Importance of Group Work for Occupational Therapy

Continuing professional development (CPD) is a focus for  healthcare professionals, with lifelong learning of as a lead component (Stead, p. 174). The Royal College of Occupational Therapist (RCOT) recognise CPD as a proficiency embedded within the profession, stating in the Code of Ethics and Professional Conduct (2015) that a therapist must continue their lifelong learning through learning activities to ensure practice is safe (p.34). The Code of Continuing Professional Development (COT 2014) sets out the expectations for therapists aligned with the Health and Care Professions Council (HCPC) requirements. The code places the responsibility for learning on therapy personnel, who must ensure that their career journey ‘fulfils’ and ‘sustains’ the profession in changing contexts (2015 p.40).

Two key ways in which an occupational therapist can demonstrate their knowledge, through continuing professional development is via group work, and by analysing and critiquing evidence bases and their significance to the continued development of the field. Group work; with its complexities, provide different challenges to bring out the professional qualities of the therapist, as well giving therapists a forum for growth. This assignment will look into the importance of group work for an occupational therapist; the significance of the skills and their transferability within the workplace, using relevant literature on leadership, group skills, reflection, and lifelong learning to unpick the theoretical arguments surrounding group work. I will also reflect on my own experiences of group work on my University course [to date] to support or challenge ideas.

The second part of this assignment will analyse the relevance and value of service user knowledge as an evidence base. Within a person-centred field, the voice of the service user should be primitive to the care provided, however, literature would suggest that there are potential issues with this construct. This assignment will analyse the literature surround service user evidence and critique its credibility in the scope of occupational therapy.

A reflection on the process and content of group/teamwork

As life expectancy in the UK increases, so have the strains on healthcare. With an aging population, there are new expectations of health and social care services, often putting unprecedented requirements on the workforce (Stead, et al. p. 174). As a result, healthcare professionals have a duty to develop their learning to cope with these increasing demands. The concept of lifelong learning was developed as a means of ensuring personal growth, with the aim of building a workforce that could ultimately work creatively and collaboratively to respond to the changes in healthcare (Stead, et al. p.174).

Groups have been used by occupational therapists since the early days of the procession. The types of groups have been influenced by changes in health-care delivery as well as the needs of individuals. (Schwartzberg, 2009, p 176). Working in groups cohesively and productively is a fundamental skill of an occupational therapist and one that must be improved upon throughout a therapist’s career. As most continued professional development occurs in cultural and social contexts, the health and social care teams in which occupational therapists work can often be rich grounds for learning (McKay 2009, p.58).  There are many theories why working in groups is productive, including Freire (1972), who states that it is through working together as a team, or as a community of practitioners, that we can work to transform practice (Freire, 1972). This module of my course has put group work as one of its key learning outcomes with the set-up of our problem-based learning groups (PBL), and many set tasks that involve collaborative thought and peer-assisted learning (Ashwin, 2002). Peer learning is imperative when partaking in healthcare placements and professional-education settings throughout a career in healthcare.

My problem-based learning group is a mix of ten females, aged from 18-31. Appendix 1 provides a breakdown of each member for reference. Our group work in PBL and mixed cohort settings provide opportunities to interact as peers, and also as professionals. Group work provides a space to practice professionalism. Professionalism carries authority and competence that, as students, we must practice and master before interacting with service users. Through having had a professional career previous to the course, I bring my confidence in handling matters professionally to group work tasks and discussions. This confidence often sees me step into the role of group chair/leader.

Cole (2018) states that an important factor in a group’s motivation is its confidence in the leader. If a leader takes command of the group with authority, the group will, in turn, be inspired and feel confident (p.11). This, in turn, will be reflected in practice; if service users feel confident in their therapist who demonstrated confidence and empathy, they will tend to be more co-operative (p.11). When exhibiting a level of leadership within a group, I have found that the perception of leadership and leadership qualities varies, depending on the group member in question. For example, a trend I have noticed is that within my PBL group, where there are younger members of the team (Appendix 1), have explained in group feedback that they find confidence can be intimidating, whereby in cohort groups with members of the same age of myself, or older, they have found it inspiring and has made them enthusiastic about a project. According to Schutz’s (1958) theory, I am currently in the control stage of development within groups. Having been through the inclusion phase, I am now in a process of questioning my acceptance within group settings; often questioning the influence I possess, do the team view me with scepticism, and potentially mistrust? As a professional, I need to be aware that this level of challenge is healthy and understand how my actions can be adapted to handle this challenge. Understanding the patterns of one's behaviour through getting impressions from others is commonly referred to as 'reality testing'. This process can take place by hearing other members' and the leader's observations. Similar to process comments, reality testing focuses on opportunities in the group for consensual validation of the member's observations with others in the group (Schwartzberg et al 2008).

Finlay (1993) suggests that groups that work together frequently; overtime the dynamics will change and develop.  However, on my experience, this isn't quite the case us as we have a more disjointed approach to our collective working. Rather than, as a team, build on our ways of previous learning and develop upon that foundation base, the PBL group can often forget what made us successful in the previous task. This could be aided through group reflection. Group reflection is an important skill to harness as a professional. Through teams coming together to share and discuss practice and events, via group reflection, it can inevitably lead to change to help improve services for clients (McKay 2009, p. 58).  The HCPC incorporates reflection into the Standards of Proficiency for Occupational Therapist specifically Section 11.1 states that the registrant must ‘understand the value of reflection on practice’ (HCPC, 2013). Winpenny et al (2006) offer an illuminating account of group reflection and explain that it is through sharing our experience and practice stories with others that we become participants in our joint practice with those in our group; gaining additional perspectives on a situation or event.  In my experience so far, we have not yet gained experience through practice-based learning, however, we each bring experience from previous employment roles or life events that we can use to enrich the group conversation on tasks. For example, Group Member 3, has experience in working in a mental health setting, which she will draw upon as a reference point when appropriate. I have experience in project management, team management, as well as knowledge of the care sector, which I bring to our group sessions. 

Storytelling is a common technique used to communicate information, develop a personal connection and establish rapport (Schwartzberg, 2002). This is a skill we can develop in our learning environment to then transfer to building connections with our service users. As learners in various group settings, we continue to bond over our storytelling sharing similar stories or different perspectives to build on our working relationships, and personal. In creating these bonds with each other over time, we can enable a better understanding of our learning needs and adapt to these accordingly. When we share stories, we are aware of self-disclosure (Mattingly and Fleming 1994) and actively decide what is appropriate to share in the aim of building our relationship and developing trust.

Ilott and Murphy (1999) state that trust is the foundation upon which the ultimate criterion of competence […] rests. We must demonstrate trust in a group as we will need to build trust with service users (Cross, 2006, p. 58). In a group, trust is fundamental to ensure it is a comfortable learning environment, where each member feels that they can contribute without judgement. Reflecting on my experience, we have had a few issues with collaborative working, which I believe could be down to not having a level of trust on which to build on. That is not to say that group members have not shown a level of trust, this has been evident when taking on tasks and ensuring that they are completed on deadline and to the expected standard. However, there appears to be generally lacking trust when it comes to communicating effectively when issues occur, and opening up about struggles, which often leads to frustration as we are not able to express ourselves. Most commentators agree that building a trusting relationship comes down to communication; creating an effective dialogue between those directly involved (Cross, 2006, p. 58).

Johns puts forward the claim that being mindful is an ‘extension of the internal supervisor.’ In that, being mindful, we are aware of our own patterns of intention and thinking (Johns, p. 8). Through reflecting on my experience within group work settings, I can see how it has contributed to my development as a practitioner. I have learnt that through being a reflective leader, I acknowledge and appreciate the differences when interacting with others, adapting my own approach to leadership dependant on the group setting. As an occupational therapy student, to work collaboratively and effectively, I need to be more skilled in conflict management, as well as helping to facilitate group communication and reflection to help build trust. This is a key skill I will need to master for when working with other healthcare professionals in a multi-disciplinary team. I am mindful of my strengths and continue to learn from others on how those strengths are perceived, as I continue my professional development and further my learning. 

An analysis of the relevance and value of service user knowledge and expertise within evidence-based occupational therapy practice.

There is an ongoing debate amongst healthcare professionals as to what classes as 'evidence'. An early definition of evidence-based practice derived from evidence-based medicine. Sackett et al (1996) defined evidence-based practice as 'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of patients’ (p. 71.) This definition is significant for laying the foundations of human-care services, indicating that therapists and practitioners may not find answers in evidence, but that the outcomes need to be applied appropriately by professional experts to find answers.

The underlining theory with evidence is the assumption that it will advance healthcare outcomes for the service and maximise the use of healthcare resources (Bick and Graham, 2010 p. 3). Service user involvement has been prevalent in the field of practice for many years, however, it could be said that service user involvement in research to inform practice has been slightly slower to develop (McLaughlin, 2010, p. ). However, Beresford (2005) put forward that, as practitioners, in order to understand service user involvement in research, we must first understand how we use service user involvement within the field of practice.

Service user perspectives are embedded within healthcare practice in the UK, with the service user also at the heart of many national frameworks in the UK (Department of Health 2001a, 2001b; Department of Health and Department for Education and Skills, 2004). Occupational therapists are trained to take a holistic, person-centred approach to the services provided. The Royal College of Occupational Therapy (RCOT) is committed to person-centred practice and the involvement of the service user as a partner in all stages of the therapeutic process (RCOT, 2015 p. V). Occupational therapy models such as Kielhofner’s (1997) Model of Human Occupation (MOHO) put service users at the centre of assessment and intervention, within the occupational therapy process.  Evaluation is key and it is imperative that therapists consider not only what outcomes are achieved through therapy, but to also reflect on how interventions were delivered to the service user. (Breckenridge et al, 2015). This poses therapists the challenge of how to take into consideration the voice of the service user in practice, while also questioning the credibility of the evidence.

Firstly, there have been queries on the idea of a service user. It’s been argued that this name is socially constructed and is forced onto an individual (Mclaughlin, 2010, p. 1593). Previous connotations of the term ‘service user’ proposes that a person is seen as ‘passive’; they are a recipient of having something ‘done to them’ (Cusack et al, 2000, p539). It ignored all the roles, which make up the person, contributing towards one’s identity. Consequently, this contradicted the values of an occupational therapist and poses a problematic approach to the person seeking services. The HCPC has since opened the construct of a service user, using it as a ‘broad phrase to refer to those who use or are affected by the services of registered professionals’ (HCPC, 2018). As therapists, we have to work out how to take into consideration the whole approach to a person, collaborating with them to record outcomes that are tangible and credible, while also being unique to the person requiring services. This collaboration exists between the service user and the therapist during intervention (Mclaughlin, 2010, p.1597).

To aid a collaborative approach, or ‘co-production’ (Momori et al., 2017, p. 21), there has been significant growth in development and use of instruments or models for evaluation. One of which are patient-reported outcome measures (PROMs) (Patrick et al, 2008) used to assess the impact of implementation. PROMs are usually self-completed questionnaires from the patient's perspective on their health concerns, symptoms or their general wellbeing (Fitzpatrick et al, 1998). The RCOT guide how therapists are to measure outcomes to develop the evidence base of the profession, regarding record keeping as a fundamental aspect of practice. The challenges with PROMs include working with the service user to identify and agree on what outcome they feel are important, as well as the opportunity for potential bias. When collecting feedback, therapists must acknowledge the complex realities of the person that often add context. There are often questions to be asked when analysing service user evidence, such as, how do we take into consideration the evidence of those who are not within the capacity to do so? How are we to judge the opinion of one individual in comparison with another? Are there factors that contribute to why we may need to disregard a specific service user as an evidence base? Was the service ‘successful’? Smith and Cantley (1985) proposed a pluralistic model of service evaluation to give all stakeholder an equal voice to judge what ‘success’ meant to them, they concluded that ‘success‘ was a measure based on personal experiences rather than a set measure. A pluralistic model differs from PROMS as more than one ‘service user’ voice is considered, although, as Salmon (2003) notes, there are issues surrounding how this data is to be generalised (p.316).

Within  evidence-based practice, there is skill required of practitioners to be able to engage with, and understand the needs of, service users. We must also learn how critically assess what is relevant and meaningful evidence to a particular circumstance (Davies, et al 2016, p. 18). The issue arises when evidence is compared with evidence from another service user. Occupational therapists are person-centred, providing unique care packages and interventions for each service user. This poses the question; how can one unique package be compared with another? There appears to be a gap in the research on how this conundrum can be solved and its place within the evidence-based practice process within occupational therapy. Although they looked at homelessness and mental health service users, Davies et al (2016) found that [generally] service users saw their place for involvement within the individual and representative levels in what Davies et al call ’the process of evidence-based practice’, however, the study confirmed that there needs to be a stronger emphasis on how the evidence is processed and analyses, in the content of the individual’s preferences and circumstances (p. 3).

Service user involvement is an established principle in healthcare. Collecting evidence from service users is enveloped within practice and evaluation, with many tools and processes available to collect this information. However, measuring service user evidence is still relatively new in occupational therapy, mainly due to the difficulties in critiquing the evidence. The RCOT is are committed to developing the evidence base of the field and creating a new research agenda (Smith, 2019) and are currently working with the James Lind Alliance (JLA) to uncover the top 10 research priorities for occupational therapists in the UK. Analysing service user evidence will likely form part of the key priorities in research, with new models, tools and frameworks likely to be developed to facilitate and support the critical appraisal of service user evidence, as the field continues to grow.

As occupational therapists, we must continue to learn and continue our professional development. I’m conscious that through the group work there are still areas of conflict management that require my focus as a professional. Also, through critiquing the service user evidence base I’m aware of its significance within the field and will watch closely as this evidence base continues to develop in the field.

References

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Appendix 1

• Member 1: Female, aged 31
• Member 2: Female, aged 29
• Member 3: Female, aged 25
• Member 4: Female, aged 23
• Member 5: Female, aged 19
• Member 6: Female, aged 19
• Member 7: Female, aged 19
• Member 8: Female, aged 19
• Member 9: Female, aged 18
• Member 10: Female, aged 18