improve services for persons
with mental illness we would really appreciate you telling us
about yourself and your experience with mental illness.
2. Given your experiences, what do you feel are the needs of
people with mental illness after leaving the hospital to improve
their quality of life?
3. What are the barriers to improving quality of life for people
with mental illness who are trying to get back into the
community?
4. What supports are you aware of that help in the process of
getting back into the community again?
5. Do you have any suggestions about how some of the
supports you mentioned, or services in general, could be
improved?
6. Is there anything else you would like to add?
Data Analysis:
The focus group transcripts were coded and categories were
developed. The researchers listened to audiotapes of the family
interviews as a group while individually coding the information.
A master list of codes and categories was negotiated amongst all
researchers. Three overarching themes supported by sub-themes
were developed by the researchers after examining the categories
(Table 2). The transcripts, audiotapes, and lists of codes,
categories, and themes were reviewed by supervisors for
triangulation purposes.
Table 2: Summary of Themes and Sub-Themes
Supports
Systems Issues
Formal
Not meeting consumers’
needs
Navigating the system
Informal
Financial
Housing
Recreation
Constraints of the system
Power imbalance/
inequality
Bridging
Awareness &
Understanding
Societal/ public awareness
Education for family
Education for consumer
Vocational Accommodation
Findings:
When reading quotes the following abbreviations will be used to
denote mental health consumers (c), family members (fm), and
service providers (sp).
Supports: The supports identified included: formal, informal,
financial, housing, and recreational supports.
Formal supports: were defined by the researchers as health care
professionals and structured support services and were identified
as a need for individuals with mental illness across all groups to
improve quality of life:
“I wanted to emphasize more is better. There’s some really
great supports out there, but it’s just not maybe enough of it to
go around”. (sp)
Informal Supports: were defined by the researchers as
unstructured supports available in the community, such as
family, friends, and peer support and were identified as a need
across all groups:
“He’s never had a good quality of life because he’s never
really developed any friendships outside of his family” (fm)
“Thank God for peer support” (c)
Financial needs were found to impact quality of life in terms of
limited transportation, housing, engagement in social and
recreational activities and basic needs such as food and clothing:
“And half the time you’re just so depressed, cause you have
nothing” (c)
Housing: Participants identified that the lack of access to
adequate housing was due to financial limitations as well as lack
of availability of housing options:
“We have clients on our unit that go to our [independent living
skills program]…and they’re doing great and wow, and that’s
wonderful you can live on your own and then, what do we do?
Into a boarding home because there’s no place available”. (sp)
Recreation: Participants indicated that participating in
recreational activities was a way to achieve structure in their
lives.
Systems Issues: This included: the system not meeting consumer
needs, navigating the system, constraints of the system, bridging,
and power imbalance. Although all groups identified systems
issues, each group had a different perspective on the focus of
these issues.
The system not meeting the consumer’s needs was identified
particularly by consumers and family as a lack of individualized
support and shuffling through the system, creating a significant
barrier to community integration.
Navigating the system: was defined by participants as being
informed of the supports available in the community after
discharge and the ability to access these supports.
“…I know there’s a lot of help out there. It’s navigating
through it that drives you crazy.” (c)
Constraints of the System: were identified by service providers as
creating a challenge in practice, making it difficult for the system
to meet the consumers’ needs. Issues such as cutbacks, staff
shortages, faster discharge, and more diverse, complex client
populations were discussed.
Bridging: refers to continuity of services from inpatient to
outpatient by providing services and supports necessary for
living in the community, while still in hospital, and by providing
follow-up.
“We find the ones that do better are the ones that there’s good
communication from in to out. There’s a good link, goals that
the client identified inpatient are going to carry through or
communicated to outpatient or follow-up.” (sp)
Power imbalance and inequality: Consumers and family
members expressed a feeling of powerlessness, and that their
concerns were being dismissed as a result of an unequal
professional-client relationship.
Awareness and Understanding: Included: societal/public
awareness, education for family, education for consumers, and
vocational accommodation.
Societal/public awareness: was identified by most participants as
a factor that impacted quality of life.
“There needs to be an acceptance of people with mental
illness… That can only be done once you get an understanding
of the disease” (fm)
Education for family and education for consumers: was identified
to decrease misconceptions and increase self-advocacy.
“I think a lot of times before they are educated they think of
the typical schizophrenia thing that you think of on movies…
So I think that it is important that before you come back into
the community that the people that you do count on for support
are educated.” (c)
Vocational
Accommodation:
Struggles
with
being
accommodated in the workplace as a result of a lack of
understanding about mental illness were identified by many of
the participants.
Discussion:
In reviewing the themes, it was evident to the researchers that
there were both similarities and differences between the
participant groups and what they felt was needed for people with
mental illness to improve their quality of life when re-integrating
into the community. Although all groups mentioned informal and
formal supports, consumers stressed the importance of informal
supports. Service providers and family members spoke more
about formal supports than did consumers. There was recognition
by consumers, service providers, and family members that there
were not enough supports to meet the needs of people with
mental illness. Each group discussed issues relating to the mental
health system; however, the groups focused on different aspects.
Whereas consumers focused more on inequities, power
imbalance, and issues with navigating the system, the service
providers focused more on constraints within the system. All
groups indicated a need for more education and awareness of
mental illness.
Limitations in the study were that the service provider group
consisted only of occupational therapists, there were only 2
family members that were interviewed individually as opposed to
in a focus group format, and that consumers needed to be
hospitalized within the past two years which limited the sample.
Recommendations:
Based on the findings, the following recommendations are
proposed:
1. Encourage the development of more peer support both for
inpatients and consumers living in the community.
2. Supports and services are needed to help consumers transition
into the community and access available resources.
3. Access to case management services.
4. Equitable access to services within the mental health system
for all mental health consumers, regardless of diagnosis.
5. Recognition and resolution of power imbalances that can exist
between consumers and service providers.
6. Advocacy for systems and policy changes at the institutional
or governmental level to address issues such as staff cutbacks
and restrictive financial supports.
7. Increased education to increase awareness, decrease stigma,
and facilitate acceptance within society.
Acknowledgements:
We would like to give special thanks to our supervisors Ivy
Morton and Muriel Westmorland (OT Reg.) for their support and
insight into the creation of this pilot study.
References:
Kelly, S., McKenna, H., Parahoo, K., & Dusoir, A. (2001). The
relationship between involvement in activities and quality of
life for people with severe and enduring mental illness.
Journal of Psychiatric & Mental Health Nursing, 8(2), 139146.
Mallik, K., Reeves, R. J., & Dellario, D. J. (1998). Barriers to
community integration for people with severe and persistent
psychiatric disabilities. Psychiatric Rehabilitation Journal,
22(2), 175-180.
Prince, P.N. & Prince, C.R. (2001). Subjective QOL in the
evaluation of programs for people with serious and persistent
mental illness. Clinical Psychological Review, 21, 1005-1036.
Schoen Lemaire, G., Mallik, K. (2005). Barriers to community
integration for participants in community-based psychiatric
rehabilitation. Archives of Psychiatric Nursing, 19, 125-132.
Recovery Outcome Measures Project
Student Researchers: Susie Gregg, Astrid Scholte, & Alisson White - MSc. (OT) Candidates
Supervisor: Susan Strong, B.Sc. OT Reg. (Ont.), MSc. (DME)
St. Joseph’s Healthcare, Centre for Mountain Health Services, Hamilton, Ontario
INTRODUCTION:
Delivering recovery-focused services is an expectation for
evidence-based mental health services. Recovery outcome
measures are required to determine if interventions and services
are helping clients progress in their recovery journeys.
Clinicians require outcome measures with proven clinical
utility to evaluate change and client progress. The purpose of
this exploratory study was to determine the clinical utility of
three recovery outcome measures for an inpatient tertiary
schizophrenia service. The three measures selected for
evaluation were: A) the Mental Health Recovery Measure
(MHRM), (Young & Bullock, 2003); B) the Recovery
Assessment Scale (RAS), (Giffort, Schmook, Woody,
Vollendorf, & Gervain, 1995); and C) the Recovery Markers
Questionnaire (RMQ) which is a subscale of the Recovery
Enhancing Environment Measures (REEM), (Ridgway &
Press, 2004).
LITERATURE REVIEW:
Recovery is composed of multiple domains, including hope,
well being; empowerment, personal responsibility and
advocacy; increased participation and activity level; coping
with symptoms and stressors; social relationships; and
development of self (Jacobson & Greenley, 2001). There are
three types of recovery measures identified in the literature,
namely: individual recovery measures (multiple domains of
recovery); component measures (one domain of recovery); and
environmental focused measures (evaluate environmental
factors that promote recovery) (Campbell-Orde, Chamberlin,
Carpenter, & Leff, 2005). Measurement of recovery is
challenging as recovery: a) has many definitions; b) is an
individual process; c) is both a process and an outcome; and d)
measures are in early stages of development. Given these
issues, clinicians need guidance in the selection of recovery
outcome measures. Adapting criteria from Law (1987), clinical
utility can be categorized into three areas: format and layout;
administration; and content/ meaningful information.
Participant Recruitment: Participants included both clinicians
and their clients. Clinician volunteers from a variety of
disciplines (social work, occupational therapy, nursing,
vocational counseling, and psychology) were recruited through
one-to-one meetings with the students, who informed them of
the purpose and project protocol. Interested clinicians used
their expertise to choose the appropriate tool to use with their
client. The researchers attempted to obtain a representative
sample of clinicians, clients, and tools from three inpatient
units, and one transitional team at the project site.
Procedure: Clinicians administered the measures (in either an
interview or self-report format) with their clients, and typically
one student researcher was in attendance. Clinical utility was
measured using client and clinician feedback forms that were
developed by the researchers. The clinical utility feedback
forms were administered by the students immediately after the
tool administration. Feedback forms incorporated Likert
scaling (1 Æ strongly disagree to 7 Æ strongly agree) for
clinicians, Yes/No questions for clients, and open-ended
questions.
DATA ANALYSIS: Descriptive analysis was performed from
a synthesis of clinician and client feedback, and student
observations. Feedback form scores were analyzed by means
and percentages for each category of clinical utility
(format/layout, administration, content/meaningfulness) and
examined for trends within the context of staff and client
comments and student observations. Data was analyzed by tool
and across tools.
RESULTS
Participants: 26 clients and 16 clinicians participated in the
project, with 6 of the 26 clients agreeing to complete two
different measures. The sample was generally representative of
inpatients of Schizophrenia Services. All three tools were used
with clients exhibiting symptoms at the time of administration.
There was a broad representation of clinician involvement seen
across disciplines and units. Nursing staff and therapeutic
recreationists, however, were proportionally under-represented.
METHODS:
Tools: 32 administrations were completed: 16 administrations
Design: This project used a descriptive study design, with
of the RMQ, and 8 administrations of both the RAS & MHRM.
mixed methodology and purposeful sampling.
Tool Selection: After critical appraisal of 25 recovery measures Format and Layout: Prior to any administrations, clinicians
suggested formatting changes be made to each measure,
identified by an environmental scan, the following selection
criteria were applied: a) developed for a seriously mentally ill including increased font size and placement of Likert scales.
population; b) had extensive consumer involvement in
Clinician Feedback: Instructions were easily understood for
development; c) representative of recovery domains; d)
both the MHRM (6.3) and RAS (6.6). Clients encountered
intended for clinical evaluations of individuals; and e) field
difficulty with the staging question of the RMQ, which lowered
tested with established items and reliability. This reduced the the mean (5.4). Clinicians agreed that clients were able to
number of measures to 18. These 18 measures were further
participate meaningfully for the MHRM (5.8), and RAS (6.6),
reduced to 11, based on whether they covered the recovery
but less so for the RMQ (4.8).
domains and environmental factors. 11 measures were
Client Feedback: Clients perceived that they had few
presented to staff at the field site for further feedback. Based
difficulties following the instructions for the measures (71% for
on staff feedback and time restrictions, 3 individual measures
MHRM, 100% RAS, 80% for RMQ).
of recovery were chosen (MHRM, RAS & RMQ) to trial.
Administration:
2
Clinician Feedback: The average administration time (in
minutes) was: MHRM-21; RAS-10, RMQ-16, varying with
method of administration. Ease of administration was usually
not an issue. Little to no preparation was required. Wording
was rated as generally understood & appropriate (MHRM 6.8,
RAS 6.6, RMQ 5.8) with a few consistent words requiring
clarification (e.g., spirituality). Clinicians rated scoring well
(MHRM 6.8, RAS 6.3, RMQ 5.6). Clinicians had to clarify
and define recovery for all, regardless of tool. Clients described
as more acutely ill or having cognitive impairment had greater
difficulty rating their answers using the 5-point Likert scale.
Client Feedback: The length of administration time was
considered acceptable by clients, with the majority indicating
that they did not have any difficulty understanding the
questions (MHRM =71% RAS= 86%, RMQ=64%).
Content/Meaningful Information:
Clinician Feedback: For most participants, items were deemed
relevant to clients’ lives; however, a few individuals for the
MHRM & RMQ were given very low ratings with comments
about clients lacking awareness of illness. The majority felt
that the MHRM (5.6) & RAS (5.8) gave clinically meaningful
information; less so for the RMQ (4). Clinicians’ ratings were
more neutral regarding relevance to clinical context (MHRM
4.8, RAS 5.5, RMQ 4.7). Both the MHRM & RAS helped to
facilitate dialogue (5.3 for both), and to a lesser extent, the
RMQ (4.3). Most clinicians felt that the information gathered
justified the time spent for the MHRM (6), RAS (5.9) and to a
lesser extent, the RMQ (4).
Client Feedback: The MHRM (86%) & RAS (85%) were rated
as relevant to their lives, whereas 64% thought the RMQ was
relevant. A high percentage thought the items helped them to
think about recovery in their lives (MHRM 75%, RAS 100%,
RMQ 75%). All MHRM and RAS participants said they would
complete the questionnaire again, although the RMQ was rated
at 64%. Most clients recommended the tools be used for others
(MHRM 71%, RAS 43%, RMQ 64%); some clients indicated
they could not speak on behalf of others
Additional Comments
Often the tools evoked feelings and questions within the client
after administration. Clinicians thought the RAS captured
illness management better than the MHRM or RMQ. There
were conflicting thoughts about whether the tools provided
clinicians with new insight, although some identified specific
things that they thought were worth pursuing. Some clinicians
thought the tools provided a venue for discussing future events
and potential issues. Many clinicians thought the tools
provided common language for recovery dialogue.
scored and administered by clinicians and almost all of the
clients were able to engage in the process when given some
accommodation for cognitive difficulties.
The RMQ was chosen twice as frequently by clinicians
than either the RAS or the MHRM, based on its perceived
simple language and items pertaining to basic needs. It was
typically chosen for clients exhibiting symptoms and described
as having less awareness of their illness. This indicates a
sample selection bias related to symptomology and awareness
of illness for the RMQ. It is hypothesized that if this same
group of clients had completed the MHRM or the RAS, similar
results would have been found.
Recommendations for Clinical Practice: These recovery
measures should be incorporated into regular clinical practice.
All 3 measures can be administered by healthcare professionals
across disciplines, and can be used with individuals displaying
positive or negative. Clinicians should use their discretion as
to when these measures are introduced to clients with limited
awareness of their illness. Findings need to be considered
within the study’s limitations re: small sample size, selection
bias, and administrations at only one point in time
It would be helpful to introduce the concept of recovery
prior to administration of the measures. Interview format is
recommended for clients with cognitive impairment. Visual
and verbal assistance may be required to help clients select an
answer using the 5-point Likert scale. These measures enable
self-discovery for the clients and assist with relationship
building, goal setting, communication, and partnership. The
measures provide clinicians with information from the
perspectives of their clients. Strong emotions may be elicited,
requiring follow-up from the clinician.
Recommendations for Future Research: As these measures
are still in the early phases of development, further research
should focus on determining sensitivity to change and clinical
significance of the scores. The relationship between the scores
and the clients’ actual performance is unclear. Further testing
for predictive validity is required.
REFERENCES:
Campbell-Orde, T., Chamberlin, J., Carpenter, J., & Leff, H.S. (2005).
Measuring the Promise:A Compendium of Recovery Measures.
Volume II. The Evaluation Centre @ HSRI, retrieved Nov. 15,
2005 from www.tecathsri.org
Giffort, Schmook, Woody, Vollendorf, & Gervain, (1995).
Construction of a scale to measure consumer recovery.
Springfield, IL: Illinois Office of Mental Health.
Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual
model and explication. Psychiatric Services, 52, 482-485
Law, M. (1987). Measurement in occupational therapy: Scientific
criteria for evaluation. Canadian Journal of Occupational
CONCLUSIONS & RECOMMENDATIONS
Therapy, 54, 133-138.
Conclusions: The sample selected for this project demonstrate
Ridgway, P., & Press, A. (2004). Assessing the recovery-orientation of
that the three measures can be used with individuals with
your mental health program: A user’s guide for the recoveryschizophrenia exhibiting both positive and negative symptoms,
enhancing environment scale (REE). Kansas: School of
and with varying levels of education in an inpatient setting.
Social Welfare, University of Kansas.
The measures can be administered and scored by healthcare
Young, S., & Bullock. W. (2003). The mental health recovery
professionals across disciplines. Formatting changes made to
measure. Available from the University of Toledo, Department of
Psychology (#918). Oh 43606-3390
the measures by the student researchers were received well by
clinicians and clients alike. Each measure had a few words that
were poorly understood by clients. The initial staging question
on the RMQ was also noted as being problematic for
individuals. In general, however, the measures were easily
ACKNOWLEDGEMENTS
We would like to extend a thank you to Susan Strong for her continued
assistance and guidance through out this project. Our thanks also extend to the
many clients and clinicians who participated in our project.
Task Analysis as a Quantitative Tool to measure the Efficacy of Rehabilitation
Students: Rhodine Thomas and Angela Rose
Supervisors: Jill Oakes OT Reg. (Ont.) and Dr. Diana Velikonja
Oakes, personal communication, November 2005). Equal
Introduction:
The Ontario Brain Injury Association estimates that over consideration is also provided for the physical and cognitive
capabilities of the patient.
50,000 Canadians sustain a traumatic brain injury each year
(Rapaport, 2003). Brain injury rehabilitation is lengthy and
Purpose:
The purpose of this pilot study is to analyze if the task
expensive with an estimated cost of $118 million per year in
analysis methodology is a more sensitive measure of change in
Ontario alone (Brain Injury Association of Canada, 2006).
the performance of ADLs than standard occupational therapy
With health care undergoing reform, there is increasing
pressure to demonstrate the efficacy and quality of treatment measures such as the FIM, BI, and KB ADL Scale in an
inpatient ABI population. It is hypothesized that Task Analysis
(Watson, Kanny, White, & Anson, 1995). Occupational
therapists utilize standardized assessments to measure changes will be more responsive to change than the FIM, BI, and KB in
this population.
in performance levels of activities of daily living (ADLs)
before and after treatment to determine the effectiveness of
Methods:
For this quantitative study, ethics approval was obtained
rehabilitation (Desrosiers, Noreau, Bravo, Hebert, & Boutin,
from Research Ethics Board of Hamilton Health Sciences. The
2003). Over the last 40 years, many ADL scales have been
study used a repeated measures within subjects design. The
developed including the Functional Independence Measure
(FIM), the Barthel Index (BI), and the Klein-Bell ADL Scale study participants (n=5) were successive admissions to the
Transitional Living Unit of the Chedoke Acquired Brain Injury
(KB) (Desrosiers et al, 2003).
Program at St. Joseph’s Hospital. Informed consent to
Literature Review:
participate in the study was obtained and demographic
Research has shown that the FIM, the BI, and KB have
information collected upon admission. The demographic
good psychometric properties. The FIM and BI are reliable
information is represented in Table 1.
and valid with high internal consistency within the acquired
Instruments Administered: Participants were rated on five
brain injury (ABI) population (Shah & Muncer, 2003).
However, they are criticised for their insensitivity to change in instruments: 1) FIM = bathing/dressing-upper body/dressingthe ABI population. The FIM and the BI do not discriminate lower body sub-scales; 2) BI = bathing/grooming/and dressing
between the types of assistance required by the individuals (i.e. subscales; 3) KB = dressing and bathing/hygiene subscales; 4)
verbal versus physical assistance) and the BI lacks graduation Showering Task Analysis; and 5) Dressing Task Analysis
in the levels of assistance required (Shah & Muncer, 2003). As Procedures: Participants were observed performing morning
a result, both measures have reported floor and ceiling effects showering and dressing routines within 72 hours of admission;
at 4-weeks and at 8-weeks post-admission; and at discharge by
and they may not detect even the smallest improvements in
function (Shah, Muncer, Griffin, & Elliott, 2000). The FIM, a rehabilitation therapist (RT). The showering and dressing
the BI, and Klein-Bell may also be better detectors of change in Task Analyses and the KB were completed by the RTs. A
physiotherapist scored the FIM and BI using proxy reports
function in individuals with physical impairments, versus
from the RTs.
cognitive impairments because the test items are weighted
Data Analysis: Raw scores for the five measures were
heavily towards physical ability (Hajeck et al., 1997; Hall,
Bushnik, Lakisic-Kazazic, Wright, & Cantagallo, 2001). This obtained at all four assessment points. An average raw score
was calculated for Showering and Dressing Task Analyses.
poses a problem in the ABI population where cognitive
Raw scores were converted into z-scores using Microsoft
impairments that affect functional performance (McNeny,
1999). The KB has poor sensitivity to change (Klein & Bell Excel. The z-scores were plotted against the four assessment
(1982), as cited by Law & Letts, 1989). Furthermore, there is points to create graphs that tracked changes in participants’
showering and dressing skills over time. Trends were observed
limited evidence of its use in ABI populations. Another
criticism of functional assessment tools in general is that they and noted.
fail to provide information about the specific components of a Results:
task that is difficult for a person to do or that a person is unable Participants’ z-scores showed that the Task Analysis performed
to do (Settle & Holm, 1993). Occupational therapists could use most similarly to the FIM over time with some minor
this information to develop treatment goals and to determine exceptions. They were most similar between the Admission
and 4-week Assessment points but showed more variability
the efficacy of treatment. These limitations question the
between 4-week and 8-week time points. There was no
clinical utility of the FIM, BI, and Klein-Bell to measure
observed change in BI z-scores over time with the exception of
change in function in ABI populations.
participant A4’s dressing assessment. The Klein-Bell showed
Task Analysis methodology attempts to address these
limitations. In task analysis, ADL tasks are broken down into greater change in z-scores compared to the BI but had greater
their component steps according to Yeun and D’Amico (1998) variability than the FIM and Task Analysis z-scores.
and the type and level of assistance are graded at each step (Jill
2.25
2.25
2
2
1.75
1.75
1.5
1.5
1.25
1.25
1
1
0.75
0.75
0.5
0.5
A1
0.25
0.25
0
0
-0.25
Figure 1: Showering and dressing z-scores of the FIM, BI, total score was used which may have affected its sensitivity.
KB, and Task Analysis measures for participants.
The KB showed the greatest variability in measuring
change compared to the FIM, Task Analysis and BI. Even
though it breaks down a task into components it does not grade
the level or type of assistance which may explain the variability
observed.
Demographic factors such as age, gender, months postinjury may have also contributed to the variability observed.
Further testing with more participants and regression analysis is
needed to see if these factors influence the measures’ sensitivity
to change.
The limitations to our study are as follows: (a) the small
sample size which prevents any significant conclusions
regarding the sensitivity of the measures to be made and (b) the
lack of standardization of administering and scoring of Task
Analysis.
Conclusion:
Task Analysis shows the potential to be useful to
occupational therapists in forming and evaluating treatment and
discharge plans. However, it requires further standardization
and refinement before being utilized to assess the efficacy of
ABI rehabilitation.
References:
Admi ssi on
4-Week
8-Week
Di schar ge
-0.25
Admissi on
4-Week
8-Week
Dischar ge
-0.5
-0.5
-0.75
-0.75
-1
-1
-1.25
-1.25
-1.5
-1.5
-1.75
-1.75
-2
-2
-2.25
-2.25
A s s e s s me nt P oi nt s
A sse ssm e n t P o i n t s
P ar t i cip ant A 2 S ho weri ng A ssessment
2.25
P a r t i c i pa n t A 2 D r e ssi n g
2. 25
2
2
1.75
1. 75
1.5
1. 5
A2
1.25
1. 25
1
1
0.75
0. 75
0.5
0. 5
0.25
0. 25
0
-0.25
0
Admi ssion
-0.5
4-Week
8-Week
Dischar ge
-0. 25
A dmi s s i on
4-Week
-0.75
8-Week
Di s c har ge
8-Week
Di s c har ge
-1
-1. 25
-1.5
-1. 5
-1.75
-1. 75
-2
-2
-2.25
-2. 25
A sse ssm e n t P oi nt s
A s s e ss me nt P oi nt s
Par t i ci p ant A 3 Sho w er i ng
2.25
2
2
1. 75
1.5
1. 5
1. 25
1.25
1
1
0. 75
0.75
0. 5
0.5
0. 25
0.25
0
0
- 0.25
P ar t i c i pa nt A3 D r e s s i ng
2. 25
1.75
Admission
4-Week
8- Week
-0. 25
Disc har ge
A dmi s s i on
4-Week
-0. 5
-0.5
-0. 75
- 0.75
-1
-1
-1. 25
- 1.25
-1. 5
- 1.5
-1. 75
- 1.75
-2
-2
-2. 25
- 2.25
A s s e s s me nt P o i nt s
A sse ssm e n t P o i n t s
P a r t i c i pa n t A 4 S h ow e r i ng A sse ssm e n t
2
2
1. 75
1.75
1. 5
1.5
1. 25
1.25
1
1
0. 75
0.75
0. 5
0.5
0. 25
0.25
0
0
-0.25
P ar t i c i pa nt A4 D r e s s i ng
2. 25
2.25
A4
Di s c har ge
-0. 75
-1
-1.25
A3
8-Week
-0. 5
Admissi on
4-Week
8-Week
-0. 25
Dischar ge
A dmi s s i on
4-Week
-0. 5
-0.5
-0. 75
-0.75
-1
-1
-1. 25
-1.25
-1. 5
-1.5
-1. 75
-1.75
-2
-2
-2. 25
-2.25
A s s e s s me nt P o i nt s
As s es s me nt P oi nt
P a r t i c i p a n t B 1 D r e ssi n g A sse ssm e nt
P ar t i c i pa nt B 1 Showe r i ng A ss e s sme nt
2.25
2.25
2
2
1.75
1.75
1.5
1. 5
1.25
1.25
1
1
0.75
0.75
B1
0. 5
0.5
0.25
0.25
0
0
-0.25
A dmi ss i on
4-Week
8-Week
-0.25
Di sc har ge
-0. 5
Admi ssi on
4-Week
8-Week
-0.5
-0.75
-0.75
-1
-1
-1.25
-1.25
-1. 5
-1.5
-1.75
-1.75
-2
-2
-2.25
FIM
BI
KB
TaskAnalysis
Di schar ge
-2.25
A s s e s s me n t P o i n t s
A ss e ss me nt P oi nt s
Table 1: Demographics
Participants
A1
A2
A3
A4
Gender
M
M
F
F
F
Age
66
58
54
24
Encephalitis
CVA
Encephalitis
53
CNS
Vasculitis
Cause of ABI
Months
Post-ABI @
admission
GCS
Marital Status
Employment
Status
Living
Arrangement
B1
MVA
2
3
4
4
72
N/A
N/A
8
4
N/A
Separated
Married
Separated
Divorced
Retired
Farmer
Nurse
Executive
Single
Unemployed
Alone
Spouse
Alone
Alone
Family
Discussion
The hypothesis was not supported by the results, instead
Task Analysis was observed to measure change similarly to the
FIM. The reason for this is hypothesized to be due to their
similar ordinal scoring systems. However, variability observed
between the measures may be due to Task Analysis describing
of the type of assistance required (i.e. verbal cueing/physical
assistance/hand-over-hand etc) which is not done by the FIM.
A possible reason for the variability observed between
measures at the 4-week and 8-week assessment points is the
type of assistance that may have changed due to change in
recovery post-ABI which was not captured by the FIM.
The BI showed the least amount of change compared to the
Task Analysis, FIM, and KB and this could be due to it being a
weighted scale with a limited range of disability in which to
capture change and secondly, only its subscales instead of its
Brain Injury Association of Canada. (2006). Putting the pieces together:
Campaign for 2006. Retrieved March 26, 2006, from biac.ronforeman.
com/National/SponsorBrochure2006RevisedFeb16_2006.pdf
Desrosiers, J., Rochette, A., Noreau, L., Bravo, G., Hebert, R., & Boutin, C.
(2003). Comparison of two functional independence scales with a
participation measure in post-stroke rehabilitation. Archives of Gerontology
and Geriatrics, 37, 157-172.
Law, M., & Letts, L. (1989). A critical review of scales of activities of daily
living. American Journal of Occupational Therapy, 43, 522-528.
Hajek, V. E., Gagnon, S., & Ruderman, J. E. (1997). Cognitive and functional
assessment of stroke patients: An analysis of their relation. Archives of
Physical Medical Rehabilitation, 78, 1331-1336.
Hall, K. M., Bushnik, T., Lakisic-Kazazic,, B., Wright, J., & Cantagallo, A.
(2001). Assessing traumatic brain injury outcome measures for long-term
follow-up of community-based individuals. Archives of Physical Medical
Rehabilitation, 82, 367-374.
McNenny, R. (1999). Activities of daily living. In M. Rosenthal, J.S. Kreutzer,
E.R. Griffith, & B. Pentland (Eds.), Rehabilitation of the adult and child
with traumatic brain injury, Third Edition. (pp. 242-253). Philadelphia,
PA: F.A. Davis Company.
Rapoport, M. (2003). Traumatic brain injury in older adults: Relevance to
psychiatrists. Retrieved March 27, 2006, from cpaapc.org/Publications/Archives/Bulletin/2003/august/rapoport.asp
Settle, C., & Holm, M.B. (1993). Program planning: The clinical utility of three
activities of daily living assessment tools. The American Journal of
Occupational Therapy, 47, 911-918.
Shah, S., & Muncer, S.J. (2003). A comparison of rehabilitation outcome
measures for traumatic brain injury. Occupational Therapy Journal of
Rehabilitation, 23, 2-9.
Shah, S., Muncer, S.J., Griffin, J., & Elliott, L. (2000). The utility of the
modified Barthel Index for traumatic brain injury rehabilitation and
prognosis. British Journal of Occupational Therapy, 63, 469-475.
Yeun, H.K., & D’Amico, M. (1998). Deriving directions through procedural
task analysis. Occupational Therapy in Health Care, 11, 17-25.
Watson, A.H., Kanny, E.M., White, D.M., & Anson, D.K. (1995). Use of
standardized activities of daily living rating scales in spinal cord injury and
disease services. American Journal of Occupational Therapy, 49, 229-234.
Acknowledgements: The researchers would like to thank the
individuals who participated in this project, Diana Velikonja
and Jill Oakes for their supervision and guidance, and
Brenda Scozzari for her administrative support.
The Provision of Social Support at Sheena’s Place: Considerations for Measurement
Students: Kaleigh Starritt and Amy Morrison; Project Supervisor: Ann Kerr
Introduction – Sheena’s Place is a community-based centre
for individuals affected by eating disorders. In 2000, a
comprehensive evaluation of Sheena’s Place was conducted
and it was determined that the centre would benefit from a
standardized measure to determine how support is provided.
Sheena’s Place is interested in finding an appropriate means of
measuring support that compliments the values and
philosophies that direct work at the centre. The purpose of the
current study is to determine the best method of measuring
support at Sheena’s Place.
Methods – Prior to commencing a literature review, the
authors became familiar with Sheena’s Place. This was
completed by reviewing the website, interviewing the Program
Director at the centre, and reading an evaluation of Sheena’s
Place carried out with funding provided by the Ontario
Ministry of Health in 2000. A thorough review of the literature
was performed to gain knowledge on support and Eating
disorders, social support theories and paradigms of support,
and existing support measures.
Search strategy:
The authors reviewed AMED (Allied and Complementary
Medicine), CINAHL (Cumulative Index to Nursing & Allied
Health Literature), EBM Reviews - Cochrane Database of
Systematic Reviews, EMBASE, Ovid MEDLINE, Database
for Health and Psychosocial Instruments, Psych INFO, Mental
Measurements Yearbook, PUBMED, Google, Google Scholar,
and the Australian Center on Quality of Life. List of
descriptors used included social support, eating disorders,
social support measures/evaluation, recovery, social networks,
theories of support, empowerment theory, and stress and
coping.
From this search three comprehensive reviews of social
support measures were obtained (Chronister, Johnson, &
Bervin, 2006; Winemiller, Mitchelle, Sutliff, & Cline, 1993, &
Willis & Shinar, 2000). An additional review of social support
measures was obtained from Australian Centre on Quality of
Life. Redundancy was reached amongst the reviews obtained
in that they included many of the same measures.
Ethics approval was obtained to survey participants at
Sheena’s Place on their experience with evaluation at the
centre however, only one participant was successfully
recruited. This did no supply sufficient data for analysis.
Interviews with key informant at Sheena’s Place (program
director) and a leader in the field of social support
measurement (Dr. B Gottlieb) provided additional information
to compliment the literature reviewed.
Results -- Social support is an important factor contributing to
health, well being, and coping (Chronister et al., 2006).
“Supportive relationships with partners, family members,
therapists and/or friends were perceived as one of the driving
force in the recovery process” (Keski-Rahkonen, 2005).
1
Unfortunately, because of the prolonged need for social
support from family members and friends, close associates are
often unable to provide the needed support for the individual
with the eating disorder. Thus, presenting the need for a
centre, like Sheena’s Place, to fulfill the needs of individuals
who are affected by an eating disorder.
There are a multitude of theories in the literature used to
explain social support. Given, the established consensus
among researchers that social support is such a broad,
multidimensional construct with no single definition; it is
essential to select a theory that guides both intervention
(provision of support) and evaluation. To accomplish this, we
used three theories as a lens to direct the understanding of
support provided at Sheena’s Place.
Empowerment Theory: Encourages individuals to direct their
own path of recovery (Aria, S, 1997).
Dynamic Systems Theory: This theory allows for all the
dimensions of support to be considered as an entire system of
inter-connected variables (rather than evaluating isolated
components)
Stress-buffering theory: Support is provided as a mechanism
to better cope with stressful life events (Cohen, 2000).
The paradigm of support which best conceptualizes support at
Sheena’s Place considers the various dimensions (or types) of
support. These dimensions are functional, structural, and
perceptual. Although, clearly defined below, these dimensions
are highly inter-connected and rarely occur in isolation of one
another.
Functional: The type and quality of support available. This
includes the following supportive functions; emotional,
instructional, informational, companionship, and validation.
Structural: The individuals social support network. This
dimension provides a quantitative means to measure support
by including quantity (size, frequency of contacts) and
characteristics (composition, density, homogeneity, and multiplexity) of social contacts in a network (Chronister et al.,
2006).
Perceptual: The subjective assessment of the social support
network to determine if the network can provide sufficient
support to the individual if and when it is needed ( Wills &
Shinar, 2000).
The dimensions of support can be affected by additional
factors including the social climate which refers to the context
within which the social interactions take place. This includes
the social, physical, and ‘institutional’ (policies/philosophy)
environments.
Review of support evaluations: All the social support
measures retrieved were reviewed and subjected to a content
analysis based on their inclusion of the dimensions of support
The Provision of Social Support at Sheena’s Place: Considerations for Measurement
Students: Kaleigh Starritt and Amy Morrison; Project Supervisor: Ann Kerr
(functional, structural, and perceptual) and additional factors
(which impact these dimensions) that were evaluated. Major
gaps were found in the existing measure of support when
considering an evaluation appropriate for Sheena’s Place.
None of the measures were specifically created to address the
unique stressors and support required for individuals with
easting disorders. Further, all of the measures reviewed
focused on the evaluation of the social support provided by
individuals rather than from a community-based agency like
Sheena’s Place. The measures failed to address all of the
dimensions of support which are provided at Sheena’s Place,
how they interact with each other, nor the social climate
within which these interactions take place. Given the complex
nature of the construct of support, it is essential to consider
there factors when efforts are made to evaluate support.
Discussion – Lack of clarity exists with the conceptualization
and definition of social support which has contributed to the
problematic nature of social support measurements in that
many of these standardized measures do not account for the
multi-dimensional and complex nature of support (Winemiller
et al., 1993).
Although all of the measures reviewed have many useful
qualities that are applicable and relevant to measuring the
support provided at the Sheena’s Place, none of them captures
completely all the aspects that relevant and critical to explore
at Sheena’s Place. These measures fail to consider components
essential to the support provided (such as being a community
based agency, empowerment of participants to choose their
own services, and the unconditional nature of support
provided). All factors which contribute to support and how
they interact with each other need to be taken into careful
consideration.
The support provided at Sheena’s Place is unique and as such,
a measure must be created in order to properly evaluate it.
This measure must be multidimensional in order to reflect the
multiple dimensions of support provided at Sheena’s Place.
Further consideration must be given to additional factors that
may impact the provision and evaluation of support including
the social climate of Sheena’s Place. The inter-connectedness
of these factors and how they contribute to support must also
be considered and thus, evaluated.
Recommendation – It is our belief that a measure of support
created at Sheena’s Place must include the participation of the
users of Sheena’s Place such that they are empowered to
contribute to the assessment of how the support at Sheena’s
Place has impacted their ability to cope with their eating
disorder. This committee should also include staff members at
Sheena’s Place as well as former users of the services. The
research committee should also include a team of researchers
in the field or related fields with the necessary expertise to
tailor the questions that were generated in order to make them
specific to Sheena’s Place.
2
Questions should be generated that include an analysis of
factors that are unique to Sheena’s Place, including the social
climate and the unconditional nature of the support that is
provided. An appropriate measure must provide the means to
understand the complex interplay of environmental,
organizational and personal factors rather then focusing on a
linear causality of these factors and how they impact support
(Dooris, 2005). This evaluation would allow for an analysis
of connections between people, environments and behaviours
to be explored, and the relationships of different participants
of Sheena’s Place to be addressed (Dooris, 2005).
A proposed format for the evaluation could be in the form of a
semi-structured qualitative interview. Items included in the
interview would be generated from the committee as described
above. The interview format would allow the opportunity to
explore some of the intricate inter-relationships that contribute
to support. Data gathered from qualitative interviews would be
subject to concept mapping which includes the exploration of
links between activities, outcomes, and contexts and takes
account of the relationships between people and their
environments (Dooris, 2005). This type of evaluation requires
an acceptance that many things ‘cannot be measured’ – that
the patterns of relationships that make up systems are
essentially qualitative and to be understood must be mapped
(Dooris, p.63, 2006). This type of evaluation presents a shift
from traditional scientific evaluation; which may be
appropriate given the unique and non-medical model of
support provided at Sheena’s Place.
References
Australian Centre on Quality of Life (2006). Bibliography of Support
Measures. Retrieved from
http://acqol.deakin.edu.au/instruments/scale_search.php on March,
21, 2006.
Chay, Y.W. (1993). Social support, individual differences and well-being: a
study of small business entrepreneurs and employees. Journal of
Occupational and Organizational Psychology. 66, 285-302.
Chronister JA, Johnson EK, Berven NL. (2006). Measuring social support in
rehabilitation. Disability & Rehabilitation. 28, 75-84.
Doeglas D, Suurmeijer T, Briancon S, et al. (1996). An international study on
measuring social support: Interactions and satisfaction. Social
Science Medicine, 43:1389-1397.
Dooris, M. (2005). Healthy settings: challenges to generating evidence of
effectiveness. Health Promotion International, 21 (1), 55-65.
Davies S. (2004). A group-work approach to addressing friendship issues in
the treatment of adolescents with eating disorders. Clinical Child
Psychology & Psychiatry, 9,519-531.
Thomson, H.(2006). Understanding the supportive role of families and
friends. UBC Reports, Eating Disorders. 52 (1).
Tiller JM, Sloane G, Schmidt U, Troop N, Power M, Treasure JL. (1997).
Social support in patients with anorexia nervosa and bulimia
nervosa. International Journal of Eating Disorders, 21, 31-38.
Rorty M, Yager J, Buckwalter JG, Rossotto E. (1999). Social
support, social adjustment, and recovery status in
bulimia nervosa. International Journal of Eating
Disorders, 26,1-12.
Winemiller, D.R., Mitchelle, E., Sutliff, J & Cline, D.J. (1993). Measurement
strategies in social support: a descriptive review of the literature
Journal of Clinical Psychology, 49(5), 638-646
Development of Modified Work Program (MWP) and Procedures
By: Sarah Sidney and Jeff Perrier
Project Supervisor: Wanda McKenna
Faculty Supervisor: Muriel Westmorland
Introduction
Approximately 8% to 12% of Canadians are off
work and receiving compensation due to workrelated injuries (1). As a result, each year there are
billions of dollars spent on benefit payments, lost
productivity, replacement workers, and increased
workers compensation premiums. Musculoskeletal
disorders are one of the leading causes of disability in
industrialized societies and make up a large
proportion of work-related injuries each year (2).
Musculoskeletal disorders alone accounted for 40%
to 60% of approximately 380 000 accepted lost time
claims in Canada in 1999 (3).
Modified work is any work that the employer can do
that is compatible with the employee’s physical
restrictions or limitations resulting from a work
related injury or illness (4). The following are
examples of how work can be modified (5):
• Reduction in hours
• Restructuring of the job and changes to the
ways in which tasks are to be accomplished
• Creation of modified or part-time work
schedules
• Provision of assistance or support staff
• Assignment of special project work
• Provision of a temporary alternate position
• Any combination of the above items
The purpose of this research project was to make
recommendations for the implementation of a MWP
for the hospitality services and physical plant
departments at McMaster University to return injured
workers to work sooner and lower the costs of WSIB
claims for the University.
Methods
A literature search included a review of
electronic databases, reports conducted by Canadian
and American universities, the Workers’ Safety and
Insurance board (WSIB) website, government
websites, and various internet sites. The “key words”
were return-to-work, workplace accommodation,
modified work, light duties, and disability
management. Articles were chosen that were related
to the effectiveness of RTW interventions including
the benefits of MWP, the barriers to implementing
successful MWP.
A final report including
recommendations and suggestions for the design and
implementation of a MWP at McMaster University
was completed.
Literature Review
Evidence from the literature suggests that MWP
facilitates RTW for temporarily and permanently
disabled workers.
Workers having access to
modified work may even double their likelihood of
RTW. Evidence has been documented that MWP
may improve the RTW rate of workers with workrelated injuries in the intermediate to long term (i.e.
for 6 months or longer) (6). Benefits of MWP
include a significant reduction in the number of lost
workdays (6, 7). MWP may therefore lead to
substantial reductions in disability and worker’s
compensation costs. Krause et al. found that MWP
may reduce direct costs by 8% when taking program
costs into consideration (6). The mental health of the
injured worker has also been investigated in the
literature. Employees staying home until RTW, with
regular duties, show a modest decrease in mental
health, whereas employees on modified duties
demonstrate slightly improved mental health (8).
The literature suggests three major barriers to the
implementation of an effective MWP (9):
1. A lack of understanding of the impact of MWP
(for both supervisors and employees)
2. A lack of social support in the workplace
3. A lack of possibilities for work task
modification
The first two barriers involve a lack of knowledge
and understanding of MWP as well as negative
attitudes towards MWP.
These issues can be
addressed through social-psychological theories as
well as communication theories with respect to
changing attitudes and behaviour through education.
The Consecutive Stages Model can be used as an
appropriate conceptual framework to improve
implementation of RTW programs (9). This model
involves 6 stages: 1) Attention & awareness, 2)
understanding, 3) changing attitudes, 4) changing
intentions, 5) changing behaviours, and 6)
maintaining behaviours.
Discussion
There are a number of recommendations to be
made with respect to MWP design and
implementation. Stock et al. proposed the following
guidelines for the implementation of a MWP (2):
1. Setting up a committee
2. Describe current situation at the University
3. Analyze University’s needs & set up program
objectives
4. Determine program content
5. Implement program
6. Evaluate program
Possible solutions to the barriers mentioned earlier
can be accomplished through continued training
sessions held by the Employee Work Life Support
Services (EWLSS). Topics to consider include the
direct and indirect costs associated with lost time; the
laws and policies governing responsibilities of
employer, supervisors, and workers; the supervisor’s
obligations and evaluations; the need for and effect of
MWP; and the rewards and benefits of MWP to the
workplace.
Negative attitudes in the workplace towards
MWP have been found to partially result from the
lack of involvement of workers and supervisors in the
design and content of the RTW program (10).
Communication and collaboration, via a MWP
committee (2), can make all key players feel valued
in the workplace (11). Separate committees would be
needed for each department, and already existing
committees such as the Joint Health and Safety
committees for each department could be used.
Representatives of all key players should be included
in the committee to incorporate all points of view in
the process of developing, implementing and
evaluating the MWP. Possible committee members
could include:
• Senior management (with decision making
power)
• Workers
• Supervisors
• Health professional (occupational health nurse,
occupational therapist, physician)
• RTW specialist
The modified work program should include activities
necessary to obtain the objectives, such as actions,
measures, tools, procedures and a realistic timeline
(2).
The literature identified the following
considerations when developing RTW programs:
• Supervisors should be held accountable for
workers utilizing MWP and evaluated during
performance appraisal (10)
• Proceed on a case by case basis
• PDA worksheets need to be completed by
individual familiar with the job/work. Or
completed by an ergonomist and an individual
familiar with the job/work together
• Ensure worker participates in process by
providing input (11)
• Follow-up with injured workers is essential
before the MWP begins and during (2)
• Follow-up person needs to be in a position to
take action if required (2)
The development of clear guidelines for MWP
processes outlining the roles and responsibilities of
each key player, including timeframes, may also
improve program implementation (11). Procedures
will need to be developed in order to create a
comprehensive guideline for injured workers and
other stakeholders to follow. Stock et al. identified
the following factors to consider (2):
•
Measures to be taken e.g. assessments,
evaluations, & forms to be completed.
• Order in which they are performed
• Identify personnel responsible at each step
• Roles and mandates of each individual
involved
• Deadlines to be met
The literature suggests that a new MWP should be
trialed in one department before implemented across
an entire company (12, 13). Therefore it may be
appropriate to trial the MWP in the physical plant
department of the University for a time, evaluate and
analyze its impact, and make any necessary
modifications. This would allow for lower costs of
implementation, and a shorter time to see the impact
of the MWP.
References
1. National Institute of Disability Management and Research
(2004). Introduction to disability management. In Code of practice
for disability management 2nd edition. (pp. 21-34). Ottawa,
Canada: National Institute of Disability Management and
Research.
2. Stock, S., Baril, R., Dion-Hubert, C., Lapointe, C., Paquette, S.,
Sauvage, J., Simoneau, S., & Vaillancourt, C. (2005). Workrelated musculoskeletal disorders: Guide and tools for modified
work. Montreal, Canada: Direction de Sante Publique.
3. Association of Workers’ Compensation Boards of Canada
(2000). Work injuries and diseases,Canada 1997–1999. National
Work Injuries Statistics Program, AWCBC, Mississauga, Ontario,
Canada.
4. Georgetown College (n.d.). Modified work program. Retrieved
fromhttp://www.georgetowncollege.edu/
5. Williams, R. M. & Westmorland, M. (2002). Perspectives on
workplace disability management: A review of the literature.
WORK: A Journal of Prevention, Assessment & Rehabilitation,
19(1), 87-93.
6. Krause, N., Dasinger, L. K., & Neuhauser, F. (1998). Modified
work and return to work: A review of the literature. Journal of
Occupational Rehabilitation, 8(2), 113-139.
7. Curtis, J., & Scott, L. (2004). Integrating disability management
into strategic plans: Creating healthy organizations. AAOHN
Journal, 52(7), 298-301.
8. Van Duijn, M., Lotters, F., & Burdorf, A. (2005). Influence of
modified work on return to work for employees on sick leave due
to musculoskeletal complaints. Journal of Rehabilitative Medicine,
37, 172-179.
9. Van Duijn, M., Miedema, H., Elders, L., & Burdorf, A. (2004).
Barriers for early return-to-work of workers with muscuskeletal
disorders according to occupational health physicians and human
resources managers. Journal of Occupational Rehabilitation, 14,
31-41.
10. Baril, R., Clarke, J., Friesen, M., Stock, S., & Cole, D. (2003).
Management of return-to-work programs for workers with
musculoskeletal disorders: a qualitative study in three Canadian
provinces. Social Science & Medicine, 57(11), 2101-14.
11. Westmorland, M.G. Williams, R.M., Amick, B.C. III.,
Shannon, H., & Rasheed, F. (2005). Disability management
practices in Ontario workplaces: employees' perceptions. Disability
and Rehabilitation, 27(14): 825-35.
12. Boseman, J. (2001). Disability Management: Application of a
nurse based model in a large corporation. AAOHN Journal, 49 (4),
176-186.
13. Burton, W. & Conti, D. (2000). Disability management:
Corporate medical department management of employee health
and productivity. JOEM, 42 (10), 1006-1012.
Productivity Consultant:
A Review of the Literature and Development of an Evaluation Plan
By: Heather Rutherford, Student Occupational Therapist
Project Supervisor: Aruna Mitra, M.Ed, B.Sc. OT
Introduction
The Productivity Consultant (PC) is an occupational therapy
role within the Calgary Health Region (CHR) that services
clients of the four outpatient mental health clinics. The
primary goal is to assist clients to engage in paid or unpaid
productive activities. The position was created based on a
needs assessment conducted in 2003, however there has been
no evaluation to date of the role’s effectiveness and no plan
for evaluation exists. Therefore, the purpose of this project
was to conduct a review of the literature, conduct a chart
review, assist the PC with selecting appropriate
measurement tools and to develop a logic model to serve as
an evaluation template. The research question guiding the
project was: What is needed to perform an effective
evaluation of the PC role? The results of the study included
a number of recommendations and those reflecting best
practice will be implemented.
Methods
Literature review: A systematic search was performed of the
major databases including CINAHL, EMBASE, Cochrane
Database, MEDLine, PsychINFO, OTDBase and OTSeeker.
Search terms included mental illness, mental disorders,
mental health, psychiatry, depression, anxiety, occupational
therapy, outpatient$, productivity, vocational rehabilitation,
work, employment and unemployment.
Various
combinations of these terms were used and titles were
reviewed. From these titles 94 abstracts were read, of which
15 articles were appraised. Those discussed in this paper
were deemed to be the best evidence applicable to the
research question.
Chart audit: An audit form was created based on suggestions
in the literature as to what demographic and historical
information may be useful in predicting outcomes of
vocational rehabilitation (Michon, van Weeghel, Kroon &
Schene, 2005). As well, items were included that the PC and
other stakeholders felt were necessary. Data was collected
regarding:
mental
health
diagnosis(es),
medical
diagnosis(es), referral location, date of intake at mental
health clinic, date of referral to PC, date of birth, address,
gender, marital status, number of dependents, level of
education, source of income, previous work experience,
client goals, barriers to productivity, services provided,
client actions, and outcomes of service.
Outcome Measures: An interview was conducted with the
PC to determine the current practices and the needs of the
role. From the information gathered, a search was conducted
for tools on the Mental Measurements Yearbook (9th – 16th
eds.) using the terms self esteem, self efficacy, career, work,
job, employment. As well, the PC’s needs were matched
with established tools used in occupational therapy. The
Mental Measurements Yearbook (9th – 16th eds.), Health and
Psychosocial Instruments (HAPI) and the internet were
searched for information on specific tools requested by the
PC.
Logic Model: The framework for the development of the
logic model was based on two resources, one specific to
occupational therapy (Letts, et al., 1999) and one that
provided a comprehensive system to logic model
development for any organization (W.K. Kellogg
Foundation, 2004). A focus group was conducted with
stakeholders to establish the long-term outcomes and main
components. A further interview was conducted with the PC
to determine tools and resources and implementation
objectives. From this information the writer and supervisor
of the project drafted short term outcomes and outputs. A
draft logic model was created and distributed to stakeholders
for further input.
Results
The key points from this literature review include:
•
•
•
•
•
•
Characteristics of any service model of vocational
rehabilitation with strong evidence include: 1.Inclusion
of a vocational or employment specialist on the team; 2.
Rapid placement; 3. Pay for work; and 4. A range of
services which are available and accessible (Kirsh,
Cockburn, & Gewurtz, 2005).
Cognitive Behavioral Therapy (CBT) may be useful
to improve perceived mental health, self-esteem, selfefficacy, life satisfaction and motivation for work
(Proudfoot, Guest, Carson, Dunn, & Gray, 1997; Rose,
& Perz, 2005).
Skills training may improve workplace fundamentals
knowledge (Mueser, et al., 2005)
There are many barriers and facilitators related to
employment for people with mental illness that include
symptoms of mental illness, service provision and
external factors such as the labour market and stigma
(Henry, & Lucca, 2004, Honey, 2003).
Volunteering has many benefits that may have
therapeutic value to people with mental illness (Black,
& Living, 2004).
Programs with a consultative occupational therapy
model of practice do exist and have been successful in
facilitating productivity for people with affective
disorders (Davis, & Rinaldi, 2004; Robdale, 2004).
Chart audit: 11 files were audited with the following
results: The average age of clients was 48 years, 64% were
male and 36% were female, 56% were married, 22% were
divorced/separated, 22% were single, 45% of the sample had
some high school, 10% had some post-secondary and 45%
had post-secondary completion. Many had multiple
diagnoses, the most common mental health diagnoses were
depression (73%), anxiety (36%) and personality disorder
(18%). Other diagnoses included adjustment disorder and
dysthymia. 82% of the sample had a comorbidity of a
chronic illness such as fibromyalgia, diabetes and Crohn’s
disease. The average time between intake at the mental
health clinic and referral to the PC was 8 months. There
1
were various sources of income and previous work
experiences for the sample. As well, there were numerous
goals and barriers listed for each client. Of note is that 83%
of the sample experienced barriers related to mental health
symptoms and 45% experienced barriers related to self
perception.
Outcome Measures: The analysis of 13 assessment tools
was a challenge due to the inability to review the manuals
and tools themselves and having to rely primarily on reviews
by others. The desired characteristics of a tool included
sound psychometric properties, clinical utility and
applicability to the population and the needs identified by the
PC. The measures that are recommended are the Canadian
Occupational Performance Measure (COPM, Law et al.,
2005), the Work Environment Scale (WES, Moos, 1994) and
the Rosenberg Self Esteem Scale (Morris Rosenberg
Foundation, 2006).
Logic Model: The process of developing the logic model not
only created a potential tool for future evaluation, it also
allowed stakeholders to scrutinize their current practices and
brainstorm ideas to improve service. From this the
following key points were established:
• The main component of intervention was divided into 3
types of service based on the needs of clients and level of
assistance needed – Brief Consult, Short-term Consult and
Direct Service
• A tools and resources section was included to identify who
is responsible for what and what tools should be used e.g.
pre-screening and referral are done by therapists and
assessment, intervention and discharge are done by the PC
• Process and outcome evaluation methods are clearly
outlined in the outputs and tools and resources sections.
Analysis/Key Recommendations:
The following key recommendations were made:
Best practice recommendations:
• Provide referrals to therapists for CBT with clients who
are experiencing self perception issues;
• Increase awareness of barriers and facilitators to
employment for people with mental illness;
• Consider the inclusion of primary care referrals to
decrease time away from work;
• Incorporate recommended outcome measures.
Evaluation recommendations from logic model process:
• Create a pre-screening checklist or algorithm for referring
therapists to decide appropriate referrals;
• Develop a coordinated system of referral, data collection
and data storage;
• Continue to use chart audit form to collect data on each
client;
• Perform chart audits on a regular basis;
• Create a follow-up questionnaire to capture appropriate
outputs and perform follow up at 6 months post-discharge;
• Create a tracking system for necessary outputs.
Discussion
The results of this project indicate that the evaluation of the
PC role is possible with cooperation from stakeholders and
with a clearly developed plan.
A number of
recommendations were made within the full report to the
CHR with key recommendation discussed in this paper
regarding methods to improve practice and to develop an
evaluation plan. The evaluation will be guided by the logic
model. The results of this project will assist the stakeholders
of the PC role to improve process and outcomes, as well as
to demonstrate the efficacy of the role. This will in turn
facilitate the long term goal of assisting clients of the
outpatient mental health clinics in the CHR to engage in paid
and unpaid productive activities; a critical component to
occupational therapy and to mental health.
Key References
Black, W., & Living, R. (2004). Volunteerism as an
occupation and its relationship to health and wellbeing.
British Journal of Occupational Therapy, 67, 526-532.
Davis, M., & Rinaldi, M. (2004). Using an evidence-based
approach to enable people with mental health problems
to gain and retain employment, education and voluntary
work. British Journal of Occupational Therapy, 67,
319-322.
Henry, A.D., & Lucca, A.M. (2004). Facilitators and barriers
to employment: The perspectives of people with
psychiatric disabilities and employment service
providers. Work, 22, 169-182.
Honey, A. (2003). The impact of mental illness on
employment: Consumers’ perspectives. Work, 20, 267276.
Kirsh, B., Cockburn, L., & Gerwurtz, R. (2005). Best
practice in occupational therapy: Program characteristics
that influence vocational outcomes for people with
serious mental illnesses. Canadian Journal of
Occupational Therapy, 72, 265-279.
Mueser, K.T., et al. (2005). The effectiveness of skills
training for improving outcomes in supported
employment. Psychiatric Services, 56, 1254-1260
Proudfoot, J., Guest, D., Carson, J., Dunn, G., & Gray, J.
(1997). Effect of cognitive-behavioral training on jobfinding among long-term unemployed people. The
Lancet, 350, 96-100.
Robdale, N. (2004). Vocational rehabilitation: The enable
employment retention scheme, a new approach. British
Journal of Occupational Therapy, 67, 457-460.
Rose, V., & Perz, J. (2005). Is CBT useful in vocational
rehabilitation for people with a psychiatric disability?
Psychiatric Rehabilitation Journal, 29, 56-58.
Acknowledgements
I would like to thank the following individuals for their
support and contributions to the completion of this project:
Aruna Mitra, the project supervisor and Site Coordinator,
Peter Lougheed Hospital, Calgary, AB; Susan Taylor,
Productivity Consultant, Calgary Health Region, Calgary,
AB and Kathleen Ryan, Clinical Leader – Mental Health,
Peter Lougheed Centre, Calgary, AB.
2
PROFILE OF AGING CLIENTS AT COMMUNITY LIVING HAMILTON
Student researcher: Sandra Rodrigue; Supervisor: Linda Armour; Faculty Supervisor: Muriel Westmorland
INTRODUCTION
The results from a survey conducted by the Ontario Partnership
on Aging and Developmental Disabilities (OPADD) indicated
that 49% of adults with developmental disabilities being services
in Ontario are over the age of 40 (Transition Planning Report,
2005). The community of Hamilton is aware of this issue and
Community Living Hamilton along with other agencies are in a
critical planning phase for putting the required services and
supports in place to accommodate this population. The issues
precipitating this need include the possible inability of aging
caregivers to continue caring for their loved ones, and the
increase in the number of clients that are part of the organization
due to longer life expectancy and de-institutionalization (Contact
Hamilton, 2004).
The purpose of the following research project was to discover
the concerns and issues related to transition planning and aging
for a population of individuals with a developmental disability
between the ages of 40-49 years, known to Community Living
Hamilton.
LITERATURE REVIEW
A literature review was conducted by the student researcher to
gather information about the challenges faced by aging
individuals with Developmental Disabilities (DD) and their
caregivers.
The health challenges faced by individuals with DD in the
literature include: arthritis, hypertension, osteoporosis, hip
fractures, cerebral vascular accidents, and cardiac anomalies. It
is also speculated that they may have higher incidence of specific
disabilities for example, high incidence of thyroid disorder,
cardiovascular disease, dementia, non-ischemic heart disorders,
obesity and visual impairments (Kapell et al., 1998). Rojahn,
Warren, & Ohringer, (1994), also state that the elder adult with
DD may be experiencing emotional disorders, anxiety, phobias
and depression that can result from physiological changes, long
term pharmaceutical use or changes in living situation or
lifestyle. The higher incidence of health concerns as individuals
with DD age, all may have an affect on their physical, emotional
and functional status, which can greatly impact the amount of
care that they require.
Family and caregivers also encounter the health and social
changes that accompany the aging process including, decreased
stamina and energy, changes in financial status, increased use of
health care resources, and changes in family roles with illness
and death of family members (Campbell, & Herge, 2000).
METHODS
Design
The study was of a quantitative descriptive design, for which
data was collected by gathering information with a semistructured interview survey that was developed by the primary
researcher and the student occupational therapist.
Ethics
approval for this research project was obtained through the
McMaster Ethics Committee and Review Board before data
collection began.
Participants
Purposeful sampling from the 169 clients between the ages of
40-49 years old at Community Living Hamilton was completed
to choose a sample of 35 individuals from 6 different day
programs.
Informed consent was obtained from all instructors who
participated in the semi-structured survey interview as well as all
clients for whom the information was being gathered.
Data Collection
A survey entitled “Profile of Aging Clients at Community
Living Hamilton” was developed by the primary investigator and
the student researcher with input from the academic supervisor.
The final result was a survey form that included 15 questions
related to information about demographics, caregivers, use of
community resources and supports, physical, emotional and
functional abilities, and emerging concerns about the participant
or their caregiver. A semi-structured interview, that used the
survey questions as a template, was conducted, by the student
researcher, in relation to each client with their corresponding
Community Living Hamilton instructor.
ANALYSIS
The data gathered from the survey forms were collated, scored
and analyzed using Microsoft Word Excel. Descriptive statistics
and frequencies were calculated to describe the study sample.
Each participant was coded by number to ensure anonymity and
protect confidentiality for the final report. Each survey question
was analyzed independently due to the variation in the type of
information obtained.
RESULTS
Sample
The sample was composed of 35 individuals; the mean age of
the sample was 44 years old, with an age range of 40-49. There
were 22 (63%) male participants and 13 (37%) female
participants in the sample. The sample was collected from 6
Community Living Hamilton Day Programs, for which
information was gathered from 9 instructors.
Semi-Structured Interview Survey Results
Results are represented for a selected number of questions on the
survey that relate most to physical, emotional, functional and
caregiver issues.
Question #3: Place of residence.
The largest portion of the sample lives with one or both
parents, 29%, or in a Boarding or Lodging home, 28%. 23% of
the sample lives in a group home, 11% lives with a family
member other than a parent, 6% lives in a long term care facility
and 3% lives alone.
Question #4: Information about the caregiver.
Information gathered about the caregiver from the instructor
included that for 20% of the sample, one or both parents are
deceased, 29% of caregivers were identified as having health
concerns and 9% were described as “ageing” by instructors.
Question #7: Client Health Concerns
One or more health concerns were reported by the instructors
for 83% of the sample. Of these clients, 29% have problems
with seizures or epilepsy, 9% have cerebral palsy, 14% have
psychiatric illnesses, 11% have high blood pressure, 9% have
heart problems, and 6% have autism. 38% of the sample has
other health concerns including obesity, Tourette Syndrome,
weeping eczema, digestion problems, fibromyalgia, arthritis, acid
reflux, thyroid problems, bone disorder, gout, hernia, sleep apnea
and diabetes.
Question #8: Physical Disabilities
The presence of a physical disability was reported by the
instructors for 29% of the sample. Problems with fine-motor coordination was reported for 23% of the sample, 6% had problems
with vision, 3% had hearing difficulties and 9% were not able to
weight bear on their legs. .
Question #9: Mobility Challenges
40% of the sample was reported as having mobility challenges
and 9% of the sample was non-ambulatory. In total 26% of
clients had decreased endurance, 6% had decreased balance, and
14% were using a mobility aid.
Question #10: Behavioural and Emotional Challenges
It was reported that 83% of the sample had behavioural or
emotional challenges. Previous instances of verbal aggression
were reported for 46% of the sample and previous instances of
physical aggression were reported for 29% of the sample. Also,
it was reported that 26% of the sample exhibited signs of
depression or depressed mood, 26% exhibited obsessive
behaviours, and 6% had difficulties with delusions or
hallucinations.
Question #11: Activities of Daily Living
Eating
86% of the sample was independent with eating, and 14%
required assistance in the form of cutting food, set up or
supervision.
Hygiene/Self Care
34% of the sample was independent with self care tasks
including bathing, and grooming. 46% required assistance in the
form of cueing, supervision, help to set up, reminders, shaving
and washing hair. 20% of the sample needed assistance for their
entire bathing and grooming routine.
Dressing
It was reported that 69% of the sample was independent with
dressing and 17% required assistance for tying shoe laces,
manipulating zippers, choosing clothes and dressing certain parts
of their body such as the bottom half. 14% of the sample was
dependent for dressing, requiring maximum assistance to dress
their entire body.
Toileting
83% of the sample was reported as independent with toileting
and 11% required assistance in the form of using a urinal bottle,
transferring to the toilet, reminders to go to the washroom or had
occasional accidents. 6% of the sample where dependent for
toileting as they wore briefs or were incontinent.
Financial and Community Management
It was reported that 54% of the sample required assistance for
financial and community management while helping with meal
preparation, laundry and household chores. 46% of the sample
was dependent for instrumental activities of daily living with
caregivers taking care of financial management and community
management exclusively.
Questions # 12: Personal Transportation Needs
According to reports by instructors, 71% of the sample used the
Disabled & Aged Regional Transportation System (DARTS),
26% of the sample used public transit with or without assistance,
9% had their caregiver drive them and 6% used other forms of
transportation such as taxis or walking.
Questions # 14: Instructor’s Emerging Concerns Related to
Caregiving Needs
It was reported by instructors that they had emerging concerns
related to the caregiving needs of 49% of the sample. These
concerns related to bereavement issues, possible violent
behaviours, onset of Dementia, weight gain, progressing illness
or health issues, increased lethargy and fatigue, adjustment issues
to new place of residence, and communication difficulties.
DISCUSSION
The presence of health concerns in this population was evident
in the results, which coincides with the literature that states that
elder adults with DD often have chronic health problems (Kapell
et al., 1998). Physical disabilities and mobility challenges were
also identified in a portion of the sample, as well as, behavioural
and emotional challenges. The functional implications of these
challenges were subsequently represented in the data gathered
about the client’s independence with activities of daily living,
including eating, hygiene/self care, dressing, toileting, and
financial/community management, for which a large portion of
the sample required assistance. A large portion of the sample
also had specialized transportation needs.
The limitations associated with this study include that the
results are not generalizable because the sample was not
randomly selected and the sample size was too small. Also the
experience and knowledge across instructors was not consistent,
therefore there was a difference in the depth of information
collected for each client.
CONCLUSION
The semi-structured interview survey was able to
identify descriptive information for clients aged 40-49 years at
Community Living Hamilton, which related to their physical,
functional, and caregiving needs. This information will be useful
to Community Living as they plan for the future transition and
caregiving needs of this population. It is recommended,
however, that the semi-structured interview survey be
administered to a larger sample of clients so that the data
gathered can be generalizable within the agency.
REFERENCES
Campbell, J.E., Herge, E.A. (2000). Challenges to aging in place:
the elder adult with MR/DD. Aging and developmental
Disability, 18(1), 75-90
Contact Hamilton, (2004) Hamilton Community Service Plan for
Developmental Services. Hamilton, ON.
Kapell, D., Nightinfale, B., Rodriguez, A., lee, J.H., Zigman,
W.B., & Schupf, N. (1998). Prevalence of chronic medical
conditions in adults with mental retardation: Comparison with
the general population. Mental Retardation, 36(4), 269-279
Rojahn, J., Warren, V.J. & Ohringer, S. (1994). A comparison of
assessment methods for depression in mental retardation.
Journal of Autism and Developmental Disorders, 24(3), 305313.
Transition Planning Report, (2005) Ontario Partnership on Aging
and Developmental Disabilities: Building a Future Where
Aging
is
O.K.
Accessed:
January
16,
2006.
http://www.opadd.on.ca/Documents/transitionreport-finalsept2005.pdf
ACKNOWLEDGEMENTS
Special thanks to Linda Armour and Muriel Westmorland for
their support and guidance throughout the development and
completion of this project. Also, thank you to the clients and
staff at Community Living Hamilton.
“What’s Next?” A Goal Setting Group for Teens
Investigators: Julie Roberts, Student OT, Cynthia Lennon, Student OT
Andrea Morrison, OT Reg (Ont), Karen Margallo, OT Reg (Ont)
Introduction:
The “What’s Next?” goal-setting group was a 5week closed group for adolescents at the Children’s
Developmental Rehabilitation Program (CDRP) in
Hamilton, Ontario who are transitioning to adulthood
and adult services.
The group aimed to serve
adolescents aged 14-21 years with a physical disability.
The purpose of the group was to teach goal setting
skills and to increase self determination.
Background:
Adolescent transition is a new area of research with
recent increases in publication due to the increasing life
expectancy for children with disabilities (Stewart, Law,
Rosenbaum & Willms, 2001).
Children with
disabilities and chronic illnesses are now reaching and
surpassing adolescence and are going through the
transition stages to adulthood as would any teenager. It
is a period of time described as, “a process of gradual
adoption of new roles and modifications of existing
roles” (King, Baldwin, Currie & Evans, 2005).
However, unlike their able-bodied peers, adolescents
with disabilities face additional unique challenges
during transition due to the types of experiences and
opportunities they have had in their lives so far
(Stewart, Law, Rosenbaum & Willms, 2001). These
opportunities often have not well prepared them for the
demands of adulthood. For example, many adolescents
hold job, however youth with disabilities are 1/3 less
likely to have been employed (Peraino, 1992 as seen in
King, Baldwin, Currie & Evans, 2005).
The guiding theory for the development of “What’s
Next?” was self-determination. Self-determination is
“knowing what one wants in life, and having the
mechanisms to achieve these goals” (Whitney-Thomas
& Mahoney, 2001). Facilitating self-determination is a
process of creating opportunities for decision-making,
goal-setting and self-exploration to achieve a realistic
understanding of one’s own skills and abilities.
The “What’s Next?” group was designed to build
self-determination primarily through the skill of goal
setting. As a key component of self-determination,
goal-setting encourages thinking about long-term future
plans, and breaking these goals into manageable steps
that the individual can begin working on immediately.
Transition and self-determination are long processes
which require more than a 5-week group. However, by
providing opportunities and experiences that foster selfdetermination, and providing teens with strategies to
identify how to build necessary skills through goalsetting, the knowledge and skills gained can be
transferred to other settings outside the context of the
group.
Methods:
Written consent (or assent) was received from all
subjects and/or parent/guardian. Subjects completed
the American Institutes for Research (AIR) SelfDetermination Scales, (Woulman, Campeau, , DuBois,
Michaug, & Stolarski, 1994) and the “What’s Next?”
Measure of Preparedness for Transition (MoP). The
AIR Scales evaluate the individual’s perception of their
capacities and the support they receive from their
environment.
The MoP was designed by the investigators to
evaluate more specifically the subjects’ perceived
preparedness for transition. It was hypothesized that
the subjects would demonstrate an increase in their
perceived preparedness for transition as measured by
the MoP, but that they would not show an increase on
the AIR Self-Determination Scales. Self-determination
is a life-long process, and the investigators were not
anticipating that the AIR would capture change during
the 5-week period. Throughout the group, modules on
each of the identified topics were presented, and the
subjects were provided with information and resources.
Active participation from the subjects was encouraged
through opportunities for problem-solving, choicemaking, goal-setting and independence. Each week
subjects also completed weekly surveys evaluating the
content of the session, as well as the evaluation
component of the “What’s Next?” goal-setting tool,
which addressed the tool’s usefulness. This goalsetting tool was specifically designed for the group to
assist the participants with the goal setting process.
After the last session, the AIR Scales and the MoP
were re-administered. A 30 minute discussion was held
to allow the subjects to offer feedback on the process
and content of the group, as well as the use of the
“What’s Next?” goal-setting tool.
Consent was
obtained to tape record the conversation
Analysis
Statistical analysis was not required for this
project, due to the small sample size. Scores on the
AIR Scales and the MoP were totaled to demonstrate
individual change, as well as total average change.
Results from weekly surveys were averaged per week,
to show any increases or decreases in topic knowledge
from each session. Weekly survey results were also
averaged across all of the sessions in order to provide a
concise description of the overall importance and
helpfulness of the content of the sessions. In order to
provide a summary of the helpfulness and usefulness of
the tool in planning and organizing goal achievement
the average from all of the scores on the goal setting
tool were compiled.
Results
Overall, the subjects reported an increase from a
total average of 29 points to 50 points in subjective
feelings of preparedness for the transition to adulthood,
as measured by the MoP (range 7-46 at baseline, 35-58
at follow-up). In regards to their ability to set goals,
two subjects reported an increase in ability (9 and 6
point increase), one stayed the same at 10/10, and two
subjects reported a decrease in ability (both 1 point
decrease).
This decrease may be the result of
overestimating abilities in the initial baseline measure,
and achieving a realignment of self-perception with real
capabilities by the end of the five-week group. Many
of the subjects reported that goal-setting was not
difficult for them, but did experience some difficulty
developing and writing personal goals throughout the
sessions.
On the AIR Self-Determination Scales, four of the
five subjects reported an increase in self-determination,
though it was minimal and not significant. The two
subscales on the AIR, capacity and opportunity, were
also evaluated. In the capacity section, the subjects are
asked to rate their ability to recognize their strengths,
plan to meet goals, and ask for help if necessary. The
opportunity section asks subjects about the support they
feel they are receiving both at school and at home. The
results of capacity versus opportunity on the AIR scales
demonstrated no consistency in change between pre and
post measures. Therefore, no conclusive statements can
be made regarding the effectiveness of the program on
the subjects’ perceptions of their capabilities or
opportunities for self-determined behaviour.
The results from the weekly surveys were very
positive. Overall, the importance of the session topics
was rated an average of 9.69/10 across all sessions.
The overall helpfulness of the sessions was rated an
average of 9/10 across all sessions.
The first question from the evaluation component
of the “What’s Next?” goal setting tool addresses
whether the tool was useful in organizing the subject’s
thoughts. There was an 81.8% positive response rate.
The second question, which examined the usefulness of
the tool in planning to achieve the subject’s goals also
had a positive (yes) response 81.8% of the time
Discussion
Results indicate that overall the subjects benefited
from the “What’s Next?” group. All subjects reported
an increase in preparedness for transition from baseline,
as indicated by an increase on almost all components of
the MoP. The results are not conclusive regarding the
group’s impact on self-determination.
In terms of the content of the group, results were
positive. Each week, subjects felt that the topic covered
was important for their transition. This may have
contributed to an increase in feelings of selfdetermination by allowing them to exert influence over
their own learning. They had previously selected the
topics for the sessions by completing the initial survey
to identify important issues. Subjects also rated the
helpfulness of sessions high each week. In isolated
cases, comments offered on the weekly surveys
informed the investigators why the subject did not find
the session as helpful.
It should also be emphasized that the subjects
volunteered for the group, and then volunteered to be
involved in the study. Several of the subjects are also
involved with other voluntary activities associated with
CDRP, and therefore may not be representative of most
adolescents with disabilities. Our sample may represent
a sub-population of adolescents with disabilities who
are highly motivated and actively engaged in their own
personal development and management.
There were mixed feelings about the goal-setting
form itself. Though results indicated consistently high
scores for usefulness of the tool, one subject noted she
would rather set goals mentally. This may have been
impacted by the individual’s difficulty with written
output. Offering an electronic version of the goalsetting tool in the future may address this issue.
Individuals could then benefit from independent goalsetting while still maintaining the benefits of having the
goal broken down into steps.
References:
King, G., Baldwin, P., Currie, M., Evans, J. (2005).
Planning successful transitions from school to adult
roles for youth with disabilities. Children’s Health
Care 34(3), 195-216.
Stewart, D., Law, M., Rosenbaum, P., & Willms, D.
(2001). A qualitative study of the transition to
adulthood for youth with physical disabilities.
Physical and Occupational Therapy, 21(4), 3-21.
Whitney-Thomas, J., Moloney, M. (2001). Who I am
and what I want: Adolescent’s self-definition and
struggles.” Exceptional Children 3. 375-389.
Woulman, J., Campeau, P., DuBois, P.,
Michaug, D., & Stolarski, V. (1994). AIR
Self Determination Scale and User Guide.
New York: American Institute for
Research.
Acknowledgements
Thank you to Karen Margallo O.T. Reg. (Ont.) and
Andrea Morrison O.T. Reg. (Ont.), supervisors for this
project. Thank you to all the group members for their
participation and feedback.
More Than Words: Community Living and Mental Health
Allison Henderson & Jennifer Neill- Supervisors: Muriel Westmorland, OT Reg. (Ont.)
Introduction: In recent decades there has been a shift from
institutionalization to community living for mental health
consumers. With this shift, the role of health care
professionals, including occupational therapists, has
expanded to include community practice (Iivalsoe &
Josephsson, 2003). Community interventions currently used
by mental health practitioners typically include supported
employment, symptom management, family
psychoeducation, and medication management (Bond,
Salyers, Rollins, Rapp, & Zipple, 2004). Though these
interventions may help to reduce symptoms, and ultimately
lead to reduced hospitalization (Lemaire & Mallik, 2005),
they may not be representative of individuals’ needs.
Literature Review: A study by Crane-Ross, Roth and
Lauber (2000), found that although mental health
practitioners have the professional experience and
knowledge of community interventions, their perceptions of
what are the most effective and efficient services did not
match the perspectives of their clients. The service providers
were more likely to focus on psychotropic medications, and
social skills development, whereas their clients focused on
community support and daily living needs.
Studies, which have used a qualitative approach to
determine the challenges faced in the community, discovered
that consumers identified family as being an important
support in the community, as they provided a sense of
dependability, safety and security (Davidson, Haglund,
Stayner, Rakfeldt, Chinman, & Tebes, 2001; Beal et al.,
2005). The participants in the Beal et al (2005) study
identified relationship building and developing social
networks as being of importance. They saw these
relationships as connecting them to the wider community
and giving them hope. An additional theme that emerged
was the importance of being a productive and contributing
member of society.
As evidenced by the above studies there appears to
be a disparity between consumers and health care
professionals’ perceptions of needed services. As evidencebased practitioners it is imperative to consider the client’s
perspective of what services they feel assist them to remain
in the community (Beal et al., 2005). The purpose of the
current study is to explore mental health consumers’
experiences of living in the community. Therefore the
research question is: What factors contribute to mental
health consumers’ ability to live in the community?
Methods: A qualitative research design was chosen to
answer the research question, as this methodology allows indepth exploration of the individual’s experience (Domholdt,
2005). The qualitative phenomenological design will allow
the participants’ individual view of the world to be
represented. Traditionally, qualitative research involves
gathering data through structured, semi-structured or
unstructured interviews (Domholdt). For the present study,
photography was selected as a means of gathering data. This
type of research methodology is called Photovoice (Wang,
Morrel-Samuels, Hutchinson, Bell & Pestronk, 2004). It
involves providing people with cameras to document their
realities. The use of photography can break down the
barriers of language and articulation that exist in traditional
interview methods (Germain, 2004). Booth and Booth
(2003) describe how using a camera in qualitative research
enables the participant to determine how they will represent
themselves and their situation.
Ethics approval was obtained from the Faculty of
Health Sciences at McMaster University prior to
commencing the study. Participants were recruited through
the Canadian Mental Health Association Nikon Pals
photography group and the Mood Menders support group.
Nine people (n=9) living in the community with a mental
illness consented to participate in the study. Each participant
was provided with an automatic film camera that he or she
was able to keep following the study. The participants met
with the investigators on three occasions. The first meeting
involved obtaining written consent to participate in the
study, a description of the purpose of the study and a brief
education session on how to use the camera. The
participants were asked to take photographs of what they felt
helps them to live in the community. The participants were
asked to obtain verbal consent from any person he or she
photographed. The purpose of the second meeting was to
obtain the film for processing. Two sets of prints were made,
one set to be kept by the participant and the second set to be
kept by the investigators. The third meeting involved a
semi-structured interview where the participants reviewed
and discussed their photographs. The interviews were
conducted at a location that was most convenient for the
participant. The interviews ranged in length from 30 to 90
minutes and were recorded on audiocassette to later be
transcribed for analysis.
The structure of the interview was informed by a
previous study that used the Photovoice methodology (Wang
et al., 2004). Wang et al describe a set of questions that can
be used to explore photographs and elicit details about the
content. The mnemonic “SHOWeD” is the title for the
series of questions. The questions are: “What do you See
here?”, “What is Happening?”, “How does this relate to Our
lives?”, “Why does this problem or strength exist?”, and
“What can we Do about it?” These questions were developed
to discuss photographs that document community issues.
The questions were modified to more appropriately address
the personal nature of the present study. During the
interview the investigators asked the participant to first
describe what was in the picture and then how this helps him
or her to live in the community.
Analysis: Information from the interviews was transcribed
and analyzed using line-by-line coding. Similar codes were
assigned a colour and were then grouped into broader
categories. The categories informed the development of
larger, overarching themes. The photographs were analyzed
and categorized following the interview data.
Results: The photographs were grouped according to the
themes that were elicited from the interviews.
The themes that were extracted from the transcribed
data are as follows:
1. Religion and Spirituality: This theme was identified
by each of the nine participants. “Religion and
spirituality is part of my natural environment, just
as much as breathing.”
2. Family and Friends: The participants described the
support that family and friends provide. “Family
and friends, that’s a big support.”
3. Pets: The importance of caring for pets was found
to be a prominent theme. “I surround myself with
life, fish, and plants”, “She’s a miracle doggie….
and I don’t know what I would do without her.”
4. Giving Back: This theme refers to the participant’s
need to contribute to society, through occupations
such as employment, volunteer work and
interpersonal relationships. “That’s part of my
healing process, to be able to help other people.” “
The more times we are selfish, the harder it is to fit
in with society, and the harder it is to keep things
straight. The more we give of ourselves is actually a
way that we can fit in and we can contribute to
society and as a whole be more stable.”
5. Creative Expression: The participants identified the
importance of creative expressions through artistic
mediums including: scrap-booking, painting,
writing, and crafts. “My painting is very important
in my life.” “I find it very relaxing and I find that
scrap-booking improves my mood.”
6. Hobbies and Leisure: This theme describes the
importance of recreational activities. “Doing stuff,
keeping busy, it really does help, people kept telling
me to keep busy, and that angered me, but they
were right, it’s good to keep busy.” “Going out and
walking, and taking advantage of nature and
scenery. It lifts my mood to go out, and have quiet
time to reflect.”
7. Community Services: The participants identified
numerous community services that they access in
Hamilton such as the YWCA, the public library,
and bus services. “I don’t have to make a lot of
plans, it doesn’t cost a lot of money, the bus goes a
lot of places. I can pay a little bit of money and go a
lot of places. It lifts my mood to get out.”
8. Mental Health Services: “When you suffer from a
mood disorder it’s good to connect with people who
do have similar stories and similar situations. It’s
good to feel that you are not alone…this is what the
group represented.” The participants identified
formal services, including support groups.
Discussion: From this study, eight themes were generated
that pertained to mental health consumers’ ability to function
in the community. The participants in this study identified
supports that are informal and personal in nature as opposed
to the traditional services that focus on supported
employment and medication management (Bond et al.,
2004). The current study validates the findings of Beal et al
(2005) and Davidson et al (2001), which identified family
support, relationships building, and being a productive and
contributing member of society as factors facilitating
community living. This study expands on these findings by
including further themes such as pets, spirituality/religion,
and creative expression. Health care practitioners may need
to go beyond traditional interventions and consider informal
supports highlighted in this study.
Photography as a medium for gathering data
allowed the participants to capture the supports that enable
community living without the barriers of language and
articulation that exist in traditional interviews (Germain,
2004). This method of gathering client information can be
integrated into clinical practice to gather information about
clients or for gathering data for research projects.
References:
Beal, G., Veldhorst, G., McGrath, J., Guruge, S., Grewal,
P., DiNunzio, R., & Trimnell, J. (2005).
Constituting community: Creating a place for
oneself. Psychiatry, 68, 199-211.
Bond, G., Salyers, M., Rollins, A., Rapp, C., & Zipple, A.
(2004). How evidence-based practices contribute
to community integration. Community Mental
Health Journal, 40, 569-588.
Booth, T., & Booth, W. (2003). In the frame: Photovoice
and mothers with learning difficulties.
Disability and Society, 18, 431-442.
Crane-Ross, D., Roth, D., & Lauber, B. (2000).
Consumers’and case managers’ perceptions of
mental health and community support service
needs. Community Mental Health Journal, 36, 161178.
Davidson, L., Haglund, K., Stayner, D., Rakfeldt, J.,
Chinman, M., & Tebes, J. (2001). “It was just
realizing that life isn’t one big horror”: A
qualitative study of supported socialization.
Psychiatric Rehabilitation Journal, 24, 275-292.
Domholdt, E. (2005). Rehabilitation in research
: Principles and applications (3rd ed.). St. Louis,
MO: Elsevier Saunders.
Germain, R. (2004). An exploratory study using cameras
and Talking Mats to access the views of
young people with learning disabilities on their
out-of-school activities. British Journal
of Learning Disabilities, 32, 170-174.
Iivalsoe, B., & Josephsson, S. (2003). Characteristics of
meaningful occupations from the perspectives of
mentally ill people. Scandinavian Journal of
Occupational Therapy, 10, 61-71.
Lemaire G., & Mallik, K. (2005). Barriers to community
integration for participants in community-based
psychiatric rehabilitation. Archives of Psychiatric
Nursing, 19, 125-132.
Wang, C.C., Morrel-Samuels, S., Hutchinson, P.M., Bell,
L., & Pestronk, R.M. (2004). Flint photovoice:
Community building among youths, adults, and
policymakers. American Journal of Public
Health, 94, 911-913.
Acknowledgements: We would like to thank our supervisor
Muriel Westmorland, the participants in our study, and the
individuals who generously donated their cameras.
INCLUSIVE EDUCATION IN OT
STUDENTS: MAGNA MOUNEIME AND ELIZABETH BUHLER
INTRODUCTION
Inclusive education is defined by the United Nations Education,
Scientific and Cultural Organization (UNESCO) as a human rights
issue that is the “process of addressing and responding to the
diversity of needs of all learners through increasing participation
in learning, cultures and communities, and reducing exclusion
within and from education” (Booth as cited in UNESCO, 2003, p.
7). Fuller et al. (2004a) emphasize the student experience, defining
inclusive education as “firstly, reducing barriers to learning and
participation for all students and secondly, learning from attempts
to overcome barriers to the access and participation of students”
(p. 455). The World Federation of Occupational Therapists
(WFOT) has proposed that a position statement be developed on
inclusive occupational therapy education. The research study was
a collaborative effort between WFOT and McMaster University to
assess and understand the current state of inclusive occupational
therapy (OT) education at an international level.
PURPOSE
The study encompassed phase 1 of the project, which included
(1) completing a preliminary literature review, (2) developing a
survey instrument, (3) piloting the survey, (4) collecting
preliminary data and feedback about the survey, (5) revising the
survey, and (5) providing recommendations for phase 2 of the
project. In phase 2, the revised survey will be used to gather
information about inclusive OT education from a larger
international sample, and the ensuing results will be used to
inform WFOT’s policy statement on inclusive education.
LITERATURE REVIEW
A preliminary literature review on inclusive education was
completed in the summer of 2005. The search revealed that there
were no existing surveys that asked about inclusive education. The
literature review findings were therefore used to inform the initial
development of the survey prior to student involvement in the
project. Subsequent to this, a second literature review was
conducted to explore the current understanding and experience of
inclusive higher education for students with disabilities. This was
important foundational knowledge for the project because as
Velde et al (2005) recognized, it is critical for educational
institutions to understand the experiences of students with
disabilities if they want to change contextual and environmental
issues that present as barriers for students with disabilities.
Although the intent was to focus on inclusive education in OT,
there was a paucity of information on the subject, and therefore
the search was broadened to include other health profession
programs and general post-secondary education. An appraisal and
annotated bibliography was completed for 10 selected articles that
fit the search criteria. Common trends in the literature included
issues around (1) staff and peer attitudes; (2) admission and
curriculum; (3) physical, equipment, and informational access;
and (4) personnel and resource supports. A trend that resonated
throughout the literature was the idea of access. Broadly speaking,
“access is a multi-layered issue encompassing the physical,
attitudinal, and curricular” (Shevlin et al, 2004, p. 17).
METHODS
Ethics approval for this research project was obtained from
McMaster University Research Ethics Board in March 2006.
Survey and Evaluation Development
A pilot survey was developed which was aimed at assessing an
OT program’s level of inclusivity in regards to their policies,
procedures, and practices. Ten subheadings were used to organize
the survey. The majority of the questions were partially openended in that they solicited qualitative narratives to expand on the
check-box responses. In addition to this, an evaluation form was
developed to gather feedback about the survey and inform the
final survey product.
Sample
Sixteen of 648 WFOT-accredited OT schools were chosen to
participate in the pilot survey. The research team recruited 13
programs from personal contacts, and an additional three from the
WFOT website. The sample included at least two programs from
each continent. Twelve programs agreed to participate, three did
not respond, and one declined but provided feedback.
Procedure
Each participant was contacted via email and provided with the
following documents: a recruitment letter, an information letter, a
pilot survey, and an evaluation form. Informed consent was
assumed if the survey and the evaluation were returned to
McMaster. If the participants had not responded by the specified
deadline, a reminder email was sent to encourage participation.
ANALYSIS
Descriptive data from the survey was entered into an Excel
spreadsheet and analyzed using descriptive statistics Feedback
from the evaluation form was compiled and summarized.
RESULTS
Survey Results
Several results from the survey are highlighted below:
ƒ Only one school had a definition of disability as formally stated
in an institutional policy.
ƒ Two programs had formal policy and procedure statements
regarding admissions. Four other programs had policies, but no
procedures. Two schools reported that while disclosure of a
disability rests with the individual applicant, the applicant was
still required to meet all requirements before accommodation
could be negotiated.
ƒ Four schools reported having no students with disabilities in the
program, while two reported having 10 and one had 16.
ƒ Eleven schools reported using at least one strategy to
accommodate students with disabilities within the program. The
strategies included: extra time for exams, volunteer note-takers
and readers, assistive technology, and sign interpreters.
ƒ Seven schools reported accommodating students with
disabilities in clinical fieldwork on a case-by-case basis. One
school implemented clinical mentorship.
ƒ Three schools reported knowing whether their graduates with
disabilities had difficulty finding employment after graduation.
ƒ Eight schools recognized having architectural barriers (such as
heavy/manual doors, and excessive travel time/distance between
classes), but only 3 had strategies in place to address these
barriers.
ƒ Four schools recognized having attitudinal barriers (such as
discrimination by fieldwork supervisors and some faculty). Two
of these programs reported having strategies in place to manage
these barriers.
Inclusive Occupational Therapy Education: A Pilot Survey
ƒ Eight schools reported having institutional policies for students
with disabilities and nine schools reported having a resource
centre for students with disabilities.
ƒ Nine schools reported being aware of government legislation
that guided their policies and procedures.
Evaluation Results
The evaluation of the pilot survey was of critical importance to
phase 1 of this project because the feedback helped inform the
revisions of the survey instrument. Results indicated that the
survey took an average of 30 minutes to complete. Six
respondents rated the survey as easy to fill out, 4 rated it as
moderately difficult, and none rated it as difficult Additionally,
nine participants revealed no concerns with the survey language,
ten found the survey well organized and easy to follow, and ten
had no technical difficulties with the survey.
DISCUSSION
An evaluation of the pilot survey and feedback resulted in
significant revisions to the survey tool. Considering significantly
more participants will be surveyed in phase 2, it was deemed
essential to add more closed-ended questions, while still providing
opportunity for some additional comments. Several sections were
also eliminated, condensed, or reorganized to focus the survey on
the questions that provided the richest data from the pilot survey,
and reflected the common trends from the literature.
There was an emphasis on barriers to participation in both the
literature and the survey responses. However, a discrepancy
existed in the nature of the barriers, with the survey respondents
commenting most frequently on physical barriers while the
literature review revealed that students with disabilities focused on
attitudinal barriers. With much of the focus on barriers, there was
little information provided about supports to participation. There
was an opportunity for survey respondents to outline support
strategies for students; however, few commented on this section.
Institutions can reflect on their level of inclusivity based on the
barriers and facilitators identified by students with disabilities. It is
interesting to note that some of the most positive experiences
emerged from the occupational therapy literature. In Velde et al
(2005) students reported that disability positively impacted their
ability to practice as OTs because it enhanced their therapeutic use
of self, and made them better advocates and more empathetic.
RECOMMENDATIONS
The results and findings from the literature review and pilot
survey will help to inform the policy statement for WFOT;
however more research is needed to fully support a position on the
issue. As such, the following recommendations have been made:
ƒ The revised survey tool should be used for phase 2 of the
project (either as a second pilot or for the final project) pending
funding. An online survey should be considered. Given that
there are 648 WFOT accredited schools, random regional
sampling should be used.
ƒ There is a need for more research on student experiences of
disability. It would be pertinent to focus this research on the
existing gaps in the literature, such as supports to inclusivity and
attitudinal barriers. Future studies should be carried out in
collaboration with students with disabilities because this is
important for ensuring effective research on disability issues
(Guenther, 2005). Although it is acknowledged that it may be
difficult to obtain information about attitudinal barriers from the
institutions, it is important to be cognizant of the discrepancy
between policies and student experiences. Therefore, future
Page 2
studies should assess both the academic institution’s level of
inclusivity and the students’ perspectives of the actual level of
inclusivity.
CONCLUSION
The current study marks the completion of phase 1 of the
project. Given that the literature review and pilot survey were
conducted concurrently, the results of each have informed the
future direction of this project. The recommendations and revised
survey launch the research into phase 2 of the project.
REFERENCES (* Denotes articles selected for annotated bibliography)
*Ash, A, Bellew, J, Davies, M, Newman, T, & Richardson, L
(1997). Everybody in? The experience of disabled students in
further education. Disability & Society, 12, 605-621.
*Bennett, S.H. (1989). My occupational therapy education as a
person with visual and physical disabilities. The American
Journal of Occupational Therapy, 43, 263-266.
*Fuller, M, Bradley, A, & Healey, M (2004a). Incorporating
disabled students within an inclusive higher education
environment. Disability & Society, 19(5), 455-468.
*Fuller, M, Healey, M, Bradley, A, & Hall, T (2004b). Barriers to
learning: A systematic study of the experience of disabled
students in one university. Studies in Higher Education, 29(3),
303.
*Gitlow, L (2001). Occupational therapy faculty attitudes toward
the inclusion of students with disabilities in their educational
programs. Occupational Therapy Journal of Research, 21(2),
115-31.
*Guitard, P. & Lirett, S. (2005). Overcoming barriers: Becoming
an occupational therapist when you cannot see. OT Now, 23-25.
*Guenther, S. (2005). Reflections on a student research project:
Experiences of university students with physical disabilities. OT
Now, 26-30.
*Pitt, V, & Curtin, M. (2004). Integration versus segregation: The
experiences of a group of disabled students moving from
mainstream school into special needs further education.
Disability & Society, 19, 387-401
*Shevlin, M, Kenny, M, & McNeela, E (2004). Participation in
higher education for students with disabilities: An Irish
perspective. Disability & Society, 19, 15-30.
United Nations Education, Scientific and Cultural Organization
(UNESCO). (2003). Overcoming exclusion through inclusive
approaches in education A challenge & A vision: Paris, France:
UNESCO.
*Velde, B, Chapin, M, & Wittman, P. (2005). Working around
"it": The experience of occupational therapy students with a
disability. Journal of Allied Health, 34(2), 83-89.
ACKNOWLEDGEMENTS
We would like to thank the project team for their support and
assistance. Thank you also to the respondents for their valuable
input and feedback, and to Tasha Kravchenko and Paul Stratford
for their research assistance.
Environmental Design and Dementia Care: Creating a Link between Research and Implementation
A Resource Guide
Students: Laura Demaiter (Motherwell) and Catherine Smith
Supervisor: Karen Allcroft (RN)
INTRODUCTION
Dementia is characterized by changes to every day
functioning as a result of a decline in memory, language,
judgment, and reasoning. Individuals with dementia often
have difficulty performing activities of daily living, such
as bathing, dressing, eating, independently (Molloy, &
Caldwell, 1998 and Alzheimer’s Society of Canada).
Psychiatric and behavioural symptoms such as social
withdrawal, agitation, wandering and depression, are also
often present. As health care professionals, we must
remember that the exhibited behaviours are often selfprotective. The behaviours are usually a means of
communication and expression of feelings to caregivers,
staff, family and friends (MOHLTC, 2000).
PROJECT DESCRIPTION
The intended purpose of this project was to create a
practical resource guide for the Alzheimer Society of
Hamilton and Halton to share with long term care homes.
This guide was intended to provide usable suggestions
from the literature pertaining to environmental design for
long-term care facilities that support individuals with
dementia.
THEORETICAL BACKGROUND
M. Powell Lawton and Lucille Nahemow’s (1973)
Ecological Model of Aging (EMA; as cited in Weisman,
Cohen & Day, 1992) is a widely used model to assess the
environment for the aged. This model addresses how
environmental press, or the demands of the environment
influence an individual’s behaviour based on that person’s
competence, or capacity of the individual to function.
Utilizing both Lawton’s model and a person-centered
approach, there is significant therapeutic potential of the
environment including: promoting well-being, increasing
quality of life, supporting functionality by compensating
for losses, and reducing or preventing dysfunctional or
disruptive behaviours (Day, Carreon & Stump, 2000).
Environments:
o Social (family, caregivers, and staff)
o Physical (physical design, sensory experiences, such
as olfactory, auditory and visual)
o Organizational (policy and programs)
The interaction between the various environments has an
impact on residents’ quality of life.
PROCESS OF RESOURCE GUIDE CREATION
The authors conducted several extensive literature
searches using the following databases: CINAHL,
Ageline, Cochrane Central Register of Controlled Trials,
Cochrane Database of Systematic Reviews, EMBASE,
Medline, and Google Scholar. Other resources used were:
design guides, evidence – based websites, and textbooks.
Separate searches were conducted on the following topic
areas: Dementia (signs, symptoms, functional implications
and progression), Environmental Theories, Environmental
Assessments for LTC, Impact on the Environment on
Individuals with Dementia, Specific Environmental
Components of LTC Facilities (i.e. kitchens, bedrooms, and
bathrooms).
The authors used these specific components of the physical
and social environments as chapter headings within the
resource guide. Each chapter follows a similar layout:
introduction to topic area, relevant study findings,
suggestions from the literature and references.
RESULTS
The following will provide examples of practical
suggestions that are found in each chapter. Please refer to
the guide for a comprehensive list and literature references.
Assessment Tools: The observational screening checklist,
the Therapeutic Environment Screening Survey for Nursing
Homes (TESS-NH), can be used as a tool to address
concepts and design issues related specifically to special
care units for individuals with dementia.
Kitchen Design and the Dining Experience: Kitchens
should be residential, provide familiar and domestic
features, and implement universal design principles.
Residents should have unrestricted access to kitchen area.
Dining areas should contain intimate table settings with
tableware different in colour to the tablecloth.
Bathroom Design and the Bathing Experience: Bathrooms
should have appropriate lighting and safety features. Natural
elements, such as pictures and sounds, as well as warm air
and water temperatures, may facilitate a positive bathing
experience.
Toilet Area Design and Toileting: The toilet should be
visible from the resident’s bed, and be contrasting in colour
from the walls and floor.
Bedroom Design: Resident’s rooms should provide privacy,
opportunities for autonomy, and a homelike atmosphere.
Private and double occupancy rooms should be available.
Corridor Design including: Way-finding, Lighting,
Flooring, Wall Colour, and General Design: Use of
meaningful memorabilia and old photographs are helpful for
resident room finding. Natural lighting should be utilized;
light directed upwards offers a more “natural light” and
decreases glare. Flooring should not have large, contrasting
patterns. Wall colour changes at doorways and transitions
are appropriate. Wandering paths should offer meaningful
views and limited dead ends.
Outdoor Spaces and Access to the Exterior Environment:
Access to enclosed outdoor spaces should be unrestricted to
Environmental Design and Dementia Care: Creating a Link between Research and Implementation
A Resource Guide
Students: Laura Demaiter (Motherwell) and Catherine Smith
Supervisor: Karen Allcroft (RN)
residents. Walking paths should be provided with shaded
seating areas.
Exit Design and Exit-seeking Behaviours: Effective
strategies for decreasing resident door-testing behaviours
involve a method of camouflaging or disguising the
doorway. Interventions that promote a non-institutional,
homelike environment should be implemented.
Non-pharmacological Interventions including: Doll
Therapy, Touch / Massage, Aromatherapy, Snoezelen
Therapy and Music Therapy: There is no high-quality
evidence supporting the use of doll or Snoezelen
therapies. Evidence suggests that touch, aromatherapy and
music therapy are possible inexpensive relatively low risk
interventions for managing agitated behaviours.
DISCUSSION
Some of the over-arching themes that are present in all
chapters of the resource guide include:
Resident-directed (or person-centered) care
o Including resident choice & control in daily activities
such as eating, dressing and bathing.
Creating a homelike environment
o Including personalization of bedrooms and resident
living spaces, such as kitchens, bathrooms and
activity rooms.
Safety
o Including ensuring unit, exits and outdoor space are
secure, and that residents feel safe during every day
activities, such as bathing and dressing.
Providing opportunities for participation in
meaningful activities
o Including multiple small activity spaces, accessible
kitchen and garden and encouraging residents
assistance in typical every day duties, such as
laundry, yard work and cleaning.
CONCLUSION
The environment is a key determinant in the overall
quality of life for residents in long term care with
dementia. However, not only is the physical layout and
design critical, equally important are the social and
organizational environments.
A safe, supportive
environment promotes meaningful activities, autonomy,
privacy, and encourages remaining functional abilities.
The suggestions presented in this resource guide are
intended to be used as considerations for alterations that
can be made to a current dementia care unit or
implemented in the development of a new facility. Every
resident will respond uniquely to changes; one
environmental modification will result in a spectrum of
reactions from different residents. The guidelines and
recommendations for environmental changes can be
implemented to varying degrees, depending on the
availability of resources. Importantly, the environmental
changes themselves will not result in positive functional
changes by residents; it is the combination of environmental
design and staff-resident interaction that will ultimately
determine the quality of life that resident’s experience.
KEY REFERENCES
An extensive number of articles, textbooks and websites
were utilized during the creation of the resource guide. The
following is a list of pivotal references:
Barnes, I. (2004). Interventions for the ten basic concepts of
dementia care. Canadian Nursing Home, 15 (3), 13 –
15.
Day, K., Carreon, D. & Stump, C. (2000). The therapeutic
design of environments for people with dementia: A
review of the empirical research. The Gerontologist,
40(4), 397-416.
Molloy, W., & Caldwell, P. (1998). Alzheimer’s Disease.
Toronto: Key Porter Books Limited.
Ministry of Health and Long Term Care (MOHLTC).
(2000). Putting the PIECES together: A
psychogeriatric
guide and training program for
professionals in long-term care facilities in Ontario.
2nd ed.
Weisman,G., Cohen, U., & Day, K. (1992). Programming
and Design for Dementia. The School of Architecture
& Urban Planning, Milwaukee, Wisconsin.
Websites:
Alzheimer’s Society of Canada: www.alzheimers.ca
Dementia Design Information: DementiaDesignInfo.org
National Guideline Clearinghouse (NGC), a public resource for
evidence-based clinical practice: www.guidelines.gov
TESS-NH Assessment: www.unc.edu/depts/tessnh/
ACKNOWLEDGEMENTS
The Alzheimer Society of Hamilton and Halton, Karen
Allcroft, RN., Psychogeriatric Resource Consultant,
Shannon Buckley, Long Term Care Resource Centre
Coordinator for her assistance in obtaining relevant articles,
Macassa Lodge, Hamilton, ON for allowing pictures of their
facility to be used in this guide, Staff and residents at Versa
Care, Grace Villa, and Extendicare long-term care facilities
in Hamilton, ON, and the Dorothy Macham Home and
Aging and Veterans Care Program at Sunnybrook Health
Science Center, Toronto, ON.
The Informational Needs of Grandparents of Children with Cerebral Palsy:
An Exploratory Study
Student Researchers: Heather McCallum, Lisa McCrea and Cynthia Perry, MSc(OT) Candidates
CanChild Investigators: Dianne Russell and Lisa Rivard
Introduction
Changes in population demographics, such as
increases in life expectancy, divorce rates, single-parent
families, women working outside the home and
decreases in family size provide greater opportunities for
grandparents to interact with, and provide support to,
their children and grandchildren (Attias-Donfut, 2000;
Bengston, 2001; Castaglia, 1999; Lauterbach & Klein,
2004; Szinovacz, 1998). Parents of children with
disabilities appear to value support provided by
grandparents. Research shows that emotional support
tends to have a greater impact on parental well-being
than practical support (Trute, 2003).
When learning of their grandchild’s disability,
grandparents, like parents, may initially experience
feelings of shock, despair, or anger (Katz & Kessel,
2002). It has been suggested that education provided to
grandparents about their grandchild’s disability,
particularly from their adult children, may help
grandparents understand and accept their grandchild’s
condition (Katz & Kessel, 2002). A study by Vadasy,
Fewell, and Meyer (1986) indicates that grandparents’
educational needs may be similar to parents’; however
this may not be reflective of current grandparents’
informational needs.
The purpose of this study was to explore the
informational needs of grandparents of children with
cerebral palsy (CP) in order to develop educational
materials for them. Ethics approval was granted by the
McMaster University Faculty of Health Sciences
Research Ethics Board.
Methods
Design:
The study was based on a mixed-model design,
which combines qualitative and quantitative research
techniques (Johnson & Onwuegbuzie, 2004). It consisted
of primarily qualitative data collection, but employed
quantitative analysis.
Sampling:
Therapists from seven children’s treatment centres in
the province of Ontario assisted the student researchers
with the recruitment of grandparents. These centres
agreed to distribute information letters regarding the
study to parents of children receiving therapy for CP.
Parents were asked to share this information with
grandparents. Information posters were also posted at
each of the centres. Grandparents contacted the student
researchers directly if they were interested in
participating in a telephone interview about their past and
current informational needs. Twelve grandparents agreed
to be interviewed.
Data Collection:
A semi-structured telephone interview consisting of
open-ended questions about past and present
informational needs and closed-ended demographic
questions was conducted with each consenting
grandparent at a time convenient for them. Interviews
lasted approximately 30 minutes. The qualitative
questions for this interview were developed from themes
found in a comprehensive literature review. A list of
possible response options for each question was
generated ahead of time to facilitate data recording.
Student researchers employed standardized prompts to
clarify and/or gather more information when needed.
Pilot testing was performed, with the feedback given
being used to modify the interview. Responses were
recorded manually on the interview data collection sheets
during the interviews and later categorized.
Analysis:
Each interview was analyzed by at least two of the
three student researchers to ensure accuracy and
consistency of analysis. Any discrepancies in analysis
were resolved through discussion among the student
researchers. Results were summarized by recording the
frequency of specific responses for each question.
Results
A convenience sample of 12 grandmothers between
the ages of 50 and 79 years participated in this study. The
majority of their grandchildren, eight of whom were
male and four of whom were female, were under the age
of 10. Most of these grandchildren were classified as
either Level II (5/12) or Level IV (4/12) on the Gross
Motor Function Classification System (GMFCS;
Palisano et al., 1997), although there was at least one
child at every GMFCS level. In addition to their motor
difficulties, many of the grandparents (10/12) reported
that their grandchild had other challenges, including
medical, communication, social or learning difficulties.
Almost all (10/12) of the grandparents lived in close
proximity to their grandchild (within a 30-minute drive
or less) and reported spending time with their grandchild
at least once per week. Grandparents reported being
engaged in a number of different activities with their
grandchild, such as playing games and socializing.
Grandparents indicated that they also provide a great
deal of support to their adult children, with many
providing practical support (e.g. respite and financial
aid). Half of the participating grandparents (6/12)
reported assisting with health related activities such as
driving their grandchild to medical appointments and
doing therapeutic exercises with them at home. In
addition, all of the grandparents stated that they provide
emotional support to their adult children, with most
being available to talk, listen and empathize. Some
participants expressed hesitation to give advice as they
did not want to interfere with the parents’ decisions.
In general, grandparents reported receiving limited
information regarding their grandchild upon his or her
diagnosis. They stated that they would have preferred to
receive more information directly related to CP at that
time. Currently, many of the grandparents (11/12) still
have concerns regarding their grandchild, most
commonly indicating that they would like information on
interventions, their grandchild’s future abilities, and
school-related issues.
According to participating grandparents, it would be
beneficial if information could be delivered through
personal communication and in written format so that
they are able to review it again at a later time. They also
indicated that they felt their role in providing support to
their adult children was very important and that having
support themselves (including knowing where and how
to access this support) would be helpful. Other
grandparents should be given information about how to
provide emotional support, as well as where to receive it.
Having practical experience with their grandchild was
noted by several of the grandparents as an important way
to learn how to provide practical support.
Discussion & Recommendations
Consistent with previous research regarding
grandparent involvement (Attias-Donfut, 2000;
Bengston, 2001; Castaglia, 1999; Lauterbach & Klein,
2004; Szinovacz, 1998), this study found a high rate of
interaction between grandparents and their grandchildren
with CP. In addition, grandparents in this study provided
a great deal of support not only to the grandchild but also
to his or her parents. These findings could be related to
the geographic proximity of the grandparents and
grandchildren in this study, as well as, to the heightened
needs of a child with CP.
Grandparents noted very specific areas of concern
regarding their grandchildren, perhaps due to high levels
of involvement with them. The topics that they indicated
were extremely important, or on which they would like
to receive more information, were: CP in general
(especially immediately upon their grandchild receiving
a diagnosis); possible interventions; their grandchild’s
future abilities; school-related issues; and how to
provide, as well as where to receive, support. It would
be important for health care professionals to address
these topics in any educational materials created for
grandparents of children with CP. In addition,
grandparents also expressed the value of having
educational materials presented in written form,
following discussion or personal communication.
Limitations
This study involved volunteer grandmothers who,
for the most part, lived close to their grandchild and
therefore, their informational needs may not be reflective
of all grandparents. Also, the psychometric properties of
the data collection tool were not assessed.
References
Attias-Donfut, C. (2000). Cultural and economic
transfers between generations: One aspect
of age integration. Gerontologist, 40, 270-
272.
Bengston, V. L. (2001). Beyond the nuclear family:
The increasing importance of
multigenerational bonds. Journal of
Marriage and the Family, 63, 1-16.
Castiglia, P. T. (1999). Extended families: Social
support systems for children. Journal of
Pediatric Health Care, 13, 139-141.
Johnson, B. R., & Onwuegbuzie, A. J. (2004).
Mixed methods research: A research
paradigm whose time has come.
Educational Researcher, 33, 14-26.
Katz, S., and Kessel, L. (2002). Grandparents of
children with developmental disabilities:
Perceptions, beliefs, and involvement in
their care. Issues in Comprehensive
Pediatric Nursing, 25, 113-128.
Lauterbach, W., & Klein, T. (2004). The change of
generational relations based on demographic
development: The case of Germany.
Journal of Comparative Family Studies, 35,
651-663.
Palisano, R., Rosenbaum, P., Walter, S., Russell, D.,
Wood, E., & Galuppi, B. (1997). The gross
motor function classification system for
cerebral palsy. Retrieved May 24, 2006, from
http://www.canchild.ca/Portals/0/outcomes/pdf/GM
FCS.pdf
Szinovacz, M. E. (1998). Grandparents today: A
demographic profile. Gerontologist, 38,
37-52.
Trute, B. (2003). Grandparents of children with
developmental disabilities: Intergenerational
support and family well-being. Families in
Society, 84(1), 119-125.
Vadasy, P. F., Fewell, R. R., & Meyer, D. J. (1986).
Grandparents of children with special needs: Insights
into their experiences and concerns. Journal of the
Division for Early Childhood, 10, 36–44.
Acknowledgements
We would like to thank the grandparents who
volunteered to participate, as well as the therapists and
supervisors at the following children’s rehabilitation
centres for their assistance during the recruitment phase
of this study: the Children’s Developmental
Rehabilitation Program (CDRP); Five Counties
Children’s Centre; George Jeffrey Children’s Treatment
Centre; Grandview Children’s Centre; KidsAbility
Centre for Child Development; Lansdowne Children’s
Centre; and Niagara Peninsula Children’s Centre. We
would also like to thank the Pollock Foundation for
funding this study. Finally, we would like to thank
Dianne Russell, Lisa Rivard and Cheryl Missiuna for
their assistance, guidance, and feedback.
Exploring the Informational Needs of Grandparents of Children with
Developmental Coordination Disorder (DCD)
Student Researchers: Jennifer Joss, Shannon Grant
Investigators: Cheryl Missiuna, Lisa Rivard
INTRODUCTION:
Parents of children with disabilities often report increased
stress levels compared to parents of children without
disabilities (Brehaut et al., 2004). Social support is
frequently an instrumental component to reducing parental
stress and grandparents are noted to provide both practical
and emotional support to parents of children with disabilities
(Findler, 2000; Schilmoeller & Baranowski, 1998; Trute,
2003). The literature has shown that both parents and
grandparents of children with disabilities would like
information regarding the future impact of the disability on
the child’s overall functioning (Katz & Kessel, 2002;
Scherman, Gardner, Brown, & Schutter, 1995). Previous
literature suggested that grandparents’ and parents’
information needs were similar, however this literature is
dated (Vadasy, Fewell, & Meyer 1986), and may not be
applicable to today’s grandparents. In addition, much of the
literature has focused on children whose disabilities are
evident at birth or soon after (Hastings, Thomas, &
Detwiche, 2002; Nybo, Scherman, & Freeman, 1998; Trute,
2003). The coordination difficulties of children with DCD
are not evident at birth and obtaining a diagnosis of DCD is
often time-consuming and difficult (Missiuna, Moll, Law,
King, & King, 2006). As a result, it may be difficult for
parents and grandparents to acquire information about
children with coordination difficulties.
PURPOSE:
The purpose of this study was to explore the informational
needs and preferences of grandparents of children with coordination difficulties. The results from this study will be
used to assist with the development of educational material
for grandparents of children with DCD.
METHODS:
Study Design: This study used a mixed model research
design. Semi-structured telephone interviews using openended questions were conducted with grandparents of
children with DCD to explore their past and present
informational needs and preferences. The interview
questions were piloted with grandparents and revised
accordingly. Ethics approval was obtained from the
McMaster Ethics Review Board.
Participants: A convenience sample of grandparents of
children noted to have “coordination difficulties” were
recruited by occupational therapists from selected
children’s treatment centres in Ontario and the private
sector. Coordination difficulties was used as the inclusion
criteria for the grandchild as many children have not
formally received a diagnosis of DCD. 15 grandparents (9
grandmothers and 6 grandfathers) ranging in age from 50
to 93 volunteered to participate. The majority of
grandparents lived more than two hours away from their
grandchild. 73% of the grandparents interviewed had
completed some post-secondary education. All of the
grandchildren were male and ranged in age from 5 to 13.
Telephone Interview: The semi-structured interview
questions consisted of 17 questions, including both closed
(demographic information) and open-ended (interview)
questions and lasted between 20 – 45 minutes. Verbal
consent was obtained from all grandparents prior to the
interview.
Data Collection: Responses to each question were recorded
manually on the interview script. Probing and clarifying
questions were asked as necessary to ensure accuracy of
recorded responses.
DATA ANALYSIS:
Demographic data was entered into a data management
program. Responses to the open-ended questions were coded
independently by the student researchers and then compared
so that a consensus was reached regarding the coding.
Frequency counts were calculated for each open-ended
question.
RESULTS:
Prior Informational Needs and Preferences:
ƒ Grandparents tended to receive information explaining
their grandchild’s difficulties from their son/daughter
through verbal discussion or the provision of written
materials.
ƒ Grandparents in this study found information provided to
them to be useful as it helped them to understand their
grandchild’s difficulties, decreased their worry and
anxiety, and enabled them to support their children.
ƒ Many grandparents also searched for information on
their own via the Internet, sought written materials and
initiated discussion with healthcare professionals.
Current Informational Needs and Preferences:
ƒ Three to five years later, most grandparents continued to
have unanswered questions regarding their grandchild
and stated they would like to receive information
regarding their grandchild’s motor difficulties, schoolrelated issues, interventions, and future abilities.
ƒ They indicated they would prefer to have this
information shared with them through discussion with
their daughter/son or knowledgeable professional,
through written materials, via the Internet, as well as
through support groups.
ƒ Many grandparents suggested that information
describing activities suited to the abilities of their
grandchild would be most helpful. They also indicated
that practical strategies on how to interact successfully
with their grandchild and information regarding the
cause of their grandchild’s difficulties would be
beneficial.
Additional Insights
ƒ Most grandparents reported noticing their grandchild’s
coordination difficulties on their own.
ƒ All grandparents reported that they provided their
children with emotional and/or practical support.
RECOMMENDATIONS
FOR
EDUCATIONAL
MATERIALS:
Content: Based on the results of this study, providing
grandparents of children with DCD with educational
materials that include information about their grandchild’s
motor difficulties, potential school-related issues,
interventions, and future abilities would be helpful.
Examples of activities tailored to their grandchild’s
abilities and practical strategies for interacting successfully
with their grandchild would also be appropriate.
Format: Facilitating discussion with the grandchild’s parents
or knowledgeable health professional(s) may be the best
mode of information sharing with grandparents, based on
the results of this study. Providing written materials,
Internet resources and facilitating support groups may also
be important as additional methods for dissemination of
information.
DISCUSSION:
This study explored the informational needs and
preferences of grandparents of children with DCD.
Understanding grandparents’ needs for information and
preferences for receiving information is important for
healthcare professionals working with children with
coordination difficulties, as the provision of information may
enhance the grandparents in their supportive role. As noted
by Findler (2000), the provision of social support may reduce
parental stress, thereby decreasing the often-elevated stress
levels of parents of children with disabilities (Brehaut et al.,
2004). Of note, all grandparents interviewed in this study
reported providing emotional and/or practical support to their
children, a finding confirmed elsewhere in related literature
(Findler, 2000; Schilmoeller & Baranowski, 1998; Trute,
2003).
Also of interest is the reported early identification by
grandparents of their grandchild’s coordination difficulties.
Parents of children with DCD have reported that teachers,
other parents and healthcare professionals do not readily
recognize their child’s difficulties (Missiuna et al., 2006).
Family members of children with co-ordination difficulties
recognize the unique difficulties experienced by their child at
an early age, yet receiving a formal diagnosis of DCD is often
difficult (Missiuna et al., 2006). Early identification of DCD
may eliminate a considerable source of anxiety for the family,
as receiving a diagnosis can be a relief for parents and can
facilitate access to services (Missiuna et al., 2006). In turn,
this information could be shared with the grandparents,
helping them to understand their grandchild’s difficulties and
perhaps assist their children with strategies to help their
grandchild succeed. Many grandparents in the present study
searched for information on their own, and having a diagnosis
is likely to expedite this process.
There are several limitations of this study to be
acknowledged. Firstly, grandparents participating in this
study were highly educated. Secondly, several couples took
part, which may have created duplication within the results,
though this possibility was investigated and spouses generally
gave different responses to the questions asked. Such
limitations reduce the transferability of these findings to other
grandparents of children with coordination difficulties.
In conclusion, this study provided insight into the
informational needs and preferences of grandparents of
children with co-ordination difficulties. The results can help
to inform health care professionals of the preferred content
and manner in which grandparents would like to receive
information.
This knowledge may enable healthcare
professionals to further satisfy the informational needs of
families of children with coordination difficulties.
REFERENCES:
Brehaut, J.C., Kohen, D.E., Raina, P., Walter, S.D., Russell,
D.J., Swinton, M., et al. (2004). The health of primary
caregivers of children with cerebral palsy: How does it
compare to other Canadian caregivers?
Pediatrics
Electronic Pages, 114(2), e182–e191 Retrieved January 3,
2006 from www.pediatrics.org/cgi/content/full/114/2/e182
Findler, L. S. (2000). The role of grandparents in the social
support system of mothers of children with a physical
disability. Families in Society: The Journal of
Contemporary Human Services, 81, 370-381.
Hastings, R. P., Thomas, H., & Delwiche, N. (2002).
Grandparent support for families of children with Down’s
syndrome. Journal of Applied Research in Intellectual
Disabilities, 15, 97-104.
Katz, S., & Kessesl, L. (2002). Grandparents of children
with developmental disabilities: Perceptions, beliefs and
involvement in their care. Issues in Comprehensive
Pediatric Nursing, 25, 113-128.
Missiuna, C., Moll, S., Law, M., King, S., & King, G.
(2006). Mysteries and mazes: Parents’ experiences of
children with developmental coordination disorder. The
Canadian Journal of Occupational Therapy, 73, 7-17.
Nybo, W. L., Scherman, A., & Freeman, P. L. (1998)
Grandparents role in family systems with a deaf child.
American Annals of the Deaf, 143, 260-267.
Scherman, A., Gardner, E., Brown, P., & Schutter, M.
(1995). Grandparents’ adjustment to grandchildren with
disabilities. Educational Gerontology, 21, 261-273.
Schilmoeller, G. L., & Baranowski, M. D. (1998).
Intergenerational support in families with disabilities:
Grandparents’ perspectives. Families in Society: The
Journal of Contemporary Human Services, 79, 465-476.
Trute, B. (2003). Grandparents of children with
developmental disabilities: Intergenerational support and
family well-being. Families in Society: The Journal of
Contemporary Human Services, 84, 119-126.
Vadasy, P. F., Fewell, R. R., & Meyer, D. J. (1986).
Grandparents of children with special needs: Insights into
their experiences and concerns. Journal of the Division for
Early Childhood, 10, 36–44.
ACKNOWLEGEMENTS:
We would like to thank the grandparents who participated
in the study and the parents, therapists and centre
administrators who assisted in recruitment of the
grandparents. We would like to extend a special thank you
to our supervisors Cheryl Missiuna and Lisa Rivard for
their support and expert advice. We would also like to
acknowledge the support we received from The Pollock
Foundation for funding the project.
Using a Program Logic Model to develop the “Work Partnership Program” A Joint Disability Management Program
By Nicole Johnson, MSc (OT) Candidate
Supervisors: Kathy Mawbey and Muriel Westmorland, OT Reg. (Ont.)
Introduction
Research Dilemma
In the past, when an employee became injured or ill
he or she left the workplace and often did not return to
that workplace or any workplace. This was causing
employers to lose valued employees and the employees to
lose their jobs and furthermore their sense of meaning as a
productive member of society. Research has been
conducted since that time to prove that there is a way of
enabling employees to remain at work or return to work
through a process call disability management (DM). “An
effective DM program can help workers with diverse
challenges, minor and/or major, to remain productive. It
can also allow organizations to remain valued and often
highly trained workers and their skills” (NIDMAR, 2003).
As defined by the World Health Organization
(WHO), “disability is an umbrella term for impairments,
activity limitations and participation restrictions. It
denotes the negative aspects of the interaction between an
individual (with a health condition) and that individual’s
contextual factors (environmental and personal factors).”
An emerging disability is that of a mental health nature.
It is predicted that by the year 2020, depression will be
the number one source of work years lost worldwide
(NIDMAR, 2003).
Specific to Canada Revenue Agency, the need for a
DM Program was established by Organizational
Solutions, via a disability management assessment report.
Organizational Solutions is firm that specializes in
disability management. In the needs assessment report
completed by Lodge and Scott (2005), it was identified
that the formerly known CRA – Southern Ontario Region
(SOR) spent approximately $3.3 million on sick leave
over 75 consecutive hours, or two working weeks, and
$160, 245.90 on worker’s compensation costs. Lodge and
Scott noted that a savings of at least 10-20% could be
realized by implementing a DM Program. The majority
of the savings would be due to a decrease in employee
time lost.
Purpose
The purpose of this paper is to: 1) discover the
elements involved in designing and implementing a DM
program in a federal government office using a program
logic model, 2) develop a disability DM program, and 3)
recommend how to implement a DM program.
Methodology
Design
Using a Program Logic Model design to develop an
implementation plan for a DM program, develop a joint
DM committee, identify the roles and responsibilities of
each stakeholder in the DM program, and formulate an
evaluation question to assess the effectiveness of the
program. Research ethics approval was not needed for
this project as it did not use human subjects as
participants rather a target group on a systemic level.
Target Group
The target group for this project was St. Catharines
Tax Services Office (TSO), which is an affiliate with
Canada Revenue Agency (CRA). This target group was
chosen because of convenience and their enthusiasm for
progression.
Program Logic Model
The process was completed using a program logic
model approach. As a simplified summary from Letts and
others (1999), a program logic model is a visual
representation of a program showing linkages between
what a program does (the ‘what’) and what it is expected
to do (the ‘results’). This method of developing and
evaluating programs has been used and published in the
development of programs in preparation for evaluation.
Letts and others (1999) developed a program logic
workbook that is used to teach occupational therapists and
students alike about program design and evaluation.
Furthermore, this method has been published as being
used for evaluating children’s rehabilitation services
(Stewart, Law, Russell & Hanna, 2004), community
health clinic (Dykeman, MacIntosh, Seaman & Davidson,
2003), and vocational rehabilitation (Lal & Mercier,
2002).
Process
1. Initiated the conversations with McMaster University
and St. Catharines Tax Services Office
2. Searched the literature to learn about legislation,
collective agreements, disability management (DM),
program logic models and current DM practices.
3. Developed a strategy for DM Program development
including program logic model development, flow
chart development and cost-benefit analysis.
4. Formulated a program logic model program logic
model development, flow chart development and
cost-benefit analysis.
5. Facilitated a DM Program steering committee to
ensure that all stakeholders involved in process to
give feedback on program logic model, flow charts
and cost-benefit analysis.
6.
Presented final version of program logic model, flow
charts, cost-benefit analysis to the Team Leader of
the Wellness Program who in turn will present to the
Regional Human Resources Director for approval.
Disability Management Steering Committee
Committee members consisted of representatives from the
following stakeholder groups:
• Injured or Ill Employee
• Management
• Union (There are 2 in the St. Catharines TSO)
• Human Resources
• DM Program Coordinator
Recommendations
• Hire a Disability Management Coordinator to
coordinate the disability management program and to
consult to managers as needed.
• Develop roles and responsibilities of all stakeholders
in the DM program.
• Develop a Job Demands Analysis (JDA) for every
job within the St. Catharines TSO
• Develop job bank for use when accommodating
employees.
• Adapt the Functional Abilities Assessment Form
(FAAF) for employees to give medical practitioner
and return to the employee’s supervisor.
• Develop a Confidentiality Waiver form for
Employees to sign when referred to DM program.
• Develop an Information Package for Injured or Ill
employees to be given by manager when employee
initially injured or becomes ill.
• Develop an Information Package for medical
practitioner(s) to be given by injured or ill employee
on first meeting.
• Develop an evaluation study or strategy for the DM
program.
• Develop a letter to give to Long Term Disability
carrier when employee has permanent restrictions.
• Educate all stakeholders on their roles and
responsibilities in the disability management process.
• Develop an employee satisfaction survey to give to
employees after discharge from DM program.
• Develop guidelines for employees and managers
regarding the use of the medical/dental appoint leave.
Future Research
In order to evaluate the effectiveness of a DM program
using a program logic model a research study would need
to be designed. This evaluation could consist of
retrospectively analyzing the illness and injury statistics
within the St. Catharines TSO prior to the implementation
of the DM program in comparison to the illness and injury
statistics after one year of DM program implementation.
The limiting factor would be the fact that there are other
variables that may impact the results including the
incidence of illness or injury during both timeframes.
This may result in skewed statistics in favour of one
timeframe over the other.
Acknowledgements
I thank Kathy Mawbey, Team Leader of the Wellness
Program for Canada Revenue Agency – ON Region and
Muriel Westmorland, McMaster Faculty Supervisor for
their support and guidance throughout this project. I also
thank Melissa Jamieson, Disability Case Manager for
Toronto Transit Commission and Leasa McLeod,
Disability Management Coordinator for St. Joe’s Hospital
in Hamilton for their valuable feedback and information
sharing. Last, but not least, I thank Tony Prosia, Director
for the St. Catharines TSO and the DM Steering
Committee at the St. Catharines TSO for sharing their
personal experiences and their honest and open feedback
with me.
References
Canada Revenue Agency (CRA). (2005). CRA illness and
injury policy. Ottawa, ON: CRA. Retrieved on
March 15, 2006 from:
http://infozone.rc.gc.ca/english/r1293860/hr/wellness
/dm/injuryandillnesspolicy.pps
Canadian Association of Occupational Therapists
(CAOT). (1997). Enabling occupation: An
occupational therapy perspective. Ottawa, ON:
CAOT.
Charlton, J. (2005). Hamilton Tax Services Office
Disability Management Tool Kit. Hamilton, ON:
Canada Revenue Agency. Retrieved on October 24,
2005 from: http://sonichamilton/disability/page1.html
Letts, L., Law, M., Pollock, N., Stewart, D.,
Westmorland, M., Philpot, A., & Bosch, J. (1999). A
programme evaluation workbook for occupational
therapists: An evidence-based practice tool. Ottawa,
ON: CAOT.
Lodge, T., & Scott, L. (2005). Disability management
assessment report. Burlington, ON: Organizational
Solutions.
National Institute for Disability Management and
Research (NIDMAR). (2003). Disability
Management in the Workplace: A Guide to
Establishing a Joint Workplace Program 2nd Ed.
HRDC.
National Institute for Disability Management and
Research (NIDMAR). (1999). Occupational
Standards in Disability Management. Ottawa, ON:
NIMDAR.
Worker's Compensation Board, Nova Scotia. (1999).
Return-to-work programs: A workplace development
manual. Nova Scotia: WCB. Retrieved on March 8,
2006 from: www.wcb.ns.ca/return-towork/index.html
World Health Organization (WHO).
Assistive Devices for Children with Disabilities: Impacts on Child & Caregiver
Stacey Henderson and Heather Skelton
Introduction
The International Classification of Functioning,
Disability and Health (ICF) defines health as the result
of a dynamic interaction between a person’s domains
(Body Structure & Function, Activity and Participation)
and two contextual factors (Environmental and
Personal) (WHO, 2001). By linking all the components
of the ICF, the model suggests that outcomes of an
intervention may be seen at any or all of those
components regardless of its specific target.
Functional impairments in children can lead to a
decrease in participation in developmentally appropriate
roles with far-reaching consequences for overall
development, independence, quality of life and
academic performance (Butler, 1991; Isabelle et al.,
2002; Skelton & Rosenbaum, 2006). One intervention
strategy clinicians may use to moderate the impact of
functional impairments is to prescribe an assistive
device. For the purpose of this paper, ‘assistive device’
is defined as an object that is external to but directly
used by a person with the aim of overcoming a
functional impairment by providing an alternate means
of accomplishing the activity.
Historically, there has often been resistance to the use
of assistive devices for children with functional
impairments, as intervention was targeted towards
remediating impairments in an attempt to promote
“normal” function. More recently, clinicians are
beginning to consider strategies that involve altering the
environment (adaptation) and the task (compensation)
through the use of assistive devices (Wiart & Darrah,
2002). Assistive devices are designed to increase
independence and age-appropriate function.
No systematic review on the impact of assistive
devices on children and their environment has yet been
completed. The purpose of this study was to undertake a
review of the child and family-centred outcomes that
have been measured when children with disabilities
have received assistive devices. In structuring these
results within the ICF framework, effects on all the
components and factors that together create a level of
health and functioning have been formally considered.
Methods
To be included, studies were required to identify an
assistive device(s) being utilized by a child less than 19
years of age. The outcomes of interest concerned the
impact of the intervention on the child and/or those in
the child’s immediate social environment including
caregivers, family and others. Studies were excluded if
they focused solely on outcomes relating to Body
Structure & Function domain of the ICF. Only primary
research (either qualitative or quantitative) published in
a peer review journal was included. Cross sectional
studies were excluded.
A search of Medline, CINAHL, Embase, AMED,
PsychInfo, Eric and Cochrane Database of Systematic
Reviews for studies published in English between
January 1996 and February 2006 was conducted. The
electronic searches used included a combination of a
participant term and an intervention term. To further
identify potential studies, reference lists of included
studies were reviewed, researchers with knowledge in
the field were contacted, and key studies were entered
into the Web of Science Citation Index.
Abstracts of identified studies were screened for
inclusion and those that met criteria were reviewed by
one of the authors. Along with study design, level of
evidence, and measurement tools, study outcomes were
identified and classified as belonging to the domains
and/or contextual factors of the ICF. If concern arose
about the appropriateness of a study it was read by the
other of the authors and discussed until consensus was
reached. Early in the reviewing process, five studies
were selected that represented a variety of designs and
interventions; these were read and summarized by both
reviewers. Results were compared and discrepancies
discussed until consensus was reached. This procedure
was repeated late in the review process and there were
no consequential discrepancies in data extraction. Good!
Results
A total of 53 studies met inclusion criteria, with the
following impairments being targeted: accessing a
computer (3), activity assistance (2), behaviour changes
(3), communication (29), independent feeding (1), living
skills (1), mobility (9), modifying the environment (1),
nutrition (4), postural stability (2).
Levels of quantitative evidence are based on the work
of Fletcher and Sackett (Canadian Task Force on the
Periodic Health Examination, 1979). In the current
review, the majority of the quantitative studies were
categorized as level IV. Sixteen of the 48 studies were
single subject designs.
Levels of qualitative evidence are based on the work
of Kearney (2001). Only five qualitative articles were
included in this review. Three were level IV
phenomenology, with the other two being a level II
ethnography study and a level I grounded theory study.
In all, 51 studies contained child-focused outcomes.
The majority of these belonged to the Activity and
Participation domains of the ICF with a lesser focus on
Environmental contextual factors. There were very few
undesired outcomes identified and those tended to
appear when nutrition was the targeted outcome of the
intervention.
Only 11 of the studies included identified caregiverfocused outcomes. Of these, only five had caregiver
outcomes as the primary focus. Unlike the child-focused
studies, caregiver-focused studies were more likely to
have outcomes addressing personal contextual factors
Assistive Devices for Children with Disabilities: Impacts on Child & Caregiver
Stacey Henderson and Heather Skelton
than activity and participation domains. Undesirable
outcomes represented a larger proportion of caregiverfocused outcomes including increased difficulty in the
activity of caregiving, impacts on personal factors and
impacts on financial, and social environmental factors.
Discussion
Overall, the multitude of positive outcomes and limited
number of negative outcomes found in this review
support the use of assistive devices for children with
functional impairments.
Activity and participation were clearly the focus of
the majority of child-focused outcomes. Many of the
outcomes that fit in the activity domain focused on
school activities including writing, using a computer and
use of speech. The results also reveal little focus on
personal and environmental contextual factors. It is
unclear if researchers have not considered the impact of
these outcomes on health status or have found them
difficult to measure in children. Caregivers and family
occupy a predominant role in a child’s life, and it was
surprising to find that no studies focused on the impact
of an assistive device on the family and less than one
third measured the impact on caregivers. As seen by the
outcomes that were measured, a caregiver can benefit
substantially from their child using an assistive device
through ease of caregiving and decreased stress.
Undesirable outcomes were identified mainly when a
gastrostomy tube was the assistive device being utilized.
While the undesirable outcomes for the child and
caregivers need to be taken into consideration they
accounted for only a small portion of the studies
reviewed and do not appear to discount the positive
outcomes observed.
It is important for the clinician, the child and the
family to be aware of the anticipated outcomes for both
the child and their family when exploring the possibility
of assistive device use. With this knowledge they will
be able to make an informed decision and have realistic
expectations as to the outcomes of device use.
Recommendations for Research
The level of evidence identified within this review
indicates a need for more rigorous research including
the use of comparison groups when measuring the
impact of assistive devices in children with disabilities.
In order for studies to demonstrate scientific rigor
standardized outcome measures need to be used that
measure the effects of an assistive device on all domains
and contextual factors of the ICF for children with
disabilities and their families. As well, there is a lack of
qualitative research which would allow exploration of
impacts of assistive devices on a variety of ICF related
factors. Researchers and clinicians need to evaluate the
impacts of assistive devices not only on body structure
and function, activity and participation, but also on
personal and environmental contextual factors.
Considerations for OT practice
A major role for OT’s is the prescription of assistive
devices. The results of this review illustrate the need for
clinicians and caregivers to consider the use of assistive
devices with children who have disabilities in an effort
to increase their involvement in activities and
participation and improve upon their personal and
environmental contextual factors. In doing so, the
effects on the child, caregivers and family must be
considered. Other factors that must also be taken into
consideration before prescribing an assistive device
include environmental factors such as cost, accessibility
to community environments, the adaptability of the
device to growth, and social acceptance of the device.
Study Limitations
The research question posed was broad and covered a
multitude of research areas resulting in a wide variety of
targeted impairments, assistive devices utilized, study
populations and outcome measurements. This allowed
inclusion of the breadth of the literature investigating
this issue, but limits the ability to translate results into
specific clinical practice recommendations. As well, the
reviewers began this process with the underlying
assumption that assistive device use in children will lead
to predominantly positive outcomes, which may have
impacted the findings.
References
Butler, C. (1991). Augmentative mobility: Why do it?
Physical Medicine and Rehabilitation Clinics of North
America, 2(4): 801-815.
Canadian Task Force on the Periodic Health Examination.
(1979). The periodic health examination. Canadian
Medical Association Journal, 121, 1193-1254.
Isabelle, S., Bessey, S.F., Dragas, K.L, Blease, P., Sheperd,
J.T. & Lane, S.J. (2002). Assistive technology for children
with disabilities. Occupational Therapy in Health Care 16
(4): 29-51.
Kearney, M. H. (2001). Focus on research methods- Levels
and applications of qualitative research evidence.
Research in Nursing and Health, 24, 145-153.
Skelton, H. & Rosenbaum, P. (n.d.). Integration of theories on
disability and development. Keeping Current In. Available
soon from
http://www.canchild.ca/Default.aspx?tabid=109&pid=0
Wiart, L. & Darrah, J. (2002). Changing philosophical
perspectives on the management of children with physical
disabilities -- their effect on the use of powered mobility.
Disability and Rehabilitation, 24(9), 492-498.
WHO. (2001). International Classification of Functioning,
Disability and Health (ICF). Geneva, Switzerland:
Author.
*For a complete list of references (including all studies
reviewed) or copies of outcome tables please contact
[email protected] or [email protected]
Acknowledgements
With thanks to Peter Rosenbaum for all his support
throughout this project.
The State of Knowledge for Obesity Care for Occupational Therapists
Student Researchers: Deanna Garraway and Jay MacDonald
Faculty Supervisor: Mary Forhan
Introduction: Obesity is defined as having
a body mass index (BMI) of over 30kg/m2
(Heart and Stroke Foundation, 2006). With an
estimated 15 % of Canadians having obesity it is
expected that occupational therapists encounter
this client population (Belanger-Ducharme &
Tremblay, 2005; Caterson & Gill, 2002).
Purpose: To understand the state of
knowledge for obesity care for occupational
therapists (OT).
Lit Review: There are many adverse health
consequences associated with obesity such as
type two diabetes, coronary heart disease,
hypertension, dyslipidemia, stroke, peripheral
vascular disease, and decreased quality of life, to
name a few (Aronne, 2001). Evidence suggests
that the greater the extreme of an individuals
body mass index (BMI) the greater the risk for
functional impairment, particularly in men and
women with a BMI above 40 kg/m² (Jensen,
2005). Negative attitudes towards individuals
who have obesity have been regarded as one of
the last acceptable forms of prejudice. Many
blame obesity on a lack of will power which is
not supported by evidence (Rogge, Greenwald
& Golden, 2004).
There is scant research on the state of
obesity care and occupational therapy.
A
thorough search of Medline, ERIC, Psych INFO,
Journals at Ovid, Pubmed, Cochrane Database
of Systematic Reviews, AMED, CINAHL,
EMBASE, Ovid Healthstar and Ageline
revealed minimal conclusive information on
occupational therapy and obesity.
Methods: Ethics approval was received
from the Hamilton Health Sciences/McMaster
University Research Ethics Board. A survey
was developed with questions that were
designed to identify areas of occupational
therapy practice with persons who have obesity,
determine the prevalence of occupational
therapy practice with persons who have obesity,
and to identify what occupational therapists
perceive their role is working with persons who
have obesity.
It was hypothesized that
occupational therapists work with persons who
have obesity but they are unsure of their role and
feel unprepared to work with this population.
Sample: A convenience sample was taken
from the OT Networker website. Approximately
3844 therapists were contacted electronically
with 830 responding for a 22% response rate.
Apparatus: The online survey was
comprised of thirteen items.
The four
preliminary
items
concerned
general
demographic information. The following six
items were designed to explore the state of
knowledge for obesity care by OT using a Likert
five point scale with disagree on the left
corresponding to one and agree on the far right
corresponding with five.
The survey was
generated by both of the student researchers.
Analysis: The data was received on March
21, 2006. Blue Wire Computer Services Inc.
condensed the results into an Excel (Microsoft,
2003) spreadsheet for analysis. The data was
managed in Excel followed by analysis with
SPSS (version 14, 2006). The data was coded in
SPSS to allow for effective analysis.
Results: The range of years of practice was
between 0.5 years to 43 years. The mean of the
sample was 14.2 years with a standard deviation
of 9.8 years. Ninety three percent of the
respondents were female with 7 % male. The
largest percentage of participants work in outpatient rehabilitation (14%) then private practice
(13%) and home based care (13%). Primary
care composed (1%), industry (1%) and
disability management/return to work (5%). Of
the sample, 65.9% work with an adult
population. The remaining participants work
with adolescents (15.2 %), Children (13.1 %) or
infants (4.4 %). In response to the statement “I
have worked with clients who have obesity” the
majority of participants agreed or somewhat
agreed with the statement for a combined total
of 83 %. Nine percent of the participants were
neutral to this statement with 8 % disagreeing
with the statement. In response to the statement
“obesity affects occupational performance”, 95.8
% of participants agreed or somewhat agreed
with the statement, 3.9 % rated neutral with 0.3
% somewhat disagreeing. In response to the
statement “Occupational therapists know the
needs of clients with obesity” 44.1 % of the
participants agreed or somewhat agreed, 41.1
% responded with neutral, with 14.7 % of the
participants either disagreeing or somewhat
disagreeing with the statement. In response to
the statement “There is a role for occupational
The State of Knowledge for Obesity Care for Occupational Therapists
Student Researchers: Deanna Garraway and Jay MacDonald
Faculty Supervisor: Mary Forhan
therapy involvement in prevention of obesity”
68.7 % of the participants agreed or somewhat
agreed, 23.7 % of participants reported being
neutral, with 7.6 % disagreeing or somewhat
disagreeing with the statement. In response to
the statement “There is a role for occupational
therapy involvement in treatment of obesity”
78.1 % of the participants agreed or somewhat
agreed, 17.6 % of participants were neutral with
4.3% disagreeing or somewhat disagreeing.
Topics of interest for the sample were
prevention of obesity (17.5 %), assistive devices
(16.5%), and weight management (14.4%). A
positive correlation was found between years
practiced and work with persons who have
obesity (p<.01).
Discussion: Occupational Therapists are
unsure of their role working with persons with
obesity as they reported they were either neutral
or disagreed with the statement “OTs know the
needs of persons who have obesity”.
There was a positive correlation between
years practiced and having worked with persons
with obesity, which is not surprising. However,
what is somewhat alarming is that even though
clinicians have been working with clients with
obesity, there is no relationship between years
practiced and perceived level of preparedness.
Occupational therapists from the sample believe
there is a role for OT with obesity intervention
and prevention with further strong agreement
with the statement obesity affects occupational
performance.
Implications for Practice:
Occupational
therapists must be aware of their role working
with individuals with obesity. They must strive
to enable clients who have obesity to meet their
occupational performance goals and participate
fully in their activities of daily living.
Recommendations: The sample of therapists
and evidence suggest that there is a role for
occupational therapy with persons who have
obesity. Due to the uncertainty of the needs of
persons who have obesity, education across all
levels of occupational therapy practice, is
warranted.
Obesity management must be
addressed within university programs with
further research needed on the effectiveness of
occupational therapy interventions for obesity.
Key References: Belanger-Ducharme, F. &
Tremblay, A. (2005). Prevalence of obesity in
Canada. Obesity Reviews, 6, 183-186.
Caterson, I. D., & Gill, T. P. (2002). Obesity:
Epidemiology and possible prevention. Best
Practice & Research Clinical Endocrinology &
Metabolism, 16(4), 595-610.
Heart and Stroke Foundation. (2006). Is 60 the
new 70? Report Cards on Health – 2006 Report
Card. Retrieved April 4, 2006 from
http://ww2.heartandstroke.ca/Page.asp?PageID=
1613&ContentID=21437&ContentTypeID=1
Rogge, M., Greenwald, M., & Golden, A.
(2004). Obesity, stigma and civilized
oppression.
Advances in Nursing Science, 27(4), 301-315.
Tjepkema, M. (2004). Adult Obesity in Canada:
Measured height and weight. Statistics Canada.
Acknowledgements: Mary Forhan, Michael
Pierrynowski, EBP groups 5 and 7
The Experiences of OTs Practicing in Northern BC
Student: Kathryn Fields; Project Supervisor: Neil Hanlon
INTRODUCTION
Recruitment and retention of all health care professionals
have been identified as key issues in northern British Columbia
(BC) (Manson & Thornton, 2000). The purpose of this study was
to explore the structure and characteristics of occupational therapy
practice in northern BC, investigating recruitment factors, the
perceived benefits and challenges to practice, the impacts of these
challenges, and the retention of therapists. The material presented
in this report is an important first step in understanding the
professional support resources that will enable greater success in
retaining occupational therapy practitioners in smaller and remote
centres.
LITERATURE REVIEW
Unequal access to health services can greatly impact an
individual’s health, recovery, empowerment, and well-being.
Unequal access is often due, in part, to a shortage of health care
professionals, which is a common issue in rural areas (Bushy,
2002). The experiences of health professionals in rural
communities have been extensively documented.
Recruitment and retention of occupational therapists in rural
areas are influenced by both professional and personal factors.
Professional factors can include professional supports, educational
opportunities, autonomy, and scope of practice (Millsteed, 2001;
Peterson, Ramm, & Ruzicka, 2003; Solomon, Salvatori, & Berry,
2001). Personal factors can include the influence of a spouse or
partner, having a rural background, and the availability of
recreation activities (Millsteed, 2001).
Many of the therapists willing to fill rural positions are new
graduates (Lee & Mackenzie, 2003) and a lack of professional
supervision and collaboration can result in decreased confidence
and job satisfaction (Steenbergen & Mackenzie, 2004).
DATA AND METHODS
A qualitative case study design was used to incorporate the
contextual component of communities in northern British
Columbia, with the experiences of occupational therapists.
Occupational therapists across the north were contacted and
recruited until 17 interviews were scheduled. The interviews were
conducted by telephone during March 2006, once the completed
consent form was returned. The same student conducted all
interviews, which followed a structured interview protocol.
Interviews lasted between thirty minutes to an hour, and both notes
and an audio recording were taken. Interviews were summarized
and submitted for participant review.
Manifest content analysis was conducted to identify broader
themes and concepts around the rewards and challenges of service
delivery in remote locations. Interviews were combined by
question, grouped into categories, and analysed for both the
frequency and the range of responses.
RESULTS
Participants were 17 occupational therapists, practicing in
northern British Columbia. Three therapists were from Prince
George, while fourteen were from smaller communities throughout
northern BC. Table 1 describes the characteristics of the
participants.
TABLE 1. Characteristics of participants
Area of Practice
Pediatrics
Hospital
Community
Long-term care
Private practice
n (%) Experience
5 (29)
New graduates
7 (41)
Practiced in lower mainland
3 (18)
Practice in other provinces
1 (5)
Practiced in other countries
1 (5) Travel
Years practicing in the north
Under 1 ½ years
4 (24)
5-6 years
10-19 years
Over 20 years
2 (12)
10
(59)
1 (5)
Minimal travel
1-2 hours drive
Extensive
travel
transportation)
Recruitment
The factors that led people to choose employment in northern
BC related both to lifestyle and practice. Lifestyle factors
consisted of (a) having a connection to the north, through family or
childhood, (b) the lifestyle of a small town, including a lower cost
of living, less traffic and fewer people, and (c) the access to the
outdoors and outdoor activities. Practice factors included (a) the
availability of jobs, (b) the nature of the position, such as having
more responsibility and the opportunity to be sole charge, and (c)
aspects of the facility. Additional factors included employment
incentives and partner-related motives.
Benefits and rewards of practicing in the north
Therapists described both lifestyle and practice benefits. The
lifestyle benefits of practicing in the north were similar to those
influencing recruitment. Regarding practice factors, over half the
therapists spoke about (a) the wide variety of conditions
encountered and opportunity to be a generalist, as well as (b) the
intimacy of communication with other professionals in a smaller
community.
You get to work with such a varied population of professionals. You
know what they look like and where they work- you can catch them
in the grocery store. So the communication is more intimate here
than in a larger setting (12).
A third of the participants noted (c) the autonomy and
freedom of the position, and described the benefit of a (d)
supportive workplace.
Other benefits mentioned included
opportunities to work “outside the box” and be creative.
It broadens your view . . . You appreciate that people live in many
different ways and what it means to function to them, living in a
little cabin, is quite different to living downtown somewhere. There
is lots of room for creativity – offering recommendations to clients,
when services are not readily available (15).
Challenges to practicing in the north
The challenges identified by over a half the participants
related to professional isolation, and dealt with (a) access to
colleagues and (b) access to education. A third of participants
identified (c) being the sole therapist or sole OT, (d) lack of (or less
access to) specialists, (e) the variety of the caseload, (f) the small
community lifestyle, (g) issues with acquiring equipment
appropriate to the northern environment, (h) the recruitment and
retention of therapists, and (i) the lack of mentoring or supervisory
support as challenges to practicing in the north.
Impacts of these challenges
The challenges impact clients by affecting (a) the quality of
OT services, (b) the availability of services, (c) access to services,
and (d) the lives of clients and caregivers.
n (%)
7 (41)
4 (24)
4 (24)
3 (18)
12
(71)
3 (18)
(air
2 (12)
I’m sure it can be frustrating as a parent or caregiver to see that
the needs never seem to really be met; it’s always a part, a piece of
the pie instead of the whole thing (6).
For therapists, the challenges can result in a (a) reduction in
competency, due to difficulty obtaining new ideas and the
subsequent limited ability to update practice.
Rural practice therapists run the risk of incompetence. . .if you are
practicing in isolation, how do you know if you are doing it right?
How do you maintain your competency if you don’t have access to
colleagues . . . (12).
The challenges also (b) produce additional work and roles,
such as building a support system and filling administrative roles,
as well as have (c) emotional impacts for therapists, including
concern about the safety of clients, frustration regarding the
effectiveness of interventions, and feeling “spread thin”.
In outlying areas, there is no follow up. So setting someone up with
equipment is horrible, because you’re thinking ‘will it be set up
properly?’ . . . .That is a huge barrier and a concern. Sometimes I
do worry about people (8).
In addition, challenges (d) limit practice by reducing time for
clients, and limiting the occupational therapy areas addressed, and
result in (e) additional time requirements, educating people on the
role and value of occupational therapy, consulting with other
therapists, and practicing with limited resources.
I feel like I am always rushed and clients don’t get the best service .
. . You don’t get to spend time with people finding out what they
really want (8).
Lastly, therapists identified (f) positive impacts, whereby the
challenges make one more self-reliant, creative, and assertive.
Retention of occupational therapists
Despite the challenges to practicing in northern BC, 13 (76%)
therapists stated they were very satisfied with their current position,
while 4 (24%) stated they were somewhat satisfied.
While one might expect to have low rates of retention in these
rural areas, 15 (88%) therapists were planning on continuing to
practice in the north. The other two therapists identified they were
unsure of whether they would remain in the north, due to a desire
to travel, to specialize, to develop skills, to move to a warmer
climate, and to be closer to family.
I would like to be able to learn from another OT so I can improve
my skills . . . This may be incentive to leave the north, to improve as
an OT (11).
DISCUSSION
Overall, the delivery of occupational therapy services in
northern British Columbia is complex and is influenced by a wide
variety of personal and environmental factors. There are certainly
some significant challenges to practicing in the north, and concerns
regarding the quality of care that therapists are able to provide
within these limitations.
Therapists identified unique concepts related to the location
of their practice, the size of the community, the complexity of their
caseloads, the supports provided through their work environment,
the availability of allied health professionals and resources, and
their own professional expectations and aspirations. Most of these
factors are similar to those identified in the literature.
Certain aspects of northern practice are both a benefit and a
challenge. The scope of practice allows therapists to gain a wide
range of experience, but makes maintaining competency a
challenge. Practicing in a small community allows more intimate
communication and lower costs of living, but also leads to
confidentiality issues and conflicts of interest. Generally, therapists
felt that occupational therapy services were not sufficient in their
communities and that they were unable to provide the kind of
service they would like.
Even though therapists described significant challenges, most
are still planning to continue practicing in the north. This is
potentially due to a “where there’s a will, there’s a way”(17)
attitude that underlies the occupational therapy profession. While
therapists are faced with challenges, the informants preferred to
problem solve with limited resources rather than saying “it can’t be
done” or leaving to practice elsewhere. In addition, many of the
therapists feel they are making a difference in people’s lives, which
may be one reason job satisfaction remains high, despite the
present challenges.
The challenges have significant impacts on practice for
therapists and clients. These areas need addressing in order to
improve client outcomes and enhance therapist satisfaction and
retention. The information provided here should be of great use to
regional officials who are in a position to provide professional
support systems and resources to improve conditions for those
committed to practice in this region.
REFERENCES
Bushy, A. (2002). International perspectives on rural nursing:
Australia, Canada, USA. Australian Journal of Rural Health, 10
(2), 104-111.
Lee, S., & Mackenzie, L. (2003). Starting out in rural New South
Wales: The experiences of new graduate occupational therapists.
Australian Journal of Rural Health, 11(1), 36-43.
Manson, D. J., & Thornton, T. (2000). Workshop Summary of the
British Columbia Rural and Remote Health Conference,
University of Northern British Columbia.
Millsteed, J. (2001). Factors affecting the retention of occupational
therapists in rural services. Occupational Therapy in Health
Care, 14(3/4), 55-72.
Peterson, C., Ramm, K., & Ruzicka, H. (2003). Occupational
therapists in rural healthcare: A "jack of all trades".
Occupational Therapy in Health Care, 17(1), 55-62.
Solomon, P., Salvatori, P., & Berry, S. (2001). Perceptions of
important retention and recruitment factors by therapists in
Northwestern Ontario. Journal of Rural Health, 17(3), 278-285.
Steenbergen, K., & Mackenzie, L. (2004). Professional support in
rural New South Wales: Perceptions of new graduate
occupational therapists. Australian Journal of Rural Health,
12(4), 160-165.
ACKNOWLEDGEMENTS
Special thanks to Neil Hanlon and Greg Halseth at the University
of Northern British Columbia, for their support, funding, and
assistance with this research, and the various occupational
therapists practicing in northern British Columbia who participated.
Funding for travel was provided through a McMaster University
GSA Travel Grant.
*Due to page limitations, some results have been omitted. Data
presented are part of a detailed project exploring service delivery
in the north and the availability of professional supports.
A SURVEY OF CANADIAN OCCUPATIONAL THERAPISTS ABOUT
THEIR KNOWLEDGE AND USE OF THE ICF
Jennifer Farrell, Stacey Anderson and Kim Hewitt, MSc (OT) Candidates
Supervisor: Deb Stewart, MSc, Assistant Dean, School of Rehabilitation Science, McMaster University
INTRODUCTION - The International Classification of
Functioning, Disability and Health (ICF) (WHO, 2001)
was adopted by the World Health Organization to
provide a universal classification system of health and
health-related states.
LITERATURE REVIEW - It has been suggested that
the ICF strengthens the theoretical base of occupational
therapy, and provides language that increases it’s
credibility and understanding by other health care
professions (Buyere, Van Looy and Peterson, 2005;
Hemmingson & Jonsson, 2005). ). Occupational
therapists (OTs) know the relationship between health,
occupation and the influence of the environment, and
therefore have an obligation to contribute to the ICF’s
further development (Hemmingsson & Jonsson, 2005).
However, As OTs are encouraged to learn about the ICF
(Stewart, 2002) and consider its use in a critical manner
(Hammell, 2004), a baseline of the levels of knowledge
and use of the ICF by Canadian OTs would be helpful,
along with strategies for knowledge dissemination.
PURPOSE –
This study utilized a mixed-method design to answer the following
questions:
1. What do Canadian occupational therapists know about the ICF
and how is the ICF being used in practice?
2. How and why do Canadian occupational therapists know of
and/or use the ICF? What benefits and barriers are involved?
3. What do Canadian occupational therapists recommend for
education and knowledge dissemination about the ICF for
occupational therapists in Canada?
METHODS - Participant Selection: Members of the
Canadian Association of Occupational Therapists
(CAOT) comprised the pool of potential study
participants. Electronic mail distribution lists were
created using the public CAOT website member profiles.
Potential participants received an email of the study’s
purpose with facts about participation, confidentiality
and contact information in order to provide informed
consent prior to starting the web-based survey. Ten
participants were purposefully selected for qualitative
interviews to have equal sample representation.
Theoretical saturation was reached. This study was
approved by the McMaster University/Hamilton Health
Sciences ethics board.
Data Collection - To address the first question, a webbased survey of 24 items was distributed to the potential
sample. Data on knowledge, use and dissemination was
gathered through closed and open-ended questions
developed using ICF literature. The second and third
questions were addressed through ten semi-structured
interviews. A template of 11 phenomenological
questions explored knowledge of the ICF, use in
practice, factors associated with knowledge and use, and
suggestions for knowledge dissemination. Telephone
interviews with 8/10 participants were recorded and
transcribed verbatim. Two interviews were conducted
in electronic format due to participant time restrictions.
ANALYSIS- Survey data was formatted from the raw
Excel version to SPSS 14. Descriptive statistics in the
form of percentages, means, standard deviations and
medians were calculated. Chi square analysis
determined differences between knowledge/use data and
demographic data. Significance was established at pvalue <.10. Two open-ended survey questions were
analyzed qualitatively with the interview data.
Qualitative procedures of content analysis were used
on the interview data, which included reviewing all
transcripts, searching for emerging categories and
reporting the full range of responses under each
category with supporting quotes. The interview results
were emailed to all participants for member checking.
Survey and qualitative interview data were
categorized and reported in congruent themes based on
the original research questions regarding knowledge,
use and dissemination.
RESULTS – Demographics: Of the 3344 surveys sent
to Canadian OTs, 587 responses were received (17.6%
response rate.) Of these respondents, 29.5% had
practiced for over 20 years. Ontario had the highest
number of respondents (43.4%). Most therapists
worked in a full-time position (67.8%) in an urban
setting (83.8%), primarily addressing physical health
concerns (49.2%) among adults or older adults.
Respondents from each province and territory excepting
Nunavut and Prince Edward Island filled out the survey.
These demographics were similar to the current CAOT
membership profile.
Knowledge: In the survey results, 69.6% of respondents
reported knowing about the ICF. Participants rated their
knowledge level of the ICF model and classification
system on a likert scale of one to ten, with one
representing “never heard of the ICF model” and ten
representing “would feel comfortable teaching the
model to a colleague”. 71.8% of the participants rated
their knowledge of the model at five or below, and
73.9% rated their knowledge of the classification system
at five or below. Of the methods whereby respondents
first learned about the ICF, top responses included
university training (33.0%) and a journal article (10.2%).
Qualitative themes indicated that although participants
revealed a diverse knowledge base, there is uncertainty
regarding how much knowledge is enough. Participants
urged a meaning that would justify investment into the
ICF. Key themes included learning academically,
people resources, diversity of knowledge, uncertainty,
investment and meaning.
Use: Of those surveyed, 122/587 (20.1%) indicated use
of the ICF in practice. Descriptive analysis regarding
use showed that 11.6% of respondents use the ICF
model, 5.5% use the classification system, and 10.8%
use both the ICF model and the classification system
within practice. 14.5% of respondents reported use of
the ICF in a research context. Qualitative themes
indicated the ICF to be beneficial to the clinician as it
offers an objective and comprehensive framework while
also offering a tool for interprofessional credibility. :
Barriers to use included lack of knowledge and
understanding of the ICF and a lack of fit with current
approaches. Key themes included framework, objective
approach, comprehensive, interprofessional use.
Dissemination: 89% of survey respondents indicated
their interest in learning more about the ICF. When
asked their preferred method to learn the ICF, top
responses included those that are web-based and that
teach therapists to apply the ICF to practice. Key themes
that emerged: meaning, format and accessibility.
DISCUSSION - Survey and interview results indicate
that the “word is out” about the ICF within occupational
therapy in Canada, as almost seventy percent of survey
respondents reported that they know about the ICF.
However, participants indicated that there is no
consistent level of knowledge. It is therefore suggested
that education about the ICF should be consistent across
Canadian occupational therapy education programs.
In this study, there appears to be a difference
between having an awareness of the ICF and cultivating
a knowledge base that allows for its use in practice.
Many participants reflected they did not know enough
about the ICF to utilize it in practice. The survey
indicated that only 20% of participants are using the
ICF in practice. From both survey and qualitative
findings, the ICF is being used most often as a
framework (the model) and not as often as a
classification system. The ability for the model to
provide OTs with a framework to work from was
supported by the majority of respondents using the ICF.
A theme of uncertainty impacted both acquisition
and development of further knowledge and use of the
ICF. It could be a matter of the ICF being in a new and
preliminary stage, or perceived as too big or daunting
for an individual, self-taught clinician to learn (Stucki,
2005). In fact, participants within this study noted a
high level of investment required at all stages of
learning and adopting the ICF.
Findings reveal that OTs need to understand the
meaning attached to applying the ICF to their current
practice. This study offers meaningful ideas for OTs to
use the ICF, such an interprofessional framework
guiding practice, opportunity for new clinical pathways
and appropriate resource allotment. Study participants
indicated that a variety of methods would facilitate
learning about the ICF. Preferred methods were
interactive, accessible in terms of time and travel, and
focused on its application.
LIMITATIONS - In this student project, sampling was
limited to CAOT members with email addresses. The
response rate was 17.5%, indicating that results may not
represent all Canadian OTs. Purposeful sampling for the
qualitative interviews may have impeded the sample’s
diversity, although redundancy in answers was reached.
The study was also limited to an English-only
presentation of the survey and interviews, potentially
limiting response from therapists working in French or
other languages.
CONCLUSION - The ICF is meant to initiate a global
conversation in healthcare about function and health
beyond the negative aspects of disease and disability.
Current literature and the study participants agreed that
it is necessary for OTs to be part of this conversation.
However, therapists need to see the relevance of the ICF
for their individual practices in order to consider
integrating it into busy practice environments.
Participants cited that meaningful applications of the
ICF related to using its common language within
interdisciplinary teams to describe function and to give
credibility to occupational therapy practice. It is
therefore suggested that knowledge dissemination about
the ICF for OTs include these findings. OTs who study
and/or use the ICF also need to publish their evidence.
Through research and knowledge dissemination, the
profession of occupational therapy will be able to
participate in the World Health Organization’s global
efforts to bring a functional perspective to health and
disability.
REFERENCES
Bruyère,S.M. et al. Rehabilitation Psychology, 50(2), 113-121, 2005.
Hammell K.W. British Journal of Occupational Therapy, 67(9), 408411, 2004.
Heerkens Y. et al. Disability & Rehabilitation, 26, 1060-1066, 2003.
Hemmingsson H.. & Jonsson H..American Journal of Occupational 4.
Therapy, 59(5), 569-576, 2005.
Stewart D. Occupational Therapy Now, 4(4), 17-21, 2002.
Stucki, G. (2005). American Journal of Physical Medicine &
Rehabilitation, 84(10), 733-740, 2003.
World Health Organization (WHO) (2001). The International
Classification of Functioning,Disability and Health. Geneva: WHO.
For full reference sheet, please contact first author.
ACKNOWLEDGEMENTS
The authors would like to thank M. Forhan MHSc. and M.
Pierrynowski, Ph.D. for their professional assistance. The time and
thought of all occupational therapists who participated is appreciated.
Comprehensive, Evidence-based Assessment of Complex Regional Pain Syndrome of the Upper Extremity
Adam Burke BSc, MSc(OT) Candidate & Lauren Sloan BScKin, MSc(OT) Candidate
Supervisor: Tara Packham
Introduction
Complex Regional Pain Syndrome (CRPS) of the
upper extremity is one of the most complex
challenges presented to practicing hand therapists1. It
is characterized by changes in sensory, motor and
autonomic function2-11, leading to a decrease in an
individual’s functional ability and quality of life.
Presently, there are no standardized assessments
specifically designed for the evaluation of CRPS, nor
could any specific assessment protocol be found in
the relevant literature. As such, it is hypothesized that
practicing hand therapists, and their patients, may
benefit from a specific assessment protocol for the
evaluation of CRPS.
This reports aims to: examine the current assessment
tools hand therapists in Southern Ontario are using to
evaluate patients with CRPS, to determine whether
therapists believe these tools are sufficient, and to
outline an evidence-based assessment protocol for
evaluation of patients with CRPS.
Method
Questionnaire Development
A questionnaire examining current assessment
practices being used by hand therapists in Southern
Ontario was developed and distributed to 11 facilities
and two local hand interest groups. The questionnaire
addressed the prevalence of CRPS in each facility,
the current assessments being used, and the perceived
need for a more standardized method of assessment.
Face validity of the questionnaire was established as
it was reviewed by two experienced occupational
therapists currently working in hand therapy.
Literature Search
A literature review was completed in order to
determine the most reliable and valid assessments
instruments used to evaluate the various signs and
symptoms of CRPS of the upper extremity. The
following databases were searched: AMED,
CINAHL, EMBASE, CDSR and MedLine.
Keywords used were: complex regional pain
syndrome,
reflex
sympathetic
dystrophy,
rehabilitation, assessment, hand, and upper extremity.
Results
Findings from Questionnaire
Ten responses to the questionnaire identified current
assessment instruments being used by local therapists
to assess patients with CRPS. All responding
therapists indicated that a more standardized method
of assessing patient with CRPS is needed, thus
supporting the writers’ hypothesis.
Table 1: Assessments used by questionnaire
respondents for evaluation of CRPS
Frequency
Assessment:
of use:
McGill Pain Inventory
Brief McGill Pain Inventory
Other Pain Scales
DASH
QuickDASH
ROM
Edema
Temperature
Grip Strength
Pinch Strength
Patient Rated Wrist and Hand Evaluation
0
0
3
4
0
9
8
1
6
6
4
Findings from Literature Search
The literature search indicated a need to assess signs
and symptoms, resulting from autonomic, trophic,
motor, sensory and functional changes, commonly
seen in CRPS.
Assessment Protocol
Autonomic Changes
Edema: Volume displacement with a commercial
volumeter has demonstrated accuracy to 1% for
upper extremities and the hand and is the recognized
gold standard as supported by the American Society
of Hand Therapists (ASHT)12.
Sudomotor: The Nihydrin Sweat Test (NST) is a
clinically useful and objective measure of sudomotor
activity and can be completed in 5-10 minutes1,13.
Vasomotor: Evaluation of vasomotor changes may be
done through clinical observation and patient report
or through objective methods such as change in upper
extremity temperature.
Temperature: The use of infrared thermometers is a
reliable and precise method of measuring skin
temperature14.
Tropic Changes
Evaluation through clinical observation should be
completed and accurately documented to track the
progression of CRPS.
Motor Changes
Range of Motion: Goniometric ROM measurements
are reliable and valid assessments of joint motion
when administered properly. It is vital that
landmarks, instruments and documentation remain
consistent across evaluations12.
Comprehensive, Evidence-based Assessment of Complex Regional Pain Syndrome of the Upper Extremity
Adam Burke BSc, MSc(OT) Candidate & Lauren Sloan BScKin, MSc(OT) Candidate
Supervisor: Tara Packham
Strength: Hand strength can be accurately measured
using a Jamar dynamometer and is the recommended
method by both the ASHT and the American Society
for Surgery of the Hand (ASSH)12.
Sensory Changes
Pain: Pain can be measured using verbal rating,
numerical rating, and visual analogue rating scales, as
well as other standardized measures. The McGill
Pain Questionnaire is clinically useful because it is a
comprehensive measure of the pain experience which
quantifies the subjective and objectives components
of pain15. A short form of the McGill Pain
Questionnaire is available. It correlates well with the
full version and takes only 2-5 minutes to
administer16.
Functional Changes
Two clinically useful assessments to measure
function in patients with CRPS are the QuickDASH
and the Patient Rated Wrist/Hand Evaluation. Both
measures are reliable, valid and responsive
(PRWHE). Each assessment can be administered in
less than ten minutes17,18,19.
Limitations
In creating this report, two major limitations became
apparent to the writers. Firstly, there was limited
access to certain online and print journals that may
have contained relevant literature. Also, in cases
where no evidence for recommendations could be
found, clinical reasoning skills were implemented to
justify recommendations.
Conclusion
It is the hope of the writers that the proposed
assessment protocol outlined in this report will
provide hand therapists some degree of evidencebased guidance when assessing patients with CRPS.
Acknowledgements
Special thanks to Tara Packham, Pam Ball & Vicki
Fraser-MacDougall at The Hamilton General Hand
Therapy Program and Susan Weiss & Nancy
Falkenstein at Exploring Hand Therapy.
References
1. Walsh, M & Muntzer, E. “Therapist’s Management of
Complex Regional Pain Syndrome (Reflex Sympathetic
Dystrophy).” In Hunter, Mackin, & Callahan’s Rehabilitation
of the Hand and Upper Extremity (5th ed.): St. Louis, Mosby,
2002.
2. Li, Z., Smith, B. P., Smith, T. L., & Koman, L. A. Diagnosis
and management of complex regional pain syndrome
complicating upper extremity recovery. Journal of Hand
Therapy, 2005; 18: 270-276.
3. Bruehl, S., Harden, N., Galer, B., Saltz, S., Backonja, M. &
Stanton-Hicks, M. Complex regional pain syndrome: are there
distinct subtypes and sequential stages of the syndrome? Pain,
95, 119-124.
4. Rho, R., Brewer, R., Lamer, T. & Wilson, P. Complex
regional pain syndrome: Concise review for clinicians. Mayo
Clinic Proceedings, 2002; 77: 174-180.
5 Turner-Stokes, L. Reflex sympathetic dystrophy-a complex
regional pain syndrome. Disability and Rehabilitation, 2002;
24(18): 939-947.
6. Vacariu, G. Complex regional pain syndrome. Disability
and Rehabilitation, 2000; 8: 435-442.
7. .Oerlemans, H., Oostendorp, R., de Boo, T., van der Loan,
L., Severens, J. & Goris, R. Adjuvant physical therapy versus
occupational therapy in patients with reflex sympathetic
dystrophy. Complex regional pain symdrome I. Archives of
Physical Medicine and Rehabilitation, 2000; 81: 49-56.
8. Phillips, M., Katz, A. & Harden, N. (2000). The use of nerve
blocks in conjunction with occupational therapy for complex
regional pain syndrome type 1. American Journal of
Occupational Therapy, 2000; 54(5): 544-549.
9. Oerlemans, H., Oostendorp, R., de Boo, T. & Goris, R. Pain
and reduced mobility in complex regional pain syndrome I:
outcome of a prospective randomized controlled clinical trial
of adjuvant physical therapy versus occupational therapy. Pain,
1999; 83: 77-83.
10. Oerlemans, H., Goris, R., deBoo, T. & Oostendorp, R. Do
physical therapy and occupational therapy reduce the
impairment percentage in reflex sympathetic dystrophy?
American Journal of Physical Medicine and Rehabilitation,
1999; 78(6): 533-539.
11. Severns, J., Oerlemans, M.,Weegels, A., van ‘t Hof,
Oostendorp, M. & Goris, J. Cost-effectiveness analysis of
adjuvant physical or occupational therapy for patients with
reflex sympathetic dystrophy. Archives of Physical Medicine
and Rehabilitation, 1999; 80: 1038-1043.
12. Wagman, R. et al. Clinical Assessment Recommendations
(2nd ed.). Chicago: American Society of Hand Therapists,
1992.
13. Perry, J., Hamilton, G., Lachenbruch, P. & Bevin, A.
Protective sensation in the hand and its correlation to the
ninhydrin sweat test following nerve laceration. American
Journal of Physical Medicine, 1974; 53: 113-118.
14. Hershler C, Conine TA, Nunn A, Hannay M. Assessment
of an infra-red non-contact sensor for routine skin temperature
monitoring: a preliminary study. Journal of Medical
Engineering Technology, 1992;117–22.
15. Melzack, R. The McGill Pain Questionnaire, main
properties and scoring methods, Pain, 1975;1: 277-299.
16. Grafton, K., Foster, N. & Wright, C. Test-retest reliability
of the short-form McGill Pain Questionnaire. Clinical Journal
of Pain, 2005; 21: 73-82.
17. Beaton, D., Wright, J., Katz, J. et al. Development of the
QuickDASH using a comparison of three item-reduction
approaches. IWH Working Paper, 2003; #233.
18. Beaton, D., Katz, J., Fossel, A., Wright, J., Tarasuk, V. &
Bombardier, C. Measuring the whole or the parts? Validity,
reliability & responsiveness of the disabilities of the arm,
shoulder, and hand outcome measure in different regions of the
upper extremity. Journal of Hand Therapy, 2001; 14(2):128146.
19. MacDermid, J. Measurement of health outcomes following
tendon and nerve repair – Article in press. Journal of Hand
Therapy, 2005; 18.
Development of a Handwriting Protocol for Primary School Aged Children
Student Researchers: Jeanette Bradley & Sarah Brunetti, MSc. (OT) Candidates
Supervisors: Julia Lockhart, BSc.(OT), MEd., & Nancy Pollock, MSc., OT Reg (Ont.)
INTRODUCTION:
Handwriting is a necessary functional task for schoolaged children. McHale & Cermak (1992) found that
children in elementary school spend approximately 31 to
60 percent of each day completing fine motor tasks.
Within this time spent on fine motor tasks, 85 percent of
the time was spent completing paper and pencil tasks.
Research has shown that children who can write
proficiently have improved self-confidence, self-esteem,
increased concentration, improved academic performance
and a greater ability to express him/her self creatively
(Naus, 2000). Thus, difficulty with handwriting can
significantly impact a child’s educational career.
Difficulty with handwriting is the primary reason for
referral to school-based occupational therapy services
(Dennis & Swinth, 2001). Handwriting difficulties
usually co-exist with a variety of other learning
disabilities; however, difficulty with handwriting is often
the first indicator that additional issues exist.
PURPOSE:
The purpose of this pilot project was to develop a
handwriting protocol for school-health occupational
therapists to use when assessing children with
handwriting difficulties. Project objectives were 1) To
revise the 1992 version of the handwriting protocol to
account for changes in the Ontario curriculum and
advances in the literature, 2) To complete a
comprehensive literature review regarding handwriting
assessment considerations, 3) To pilot the assessment
protocol with children with identified handwriting
difficulties and developmentally appropriate controls
(grades senior kindergarten to grade three), 4) To analyze
the samples using a grade-specific handwriting analysis
checklist, 5) To create case study analyses.
The end goal of this project will be to formulate a
handwriting assessment manual that incorporates the
finished protocol, current literature, case study analysis
and grade appropriate copying samples. Once complete,
access to this resource will be free of charge and
available on the CanChild website.
LITERATURE REVIEW:
Several databases were searched to obtain information
regarding handwriting assessment considerations. The
databases that were searched included: CINAHL,
EMBASE, OVID, MEDLINE, ERIC and PubMed. All
databases were searched until redundancy was reached.
The search terms that were used were variants of the
following keywords: handwriting, occupational therapy,
posture, grip, behaviour, pressure, fatigue, speed, written
expression, language, learning disabilities, assessment,
legibility, visual motor integration, kinesthesia and paper
positioning. The most relevant articles are listed as key
references.
METHODS:
Ethics approval from the McMaster University Faculty of
Health Sciences was obtained prior to the commencement
of this project.
The research project consisted of three main components,
as described below:
1) Literature Review:
A comprehensive literature review regarding handwriting
assessment considerations was completed to guide the
development of the revised protocol.
2) Handwriting Assessment Protocol
Based on current literature, a comprehensive handwriting
assessment protocol was developed to address a variety
of assessment considerations. Assessment considerations
included workstation set-up, postural control, use of tools
and materials, behaviour, speed, and legibility.
3) The Protocol Pilot
The devised protocol was piloted with:
ƒ
Children with identified handwriting difficulties
ƒ
Children with developmentally appropriate
handwriting abilities.
Recruitment:
Children With Identified Handwriting Difficulties: To
recruit participants, project investigators allied with
Community Rehab and REACH Therapy agencies to
refer clients with identified handwriting difficulties to the
research project. Occupational therapists working for
these agencies identified appropriate study subjects,
briefly described the research project to the guardians,
and obtained verbal consent for the student investigators
to contact the child’s guardians. When consent was
obtained, the student investigators contacted the family to
obtain verbal consent for participation and to arrange an
appointment for assessment.
Typically Developing Children: Children with age
appropriate handwriting abilities acted as developmental
norms. Controls were recruited through personal contacts.
Sample:
A total of 16 students were recruited to participate in the
research project. All students were within the grade
range of senior kindergarten to grade three. Children
were excluded from the study if they experienced
difficulty with handwriting as a result of Autism
Spectrum Disorder, English as a second language or
physical disabilities.
Assessment:
Formal written consent was obtained prior to the
commencement of all assessments. Assessments were
facilitated by both student researchers (one student
researcher conducted the tasks of the assessment and the
other completed the protocol observation form).
Assessment duration ranged between 15 to 45 minutes
depending on the degree of handwriting difficulty and the
grade-level of the student. Assessment tasks included
writing from memory, near-point copying, far-point
copying, dictation and spontaneous composition.
ANALYSIS
Analysis of the project took place in several stages. First,
the results of the handwriting assessments were analyzed,
followed by an analysis of the actual tools designed to
collect and interpret the samples.
Analysis of Handwriting Samples:
In order to complete this analysis, the project
investigators developed a Handwriting Analysis
Checklist. Drawing upon Levine’s 1998 research, the
investigators created a checklist that evaluated both the
appearance and content of the handwriting samples. The
final checklist consisted of 24 observable handwriting
dysfunctions (e.g. poor letter formation, letter reversals,
word omissions etc). Upon review of the 16 samples,
each project investigator (both student researchers and
supervisors) indicated the handwriting dysfunctions
observed and recorded their results on the checklist. The
project investigators then assembled as a group to discuss
the analyses and to determine inter-rater reliability of the
checklist.
Analysis of the Handwriting Analysis Checklist:
Within the aforementioned meeting, the project
investigators also discussed their usage of the
handwriting analysis checklist. Each individual
commented upon what they perceived to be the strengths
and limitations of the checklist and suggested ideas for
revision of the tool.
Analysis of the Handwriting Assessment Protocol:
Following the completion of the pilot assessment phase,
the project investigators met to discuss their usage of the
assessment protocol. Each individual commented upon
what they felt were the strengths and limitations of the
tool and suggested items for revision.
RESULTS
Throughout the various phases of analysis it became
evident that several revisions to the project were
necessary in order to move the project towards its end
goal. Within analysis discussions, the project
investigators identified the revisions that should be
implemented to improve the quality and ease of use of the
finished product. The investigators of this project have
suggested that changes be implemented within the
literature review, handwriting assessment protocol
observation form and handwriting analysis checklist. The
majority of these changes will not significantly alter the
content of the protocol, but rather, will serve to improve
the flow, efficiency and comprehension of the
handwriting manual for school-health occupational
therapists.
FUTURE DIRECTIONS
This protocol will remain a work-in-progress and both
project supervisors, Nancy Pollock and Julia Lockhart
will continue to move the project forward. The
completion of the pilot phase has determined a number of
revisions to the protocol that need to be implemented in
the future. Upon these revisions, further trials and
analysis of the revised handwriting protocol will take
place.
Once completed, the final online version of the
handwriting protocol will include relevant literature
reviews, a revised version of the assessment protocol,
Ontario curriculum grade appropriate copying passages
and case study analyses to demonstrate assessment and
analysis of handwriting using the protocol.
REFERENCES
Amundson, S. J. (2005). Prewriting and handwriting
skills. In J. Case-Smith (Ed.), Occupational therapy
for children (5th ed., pp. 587-614). Missouri: Mosby.
Dennis, J.L. & Swinth, Y. (2001). Pencil grasp and
children’s handwriting legibility during differentlength writing tasks. The American Journal of
Occupational Therapy, 55, 175-183.
Levine, M.D. (1998). Writing and spelling. In M.D.
Levine (Ed.). Developmental variation and learning
disorders (2nd ed., pp. 347-397). Cambridge:
Educators Publishing Source.
McHale, K. & Cermak, S. (1992). Fine motor activities in
elementary school: Preliminary findings and
provisional implications for children with fine
motor problems. The American Journal of
Occupational Therapy, 46, 898-903.
Naus, J.M. (2000). Helping hands: A world of
manipulatives to boost handwriting
skills. Teaching Exceptional Children, 32, 64-70.
Tseng, M.H. & Cermak, S.A. (1993). The influence of
ergonomic factors and perceptual-motor abilities on
handwriting performance. The American Journal of
Occupational Therapy, 47, 919-924.
ACKNOWLEDGEMENTS
We would like to thank our supervisors, Nancy Pollock
and Julia Lockhart, for their assistance, expertise,
guidance and time. We would also like to extend our
thanks to Community Rehab and REACH therapy for
their participation in this research project. Without their
involvement, the success of this project would not have
been possible. Lastly, we would also like to thank the
students and families who participated in our assessments
and invested their time in our project.
The Family Doctors’ Role in Timely Return to Work: A Survey of the Key Issues
Jennifer Appelton and Kevin Campbell, MSc(OT) Candidates
Introduction
Family physicians, employers and the Workplace Safety
Insurance Board (WSIB) have been working in isolation of
each other. In particular, this becomes an issue when an
injured worker presents him/herself at a family physician’s
office asking for help. Often both the patient and the
physician are unaware of what series of steps to take to
navigate through the health care-workplace-compensation
systems. With the changes in legislation resulting in
downloading of return to work (RTW) responsibilities to
employers, and many employers having few structures in
place to manage workplace injuries, the case management of
an injured worker often lands with the family physician.
Even when there are disability management practices at the
workplace, injured workers will turn to their family
physician as a familiar support person or as someone who is
seen as working in their best interest. The formal training of
physicians does not prepare them for responding effectively
to injured workers’ needs, and no post-graduate training
exists. This project addresses this need by determining what
family doctors perceive are the key issues in the successful
management of patients injured in the workplace and their
preferred method of acquiring relevant information
concerning best practices.
Research Question
What do family doctors perceive to be the key issues in the
successful management of patients injured in the workplace
to RTW safely? What is their preferred method for
acquiring relevant information concerning best practices?
Literature Review
A comprehensive literature review was completed as part of
this project, serving as one of the seed documents for a
larger study submitted for funding to the WSIB Research
Funding Call in February 2006.
Safe and timely RTW is cited as an important concept in the
majority of best practice documents regarding management
of patients who are returning to work (Alberta Medical
Association, 1994; American Academy of Orthopaedic
Surgeons (n.d.); American College of Occupational and
Environmental Medicine, 2002; American Medical
Association, 2004; Canadian Medical Association, 2000;
Ontario Medical Association, 1994). These programs aim to
improve patients’ quality of life and prevent deconditioning
and the development of psychological behaviour patterns
that often accompany illness or injury (American Academy
of Orthopaedic Surgeons, n.d.). Safe and timely RTW is
based on the principle that prolonged absence from one’s
normal roles, including work, can be harmful to a person’s
physical, mental and social well being (American College of
Occupational and Environmental Medicine, 2002).
Physicians should encourage patients to return as soon as
possible to all feasible functional activities, including work,
provided that RTW does not endanger the patient or others
(American College of Occupational and Environmental
Medicine, 2002; Canadian Medical Association, 2000). The
primary care team is advised to play a role in highlighting
both the risks of prolonged sick leave and the positive health
benefits of RTW (Gunnyeon et. al., 2005). RTW position
Supervisor: Professor Sue Baptiste
statements emphasize that a patient does not have to be fully
recovered to resume modified work (Alberta Medical
Association, 1994; Black et. al., 2000; Gunnyeon et. al.,
2005). Provided that recommencing work does not present a
risk to the patient or to others, RTW is often safe and
beneficial for a patient even before complete recovery
(Black et. al., 2000).
Overall, the role of the primary care physician in RTW is to
present the worker with prompt treatment, suggestions for
rehabilitation and medical restrictions that are as evidence
based as possible and support the worker’s disease-specific
abilities (Gunnyeon et. al., 2005). The best practice
documents consistently describe the physician’s role in
managing patients returning to work as including: 1)
determining patient limitations, 2) determining job demands
and requirements, 3) establishing workplace restrictions, 4)
encouraging safety and prevention measures, 5) providing
certificate of illness, and 6) assessing fitness of duty.
Methods
Purpose:
This research is of relevance and importance since it will
enable family doctors and other stakeholders (e.g. WSIB,
employers) to return injured workers to the workplace in a
safe and timely manner.
Study Design:
Literature review, qualitative survey and focus group.
Sample:
Using a snowball sampling technique, we contacted family
physicians and occupational health specialists in the
Hamilton medical community. Physicians from the
McMaster family practices and McMaster Occupational
health diploma course were contacted. Twelve physicians
completed the survey and one was interviewed.
Procedures:
1) Obtained ethics approval through the Ethics Review
Board
2) Development of survey
3) Review of literature
4) Completion of annotated bibliography
5) Collection of data
6) Analysis of data
7) Development and facilitation of interview
Data Analysis
Survey results were analyzed for trends and physician
educational preferences, then compared to literature review
findings and confirmed through an interview.
Limitations
Due to the time limitations of this project and the time
constraints of physicians, few participants were able to
complete the survey and participate in interviews.
Results
Survey Results:
Of the twelve participants, 67% were family physicians,
25% were occupational health specialists and 8% were other
physicians.
The physicians surveyed had varying degrees of experience
practicing medicine. 0 to 5 years (8%), 6 to 10 years (8%),
11 to 15 years (17%), 16 to 20 years (17%), 21 to 25 years
(25%) and 26 to 30 years (25%).
Practice settings also varied with 27% stating individual
practice, 46% large group practice (>5 doctors) and 27%
other (industry medical clinic, onsite workplace based
consulting).
The participating physicians made the following comments
regarding their role in RTW:
• “safe and early return to work”
• “appropriate work accommodation to fulfill maximum
medical recovery and prevent recurrence”
• “facilitate readiness of the workplace for the
accommodation needs of the patient”
• “fighting with insurance companies”
• “assessing their readiness to return, prevention of the
recurrence of the problem, relief of their symptoms”
• “in some instances facilitating; in some instances gentle
insistence”
Physicians prefer the following methods of acquiring
knowledge about managing patients’ RTW: 83% individual
learning, 83% small group learning, 75% review of the
current evidence, 33% educational CD-ROM, 42% personal
communication with RTW experts, 17% email newsletter,
42% regular updates on RTW best practices and 33% lunch
and learn session.
84% of physicians report that less than 20% of their practice
focused on RTW. Only 8% of participants reported that
more than 80% of their practice focused on RTW.
73% of participants reported that there were gaps in their
knowledge and awareness of the literature related to best
practices regarding RTW.
Interview Findings:
• Participant agreed with survey results
• Participant was surprised by the number of physicians
indicating they had <20% RTW patients
• Participant noted that physicians’ opinions of their role
are quite general and sometimes negative-focusing on
patients’ restrictions rather than abilities
Discussion
This project has begun to determine what family physicians
perceive are the key issues in managing patients injured in
the workplace and their preferred method of acquiring
information about RTW best practices. Consistent with the
literature review findings, the majority of survey participants
(73%) identified a gap in their knowledge and awareness of
RTW best practices. It is important to recognize that 25% of
our respondents are occupational health specialists, experts
regarding RTW, and therefore the gap would likely be even
more pronounced with a group comprised solely of family
physicians.
Alarmingly, 84% of respondents indicated that less than
20% of their practice involved RTW. Physicians may not
recognize their role in the RTW practice and may not
consider RTW when managing injured patients. Physicians
need to realize they are an integral part of the RTW process
and RTW should be a part of their treatment plan.
While physicians identified several aspects of their role that
are consistent with literature review best practice guidelines,
such as early and safe RTW, some of their comments
depicted a negative view of RTW. Physicians seemed to
focus on RTW restrictions as opposed to patients’ abilities
and expressed frustration related to insurance companies and
paperwork.
It is important to highlight that only 33% of participants
indicated that they have participated in continuing education
focused on RTW. Our interview respondent confirmed this,
stating that it is not surprising considering the lack of
financial support for such education from pharmaceutical
companies, a major sponsor of medical continuing
education. When asked how they would like to remain
informed on RTW, 83% indicated that they would benefit
from small group learning sessions and an understanding of
the current evidence and only 33% would appreciate lunch
and learn sessions. This is an exciting finding as the
literature highlights the strengths of small group learning.
Future Directions
These findings will help direct a larger study which has been
submitted for funding to the WSIB in order to enable
physicians and other stakeholders to work together to return
injured workers to their workplace in a safe and timely
manner. In addition, the results clearly identify a need for
physicians to be better informed about RTW best practices
and highlight physician preferences for continuing education
opportunities in order to address this need. More research
with larger samples needs to be conducted in this area.
References
American Academy of Orthopedic Surgeons (n.d.).
Positions Statement: Early Return to Work Programs.
American College of Occupational and Environmental
Medicine (2002). The Attending Physician’s Role In
Helping Patients Return to Work after an Illness or Injury.
Alberta Medical Association (1994). Position statement:
Early return to work after illness or injury.
American Medical Association (2004). Report 12 of the
Council on Scientific Affairs (A-04) Full Text.
Black, C., Cheung, L., Cooper, J., Curson-Prue, S., Doupe,
L., Guirguis, S. et, al. (2000). Injury/illness and return to
work/function: A practical guide for physicians.
Canadian Medical Association (2000). CMA Policy: The
Physician’s Role in Helping Patients Return to Work after
an Illness or Injury (Update 2000).
Gunnyeon, B., Parker, G., Sharp, C., Sears, C., Watson, D.,
Chambers, R. et. al. (2005). Patient care and
occupational health: A partnership guide for primary care
and occupational health teams.
Ontario Medical Association (1994). Position in support of
timely return to work programs and the role of the
primary care physician.
Acknowledgements
We would like to thank Professor Sue Baptiste, Dr. David
Verna, Dr. Russell Springate, and all physicians who
participated.
1
Catholic Family Counselling Centre: Local Providers Meeting the Needs of EAP Clients
Natasha Annett-Lawrence & Andrea Oattes, MSc (OT) Candidates
Sue Baptiste, Supervising Professor & Kathie Must, EAP Director, Catholic Family Counselling Centre, Kitchener
___________________________________________________________________________________________________
communication, and flawed decision making (Health
Introduction
Canada, 1999; Wang & Patten, 2001).
Maladaptive
An Employee Assistance Program (EAP) provides
responses to these sources of stress can lead to negative
employees with access to counseling, advice, and
emotions, which can eventually lead to physiological and
assistance that is either directly provided by or funded by
psychological illnesses (Carman Copel, 2004). In these
an employer. It is intended to help employees and their
cases, counselling services offered by an EAP can assist
families better manage stressors in their daily lives
with alleviating stressful situations by teaching coping and
(Cooper & Highley-Marchington, 1997).
Catholic
reappraisal skills. Current literature suggests that EAPs
Family Counselling Centre (CFCC) is an external EAP
should be more involved in primary intervention of mental
provider that offers a variety of counseling and family
health issues, in a more traditional health promotion role
support services in Kitchener-Waterloo. For the past
(Kelloway & Day, 2005).
several years, CFCC has been implementing quality
control outcome measurements using a client
questionnaire. Our role involved conducting a secondary
Method
The method followed a three tiered approach consisting of
analysis of the EAP survey data in order to suggest areas
data collection and analysis. The majority of the survey data
of program development and future research.
was gathered from participants upon admission to the
agency. Individuals who had completed an initial outcomes
Literature Review
survey at pre-admission during the past twelve months were
A literature review was conducted to establish a
included for this analysis. The first stage of data collection
background for our analysis of the current EAP services
involved gathering post-service data through a telephone
at CFCC. A wide variety of articles were reviewed
follow-up interview. The participants were selected from
pertaining to EAP services in general, with an additional
the HOMES outcomes software based on their inclusion in
focus on the key search terms “organizational health”
an EAP, consent for follow-up, and age of majority. With
and “healthy workplace outcomes”. Current literature
this list (N=178) participants were contacted by telephone
reveals several evolving trends in EAP service provision.
between the evening hours of 3 and 8 pm, and interviewed
One of the largest problems facing employers in the next
using a standardized telephone script. This EAP specific
10-15 years will be handling the needs and stressors of
data (N=50) was then compared with the original agency
the aging “baby boomer” population. EAP services need
wide pre-survey data (N=1000). The data was extracted
to be able to better meet the needs of the older workers
from the HOMES outcomes system and analyzed for each
and those who are facing the stress of caring for older
area of interest in the outcomes survey. A second tier of
adults (Ruiz, 2006). Current literature also outlines an
analysis was conducted using pre-surveys from EAP clients
arising need for spiritual counselling. An EAP provider
form January to April of 2006. These surveys were sorted
who can offer faith-based or non-secular spiritual
based on EAP company and individual results were
services is seen to be more valuable than those who do
formulated for each company using Excel spreadsheets and
not (Meyer & Davis, 2002). In the area of quality
graphs. This subset was then compared to the above data.
control, current research outlines the importance of high
quality services, which can be maintained through
ongoing assessment and quality assurance.
Results
Data was extracted from the survey for the following
The literature on healthy workplace outcomes and
categories: Core: Functioning/Family, Functioning at
organizational health focused primarily on addressing the
Home/Work, Satisfaction with Life, Social Relationships,
relationship between employee health and workplace
Distress Symptoms, Family Stability, Satisfaction with
outcomes. As a framework for healthy workplaces, the
Partner Relationship, Conflict Resolution in Partner
National Quality Institute (NQI) has developed a
Relationship, All Employed Adults, and Client Satisfaction.
resource for Canadian businesses called the Canadian
For the purposes of this analysis, the focus will be on a
Healthy Workplace Criteria. This resource was used as a
discussion of the distress symptoms and outcomes pertaining
beginning framework to focus this analysis. The
to employed adults. Distress symptoms deal with the
literature outlines a healthy workplace in terms of
psychological symptoms that a person is experiencing,
“holistic workplace health”, which includes physical,
which can affect his/her performance at work. The
social, personal, and developmental support “to improve
outcomes discussed in the distress symptoms category were
overall employee quality of life both within and outside
significantly decreased post-service across all outcomes.
of the workplace” (Health Canada, 2004). Current
Based on the initial discussion about the role of stress on
research outlines the most common sources of job stress
psychological and physiological symptoms, these distress
and home stress, which have been associated with
symptoms indicate that clients are initially experiencing
detrimental effects such as increased absence,
maladaptive coping. However, the post-data indicates that
compromised worker safety, poor job performance,
the client’s ability to deal with the stressful situation and/or
increased
likelihood
of
turnover,
impaired
2
modify the situation has occurred, given the decrease in
the self-report of distress symptoms. This outcome also
deals with the current concept of “presenteeism”.
Presenteeism is a phenomenon in which an employee is
physically present at the workplace but essentially
unproductive due to stress, illness, injury, or depression.
There is a great deal of current literature on the effects of
presenteeism, as described in the review article by Druss,
Schlisinger & Allen (2001).
The indicators for Employed Adults pertain to workplace
satisfaction and engagement issues, which directly reflect
the literature on healthy workplaces. Therefore, a
discussion of this outcome will be most fruitful for this
analysis. These outcome indicators pertain directly to the
outcomes discussed in the majority of healthy workplace
literature, as well as in the NQI’s Healthy Workplace
Criteria. The clients are asked to give a response of
“better than average”, “average”, or “worse than
average”. The “better than average” scores changed
dramatically from pre-survey to post-survey, pre: 27.3%,
post: 56%. Given this change in score, CFCC services
can be associated with impacting a 29% shift to “better
than average” scores.
Overall
CFCC agency counseling services are associated with a
decrease in self-report of distress symptoms. Since
psychological distress symptoms are associated with
employee absence and decreased job satisfaction (Wang
& Patten, 2001), CFCC services can have an impact on
increasing attendance rates and creating higher rates of
job satisfaction. These findings are supported by the
data from “All Employed Adults”, which shows a
significant shift to “better than average” scores on a
variety of healthy workplace outcomes.
Healthy
workplace outcomes are also associated with
organizational outcomes such as turnover, performance,
reputation, and customer satisfaction. Therefore, CFCC
service, specifically face-to-face counseling, is an
important element in creating healthy workplaces and
increasing
organizational
health
and
positive
organizational outcomes.
Recommendations
1. CFCC should offer educational sessions to EAP
managers on identifying employees who are in need of
EAP services (Cutbell, 2004).
2. CFCC should offer education to managers on
recognizing the workers who are suffering from
presenteeism. Current literature outlines the widespread
problem of presenteeism in the workplace, which is seen
as a larger problem than absenteeism.
3. CFCC should offer education to EAP managers on the
importance of healthy workplaces, which includes
strategies to decrease employee burnout and stress. .
4. CFCC should ensure that managers maintain an
ongoing dialogue with workers and to educate them
about services available. Workplace advertisements and
promotion of the services is essential to employee use (Riuz,
2006).
5. CFCC should prepare literature for potential EAP buyers
that answers the “key questions” that are prevalent in the
literature. This will demonstrate CFCC’s transparency and
awareness of current trends in the literature.
6. CFCC should ensure that potential and current EAP
customers are aware of the outcomes project. Current
literature outlines the importance of measuring and
maintaining quality in an EAP program. CFCC measures
quality through the outcomes program and should promote
this to potential consumers as it shows that they are
upholding professional standards and working to stay current
(Megranahan, 1995).
7. CFCC should offer services to meet the needs of
employees managing senior care. One of the most important
issues to address within the next 10-15 years will be the
aging workforce and the “baby boomers”.
8. CFCC should promote the fact that they offer non-secular
spiritual services in an effort to increase self-referral.
Literature shows that men may be less willing to seek out
counseling but more willing to seek spiritual guidance
(Meyer & Davis, 2002).
References
Carman Copel, L. (2004). Homeostasis, stress & adaptation. In S.C.
Smeltzer & B.G. Bare (Eds.), Brunner & Suddarth’s Textbook of
Medical-Surigical Nursing (pp. 80-98) Philadelphia: Lippincott
Williams & Wilkins.
Cooper, C. & Highley-Marchington, C. (1997). Employee Assistance
Programmes and Workplace Counselling. Toronto: John
Wiley & Sons.
Health Canada. (1999). Influencing employee health. Canadian Fitness and
Lifestyle Research Institute, 1, 2-9.
Health Canada. (2004). About Healthy Workplace. Retrieved January 28,
2006 from www.nqi.ca/healthyworkplace
Jex, S.M. (1998). Stress and job performance: Theory research and
implications for managerial practice. Thousand Oaks: SAGE
Publications.
Kelloway, E.K., & Day, A.L. (2005). Building healthy workplaces: What
we know so far. Canadian Journal of Behavioural Science, 37,
223-235.
Megranahan, M. (1995). Quality control for an EAP. Personnel Review,
24, 54-65.
Meyer, J. & Davis, E. (2002). Workplace chaplains: filling a need
traditional EAPs can’t meet. Benefits Quarterly, third quarter,
22-26.
Quick, J.C., Quick, J.D., Nelson, D.L., & Hurrell, J.J. (1997). Preventive
Stress Management in Organizations. Washington: APA Books.
Ruiz, G. (2006). Expanded EAPs lend a hand to employers’ bottom lines.
Workforce Management, 85, 46-47.
Simson, S. (2004). Measuring the quality of an EAP. Canadian HR
Reporter, 18, 8.
Wang, J., & Patten, S.B. (2001). Perceived work stress and major
depression in the Canadian employed population, 20-49 years
old. Journal of Occupational Health Psychology, 6, 283-289.
Attitudes of Health Sciences Students Towards Interprofessional Learning
Penny Salvatori, Associate Professor, School of Rehabilitation Sciences
Kevin Eva, Assistant Professor and Associate Director, Program for Educational Research and Development
Anna Cleverly, Research Assistant
Samantha Yeung, MSc(OT) Candidate
Introduction
In response to increasing pressures from the World
Health Organization (1978) and the Canadian
government (Romanow, 2002) to better prepare
health care professionals for interprofessional
collaboration in the delivery of health care, the
Faculty of Health Sciences at McMaster University
plans to implement a mandatory interprofessional
education (IPE) curriculum in the fall of 2006 for all
incoming students in the health profession programs.
Purpose and Research Questions
The purpose of this study was to explore the attitudes
of current McMaster students in the health
professions towards interprofessional learning
PRIOR to the introduction of the mandatory IPE
curriculum. We hypothesized that differences would
exist within the education programs (junior vs. senior
level students) and across education programs
(Medicine, Nursing, Midwifery, Occupational
Therapy, and Physiotherapy).
The specific research questions were:
1. Are the attitudes of junior level students more
positive towards interprofessional learning than
senior level students?
2. Are students in any one program more positive
towards IPE than students in other programs?
3. Is there a relationship between students’ gender,
age, previous education or degree, previous
clinical experience, and/or previous IPE
experience and their attitudes towards
interprofessional learning?
Methodology
Students (n=1100) from all five health profession
programs (Medicine, Nursing, Midwifery,
Occupational Therapy, and Physiotherapy) were
asked to complete an on-line survey in November
2005. The survey was used to collect demographic
data and student responses to the Readiness for
Interprofessional Learning Scale (RIPLS).
Demographic data included: (1) professional
program; (2) year/level in program; (3) age; (4)
gender; (5) previous degree(s); (6) previous clinical
experience in health care; and (7) previous
participation in IPE activities.
The RIPLS was developed by Parsell and Bligh
(1999) at the University of Liverpool. The scale is
comprised of 19 items that examine individual
attitudes towards interprofessional learning. Previous
studies have shown the tool to be reliable and valid
(Parsell, Stewart, & Bligh, 1998) and it takes only 7
to 10 minutes to complete.
A linear regression analysis incorporating all seven
demographic variables was used to determine which
were most predictive of attitudes towards
interprofessional learning.
Results
441 students participated in the survey which
represents an overall 40% response rate. More than
50% of the nursing, OT and midwifery students
responded, whereas only 30% of the PT students and
less than 20% of the MD students responded.
Respondents ranged in age from 17 to 49 years. The
majority of respondents were female (88%).
Figure I. Percentage of participants by degree.
9%
16%
8%
Medicine
Nursing
13%
OT
PT
Midwifery
54%
A factor analysis of the scale revealed 4 subscales
which is consistent with a recently posited factor
structure described by McFayden et al. (2005).
Reliability analysis of the RIPLS was also consistent
with the original psychometric data presented by
Parsell and Bligh (1999). Cronbach’s alpha = 0.90 for
the overall scale and internal consistency scores
ranged from 0.45 to 0.86 across the four subscales
(Table I).
Table I. Internal consistency of RIPLS subscales
Teamwork and Collaboration
Negative Professional Identity
Positive Professional Identity
Roles and Responsibilities
Total
No. of Items
9
3
4
3
19
Cronbach’s α
0.86
0.71
0.83
0.45
0.89
Regression analyses revealed that the students’
discipline (professional program) was the only
significant predictor of total RIPLS score (Figure II).
Analysis of Variance determined that this difference
arose because MD students assigned lower scores
than students in all other professions (p < .05). None
of the other professional groups of students were
different from one another (Table II). Using the fourfactor structure described by McFayden et al. (2005),
the difference between the MD students and the other
health professional students was most dramatic on
questions pertaining to the positive identity (p < .06)
and roles and responsibilities (p < .001) sub-scales
(Figure III).
Figure II. Estimated means of total RIPLS scores.
4.4
Mean Scores
4.3
4.2
4.1
4.0
3.9
Medicine
Nursing
OT
PT
Midwifery
Table II. Estimated means of subscale scores.
Comparison by degree.
Degree
Mean
Std.
Sig. 95% Confidence
Difference Error
Interval
Medicine Nursing
-0.22*
0.07
0.02 [-0.41, -0.03]
Medicine
OT
-0.26*
0.09
0.03 [-0.50, -0.20]
Medicine
PT
-0.34*
0.10
0.01 [-0.62, -0.06]
Medicine Midwifery
-0.24
0.10
0.13 [-0.51, 0.04]
* The mean difference is significant at the p<0.05 level.
Figure III. Estimated means of subscale scores.
Comparison by degree.
4.6
Teamwork and
Collaboration
4.4
Mean Score
Negative Identity
4.2
Positive Identity
4
Roles and
Responsibilities
3.8
3.6
3.4
Medicine
Nursing
OT
PT
Midwifery
Conclusion
There was no difference in student attitudes towards
interprofessional learning on the basis of level in the
professional program, i.e. junior vs senior students.
There was a difference, however, on the basis of
discipline with MD students demonstrating more
negative attitudes than other students. This finding is
consistent with the literature on interprofessional
education (Banks & Janke, 1998; Richardson,
Montemuro, Mohide, Cripps, & MacPherson, 1999;
Schmitt, 2001). None of the other demographic
variables were predictive of attitude scores. The
results of this study will provide baseline data for
comparison with future student cohorts following the
implementation of the new IPE curriculum in the fall
of 2006.
References
Banks, S., & Janke, K. (1998). Developing and
implementing interprofessional learning in a
faculty of health professions. Journal of
Allied Health, 27, 132-6.
McFayden, A.K., Webster, V., Strachan, K., Figgins,
E., Brown, H., McKechnie, J. (2005). The
readiness for interprofessional learning
scale: A possible more stable sub-scale
model for the original version of RIPLS.
Journal of Interprofessional Care, 19, 595603.
Parsell, G. & Bligh, J. (1999). The development of a
questionnaire to assess the readiness of
health care students for interprofessional
learning (RIPLS). Medical Education, 33,
95-100.
Parsell, G., Stewart, A.,& Bligh, J. (1998).
Educational principles underpinning
successful shared learning. Medical
Teacher, 20, 522-529.
Richardson, J., Montemuro, M., Mohide, E.A.,
Cripps, D., & Macpherson, A.S. (1999).
Training for interprofessional teamwork –
Evaluation of an undergraduateexperience.
Educational Gerontology, 25, 411-424.
Romanow, R. (2002). Building on values: The future
of health care in Canada. Ottawa, ON:
National Library of Canada.
Schmitt, M. (2001). Collaboration improves the
quality of care: Methodological challenges
and evidence from US health care research.
Journal of Interprofessional Care, 15, 2-21.
World Health Organization (1978). Learning together
to work together for health. (Tech. Rep.
Series 769). Geneva: Author.
Understanding current OT practice in the homecare setting: Are we able to do our job?
Laura Bradley MSc OT (candidate); Kathryn Schnarr, MSc OT (Candidate)
Supervisors: Jackie Bosch, MSc, BSc OT Reg. (Ont.); Lori Letts, PhD, OT Reg. (Ont.)
Time Limitations in Practice
The survey asked participants to indicate time
allocations and perceived time limitations across their
homecare practice (Figure 1). Perceived limitations did not
exceed 35% in any one practice area while 6 (35%)
participants did not perceive time limitations in any area of
their homecare practice.
70%
60%
50%
40%
30%
20%
10%
Time Limitation
in at least one
area (n=17)
Follow-up
(contacts/client)
(n=14)
Duration on
caseload
(weeks) (n=16)
Total # Visits
(visits) (n=17)
Length of Ind'l
visits (mins/visit)
(n=17)
0%
Documentation
of Ax
(mins/client)
(n=17)
Methods
This study employed a cross-sectional, 35-question
survey regarding time limitations in relation to practice.
Sections covered in the survey included: informed
consent, practice description, initial assessment,
intervention, follow-up and conclusion, which discussed
participants’ overall practice. Questions were of closedended format with the final question open-ended. The
survey was administered using a web-based forum from
February to April, 2006. Ethics approval was obtained
from the McMaster Research Ethics Boards (REB) in
Results – Description of Participants
In accordance with the survey’s focus, all participants
worked with adults in homecare (n=17). The participants
worked on average 32.1 (SD 9.2) hours per week in total,
with 24.6 (SD 11.9) of these hours dedicated to work in
adult homecare (n = 17). In relation to the types of clients
seen, 15 (88%) indicated they most often work with clients
who are “frail elderly” (n = 17), followed by clients with
musculoskeletal (6, 35%) or neurological diagnoses (6,
35%) (n = 17). One participant noted that she most often
works with mental health clients (n = 14).
Participants were asked to identify their clients’ “key”
occupational performance issues (OPIs) based on the
categories of activities of daily living (ADLs);
instrumental activities of daily living (IADLs); leisure, and
work. Most commonly addressed were ADLs, followed
by IADLs and then areas of leisure. Work was not often
addressed.
Initial Ax
(mins/client)
(n=17)
Purpose
To answer the question: do therapists perceive
limitations in time for service delivery in their current
homecare practice?
Analyses
Analyses were completed through use of descriptive
statistics. Frequency distributions were completed for
each question. The mean and standard deviation (SD) were
calculated for normally distributed data. Results are
presented in terms of the number of people who answered
the question (n).
Travel time
(mins/visit)
(n=14)
Literature Review
A literature review was conducted to find research
evaluating the effectiveness of OT homecare
interventions across adult practice populations. Relevant
databases were searched, including AMED (1985-2005),
CINAHL (1982-2005), OT Seeker, MEDLINE,
EMBASE (1980-2005), and EBM reviews Cochrane
Register of Controlled Trials, 4th Quarter, 2005. Areas
of OT intervention were grouped into five categories as
identified by the student researchers: ADL/IADL retraining, provision of adaptive equipment, falls
prevention education, cognitive rehabilitation and
caregiver support. This review showed that there is
inconsistent evidence for the effectiveness of OT
interventions in the homecare setting in maintaining or
improving functional abilities.
This indicates that there is a need for a future RCT to
evaluate the effectiveness of OT homecare with adult
populations. In order to direct the RCT structure,
evaluation of time limitations in current practice is
warranted. If time is identified by therapists as a
potential impediment to the delivery of OT services, the
trial would involve a control group, a usual care group,
and a third group, which would allow for flexible time
provision. If therapists indicate that time is not a limiting
factor a two arm design would be employed.
January 2006. Participants were gathered through public
and member accessible CAOT databases, and through
invitations to CCAC companies in the Region of Waterloo.
Twenty-nine therapists working in adult homecare were
contacted to participate: 17 therapists completed the
survey, 5 indicated they did not meet inclusion criteria, 7
did not respond, resulting in a 76% response rate (59%
completion rate).
Percent of Participants
Introduction
Occupational therapists (OTs) work in homecare
settings with clients with the aim of enhancing or
maintaining functional independence, or to offer support
to caregivers (Health Canada, 2005). Further knowledge
regarding current OT homecare practice and its
effectiveness is required. This paper presents the results
of a survey of OTs in the Region of Waterloo and
describes their perceptions of time limitations in their
current homecare practice. Survey results will serve to
inform a future RCT regarding OT effectiveness in
homecare settings.
1
Areas of Practice
Figure 1: Areas of Time Limitation in OT Practice
Understanding current OT practice in the homecare setting: Are we able to do our job?
Laura Bradley MSc OT (candidate); Kathryn Schnarr, MSc OT (Candidate)
Supervisors: Jackie Bosch, MSc, BSc OT Reg. (Ont.); Lori Letts, PhD, OT Reg. (Ont.)
Number of Occupational Therapists
Time limitations were most perceived in travel time,
length of individual visits, and total number of visits.
Eleven therapists (65%) perceived limitations in at least
one area of their homecare practice.
Time limitations were also noted in areas related to
intervention, categorized in the Person-EnvironmentOccupation (PEO) model (CAOT, 1997). Currently,
most therapists focus on aspects of the environment
(Figure 2).
16
14
12
most often
10
sometimes
8
least often
6
do not address
4
2
0
Person (n = 17)
Environment
(n=17)
Occupation
(n=17)
Areas of Intervention Focus
Figure 2: Areas of OT Intervention
When asked: “if you had more time, would the focus of
your interventions change?”, seven (41%) participants
stated yes (n = 17). Of these seven, four (57%) would
change to focus on the person, and 3 (43%) to focus on
occupations.
Participant Comments
The final survey question allowed open-ended
responses to identify areas in which participants felt the
survey was not representative of their practice. Thirteen
participants chose to make comments.
Three participants stated that the survey was difficult
to answer as they are paid per visit which includes all
associated indirect client care (travel time, documentation, phone calls and paperwork) (2). Other time limitations which arose involved pressures associated with
caseloads and waitlists (3), variations in time allocation
based on clients’ needs (3) and time limitations due to
extra time completing indirect services for which they
therapists feel they are not compensated (5).
Discussion
This research has shown that 65% of surveyed
therapists perceive at least one time limitation in their
homecare practice, however no individual area was
indicated as a source of limitation by more than 35% of
participants. Although three areas of practice were
associated with slightly higher limitations, it remains
difficult to conclude if these may be representative due to
a small sample size.
Based on the survey results, length of visits were the
most frequent source of perceived limitations, followed
by the number of individual visits. However, it is
unknown why this may be. Potentially the amount of
direct client time can be affected by the demands of
2
indirect client care. Data from some participants’ comments reflected time limitations which indirect client care
creates. Potentially, the indirect time therapists need for
background and preparation work affects the time they
have for face-to-face interactions and/or therapists are
putting in uncompensated work time to counter extra time
spent in indirect care.
Travel time was also a commonly cited time limitation.
However, exact analysis of allocations and limitations was
difficult. Many therapists entered textual data, explaining
travel time is included in their overall visit, making a
specific time allocation difficult to measure. Despite the
difficulty in answering the question, there does appear to
be a limitation in this area for many therapists. If travel is
included in the overall allocation, the distance required to
get to the client may have a direct influence on other
aspects of client care.
A final common limitation was found in intervention
focus. Given more time, five therapists indicated that they
would change their intervention focus from environmental
issues (i.e. equipment and assistive devices) to instead
address components of the person, or occupations in which
the client would like to participate. The change of focus
indicates that there may be a connection between time and
the focus of interventions.
Time limitations which arose in the participant
comments provide areas for future investigation as the
survey did not specifically ask all participants about these
areas.
Conclusion
Homecare services are an important component in the
Ontario health system to assist people to remain
independent in their homes for as long as possible (Health
Canada, 2005). Based on the student researchers’ literature
review, research evaluating OT homecare interventions
have found inconsistent results. This exploratory study has
shown that some occupational therapists in the Region of
Waterloo perceive time limitations, however further
exploration is needed to determine if these areas are
representative of that region’s homecare practice. At
present, there is some indication for the need of a third arm
in the RCT, but further exploration will be needed to
determine which elements of homecare practice this arm
should address.
References
Canadian Association of Occupational Therapists. (1997). Enabling
occupation: An occupational therapy perspective. Ottawa, ON:
CAOT Publications ACE.
Health Canada. (2005). Health care system: Home and community care.
Retrieved March 16, 2006 from http://www.hc-sc.gc.ca/hcssss/home-domicile/commun/index_e.html
Acknowledgements
The authors would like to thank study participants, and our supervisors:
Jackie Bosch and Lori Letts, Associate Professors, School of
Rehabilitation Sciences, McMaster University, Hamilton, Ontario.