Donald Fogelberg

A complexity science approach to occupation: Moving beyond the individual

Contemporary scholarship in occupational science ranges from the biological to the cultural, which highlights the need for a systematic framework capable of addressing occupational phenomena at multiple levels of analysis. One way theorists in occupational science, as well as in other social and biological sciences, have addressed similar needs has been through models based on systems theory. These theories encourage a non‐reductionist, non‐linear approach to studying complex phenomena, and allow for the inclusion of multiple levels of analysis, from the micro to the macro. However, most of the previous applications of systems theory in occupational science have adopted a relatively narrow focus, stressing the occupation of individuals as the primary unit of analysis and viewing social and cultural phenomena as background factors influencing those occupations. Occupations performed by groups of individuals acting collectively have not been incorporated. In this article, we argue that social collectives, such as groups, communities, and populations also act as producers of occupation and that these collective occupations are also legitimate units of analysis for occupational science. We propose an analytic framework for understanding occupation which is grounded in complex systems theory, integrates across multiple levels of analysis, and highlights the socially distributed nature of occupation.

Client Centeredness and Health Reform: Key Issues for Occupational Therapy.

Health reform promotes the delivery of patient-centered care. Occupational therapys rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapys perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapys research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

Expanding client-centred thinking to include social determinants: a practical scenario based on the occupation of breastfeeding

Abstract Background: Client-centred thinking in occupational therapy underemphasizes the influence of social determinants and societal-level factors on occupation across the life course. When client-centred thinking focuses solely on the local or immediate contexts of individuals, therapists may not fully recognize or understand how social determinants can create barriers to occupational participation and performance. Aim/Objectives: This article critically examines gaps in traditional thinking concerning client-centredness and demonstrates how the complex interplay between social determinants and societal-level factors may lead to occupational injustices. Material and methods: A practical example from a recent study on breastfeeding and accompanying scenario is used to examine limitations in current client-centred reasoning. The Life Course Health Development framework, a theoretical framework examining contexts of health disparities, is applied to illustrate the opportunity to expand thinking about client-centredness. Results: The Life Course Health Development framework may be a useful addition to client-centred thinking about social determinants of occupation. Conclusion and significance: Expanding client-centred thinking to include awareness, understanding, and respect for social determinants of occupation may enhance therapist–client interactions and outcomes of the occupational therapy process, and address gaps in current thinking that may contribute to occupational injustices.

Comparison of Self-Report Sleep Measures for Individuals With Multiple Sclerosis and Spinal Cord Injury

OBJECTIVE To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING Community based. PARTICIPANTS Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point. INTERVENTIONS None. MAIN OUTCOME MEASURES Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form. RESULTS Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P<.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P<.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069). CONCLUSIONS Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction.

Napping and Nighttime Sleep: Findings From an Occupation-Based Intervention

OBJECTIVE To describe sleeping behaviors and trends over time among an ethnically diverse group of community-living older adults. METHOD A descriptive secondary data analysis of a subsample (n = 217) from the Lifestyle Redesign randomized controlled trial was done to explore baseline napping and sleeping patterns as well as 6-mo changes in these outcomes. RESULTS At baseline, the average time sleeping was 8.2 hr daily (standard deviation = 1.7). Among all participants, 29% reported daytime napping at baseline, of which 36% no longer napped at follow-up. Among participants who stopped napping, those who received an occupation-based intervention (n = 98) replaced napping time with nighttime sleep, and those not receiving an intervention (n = 119) experienced a net loss of total sleep (p < .05). CONCLUSION Among participants who stopped napping, the occupation-based intervention may be related to enhanced sleep. More research examining the role of occupation-based interventions in improving sleep is warranted.

Occupational Therapy and Management of Multiple Chronic Conditions in the Context of Health Care Reform

One in four individuals living in the United States has multiple chronic conditions (MCCs), and the already high prevalence of MCCs continues to grow. This population has high rates of health care utilization yet poor outcomes, leading to elevated concerns about fragmented, low-quality care provided within the current health care system. Several national initiatives endeavor to improve care for the population with MCCs, and occupational therapy is uniquely positioned to contribute to these efforts for more efficient, effective, client-centered management of care. By integrating findings from the literature with current policy and practice, we aim to highlight the potential role for occupational therapy in managing MCCs within the evolving health care system.

Qualitative Experience of Sleep in Individuals With Spinal Cord Injury

Poor sleep contributes to adverse health outcomes making it important to understand sleep in medically vulnerable populations, including those with spinal cord injury (SCI). However, little attention has been paid to circumstances specific to SCI that may negatively affect sleep, or to consequences of poor sleep in this population. The objective of this study was to examine the experience of sleep among individuals with SCI. Secondary analysis using thematic coding of qualitative data from an ethnographic study of community-dwelling adults with SCI was conducted. Sleep-related data were found in transcripts for 90% of the sample. Participants described diminished sleep duration and irregular sleep patterns. Several factors contributing to poor sleep were identified, including SCI-related circumstances and sleep environment. Participants also discussed how poor sleep affected occupational engagement. This study highlights the extent of sleep disturbance experienced after SCI and the subsequent impact on occupational performance, and provides direction for clinical practice.

The role of habit in recurrent pressure ulcers following spinal cord injury

Abstract Background: Despite the existence of numerous prevention strategies, pressure ulcers remain highly prevalent in those with spinal cord injury (SCI). The concept of habit, broadly defined, may help understand the persistence of this problem and offer strategies for its mitigation by occupational therapy. Aim: The aim of this paper is to describe the relationship between habits established prior to sustaining an SCI and post-injury habits that impacted on pressure ulcer risk. Methods: Secondary analysis of qualitative data collected during an ethnographic study of community-dwelling adults with SCI. Results: Participants’ habits appeared to substantially affect their risk of developing pressure ulcers. Habits established before incurring the SCI either facilitated or hindered the acquisition of new habits intended to prevent pressure ulcers. Conclusions: An understanding of the individual’s pre-existing habits may be important when designing a rehabilitation programme intended to minimize risk of pressure ulcer development following SCI. Habit-change strategies could be used to supplement education in pressure ulcer prevention techniques. Significance: Occupational therapists have a longstanding interest in habit. A more comprehensive understanding of this concept may provide important insights into the persistence and management of pressure ulcers following SCI.

Comparison of Sleep Problems in Individuals with Spinal Cord Injury and Multiple Sclerosis

STUDY OBJECTIVES Sleep problems are common in spinal cord injury (SCI) and multiple sclerosis (MS). However, the degree to which sleep problems differ between these distinct clinical populations has not been evaluated. In this study, we examined self-reported sleep problems in individuals with SCI and those with MS, and compared these clinical groups on the Medical Outcomes Study Sleep Scale (MOS-SS). METHODS Participants were 1,677 individuals (SCI = 581; MS = 1,096) enrolled in longitudinal study of self-reported health outcomes in SCI and MS. Univariate and multivariate analysis of covariance examined group differences on global sleep problems and domain-specific subscales of the MOS-SS. RESULTS Individuals with SCI reported an average of 30 fewer min of sleep per night (Sleep Quantity subscale) and significantly greater difficulty initiating and maintaining sleep (Sleep Disturbance subscale) compared to individuals with MS. However, groups did not differ on global sleep problems (Sleep Problems Index 9). CONCLUSIONS Although global sleep problems are more common in SCI and MS than in the general population, these groups exhibit differing sleep problem profiles, and thus may require unique treatment approaches to address the specific domains of sleep affected. For individuals with SCI, an additional focus on increasing sleep quantity and reducing sleep disruptions may be warranted.

Capstone Projects as Scholarship of Application in Entry-Level Occupational Therapy Education

ABSTRACT Capstone projects are integrative student learning experiences used in higher education. This article describes the value and merit of capstone projects as scholarship of application within an entry-level occupational therapy education program. The capstone process is outlined and roles and responsibilities of student, faculty members, and community mentors described. Summative curricular evaluation from 5 years of capstone projects indicated that project characteristics and objectives aligned with the theory and desired outcomes of applied scholarship in the areas of student learning, faculty practice and development, and community service. Challenges identified can further inform development of the capstone experience in occupational therapy education.