Arriving back at campus after a day at hospital, conversation with my classmates inevitably turns to fieldwork. After the initial bout of complaining about our varying levels of impending insanity, the positive stories start to emerge.
A patient with no previous active movement has just started getting finger flexion back. A woman who could barely sit up in bed due to fatigue can now engage in a 15 minute activity. A child with a learning disability has just learnt to distinguish shapes from each other.
These stories renew our commitment towards OT and remind us why we chose this course. However, none of these stories are mine.
Working in an acute setting, I have yet to report significant progress in any of my clients, simply because out of the eleven patients I've had so far, only two of them remained in hospital long enough to be seen more than twice before transfer or discharge. While this has been extremely beneficial in pushing me to develop rapid assessment and treatment skills, it leaves me with many questions about the effectiveness of my therapy. Without being able to see the end result of my work, I find it difficult to gauge whether the little therapy I have done and the home programmes and assistive devices I've given where possible have actually been useful.
Many students at more chronic physical facilities seem to have the opposite problem: their clients remain within the facility for so long that the students have trouble coming up with enough sessions to address performance component deficits. Often, the clients have already plateaued, leaving little room for progress during the students' time with them.
Although we sometimes become frustrated when there isn't a lot we can do for our clients, it's important for us to remember that an OT role sometimes is limited to maintaining existing function, or where this cannot be achieved due to severe illness or progressive conditions, simply ensuring the best quality of life for the client as possible.
To ensure progress of the client, the session must be therapeutic. To ensure the session is therapeutic, the session must be pitched at the correct level for how the client presents on that particular day. As a result, grading of the activity becomes critical.
Of the two clients I was able to work with for slightly longer, both presented differently from the first therapy session to the second or third, prompting a change in the actual session. On-the spot grading then became an essential part of my treatment plan, as it determined whether my treatment was actually therapeutic, or whether I was simply entertaining the client.
I found this difficult, as I had not anticipated the degree to which these clients' performance skills would differ from my initial encounter with them. The most recent example would be the CP child I had worked with. From the first treatment session, in which she was starting to show response to auditory stimuli, to the second session, her chest infection had worsened, resulting in her being distressed and on a nebuliser.
The NDT positioning and sensory stimulation session was therefore pitched too high for her. I attempted to apply some of the tone inhibiting principles of elongation and asymmetrical to symmetrical movements, using the rattle as a stimulus, but because she was unable to be brought into sitting, the important weight-bearing aspects were absent. She was also too distressed to respond appropriately, diminishing the therapeutic value of the session. This has served to build my experience, but also highlights the importance of a thorough understanding of the diagnosis, and the many complications and co-morbidities associated with it, to be able to draw up appropriate grading principles.
The same can be said for clients who improve from one session to the next. My current CVA client was unable to raise her affected arm beyond 26 degrees upon initial assessment, which was likely due to fatigue following an intensive physiotherapy session. A few days later, during a upper body dressing session, she was able to increase this range to 45 degrees, thus being able to complete the dressing exercise quicker than expected, with only minimal assistance required for the buttons. Hence, I was able to upgrade by incorporating other aspects into the session, such as balance and preparation for lower limb dressing.
I hope that as the next 4 weeks of fieldwork unfold, and as I push for progress with each of my clients, I begin to see the improvement I'm waiting for. Until then, I'll continue doing the best I can in the time I have with each person that comes into my care.
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