Carolyn A. Unsworth

Factors that lead to successful community integration following severe traumatic brain injury.

ObjectiveTo assess and identify predictive factors of community integration of people 3 to 15 years after severe traumatic brain injury (TBI). ParticipantsForty participants with severe TBI (an average of 8.8 years postinjury). Main Outcome MeasuresThe Community Integration Questionnaire, the Community Integration Measure, and the Sydney Psychosocial Reintegration Scale. Data related to factors that may predict community integration were also collected. ResultsThere was considerable variation in the level of community integration. Discriminant function analyses identified the following factors as predictive of the level of community integration: severity of injury, age at the time of injury, level of disability, and challenging behavior. ConclusionInterventions that minimize challenging behavior and disability may make a significant difference to the level of community integration experienced by people with severe TBI.

The Concept of Function

It appears that the focus of occupational therapy on function has moved away from the concept to centre on assessments. Conceptual debate concerning function has been muted and lost in the technicalities of the measurement process and measurement theory. Numerous reviews of functional assessments have recently appeared in the occupational therapy literature.1–5 Current discussions appear to be driven by technical issues, such as the demonstration of the reliability and validity of specific measures, rather than the extent to which the design and structure of the measures form the most appropriate conceptualisation of function. A re-centring of this issue towards conceptual discussions and away from measurement technicalities is highly desirable. The purpose of this article is to review the ways function is currently perceived and to raise many of the questions that the profession must debate and resolve regarding this issue.

The Clinical Reasoning of Novice and Expert Occupational Therapists

Over the past 15 years, research in health sciences has consistently shown that differences in the performance of novice and expert clinicians are predominantly due to their clinical reasoning abilities. Furthering our knowledge of the ways expert and novice occupational therapists reason can help us to explicate the complexities of practice and ultimately assist novices to think like experts. This paper presents the findings of a study which investigated qualitatively and quantitatively the clinical reasoning of novice and expert occupational therapists. Three expert and two novice occupational therapists working in rehabilitation settings wore head-mounted video cameras while completing three therapy sessions (assessment, treatment, discharge planning). Therapists then viewed the videos and reported back on their reasoning. These verbal reports were transcribed and analysed. While the quantitative results indicated several differences in both the amounts and types of clinical reasoning used by novices and experts, the qualitative analyses were more useful in revealing differences in the ways these two groups presented their clinical reasoning. The findings suggest that novice therapists could benefit from spending more time reflecting on the therapy process, and discussing their therapy with expert colleagues.

To Continue, Modify or Relinquish Driving : Findings from a Longitudinal Study of Healthy Ageing

Background: The number and proportion of drivers among people entering later life continues to rise. More information on patterns of driving for older adults is required to improve service provision and traffic planning. Objectives: To map the changes in driving status for a sample of drivers aged 65 years or older over the period 1994–2000, and to identify factors associated with older people continuing, modifying or relinquishing their status as drivers. Methods: The 752 participants were drawn from the Melbourne Longitudinal Studies on Healthy Ageing (MELSHA) program, a longitudinal study of people aged 65 years and older living in the community. Participants were interviewed or contacted for follow-up in 1994, 1996, 1998 and 2000 on a range of topics including their health, functional independence and driving status. Results: Although the number of recent drivers was smaller as participants died or were admitted to nursing homes over the 6-year data collection period, relatively few participants relinquished driving while remaining in the community. Many drivers reported modifying their driving habits over time, including decisions to restrict their driving to their local area during daylight only. Relationships were explored between driving status and the key variables of age, gender, marital status, instrumental activities of daily living (IADL) independence and self-rated measures of income, health, eyesight and hearing. Multivariate analyses indicated that drivers were more likely to modify their driving habits if they were older, dependent in IADL, and rated their eyesight as poor. Similar factors predicted relinquishing driving, but in addition, women were three times more likely to relinquish driving than men (even when health and disability were taken into account) and people who rated their incomes as ‘comfortable’ were more likely to relinquish driving than those with lower incomes. Conclusions: This study confirmed previous evidence that older drivers self-regulate by modifying their driving behavior as they age. However, since few drivers voluntarily relinquish driving, further research is required to identify ways of supporting older drivers to continue to drive safely.

Clinical Reasoning: How do Pragmatic Reasoning, Worldview and Client-Centredness Fit?

Using both clinical reasoning data and literature from the past 20 years, this paper sought to examine the relationship between client-centred practice and clinical reasoning, to explore the concept of pragmatic reasoning and to present a diagrammatic conceptualisation of our knowledge of clinical reasoning in occupational therapy. The clinical reasoning literature published between 1982 and 2001 was reviewed and this information was combined with the findings from a study which used a head-mounted video camera to collect data and then explore the clinical reasoning of 13 experienced occupational therapists. The data were collected and analysed within a focused ethnographic framework. The findings showed that clinical reasoning occurred in the context of client-centred practice, but that a reciprocal relationship appeared to exist between client-centred practice and interactive reasoning. It also appeared that pragmatic reasoning was related only to the therapists practice context and that all forms of reasoning were influenced by the therapists worldview. A diagram was developed to depict this current understanding of the modes of clinical reasoning. While clinical reasoning has been described as the guiding force in a therapeutic practice, we are only just beginning to understand the nature of reasoning and reflection and how clinicians think. Further research is required to build and test the emerging theory of clinical reasoning in occupational therapy.

Rehabilitation team decisions on discharge housing for stroke patients

For older people who have had a stroke, appropriate housing can promote independence and well being. However, suboptimal team accommodation recommendations may result in placement of an individual where their needs are not met, and their skills are not maximized. Although clinical judgments regarding patient discharge are routinely made by rehabilitation teams, this area has received limited research attention. This study examines how rehabilitation teams determine the most appropriate housing to recommend to stroke patients after their discharge from hospitals. A Social Judgment Theory approach was used to document and analyze the accommodation recommendations and policies of 13 rehabilitation teams (clinician n = 74). Teams were asked to consider 50 hypothetical stroke patients, and determine the most appropriate discharge housing to recommend to these patients. Each stroke patient was described in terms of 8 attributes: mobility status, ability to manage their own affairs, patients choice of housing, personal activity of daily living (ADL) skills, domestic and community ADL skills, general health status, social situation, and premorbid living arrangements. Clinicians were provided with a response scale on which to record their recommendations. The results showed considerable yet reliable differences among teams concerning recommendations made, and judgment policies adopted. Although the highly structured and hypothetical nature of this research limits the external validity of findings, the results suggest that teams may also face difficulties with housing recommendations in the more complex clinical environment. Further studies to assess actual clinical team decision making are needed. Such studies could lead to the development of a standardized research-based protocol to help teams formalize and optimize their housing recommendations.

The importance of pretend play in child development: an occupational therapy perspective

Play is a complex behaviour and is defined as being more internally than externally motivated, transcending reality as well as reflecting reality, controlled by the player, involving more attention to process than product, safe, usually fun, unpredictable, pleasurable and spontaneous and involving non-obligatory active engagement (Bundy 1997, Stewart et al 1991). Pretend play, which occurs between the ages of 18 months and 6 years, reflects these qualities of play. Using the World Health Organisations classification of body functions and structures, activities and participation (ICIDH-2, WHO 1999), this paper outlines the skills that are essential for pretend play ability and asserts that if there are any impairments in these skills the child experiences a reduced ability to pretend play. This leads to possible participation restrictions in the childs life, such as difficulties in fulfilling usual social roles. Cognitive, social and emotional skills are presented as having the biggest impact on pretend play development, while the motor and sensorimotor skills that enable the child to manipulate objects in the environment are presented as being of secondary importance. Two models are offered which illustrate the importance of pretend play to child development and the sequence of play development. The paper concludes by recommending that occupational therapists address and reduce the participation restrictions that some children experience in learning and social situations by enabling a child to increase activity in pretend play.

A systematic review of hospital experiences of people with intellectual disability

BackgroundPeople with intellectual disability are at risk of poor hospital experiences and outcomes. The aims were to conduct a content and quality review of research into the acute hospital experiences of both people with intellectual disabilities and their carers, and to identify research gaps.MethodA systematic search was conducted of primary research between 2009 and 2013 that addressed the experiences of the target group in general acute care hospitals. Quality appraisal tools yielded scores for quantitative and qualitative studies, and overarching themes across studies were sought.ResultsSixteen studies met inclusion criteria. Quality scores were 6/8 for a survey, and 2/11-9/11 (mean =5.25) for qualitative studies/components. Content analysis revealed seven over-arching themes covering individuals’ fear of hospital encounters, carer responsibilities, and problems with delivery of care in hospitals including staff knowledge, skills and attitudes.ConclusionsOur review of eligible papers revealed that despite 20 years of research and government initiatives, people with intellectual disability continue to have poor hospital experiences. The need for research to identify and investigate care at specific points of encounter across a hospital journey (such as admission, diagnostic testing, placement on a ward, and discharge) as well as to include people with a diversity of disabilities is discussed in terms of potential to influence policy and practice across health and disability sectors.

Development of a Standardised Occupational Therapy – Driver Off-Road Assessment Battery to Assess Older and/or Functionally Impaired Drivers

INTRODUCTION Research has been conducted over several years to develop a new off-road assessment battery referred to as the Occupational Therapy - Driver Off-Road Assessment Battery. This article documents the development of the Battery, and provides preliminary research evidence to support its content and predictive validity. METHODS Literature reviews and a focus group with nine driver assessor occupational therapists were undertaken, as well as data collection using the Occupational Therapy - Driver Off-Road Assessment Battery with 246 clients. A Classification and Regression Tree model was constructed to ascertain the predictive validity of the Battery, with fitness-to-drive as the outcome. RESULTS Twenty-one physical, 13 sensory and seven assessments of cognition/perception were identified as being reflective of the skills required for driving. Following rating of their psychometric properties, the best assessments were presented to focus group members. The driver assessors supported the inclusion of several assessments and encouraged the development of new assessments. A draft version of the Occupational Therapy - Driver Off-Road Assessment Battery was tested and found to have excellent predictive validity for client on-road performance of 82.6%. The Classification and Regression Tree model showed that client performance on tests included in the Battery should be used together, rather than in isolation, to support fitness-to-drive recommendations. CONCLUSION This research identified the most suitable physical, sensory and cognitive assessments to include in the Occupational Therapy - Driver Off-Road Assessment Battery, and provided support for its validity. The development of this standardised battery assists driver assessors to accurately and consistently assess and report the off-road driving capacity of clients.

Developing Skills in Everyday Activities and Self-Determination in Adolescents With Intellectual and Developmental Disabilities

Autonomous functioning, an essential characteristic of self-determined people, has been categorized behaviorally according to everyday activities in Self & Family Care (SFC), Life Management (LM), Recreation/Leisure (RL), and Social/Vocational (SV) skills. The effectiveness of a short-term (8–10 weeks) educational residential program to improve skills in these categories of everyday activities in adolescents with intellectual and developmental disabilities was examined, and the effect on participant self-determination was also measured. Results from this single-group, quasi-experimental research with three data collection points (n = 31 from five cohorts over an 18-month period) found that participants’ skills in SFC/LM and RL had improved significantly with large effect sizes at postprogram and 3-month follow-up. Skills needed for SV activities did not show the same level of improvement, but participant-rated self-determination scores (as measured by the AIR Self-Determination Scales) improved significantly with small effect size at postprogram and moderate effect size at follow-up.