Blog Posts

Contact Email Address: samantha.fordham@nhs.net, becky.glassman@nhs.net

Blog Shot by @Helen_OTUK

After a whirlwind two days the conference was almost over. This was the last session I would attend before the closing plenary and my mind was already buzzing with thoughts from other sessions I had seen. I wondered if I had made a mistake signing myself up to cover a session so close to the end of the conference. However, when Kathryn Jarvis sprung into life on stage I knew it was going to be an engaging and thought provoking session…

Implementing constraint induced movement therapy: a mixed methods study

Kathryn provided a simple outline of constraint induced movement therapy (CIMT);

A complex intervention to increase upper limb function, usually post stroke, made up of two components:

1. Constraint of the less affected upper limb with a mitt or sling.
2. Intense training of the affected limb.

She then relayed a story of a “bouncy” consultant who had heard about CIMT and with enthusiasm had asked – why aren’t we doing it? This question has stayed with Kathryn and prompted her to think critically about the evidence base for CIMT, and start her own research in to the area.

CIMT is not widely used in practice, and where it is practiced we are not using existing evidence based protocols. Kathryn’s mixed methods design used both quantitative outcome measures and qualitative interview to capture the impact of CIMT for four participants. For me, one of the most interesting aspects of Kathryn’s presentation of this research was her acknowledgement that where she expected to see the most gains in terms of performance (and there were improvements in performance for all four participants, some more marked than others), the biggest observable benefits of the CIMT protocols were in areas of volition and habituation. Kathryn thinks that “mixed methods ROCK” because had they not been using qualitative methods alongside the quantitative outcome measures, this aspect would not have been captured in the research.

What Kathryn’s research reveals is that evidence based protocols for CIMT are feasible for patients, with patient’s benefiting from a protocol that involves 3 hours training and 3 hours constraint. Feasibility in practice is not necessarily the same, the intensity of the training requires huge investment of time from staff and the trust where this research was carried out are still not implementing this protocol. Kathryn also highlighted that we still do not know what the active ingredients of CIMT are – we know the core components are training, constraint, routine, hope and the role of the therapist, but which elements are producing the outcomes? Complex interventions require a complex web of research.

Application of a conceptual framework to facilitate return to paid work following a brain injury

Karen Beaulieu has over thirty years experience as an occupational therapist working with patients who have had a brain injury. Both her own experience and the existing literature highlighted to her that returning to work is often a high priority for those who have experienced a brain injury, however a return to sustained paid employment is very difficult. Karen has conducted qualitative phenomenological research with 16 brain injury patients who have returned to work, and 11 employers who have been involved in this process, to explore how we as occupational therapists can begin to better facilitate this priority goal for our patients.

Karen acknowledged the short window of time she had to discuss this complex piece of research, and discussed her plans to take this research project forward. In the mean time, though she wants to be sharing the conceptual framework she has devised from her research and urges us to think about applying it. The four key themes of facilitating factors that came out of her research were occupational needs (including neglected areas such as drive and engagement), experiencing loss, grief and adjustment, looking at self identity (How are they different? What anchors them to their former selves?), and the importance of social inclusion and understanding in returning to work. These themes then lead to the conceptual framework below:

Karen urged all those who work with brain injury patients to be thinking about the elements outlined in the framework much earlier than usual, starting this process of managing expectations and addressing the grief from the beginning of a patient’s rehabilitation. I really look forward to seeing how this framework develops and hearing more of Karen’s findings in this area.

By Ayla Greenwood, @AylaOT

Journal Club: An exploration of the attitudes, knowledge and ability of occupational therapists in applying evidence to practice.

The interactive journal club format is new for COT2017 and I jumped at the chance to cover one of these sessions. I’m particularly interested in this format as it is something we have been discussing setting up at my workplace and having never attended a journal club before I was keen to see what the format could offer.

Sam Turner started by providing an overview of the article and outlining the key findings as well as a brief critique of her own. She proclaimed she was by no means an expert but has had experience of running journal clubs in the past and hoped for it to be an interactive critical discussion. The article she had chosen was brilliantly linked to overall conference themes around engagement in research and evidence based practice, as well as the CPD theme of this combined session.

The key finding of this systematic review is that there is disparity between our attitudes to evidence based practice and our actual real-world application of it. Perceived benefits include helping occupational therapists to demonstrate the effectiveness of our interventions, as well as fill gaps in our knowledge. However, the article also showed that there are negative perceptions of evidence based practice in terms of physical/financial resources and therapist time required, as well as the view that it can stifle creativity. What came out most strongly from this Sam’s introduction to the article was that organisational challenges and perceived barriers to implementing evidence based practice remain a key concern.

Sam’s critique touched on the validity of the research question, the methodology of the systematic review and her positive thoughts about the resulting recommendations of the article. She then opened the session up to the floor for comments and for a moment the room fell completely and utterly silent. But bit by bit the delegates, myself included, began to speak up – and what followed was an interesting and lively discussion.

Whilst some of this discussion did diverge from critiquing the research, pre-prepared guiding questions were a great way to ground the session in the article and keep us thinking about what it meant for our practice and ongoing development. Sam’s skilled facilitation allowed discussion to play out amongst delegates with some interesting points being made:

• In order to support and encourage evidence based practice we need a strong occupational therapy presence at higher levels within organisations to allow room for the application of evidence to happen. Applying evidence to practice is not easy and practitioners need to feel supported from above if they are to drive change.
• Evidence based practice isn’t just about journals. One delegate suggested for RCOT to start collecting data of when their guidelines are downloaded in the form of a quick tick box survey to capture the who/how/why/where/when of guidelines usage.
• We all do evidence based practice more than we talk about it – even a quick look at a guideline counts and we need to shout about this!
• We need to empower our service users to challenge us regarding our practice and the evidence behind it. They are the people who experience what works and what doesn’t.
• Further engagement with social media is key. OTalk has been a great forum for getting people talking about evidence based practice and we should be encouraging the use of this new technology and communication methods we are so lucky to have.
• Journal clubs are a great way to get people engaged in evidence based practice and should include all levels of therapist – combined top-down and a bottom-up approaches provide the best ideas and discussion.

That is where the session had to come to a close. Everyone was so engaged I think it could have gone on much longer. I hope the Conference Development Team decide to keep this new journal club idea going in 2018 and give just a little more time for sessions.

As a newly qualified occupational therapist there was so much to gain from seeing more experienced therapists discuss their thoughts and ideas all sparked by one piece of research, and a real confidence boost to know I could contribute to the discussion. I’m excited to take what I learnt from this experience back to my workplace and plan to taking our own journal club plans forward with renewed enthusiasm!

By Ayla Greenwood, @AylaOT

Alexandra Thompson from West London Mental Health Trust shared her thoughts on the pros and cons of preceptorship. She gave a balanced view of some of the challenges that a preceptorship can bring, and the specific factors that she feels made her preceptorship a positive one.

Alexandra’s evaluation of her preceptorship experience listed some positives as regular meetings led by an experienced therapist, the opportunity to share things she was doing in practice that she was proud of, prompts to think critically about core OT skills and a structured way to start building a CPD portfolio. The challenges were around finding time to work on the preceptorship portfolio and that programmes can be very nurse led and lacking those opportunities to address core OT issues.

Working for a trust who have recently moved away from an OT preceptorship in favour of a multidisciplinary band 5 development programme and having never experienced the other side of this, Alexandra’s Brag & Steal offered some insight in to why an organisation might instead move towards a discipline specific preceptorship programme. Alexandra encouraged delegates to speak to their seniors about implementing this kind of programme in their workplace, with parting thoughts around it being a great initiative to encourage service development, and a medium that helps newly qualified staff to increase their confidence in practice early on in their careers.

Paper: Occupational Therapists’ research engagement: enablers and challenges

I was excited to see fellow BlogSquader Laura di Bona present her research experiences and once I had grasped the idea of a Randomised Control Trial being like a big Ferris wheel with lots of different components that you can’t just set up at once I understood what we were talking about; a specific phase of a larger piece of research during which Laura and her colleagues were developing an intervention around Community OT in dementia requiring the therapist participants to act in a dual role of clinician but within a research initiative, and the challenges that this brought for individuals.

The four main challenges for the participating occupational therapists were around learning the intervention, recruiting participants, fidelity and paperwork but what I really took away from this session were the enablers. Positive attitudes was the first, with Laura and her colleagues finding that a belief that it would happen and that research has true value being a big enabler in terms of therapist engagement in the research. Next came peer support on both a practical and emotional level, as well as management support. Laura outlined the importance of experienced management supporting therapists engaging in the research by providing links to research departments, funding to backfill protected time for research engagement and promoting the value of research within their teams. Finally came protected time, for which engagement in research needed to be considered a priority on a systems level.

Laura ended her portion of the session by saying that for occupational therapists to drive forward the research agenda being promoted at the conference there needs to be a change in research culture to increase practitioner engagement. Just as we would personalise an intervention for a client, we need to be personalising research for therapist participants and their contexts – keeping the design relevant and practicable, ensuring support structures are in place and avoiding the ‘research bubble’ that if anything is a hindrance to creating a culture of active engagement in evidence based practice.

Written by Ayla Greenwood, @AylaOT

This was a lively and thought provoking debate on the motion:

“This house believes that diverse roles are a vital tool in the future of our profession.”

It’s somewhat of a challenge to distil the variety of shared viewpoints and experiences in a limited character count, and I’m very aware of the potential to upset someone on either side of the fence! However, I’ll do my best to hone in on key points, and hope it’s simply a bridge to further insight and discussion.

Session chair David Brindle, Public Services Editor at The Guardian, took an early vote before the motion was argued, to establish a baseline of opinion. In a room of 143, the vast majority were in favour, with 9 against and 1 abstention.

Miranda Thew, Senior Lecturer at Leeds Beckett University, was speaking for the motion, with the support of Yvonne Thomas, Principal Lecturer and Academic Lead for Allied Health Professions at the University of Worcester. Miranda is a passionate advocate for diverse roles, having devoted much time and research to this area, yet she opened by describing the tussle she has had with the premise of what is ‘diverse’.

She cited opportunities for diversity in most areas of practice, but how the constraints of some settings stifle the ability to practice in a person-centred, occupation focused way.

Diverse practice was linked with occupational justice, in relation to the occupational therapists who support those not able to access traditional healthcare settings, including prisoners and traveller communities.

Diverse roles at initial points of access were also referenced: GP surgeries, A&E, the ambulance service and care homes. These are diverse roles, but ones that could ensure our future in an NHS that appears to have side-lined occupational therapy in many future strategy documents.

Speaking against the motion was Kee Hean Lim, International and ENOTHE lead for occupational therapy at Brunel University. He was joined by Gabrielle Richards, Professional Head of Occupational Therapy and Trust Social Inclusion and Recovery Lead for South London and Maudsley NHS Foundation Trust.

Arguments against the motion addressed its wording – are these roles ‘vital’ to our future, or just another opportunity? The speakers also warned about the risk of diluting occupational therapy into generic therapy, rehab or care coordination roles, and trying to do all things for all people. When the profession has a hard enough challenge of promoting its worth, should it not be clear about what it is, what it does and its territory? Should occupational therapy students not be mastering basic skills and building their professional identity first, before exploring roles outside of traditional practice?

Citing the numbers of occupational therapists in the NHS, the speakers argued that we are not in a position to treat ourselves as a luxury to work across so many settings. The danger may be, we’ll spread ourselves too thinly. Another argument was the need to fill existing vacancies as a way of securing the future of the profession.

When the debate was opened to the floor, the first comment struck me: “Diverse doesn’t’ mean doing all things, it’s doing ‘real OT’ in diverse settings.” It was encouraging to hear fellow students engaging in the debate, sharing their (mostly positive) views of role-emerging placements, as an opportunity to directly translate learning into practice. Most were advocates for an experience that had allowed them to engage in unrestrained and truly occupation-focused practice.

As the final vote was cast, the number ‘against’ the motion had increased slightly, as had the rate of abstention, but there was a clear majority in support of diverse roles as a vital tool in the future of occupational therapy.

This session provided food for thought, especially the notion that role emerging placements can offer direct application of classroom learning, and help to build skills that may not be accessed elsewhere.

 Bev Goodman
1^st year pre-reg MSc student at the University of Essex
@BevG_studentOT