Week 0: Preparation for Psychosocial Prac

Prep for Prac

As July draws to a close and August sets in, a new fieldwork block begins: Psychosocial Fieldwork, a journey across the underside of the coin, where concrete shifts to abstract and a deeper understanding of OT emerges.

 A glance at the tabs on my Internet Explorer reveals the shift into prac mode: a row of academic websites interspersed with the odd Gmail tab has replaced the Facebook, Pinterest and movie sites.

It's tempting to let my finger slip and open up 'Iron Man 3', but the pressure of fieldwork looming closer has been a good motivator to leave the movies for the weekend and get some solid work in before all stress breaks loose.

I've spent the past few days collecting resources. My aunt's old copy of Kaplan and Sadock's 'Synopsis of Psychiatry' lies atop a pile of Psychology books on my bedside table, a library-loaned edition of 'Actions speak Louder' lies on the corner of my desk, underneath a few other miscellaneous books I found in the library on OT in mental health. A series of articles and e-books for later reading clutter the download file of my tablet.
Collecting my resources was easy, but the reading part posed more of a challenge...

I've found that structure works well for me. Deadlines or physical tasks that I need to complete are easy for me to work through, but vague concepts, like 'do research' are where the problem comes in.
It was only once I found a quote by David Blackwell floating across the internet that I figured out how to unlock my inherent curiosity, necessary to wade through all the pages of interminable jargon:

"Basically, I'm not interested in doing research and I never have been. I'm interested in understanding, which is quite a different thing." --- David Blackwell

The bluntness of this quote struck me first, then got me thinking a bit deeper about my interests and the real purpose of research. To me, this means that there must be an underlying motivator to guide research; it's not the research itself that's the objective, but the understanding of a particular concept and alteration or addition to an existing worldview that makes research valuable. I began to question what my motivator was...

 In 2013, I transferred to OT from a BSc. because the cold, clinical nature of the pure sciences jarred with my sense of empathy and interest in people: why we do what we do and what happens when things go wrong, emotionally, biologically, mentally and spiritually. But the part of me that loves to discover new ideas and figure things out, the reason why I applied for a BSc. in the first place, is still present.
To combine these two facets and link my interests with my work, I tried a new avenue: I began to read narratives of people with psychological disorders, and those who work with them.
I discovered Vicki, who had climbed out of 'the black pit' of depression, Jamie, who'd had a manic and psychotic episode in the middle of a trip to Spain, and Tish, who punished herself for not coping with PTSD by starving herself.

(Government of Western Australia Mental Health Commission, http://www.mentalhealth.wa.gov.au/mental_illness_and_health/stories/diagnosis.aspx)

These narratives gave me a glimpse into the world of those with mental illness, and provided the impetus to open the heavy textbooks and start building knowledge bridges, so that I could in some way help people like the ones I had 'met' in the narratives I'd read.

My first stop was Occupational Therapy in Mental Health, to get an overview of exactly what the OT role is in the psych setting.
According to Stoffel, who quoted the American Occupational Therapy Association,

'Occupational Therapy has as its primary domain an emphasis on "supporting health and participation in life through engagement in occupation", which takes place within a context, including the social and physical environments' 

(Stoffel and Brown, 2011: page 3)

 To me, this means that my role will be to identify barriers that prevent my clients from achieving competence in their daily occupations, whether it be poor social skills, impaired thought processes or a lack of constructive coping skills, and then work towards adapting behaviour, environment or methods of task completion to enable the client to participate optimally, thereby improving wellbeing and quality of life.

As open-ended as this sounds, it's a reminder to me that clients cannot be boxed into a textbook intervention programme, but that the intervention depends entirely on the client, their needs and their context.

An interesting term I found in the same text is Crowley's "procovery", the "process of attaining a productive and fulfilling life regardless of the level of health attainable" (Stoffel and Brown, 2011: page 3). I think this term provides a refreshing sense of hope that people with mental illness are fully capable of achieving functional goals, with the assistance of healthcare providers and a supportive environment.

The next stop on my research journey, before I revisit OT in Mental Health again, is Kaplan and Sadock's 'Synopsis of Psychiatry'. I particularly like this book because it provides an overview of all the more common psychiatric disorders I am likely to encounter, grouped according to their presentation. It also gives differential diagnoses, which are valuable in the SA healthcare system, where diagnoses are sometimes incorrect, have not been revised for many years or have not been confirmed. Going through this book gives me a broad idea of what I can expect when fieldwork commences, and allows me to prepare better for potential scenarios. Like many OT students before me, I find the intricate balance of the human brain fascinating, and this keeps me motivated to continue the study of the many ways in which this balance can be disturbed.

 With the weekend ahead, my desk is piled with books and my head with ideas. I have discovered what all students eventually do: that the more you study, the more you realise how little you know and how much there still is to explore. So let the journey continue...

 Stoffel, V.C, Brown, C (2011). Occupational Therapy in Mental Health : A Vision for Participation.  FA Davis: United States

 

Government of Western Australia Mental Health Commission (2010).  Personal stories by people with a mental illness, their families and friends. Retrieved from:http://www.mentalhealth.wa.gov.au/mental_illness_and_health/stories/diagnosis.aspx)

Week 10: Touchdown

Week 10: 12-15 May...

Taking off on fieldwork ten weeks ago was the start of a terrifying, yet exhilarating journey. Navigating the ups, down, U-turns and dead ends pushed me to my maximum, but I can finally release a deep breath at having landed unscathed, yet stronger.


The first few weeks of fieldwork felt as though I was flying blind in a maze of hospital corridors, treatment principles and long lists of rules and regulations. Through trial and error, I began to slowly inch my way through understanding what was required of me for each of my clients. I feel as though I walked through the first few weeks with a perpetually confused expression on my face, asking dozens of questions as I slowly got my bearings.


Within the next few weeks, I gained some altitude, but with it came bouts of turbulence in the form of patients unexpectedly discharged, and a range of new conditions I had never worked with before.

 By this time, thankfully, I was more comfortable in the hospital environment, leaving my mind free to focus on the needs of each client. I found myself becoming more driven to research each condition, and try things that I had previously been unfamiliar with. I began to understand two things at this stage:

1. To paraphrase Shakespeare's Hamlet: There are more conditions in heaven and earth, OT student, than are mentioned in your lectures

2. Real clients don't present like textbook clients: the human body is a complicated structure- when one thing goes wrong, a whole chain of events are set off, meaning that healthcare professionals have to be exceptionally observant, a skill I still need to develop.


I also began to get a better understanding of what the OT role is within the MDT for various conditions, only realising during fieldwork that my idea of the OT role had previously been worryingly hazy.


As the final few weeks began to unfold, my flight through fieldwork began to smoothen out as I began to figure out the controls.

I began to understand the therapeutic process better, moving from assessment to drawing up aims, to application and review of intervention. For the first time, I felt more in control of my own therapy as I began to learn how to plan for the future and not just from session to session.
Once I was more comfortable with treatment planning, I found that I began to enjoy sessions with my client and develop a deeper rapport that was no longer clouded with uncertainty and nerves.

Finally, as fieldwork has drawn to a close, and  I feel relieved to be on solid ground again, I remain grateful for the opportunity we have been given to develop our skills within the real hospital environment.
This journey has been one filled with trials and shifting emotions, but also with successes and the building of new friendships and bonds.
Until I board the next fieldwork flight, I endeavour to keep my feet firmly on the ground and recuperate before the adventure starts over next semester...

Week 9: Under the Microscope

Reaching the final week of fieldwork, it's time to take to shift the lens away from my clients and on to myself, to a look back and scrutinise my development over the last 9 weeks, what skills I've developed, and what aspects I still have to work on.

Over the time I've been at hospital, I've found that I am able to assess much rapidly than previously, through having learnt how to select appropriate assessments, use observation accurately and work through assessment forms faster. This is no doubt the result of having the opportunity to be in an acute setting, where rapid assessment ensures more time available for intervention.

I've found improvements in my ability to build rapport with a client in the limited window of time, allowing them to open up more during therapy, and actively assist in the treatment process.
I've found that simply asking a client what they perceive to be their biggest problem, using listening skills and well-timed questions, often goes a long way towards building a holistic view of the client, instead of running through the set list of interview questions, in which more time is spent writing down every word the client says than actually listening.


Over time, I've found that it has become easier to select relevant therapy for the client. There are still many instances where I have to refer back to textbooks and the Internet (the saviour of students everywhere) to get a better idea of the condition and appropriate OT intervention, but slowly, my small knowledge base is expanding and I can see things starting to fall into place within the OT lobe of my brain.

It still takes me a while to sift through the assessment findings, organise them into a comprehensible whole and develop a relevant programme, but that has been slowly improving. There are times when I miss things completely, like in the case of phantom limb sensation of my current client during the sensation assessment, and have to go back and check on aspects again in subsequent sessions. Over time, I am sure that experience will be the best teacher.

Another thing I have to work on, also a difficulty related in part to limited experience, is on-the-spot grading within treatment. Often, clients change at varying degrees from one session to the next, therefore it becomes crucial that I make allowances for these changes in my grading plan. I still find it difficult to come up with adaptations rapidly within the session, meaning that until I develop this skill, a lot more thought needs to into drawing up my grading section of the session write-up.  


My time-management skills, having never been a strong talent of mine, have shown improvement, as I'm no longer rushing to scribble forms or complete activities during the last ten minutes of the day. It helps that filling in patient files takes me a lot less time now that SOAP notes are more familiar to me, and that I have a better idea of the nursing schedule, so much less time is lost waiting for bandage changes or feeding time.





Overall, I am confident that I have benefitted from fieldwork, and it has been invaluable in adding to the skills I will need to be a successful OT one day. Although there are still many weaknesses I still have to address, I can see that I have begun to develop already, and hope I will continue to do so throughout the next 18 months of my course (I pray) and the many years of practice that lie ahead.

Week 8: From Paper to Plinth

Week 8: 28 April-1 May...

Reaching the last 2 weeks of fieldwork, I'm over the moon to have two constant clients, with whom I've been able to work with for at least three sessions already.

Planning treatment sessions has become easier, now that I have a better idea of my clients, and can anticipate their reaction to treatment more accurately. I have a better idea of how to structure items to achieve the desired movements, and how high to pitch the activity. Having established a better rapport with the clients, it becomes easier to decide on appropriate activities within the treatment regimen.

Implementing treatment according to the plans I've drawn up has become easier, but there are still aspects I have to work on. The therapist must always be one step ahead of the activity, evaluating and grading as the activity unfolds. With my limited experience, I find myself becoming caught up in the present of the activity thus missing many therapeutic implications, opportunities and considerations until after the session, when I begin to critically think through and evaluate it.

I've also found that while I'm beginning to be more assertive in getting the required action from the clients, I tend to adopt a gentle, encouraging approach to prevent the breakdown of the rapport I've established. This has worked for my clients so far, but when I face more difficult clients, I will have to work hard to find the balance between  maintaining the client-centeredness of my treatment and still achieving the aims of therapy.

With my burns client on Tuesday, I had planned to do a bed-mobility activity. However, the client was in pain, had just had blood taken from her and a drip inserted. She was seated in a chair and was not willing to transfer to the bed as she was fearful of falling. Here, I faced the assertiveness dilemma once again: should I do my best to convince the client to comply with the treatment plan by explaining the importance of being able to mobilise, especially given her developing pressure sores; or should I simply respect her decision and pain, and do another activity instead?


After trying to convince the client that I would not let her fall, and could even get someone to help me just to be safe, she continued to refuse. Hence, I decided to do some upper limb mobilisation, encouraging the client to reach for food items and make use of the affected arm for bilateral hand movements during the task of eating her lunch. This way, she was still receiving therapy, but was able to remain in the chair as per her wishes. In subsequent sessions, I intend to continue with the mobility programme, as I feel it has become a priority, perhaps using incentives, such as a sweet treat, to encourage participation.


With my CVA and below-knee amputation client on Tuesday, I decided to focus on bilateral hand function in self-care, using a grooming activity.
I incorporated dynamic weight-bearing over the affected arm into my structuring to normalise muscle tone for activity participation.  The items required for the preparation and grooming task were placed to the right of the client, allowing weight-bearing to occur when she reached over to fetch the items with her left hand.

This helped to normalise muscle tone, allowing for better right arm movement during the actual activity, as she was able to hold the comb, with the help of a built-up handle, and raise it to her head. She required assistance at the elbow joint to lift her arm up to her hair, so support was provided at the elbow joint.

To prevent compensatory shoulder elevation during arm movements, a mirror was placed in front of the table at which the client was seated, allowing her to correct her own movements through visual feedback.

One aspect of structuring that could have been improved was the distance at which the client's chair was placed from the table. To allow for better posture and weight-bearing, the chair should have been closer. However, once the client had transferred herself to the chair, it was difficult to shift her forward due to her weight and the angle of her left prosthesis. The wheelchair-to-chair transfer will have to be carefully managed in the next session to ensure the client is seated the correct distance way from the table.

The best part of session was hearing from the caregiver that she has found in improvement in the client's hand function since therapy has begun. For me, this only increased my motivation to continue planning and implementing therapy that would increase the client's hand function even more.

Week 7: Dismantling the Box

Week 7: 21-24 April...

Over the last 7 weeks of fieldwork, the same realisation has been reiterated: when it comes to OT, no amount of theory can equal the hands-on experience of being on prac. In  a profession that is so inherently client-centred, theory can only serve as guideline that must be added to and adapted to suit the needs of each client.

During our theory lectures, clients seem like neatly boxed entities that fit all the diagnostic criteria and follow a pre-determined rehabilitation progression from admission to discharge. It becomes easy for us to believe that we can simply pick an intervention session out of the set programme and apply it to our client. However, humans are complicated creatures, a feature that is only multiplied with injury or disease.

Pain, personality & context make each client unique, limiting our ability to rely purely on theory to achieve successful rehabilitation of the client.

 

 

With my current burns client, the first I've had, there were many things that theory could not prepare me for.

Although we had discussed it during theory lectures, the sight and smell of burn wounds was something I had underestimated and had to get used to quite quickly, given the close proximity we have to our patients. 

 

Implementing theory was slightly difficult with this client, because there were aspects, such as the language barrier and the client's severe pain, that cast a spanner in the works.

I know from theory that maintaining range of motion becomes one of the most important aspects to focus on during acute burns treatment. However, it's one thing to know that the activity must be structured around mobilising the affected limb, and quite another trying to convince a woman in excrutiating pain to use her badly burnt right arm for the activity instead of her functional left arm. 

I got around this dilemma by starting with a simple, familiar task of washing her face, using a scented cream and plenty of encouragement as motivation to participate. Whereas she was previously reluctant flex her shoulder & extend her elbow, she managed to achieve these motions by reaching for the items placed nearby.

 

To achieve reach, structuring becomes an important aspect to consider. In a hospital setting, there is not always furniture of the right height to achieve the desired degree of reach or facilitate specific movements. Hence, improvisation , using things like cushions , boxes and chairs becomes an important skill to develop, something that only comes with practical experience.

 

 

 

On Friday, we ran a paediatric stimulation group. Not having covered the theory of paediatric therapy in much detail, we read up on the sort of principles that would be applied. However, with children in particular, once again, there was only so much that could be learnt from reading. With the sort of spontaneity and short attention span of children, experience is the best teacher. Having these opportunities to try what we have learnt in the real therapy environment has been a challenging, but amazing and valuable gift.  

Throughout fieldwork, I have realised that theory is just a framework for us to be able to orientate ourselves once we begin treatment. The real learning comes in through our attempts to apply this theory to each of our patients.

Applying what I've learnt is difficult, and there are still times when I only join the dots and reach a 'Eureka' moment a few hours after I've left the hospital.

However, I know that as I make errors, learn from them, and begin to understand more than our lectures and textbooks can possibly include, I have begun the long transition from student to therapist.

Week 6: Pushing for Progress

Week 6: 14-17 April...

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.

Week 5: Back to Prac

Week 5: 7-10 April 2015...

 

After a welcome week of midterm break, Tuesday morning saw us delve straight back into fieldwork.
Having gone straight from midterm demo's & case presentations into the holiday, we'd had plenty of time to think through our first month of fieldwork over the break.

 

Being assessed for midterms had been quite an experience: not only had my body chosen that particular week to succumb to food poisoning , but my only remaining client had been transferred to another hospital just before my treatment demo was to take place. Luckily, one of my fellow student colleagues was able to stand in for my client so that we could simulate the treatment session I had planned: a grooming activity involving the tying of a traditional African doek.

 

Apart from enabling the client to perform her own self-care tasks independently and thus improving her sense of autonomy and self esteem, the task also focused on many of the performance components that had been affected by the injury. Having to reach upwards holding the comb and doek ensured that full range of motion and muscle strength of the unaffected arm was being maintained. This made sure that prolonged hospitalisation would not prevent the client from performing home management and self-care activities once she returned home. The repetitive above head motions also required a significant amount of energy and concentration, ensuring that physical and mental endurance was maintained.

 

Although we bandaged the student's arm in the same way as the client's to simulate the same diagnosis, and used similar structuring, the student's response to the activity was different to the imagined response I'd had for my client. To me, this highlighted why such importance is placed on the client's context over and above their diagnosis.

The student was younger, fitter and, as a white female, had soft, straight hair and had never tied a doek before. This meant that the activity was completed in a much shorter time as it would have with the actual client, because the good physical endurance of the student meant that there was no need for rest breaks, and that movements in general were faster. Because the student had soft hair, it was faster to brush, but more difficult for her to tie the doek one-handed without it slipping off her head. As she was unfamiliar with doek-tying given her cultural context, the end product was not as neat as I'd expected my client's to have been, and she was not as motivated to ensure a perfect end product.  There were aspects, such as posture, that I would have had to correct for my client, but that were irrelevant for the student.

It was eye-opening to see how the same session, performed on someone with the same 'diagnosis' could yield such different interpretations and results when applied to someone with a different context and value set.

 

 

Following the treatment demo's came the case presentations: presenting our entire plan for our client based on their background within 20 minutes. Prioritising what to include in the presentation proved to be a challenge, ensuring that while a comprehensive picture of the client was presented, sufficient time was given to the treatment plan. My presentation ran two slides over time, indicating that I would benefit from doing a quick timed run-through before my final case presentation to ensure timing is optimally utilised.

 

 

 

With the new term came a new challenge: my first paediatric client. Diagnosed with cerebral palsy secondary to TB meningitis she contracted at the age of one, the little 6-year old weighed just 9kg and had no active movement. She did not respond to visual stimuli , and only responded to auditory stimuli during the second session by a flicker of her eyelids.

 

My first treatment session consisted of basic positioning and sensory stimulation, which were all done passively as the child had no active movement. As the child was drowsy, possibly due to medication, it was not surprising that there was no response apart from the flickering of her eyelids. It will be a good idea to see the child at different times of the day to determine whether the lack of response is a permanent factor, or whether it is only present after medication.

   

With her lack of responsiveness, it will be important for me to consider all the necessary downgrades that will be needed when applying the relevant NDT principles. I know that for my treatment to be successful, a great deal of research will need to be done on this client's condition and presentation so that therapy is pitched at the correct level for her.

 

For the first time, I also have two other clients to look forward to next week: a client with a dual CVA and below-knee amputation and a rheumatoid arthritis client.

The variety of conditions, comorbid factors and aspects of client context that need to be taken into consideration means that I have a great deal to consider and research over the weekend so that, come Tuesday, I can tumble into prac feet first.