Z is for zeitgeber.......

Zeitgeber- literally ‘time giver’.

Our daily rhythms and routines are governed and influenced by a number of factors. Internal factors set by hormonal levels and circadian rhythms such as sleep/wake cycles may operate at a cellular level and remain roughly consistent but not exactly in synch with a 24 hour clock. Zeitgebers exert influences on our internal ‘body clocks’.

Examples of physical zeitgebers are noise or daylight, social zeitgebers could be meal times or bed time rituals. Zeitgebers are very important to maintain synchronicity between an individual and their environment e.g. helping to conform to the 24 hour cycle that governs most people’s lives as work and other activities are arranged to start and finish at set times daily.

We can experience the disruption of this relationship when we travel across time zones and have ‘jet-lag’. Any disruption in zeitgebers, such as a traumatic life event, can lead to a period of instability as usual routines are disrupted, literally enough to disrupt internal rhythms as the expected prompts no longer occur- perhaps this is why family holidays are said to be one of the most stressful occasions!

Zeitgebers can be used to help ‘train’ into a desired pattern of daily life or to reinforce and maintain stability. In order to perform at our best we need to be in balance with our internal rhythms. Occupational therapists may find that considering the implications of this can be helpful when working with individuals, especially those who are in a disrupted situation, such as an acute admission to hospital.

Y is for Yerkes-Dodson....

 

Yerkes & Dodson were the psychologists who defined the Yerkes-Dodson Law in the early 20^th Century.

This theory shows that human performance and learning of new skills varies with ‘arousal’ level. Arousal means interest, excitement or stress- a certain amount is good and increases ability to learn, but too much and performance begins to deteriorate. There are some classic graphs that demonstrate this- here is a link to a website that explains it in simple terms and gives the original reference too.

I chose this subject for my Y post as I thought it links quite closely with the concept of ‘flow’ (see F) used in occupational therapy. Flow occurs when someone is fully engaged in an activity, the activity needs to have the right balance of challenge and skill, so a certain amount of stress is involved- flow will not occur of the task is boring, but too much stress i.e. the task is too difficult, and flow will not occur either.

Whether we think of it as the Yerkes-Dodson Law or as the concept of ‘flow’, these are both ways of helping us understand the importance of pitching activities at the right level if they are to be effective, and that level will be different for every individual.

X is in neXt....

 

As in what’s next for this blog- OK cheating a bit I know, but X is difficult!

This blog began as a diary of the study visit I carried out earlier this year. I will continue to use it beyond the end of the A-Z challenge to record the experiences I have of putting my learning into action and sharing what I have learned. This will be an evolving process over time, so I will have plenty to write about.

The other day I did an informal presentation to the Occupational Therapy Support Workers group where I work, we had some really interesting discussions about the experiences I had and the similarities and differences between our workplace and those I visited. I was really inspired by their enthusiasm, interest and openness to new ideas.

I hope some of you who have become followers of this blog during the A-Z challenge will continue to follow and find this blog interesting and informative. I’ll try to keep it that way!

 

W is for Winston Churchill Memorial Trust…

 

Winston Churchill is an iconic figure in British history, best known for having been Prime Minister during the Second World War. On his death in 1965, a memorial fund was set up and the decision was made that instead of a building or statue, a ‘living memorial’ would be created. The Winston Churchill Memorial Trust (WCMT) funds travel awards for British citizens to travel abroad to learn and share knowledge and skills for the benefit of themselves, for Britain and for the countries they visit. WCMT’s slogan is ‘travel to make a difference’.

The study visit to Los Angeles that I undertook earlier this year has been the subject and inspiration for this blog. I owe a great debt of thanks to the WCMT for funding my visit and for their support throughout the whole process.

Last weekend I attended the Scottish Winston Churchill Fellows AGM. Three recent fellows gave presentations that demonstrated the wide range of subjects that are included. One was about hydro-electric schemes in Africa, one about early years parenting skills in Italy and the Netherlands and one about reducing losses in fishing vessels in North America. They were all fascinating and it was clear why the speakers had chosen their topic and how they planned to make use of their learning.

WCMT is developing the ways that it supports fellows once they return from their studies and is working to develop links and mentorship for key areas of study.

The whole experience has been a real once in a lifetime opportunity, and in many ways, the visit is only a beginning. I would very much encourage you to follow this link to the WCMTwebsite for more information.

V is for Value....

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‘Valuing the ordinary’ is a concept used in the development and use of the Lifestyle Redesign® approach in Occupational Therapy (OT). It can be incorporated into any OT intervention.

Valuing the ordinary simply means taking note of and seeing as important, the everyday ‘trivia’ of someone’s life. Our lives are all made up of a patchwork of everyday small tasks and concerns that create a whole.

Allowing some time to focus on small and seemingly unimportant matters, can have positive effects in that it allows the person, rather than the illness or problem to be the focus. Exploring the ordinary may give the starting point that allows someone to begin to envision a new possible self as the OT uses the opportunity to be positive about progress and to help someone see new possibilities for the future.

Reading about this, I was reminded of the quote from one of the OTs working in the Pressure Ulcer Prevention Study at the University of Southern California during my recent study visit there: “If it’s valuable to you, it’s valuable to me”.

U is for University of Southern California...

 

The University of Southern California (USC) is a privately funded university located across 2 campuses in central Los Angeles. Occupational Therapists (OTs) have been educated here since 1942 and many of the profession’s famous names are alumni e.g.Mary Reilly and Gary Kielhofner.

Mission and Vision

‘The mission of the USC Division of Occupational Science and Occupational Therapy is to maximize the potential of people to construct healthy, satisfying and productive lives by generating knowledge of value to society, advancing the profession and educating generations of practitioners, researchers and leaders.

Our Vision

We envision the Division of Occupational Science and Occupational Therapy as a hub of innovation and leadership where we study participation in daily activities defined in the discipline as “occupation” and its relationship to healthy living over the lifespan. We aim to establish occupation as an essential component in health and well-being. We promote this perspective by educating a global community of researchers and practitioners and advancing practice models about occupation that are science-driven and address health and societal needs.’

(Division website at http://ot.usc.edu/)

In addition to the two University owned hospitals, close links are maintained with clinical partners at Rancho Los Amigos National Rehabilitation Centre, Children’s Hospital and others. A global network of contacts including Ghana, Hong Kong & Romania is well established.

There are 3 main ‘arms’ of the Division’s work:

·      Research- the Division is currently operating with a research ‘portfolio’ of over $8 million. The studies in progress have potentially powerful implications for OT practice and range from community based lifestyle interventions to neuro-imaging following stroke to improve rehabilitation methods. Numerous peer reviewed publications have contributed to the aim of generating ‘rigorous science with clinical relevance’

·      Clinical Practice/Care Services- clinical OT staff work within the USC Occupational Therapy Faculty Practice and Keck Medical Center at USC Hospital. Lifestyle Redesign® forms the basis for the Faculty Practice programmes. In addition to meeting patient needs, the clinical practitioners are closely involved with the teaching and research ‘arms’.

·      Training/Education- the entry-level Masters programme has recently been remodeled and includes foundations and essential core studies, practice ‘immersions’ (Paediatrics, Mental Health & Adult Physical Rehabilitation/Geriatrics), academic fieldwork, leadership development and specialty focused elective placements.

 During my visit I had the opportunity for involvement in all three areas and was able to gain an appreciation of how closely interwoven they are and how Lifestyle Redesign® is applied in many different situations.

The opportunity to have this in depth experience was made possible by a Winston Churchill Memorial Trust travel award (more about this when we reach W). The purpose of my visit was to investigate how Lifestyle Redesign® could be used to improve the hospital/home interface for older people. This blog began as a record of my experiences during the visit and now continues as a reflection and record of progress since my return to the UK.

S is for Story...

 

Storytelling and Story making are my subject for today.

Occupational Therapy (OT) is a ‘doing’ not a ‘talking’ therapy, but ‘storytelling’ and ‘story making’ can be an important part of the process of change for individuals.

OTs see people as ‘occupational beings’, ideally fully engaged in the world of activity with a balance of work, rest and play. Illness, disability or old age can disrupt this balance, sometimes suddenly and catastrophically, sometimes gradually and imperceptibly. The strategies that someone used earlier in their life to overcome problems may no longer be viable.

OTs can help someone envision a new possible self. Story telling and story making may be used explicitly, or the OT may be alert to naturally occurring opportunities. Storytelling occurs very naturally during the ‘doing’ of activities, therefore it naturally happens in group based interventions. This can be facilitated into a discussion that allows consideration of new possibilities that are continuous with the previous occupational life of each person. One individual described the process as “recycling the old me into the new me” (Clark in Zemke & Clark 1996).

Storytelling provides valuable insight into an individual’s previous life, what they valued and why. This provides resources that can be used in the building of a new self-identity and future.

Story making uses these insights and may include ‘coaching’ and encouragement to develop what has been learned to develop a new occupational being. This process moves beyond the basic activities of daily living that often become the focus for rehabilitation and into the domains that make someone value their life and includes activities that promote health and well-being.

For anyone interested in learning more about this complex and fascinating process, a couple of key texts to begin with are:

Clark FA (1993) Occupation embedded in a real life: Interweaving occupational science and occupational therapy. American Journal of Occupational Therapy 47:1069

Clark F, Ennevor BL & Richardson P (1996) A Grounded Theory of techniques for Occupational Storytelling and Occupational Story Making in Zemke & Clark !1996) Occupationall Science: the Evolving Discipline. USA.

R is for Risk.....

 

As Occupational Therapists we are often asked is it ‘safe’ for an older person to return home from hospital; what are the ‘risks’? Generally, this is referring to physical safety risks- will the person fall? Is there a steep stair-case with no rails? Might they set the kitchen on fire by forgetting a pan left on?

There is always a push to get patients home and free up beds, and of course hospital is not a good place for an older person to be. There is not the luxury of unlimited time to spend following up on someone who has recently got home from hospital. All these factors can mean that in planning for an older person’s return home, the emphasis on ‘safety’ means requiring them to not engage in certain occupations or use certain parts of their home, to become dependent instead of independent. There is a balance to be struck, and sometimes the person feels it is time to let go of previous occupations themselves, but there is a danger of discouraging valued occupations that contribute to an individual’s sense of self-efficacy and well-being.

In my J post, I looked at a paper by Jackson (in Zemke & Clark 1996- see books tab at top of page) called “Living a Meaningful Existence in Old Age’. One of the factors that she identified as contributing to a meaningful life was the chance to take ‘risks’. This did not mean doing dangerous or foolhardy things, but that people still wanted the opportunity to try new things, to learn new skills, to succeed or fail, to experience new things, to have challenge and excitement. It could also mean choosing to continue to engage in an activity that is personally meaningful. When an individual becomes disabled, they are often deprived of these opportunities.

As OTs our job is to enable individuals to participate in their chosen occupations as safely as possible, not to stop them! I’d be very interested to hear people’s thoughts on this.

Q is for Questions..

Questions I have been asked since my study visit to learn about the Lifestyle Redesign® occupational therapy approach. I wanted to investigate how it could be used to improve the hospital/home interface for older people.

Q- So what is the difference between Lifestyle Redesign® and Occupational Therapy?

A- I heard several different OTs, lecturers, researchers and clinicians give their view on this during my visit- “Lifestyle Redesign® is occupational therapy!”

Q- Why the trademark?

A-   The Division of Occupational Science and Occupational Therapy at University of Southern California (USC) developed the approach. Only OTs who have completed certification at USC can use interventions called Lifestyle Redesign®. The Division wanted to protect the quality of any research (and therefore evidence base) that used an approach calling itself Lifestyle Redesign®. The methodology has been widely publicised and use of it its welcomed, however programmes need to be entitled something different e.g. the Lifestyle Matters programme developed in the UK (Craig & Mountain 2007- see books tab at top of page).

Q- But how are things like weight management groups relevant to OTs working in hospital settings? Most OTs don’t work in that sort of way?

A-   While I was on my study visit I experienced the approach being used in many different settings and with many very different client groups. This demonstrates it’s versatility and adaptability to many different areas of work. Lifestyle Redesign® is a conceptual approach that can be used to develop programmes for individuals or groups, but it is not an instruction manual. There are complex issues to be understood and incorporated into interventions.

The approach takes an occupational view of individuals functioning and emphasises the health promoting aspect of redesigning an individuals occupations in a way that is meaningful for them.

Preventative work is an area where OT has a lot to offer (see my P post yesterday) and is a key area of current UK health care policy.

Q- But we haven’t got time to do this sort of thing!

A-   This approach provides a person centred, evidence based, health promoting approach using core OT skills. If used with older people at the hospital/home interface, it has the potential to improve outcomes and reduce readmission rates, thereby reducing costs. Changing practice is always difficult, especially in fast moving acute services, but we need to consider the old question of whether we are ‘doing the job right- or doing the right job’!

P is for prevention...

 

Prevention is better than cure, so the saying goes. As the population in the developed world ages and there are many more people who have chronic conditions and illnesses many of which are lifestyle related, government policy is changing. Services like the National Health Service were set up to treat illness. Now the emphasis is changing and there is more focus on prevention of illness and on helping people who have chronic conditions to manage their illness. There is a greater emphasis on health and wellbeing.

Occupational Therapists (OTs) have traditionally worked in rehabilitation or recovery settings, but have the skills and in depth knowledge to deliver preventative programmes based on occupation, or peoples’ daily routines that are effective and sustainable.

Last year I heard Dr Sheena Blair speak at the Student Occupational Therapy Links Scotland(SOTLS) conference in Glasgow. Dr Blair concluded that as occupational therapists, our next big challenge and emerging area of practice is in public health and in the prevention of illness. Follow this link to read my post about the conference.http://www.blogger.com/blogger.g?blogID=7020627754640309197#editor/target=post;postID=7331785227788042008

During my recent study visit to the University of Southern California to investigate the Lifestyle Redesign® occupational therapy approach developed there, I learned about it’s use in many different areas f practice, including prevention.

Preventative occupational therapy can be categorised into three areas, primary, secondry and tertiary. The examples given below to illustrate this are from the Lifestyle Redesign® Diabetes Programme developed by Dr Chantelle Rice, but could easily be applied to other situations or conditions.

Primary prevention is defined as education or heath promotion strategies designed to help people avoid the onset of unhealthy conditions, diseases, or injuries.

• Example: Both of an individual’s parents have diabetes and he/she is overweight with high blood pressure and elevated blood sugar levels.

Secondary prevention includes early detection and treatment designed to prevent or disrupt the disease process.

• Example: An individual was just diagnosed with diabetes and according to lab results, their physician believes that he/she has had diabetes for approximately 6 months. He/she does not have any of the chronic conditions associated with diabetes and should focus on healthy eating routines, physical activity and other healthy habits to control blood sugar, lipids and pressure.

Tertiary prevention refers to treatment and services designed to arrest the progression of a condition, prevent further disability, and promote social opportunity.

• Example:An individual has had diabetes for 10 years, has suffered from a stroke, and currently lives with diabetic retinopathy, tingling in their fingers and numbness in their feet. Facilitating the implementation of healthy lifestyle habits to prevent the further development of chronic conditions, or additional conditions, and increase ability and function in activities of daily living.

Reference

Brownson, C. (2001). Occupational Therapy in the promotion of healthy and the prevention of disease and disability statement. The American Journ Occupational Therapy, 55 (6), 656-660.

O is for Occupational Therapy...

‘A simple of definition of Occupational therapy is that it helps people engage as independently as possible in the activities (occupations) which enhance their health and wellbeing

Occupational therapists, with the assistance of OT support staff, help people of all ages who have physical, mental or social problems as a result of accident, illness or ageing, to do the things they want to do. These could be daily activities that many of us take for granted, from grocery shopping or brushing your teeth, to more complex activities such as caring for children, succeeding in studies or work, or maintaining a healthy social life.’

(College of Occupational Therapists, UK)

Earlier this year I undertook a study visit to the US to find out more about an OT approach developed at the University of Southern California. Using the Lifestyle Redesign® approach in OT very much fits with this definition, in particular it makes explicit the health-promoting aspects of meaningful occupation and the positive impact this has on health and well-being.

Because OTs work in such diverse areas, it is often difficult for others to  understand what OT really is. I’d like to share with you a recent blog post by Dr Florence Clark, AOTA President and Associate Dean of the Division of Occupational Science and Occupational Therapy where a spent my study visit. She offers 20 ‘sound bites’ to explain what OT is. Follow this link to read Dr Clark’s blog, meanwhile, here are a few of my favourites:

‘OT practitioners can help older people maintain their independence by customizing a daily living plan for them and adding design elements to their homes. Just as there is no diet that fits everyone, there is no plan that guarantees independence for everyone. What OT practitioners do is customized life design.’

‘Occupational therapy practitioners are like engineers, trained in multi-faceted educational content. We rebuild broken lives which requires not only preparation in biomedical conditions, but also in the theories of health behavior and activity participation.’

‘When catastrophic illness or disability occurs, walking may stop but life goes on. Occupational therapy practitioners help people get back to life, to family, to work, and to the community in order to “live life to its fullest” no matter what.’

N is for Nutrition...

Nutrition seemed to come into everything during my recent study visit to the University of Southern California.

As a UK based Occupational Therapist (OT), this was unexpected. I found the Lifestyle Redesign® approach being used in areas of work such as weight management where, of course the emphasis was explicit. In other areas of work, such as the group I spent a session with who had had a stroke and were working on lifestyle issues to help prevent another, it formed an important aspect of the intervention. I attended the first 8 weeks of the Masters programme course on Lifestyle Redesign® where learning about nutrition, and about the factors that drive ‘conditioned hypereating” (David Kessler 2009- see the books tab at the top of this page).

Initially I wondered if it would be more appropriate for a dietician to be involved, but I came to understand that using this approach takes an occupational view of the issue and individuals were enabled to develop strategies that allow them to develop new routines and habits in their daily lives that are health promoting and sustainable, and that is the definition of Lifestyle Redesign®.

It might be too big a step for OTs to work in exactly that model in the UK, but there is certainly scope to reflect on whether and how we should be bringing more focus onto nutrition for many of our clients. I think about some of the older people I work with who are reliant on visits from carers to provide all their meals. Time constraints mean that they are often eating ready microwave meals daily and sometimes at almost every meal. Poor nutrition has an impact on function and on quality of life. So is it an issue for OTs to address? I’d love to know what people think...

M is for Motivation....

Or more precisely Motivational Interviewing (MI).

MI can be defined as ‘a client centred, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence’.

This definition comes from Miller and Rollnick’s 2002 book, Preparing People for Change.

MI skills are important for Occupational Therapists (and of course other professionals) as a therapist with these skills can greatly increase the efficacy of their interventions with clients, particularly when working on any process of changing to develop health promoting habits and routines.

To use MI skills most effectively, it is important to understand the stages of the change process. A well known model is that of Prochaska & Norcross in their book Changing for Good (1994). They set out the following stages (imagine making a change such as trying to give up smoking and they will probably make sense):

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination

In understanding what point in the process someone is at, a skilled therapist can tailor thier MI skills in the most appropriate way. Of course, change is sometimes enforced, not chosen e.g. after illness of accident. The process of change does not happen in as neat and linear fashion as the model above might seem to suggest. Using the example of giving up smoking, it can often take several attempts and the stages need to be gone through more than once.

AS OTs, developing our MI skills can help us make the most effective use of our often limited time with clients, and to help them towards their goals more effectively.

L is for Lifestyle Redesign®...

 

Lifestyle Redesign® is ‘a process of acquiring health promoting habits & routines in daily life” (Clark et al 1997- see Books tab at top of page)

 ‘Is the process of incorporating health-promoting habits & routines into your daily life. OTs look at how you “occupy” your time, and how the daily activities you engage in affect your overall health, wellness and life satisfaction”-USC OT Faculty Practice

 Four core beliefs of the OT profession informed the design of Lifestyle Redesign®:

• Occupation is life itself
• Occupation can create new visions of possible selves
• Occupation has a curative effect on physical and mental health and on a sense of life order and routine.
• Occupation has a place in preventive care. (Mandel et al 1999)

Earlier this year I visited the University of Southern California Division of Occupational Science and Occupational Therapy in Los Angeles to learn more about Lifestyle Redsign® and to look at how it could be used to improve the hospital/home interface for older people. My visit was funded by a Winston Churchill Memorial Trust travel award (more on this when we get to W). This blog began as a record of my visit. I am continuing it to record my experiences following the visit and to reflect on my learning.

The ‘®’ symbol denotes that Lifestyle Redesign® is trademarked. This prevents anyone not fully qualified by USC from carrying out interventions called ‘Lifestyle Redesign’. The trademark was acquired by USC to protect the quality of research being done using this approach, not to prevent use of the methodology. Many OTs have drawn on the concept and this is welcomed, but programmes need to be entitled something different e.g. the Lifestyle Matters programme developed in the UK (Craig & Mountain 2007).

K is for Keck Hospital....

Keck Hospital Occupational Therapy service carried out a small scale pilot using Lifestyle Redesign in the acute hospital setting. A poster was produced that was presented at the American Occupational Therapy Association conference.

The patients were a group who were in hospital and had Venticular Assist Devices (VAD) while awaiting heart transplant. This is a highly complex procedure and very limiting to normal lifestyle and activities. The OTs worked with the patients using a variety of methods to address each individual's issues and needs. For all there was an emphasis on trying to include the 'ordinary', a challenge in such an acute hospital setting. Most patients required stress/anxiety management as part of their programme.
Despite some limitations due to the setting and varying medical fitness of patients to participate, the pilot study concluded that:

'Utilizing Lifestyle Redesign® tools in an acute care setting bridges the gap between traditional care and health promotion yielding greater access to occupational health and wellness potential for our clients and those that care for them.'

I am grateful to the authors of the study Whitney Pike OTR/L, CLT, Katie Jordan OTD, OTR/L and Camille Dieterle OTD, OTR/L for permission to share the poster.