People inhabiting within a psycho-socially fit environment displays positive attitudes and strong cultural values that are essential for instituting an industrious society. Accessibility of equal health opportunities to all and fairness to access healthcare entrenched at all levels in the society, signifies the economic prosperity and system.
The economic conditions of a country can be significantly improved by employing the dynamic people within prolific occupations however; the ethical and moral values of a society deteriorate if mentally or physically challenged people are neglected (Seebohm and Secker 2003).
People can maintain a balanced life role through skill development within the spheres of physical care, productivity and leisure if adequate employment or occupational opportunities are provided whereas; unexpected illness; disability or excessive stress can lead to occupational dysfunction which is unhealthy for the respective environment (Broom et al. 2006).
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Occupational therapy paradigm assesses individual needs and devices essential measures to improve physical and psychological well-being through active living. Similar to other developed countries, the government of UK has also introduced the policy of economic efficiency that incorporates social justice model that is aimed support people and encourage them to adopt a healthy and balanced lifestyle.
The Health and Safety Commission has stipulated provisions of vocational rehabilitation, which is meant to generate alternative occupations for elderly and disabled (Health and Safety Commission 2003). The main objective of the study is evaluate the government policies and legislative drivers which are influencing occupational therapy practice and demonstrate a critical understanding of the relevant practice-based theory in relation palliative care for elderly patients of COPD.
1.1 Study Routing
The study has been structured as a report in three distinct segments, each of which is aimed to discuss the occupational therapy paradigm. The initial segment of the study is designed to examine the external influences by particularly emphasising on the legislations, funding criteria, innovativeness, and regulatory reforms pertaining to the field of occupational therapy.
The mid segment is aimed to discuss current drivers influencing occupational therapy and also provides critique on two interventions relevant to the application of MOHO on the case study of Gladis, who has been diagnosed with moderate COPD together with diabetes and obesity. The third segment of the study is aimed to reflect upon the learning experiences followed by critical evaluation on the implications of study on future professional practice. Finally a small summary has been presented to conclude the study in a creative manner.
2. EXTERNAL INFLUENCES
Poor work conditions, low pay rates and unregulated work pattern significantly affects the psycho-social well being of an individual (Broom et al. 2006) and therefore policies and procedures are designed to address the underlying issues pertaining to strengthen the objectives behind occupational therapy.
It is the key responsibility of the government to entrench an effective policy that is not only targeted to facilitate the unemployed but also provides directions to ensure that the standardised health and safety requirements pertaining to the workplace and work practices are maintained at all times.
This segment is designed to overview the external influences by particularly emphasising on the legislations, funding criteria, innovativeness, and regulatory reforms pertaining to the field of occupational therapy.
2.1 Policies Affecting Occupational Therapy
Policies and legislative drivers to occupational therapy are shaped up to embark several lawful obligations with intent to specify the roles, responsibilities, methods and guidelines for occupational therapists in order to preserve the smooth progression of rehabilitation process.
Similar to other developed countries, the government of UK has proposed several constitutional acts as for instance, Health and Safety at Work Act (1974), Disability Discrimination Act (DDA), Human Rights Act (1998), Employment Rights Act (1996), Employment Act (2002) and Welfare Reform Act (2009); all of which embrace definite parameters to support occupational therapy on the grounds of public welfare.
Health and Safety at Work Act (1974) establishes employer’s responsibility towards its workforce by specifically indicating the need for maintaining absolute standards of health and safety at workplace to protect the employees from unforeseen hazards. Health and Safety at Work Act (1974) obligates the employers to supply suitable arrangements within the business premise to uphold highest levels of health and safety standards.
The Health and Safety at Work Act (1974) not only specifies the responsibilities of an employer but also emphasises on reducing the trust deficit by strengthened employer-employee relationship through integrating safe working practices by the employer and espousal of those measures by the employees. On the other hand, it has been observed that elders or disabled people are usually exposed to prejudice or neglect as they are not considered to be an active constituent of business cycle.
The purpose behind introducing Disability Discrimination Act (1995) and (2005) was to ensure that the discriminating behaviours in the workplace can be significantly discouraged. The Disability Discrimination Act (1995-2005) supports the schema of occupational therapy by reinforcing the rights to access jobs, academics, transport, licenses etc. for the disabled and stipulating the need for public sector to encourage equal opportunities to all.
The Human Rights Act (1998) also supports the occupational therapy paradigm as it constitutes that autonomy in the fundamental rights to every individual is exceedingly crucial as egalitarianism is the core constituent of human rights model. It is important to note that human rights model establishes the basic grounds of fairness and equality within the occupational rehabilitation theory, as it stipulates the fundamental rights of people by advocating freedom from slavery and forced labour, right to live and freedom of speech.
The most crucial aspect of Human Rights Act (1998), in context of occupational therapy is to bestow certain limitations to impede the interference of people with the fundamental rights of others, both within the organisational capacity and in general.
Occupational therapy is also influenced by the Employment Rights Act (1996), which is meant to promote for the rights of employees against undemocratic behaviour of employer at workplace or an unfair dismissal based on ageing or disability.
Employment Act (2002) regulates the occupational therapy paradigm through constitutional amendments that are meant to resolve the workplace issues by initiating effective dialogues between both the parties under the established system followed by statutory minimum dismissal and disciplinary and grievance procedures.
The Welfare Reform Act (2009) further strengthens the occupational therapy by improving the prospects for the disabled obtain suitable employment opportunities to equally contribute in the development of a welfare state. These legislatures and policies are designed to facilitate the occupational therapy movement within workplace environment by encouraging equality and fairness to all regardless of physical and mental capacity.
2.2 Funding Criteria and Implications on OT
Occupational therapy is a potentially powerful catalyst to reform systems, policies and practices within workplace settings by employing advanced skills or resources (Department of Health 2002).
Organisations like MIND and Age Concern provides both individual and collective support to empower people by supporting the disables and voiceless to reach out to the facilities they deserve (Ro, Treadwell and Northridge 2003).
On the other hand, NHS complaint handling and advocacy services, PALS and the Independent Complaints and Advocacy Services (ICAS) have also been developed to assist in speedy process of occupational rehabilitation.
However, the politicisation of these organisations has raised many questions on the autonomy of their bureaucratic system in facilitating the disadvantaged groups (Dixon, Le Grand, Henderson, Murray and Poteliakhoff 2003).
There has been an enhanced interest in occupational therapy among government departments however; the conceptions pertaining to its functioning might significantly differ specifically in context of funding and development.
It has been observed that unplanned and impromptu structure of funding has resulted in patchy provisions that considerably affect the progression of occupational rehabilitation process (Department for Constitutional Affairs 2004).
In addition to the issues like inadequate and unreliable funding procedures the piecemeal and disjointed policies has made it extremely unreasonable system which given a right to small disadvantaged groups to access funds whilst a larger segment is disregarded.
Long-term funding through contracts and service-level agreements are required to benefit the occupational rehabilitation however, the autonomy of funding from statutory services might be compromised through this route (Department of Health 2004).
The health of disadvantaged communities is financed by King’s Fund to improving the access to health services by significantly addressing the issues pertaining to social, economic and environmental factors, affecting the lives of common men.
Shortage of funding is the major impediment in the swift progression of occupational therapy projects, which have been observed to shamble due to insufficient or insecure short-term source of financing (Silvera, Kapasi, King’s Fund, and SILKAP Consultants 2000).
It has been observed that the funding capacity significantly lacks in dealing with the high demands of occupational therapy and the issue seems to further exacerbate as recent legislations including the new Draft Mental Health Bill, Valuing People, National Citizen Advocacy Network for Learning Disability and other policies have been giving legal rights of access to new client groups without appropriate funding (Swann and Morgan 2002).
This indicates a substantial lack of strategic approach by the government to develop a generic occupational rehabilitation policy within national regulatory framework thus, necessitating corroboration of groundwork to embrace occupational rehabilitation through local planning and co-ordination for nationwide regulatory reforms.
2.3 Innovativeness in Healthcare Service Delivery
Local authorities make use of direct payments methods which are cash payments in lieu of providing social care services which includes personal care, day care and daily living equipment (DH CIPFA 2004).
Significance of utilising the methods of direct payment can be characterised by empowering people to access social care services whilst maintaining variety, control and sovereignty over their physical and mental health and social well-being.
Social care staff which is meant to assess the individual needs, is adequately trained to offer the alternative methods of direct payment as a supplementary option to direct provision and the individual has the right to choose between both (DH CIPFA 2004).
The legal influence of local authorities to make direct payments pertaining to the healthcare services is synchronized through the Health & Social Care Act (2001), its revised policy and other associated regulations.
It has been studied that Health & Social Care Act (2001) does not encompasses the comprehensive solutions to access NHS services via direct payments however, the Section 31 of the Health Act (1999) comprised of the integrated working arrangements and the delegation of certain functions enables the direct payment for social care equipments through Primary Care Trusts on behalf of local authorities.
The assessment of need is based on eligibility criteria i.e. Fair Access to Care and Guidelines for the Provision of Equipment & Minor Adaptations based on an individual’s requirement of specific equipment (DH CIPFA 2004).
During the initial phases, the implementation of policies is required to be under the strict supervision of community occupational therapists that are capable of dealing with highly specialised equipments for the assessments of children with disabilities. Followed by the detailed assessments care plans are designed to identify the required equipments and their value and once the commissioning manager approves and authorises the expenditure, service users or their representatives can purchase it.
The most beneficial aspect of direct payments to occupational therapy is that VAT is not charged from the service users with chronic, disabling conditions (HM Customs and Excise Notice 701/7) and on the other hand, service users that topped-up direct payments can benefit from reimbursement of a percentage of their contribution, on returning the equipments.
2.4 Analysing Regulatory Reforms on Palliative Care
Patients regardless of their age have access to comprehensive and high-quality palliative care provision, (The National Council for Palliative Care 2009b) and it has been studied that palliative care needs of the elderly require specific attention (Department of Health 2001). Recent years have been observed to be much favourable to the field of palliative care in context of central funding for service development (Department of Health 2001b).
With intent to improve provision of general palliative care, certain initiatives have been taken which includes, Gold Standards Framework, Liverpool Care Pathway for the Dying and the Preferred Place of Care Document (National Health Service 2006).
However, it has been studied that advanced research is required to meet the standards of these initiatives to the need of older people (The National Council for Palliative Care 2005a). Shortfall of specialist palliative care professionals has been anticipated to persist and therefore, it is essential to establish and monitor best ways to exploit the existing services.
There is a growing need to improve palliative and terminal care in hospitals and care homes (Marie Curie Cancer Care 2006) for which, a system-based approach needs to be entrenched at all levels within the services by harnessing patients, carers, service providers and commissioners. It is however, very hopeful to note that the national policy documents including national service frameworks (Department of Health 2005) and command papers have been excessively emphasising on the improvement of palliative care.
Whilst developing new theories and models to develop the field of palliative care, an enhanced evaluation and knowledge sharing practices needs to be established within the existing system as the recent policies indicate the reconfiguration of existing resources and therefore, occupational rehabilitation process shall be tailored in context of relevant professional expectations (Davies and Higginson 2004).
3. CONTEXTUAL INFLUENCES
Studies suggest that the core population of patients requiring palliative care is ageing as indicated by the demographic trends and rise in chronic diseases (Lopez et al 2006, p. 1749) and therefore, worldwide responsiveness towards palliative care is increased.
Essential measures have been taken by local governments to ensure that accessibility to palliative care especially for elders gets easier and the complex and co-existing needs identified by international public health organisations, can be effectively addressed (WHO 2004).
In recent years, the policies and frameworks in UK regarding the healthcare of elderly has been radically shifted in terms of separating the term palliative care from dying (Department of Health 2008).
This segment of the study is designed to evaluate the contextual influences by critically evaluating the theoretical underpinnings pertaining to the occupational therapy and the role of MOHO in providing palliative care to the elderly COPD patients. This section is meant to examine the current drivers influencing the subject area and also provides critique on two interventions relevant to the selected case study.
3.1 Model of Human Occupation (MOHO)
MOHO is a systemic and holistic approach encompassing diverse needs of people across the lifespan whilst stressing on the significance interconnectedness between human mind and body.
The theory explicates a strong linkage between the internal and external behaviours by analysing the relational aspect of motivational and performance of occupations in temporal, physical, and socio-cultural context.
The conceptual Model of Human Occupation (MOHO) can be defined as the translation of evolving theoretical arguments into specific technology for practice that is refined and tested through research (Kielhofner 2008, p. 5).
In accordance with the theory, the performance outcomes are followed by motivation that has been induced by human interaction with the environment. Model of MOHO is primarily based on the three variables i.e. motivation, behaviours and performance that has been classified into sub-systems of volition, habituation and performance capacity; respectively (Cole and Tufano, 2008, p. 29).
The closely knitted web of thoughts and feelings behind the choice of occupations define volition. Volitional thoughts and feelings are interpreted in accordance with the hierarchal order of anticipation, choice, experience and performance outcomes respectively.
It has been studied that personal causations determines the effectiveness of individual’s capacity to perform and; analyses the compliance or resistance of life towards individual efforts (Kielhofner 2008, p. 55). On the other hand, individual’s choices are gravely influenced by value and belief systems that develop aspirations towards achieving specific goals (Kielhofner 2008, p. 55).
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The availability of opportunities to engage one within certain occupations develops interest. It has been studied that challenging the optimal capacities significantly results in interest based on attraction towards positive experiences (Kielhofner 2008, p. 57). Literature suggests that volition is the primary element which prompts an individual to behave in a certain way in anticipation of possibilities subsequently leading to the desired outcomes (Kielhofner 2008, p. 60).
Habituation is a process though which an individual automatically familiarise oneself with the environmental attributes and conditions and thereby, develops a collaborative routine to match them (Kilehofner, Baz, Hutson and Tham 2002, p. 97). The pattern of actions related to habituation involves habits and roles.
It has been studied that behaviours are regulated by habits through methods that are capable of addressing the environmental contingencies (Kilehofner, Baz, Hutson and Tham 2002, p. 97). On the other hand, interactive behaviours tend to internalise an identity and outlook of an individual followed by certain manners, all of which collectively characterise a role (Kielhofner 2008, p. 60).
3.1.3 Performance Capacity
Performance capacity encapsulates mind-brain-body sub-system which includes musculo-skeletal, neuro-logical, cardio-pulmonary and symbolic constituents representing individual’s capacity for occupational performance.
The new MOHO illustrates mind and body together as dual aspects of the same thing by conceptualising the relations between mind-full body and the mind embodied (Kilehofner, Baz, Hutson and Tham 2002, p. 105). The most significant aspect of this theory is to conceptualise the personal intelligence of a body in context of regular routine work within the environment. The theory also appraises the foundations of abstract mental process within bodily experiences.
3.2 COPD & Elderly Palliative Care
Chronic obstructive pulmonary disease has been identified as the major cause of morbidity and mortality of elderly patients across the globe (Freeman and Price 2006, p. 188) and it has been observed that the utilisation intensive care units and healthcare has been radically increased as elderly patients suffering from severe COPD having acute exacerbations were exceedingly hospitalised (Soriano and Maier et al 2000, p. 792).
Significant impairments in physical daily activities, severe dyspnoea, fatigue, pain and psychological morbidity due to anxiety and depressive symptoms have also been reported by elderly European COPD patients (Punekar et al 2007, p. 665).
Palliative care is a multidisciplinary approach which enables enhanced communication between patient, family, and physician to determine a strategic healthcare plan designed in accordance with patient’s preference to choose between continued treatment or end of life option (Morrison and Meier 2004, p. 2587). On the other hand, palliative care also enables the patient to adopt self-management by providing optimum psychosocial support to boost patient’s confidence thereby, facilitating in improving the quality of life.
3.2.1 Case Study
Gladis is a 78 years old female cohabiting with her 80 years old husband in a warden controlled ground floor apartment. She has been diagnosed with moderate COPD, Diabetes and Obesity and has been reported to get breathlessness both at rest and on exertion. Her medical history reveals that admittance to n elderly medical unit (EMU) with a chest infection has significantly exacerbated the condition followed by which she has been referred to Intermediate Care (IC) for further assessment and rehabilitation.
3.2.2 Treatment Plan:
Gladis’s condition has shown significant improvement whilst managing COPD at home as her current level of functioning during ADL is sustained. The treatment plan incorporates, providing additional care and support to maximise her functional autonomy at home. OT interventions include assistive equipment and devices to facilitate convenient mobilisation for energy conservation.
3.4 Gladis’s Case Study: Application of MOHO
The application of MOHO to a COPD patient requires careful assessment and MOHO assessment instruments are both structured and unstructured. Considering the nature of Gladis’s health condition, the structured assessments followed by observational measures, self report questionnaires and checklists, and structured interviews have been adopted to enable the occupational therapist to empathies with the patient whilst designing a strategic approach towards her treatment plan and effective interventions.
Gladis’s volitional thoughts and habituations have been examined to determine her capacity of performance and thereby, it has been constituted that the initial intervention includes adaptive and assistive equipments to facilitate Gladis to improve her performance capacity by energy conservation. On the other hand, long-term intervention includes tele-care facility as it has been observed that Gladis’s health condition doesn’t allow admittance to EMU within the hospital environment.
3.5 Critiques on the Interventions
Interventions must be targeted to benefit the patient in terms of improving the occupational performance by substituting the maladaptive solutions with adaptive ones. Patients can be provided with the potential opportunities to self-manage their health conditions by effectual interventions that offer change in the existing environment. It is significantly important to incorporate interventions within strategic healthcare plan that are aimed at skilled performance within natural environment. Followed by the application of MOHO, these two interventions have been critically assessed and espoused for Gladis’s treatment plan.
3.5.1 Intervention 1: Assistive Equipments
Assistive equipments are primarily designed for energy conservation and since Gladis is not only suffering from COPD but has also been diagnosed with obesity and diabetes therefore, assistive or adaptive equipment can significantly improve her performance capacity. Occupational therapists can facilitate Gladis in developing volition towards adapting her habituation in accordance with these interventions so that she neither remains idle and nor takes exertion, both of which seem to exacerbate her illness (Gulrajani 2010, p. 17).
Perching stools and supporting hand rails enable flexible and easier mobilisation and Gladis would have the opportunity to bring positive environmental changes whilst putting-in too much effort. The option of ready-made or microwave meals is also equally favourable to Gladis, since she can direct her husband to get prepared food within no time and without employing additional efforts to cook food from the scratch (Robinson 2010, p. 14).
3.5.2 Intervention 2: Tele-Care
Pulmonary rehabilitation can be induced by utilising tele-care technology with video conferencing in order to deliver the healthcare service to reach-out to COPD patients like Gladis, having fragile health and travel constraints. Tele-care can substantially reduce the difficulties faced by Gladis to access the rehabilitation programmes within the hospital setting.
The main objectives behind pulmonary rehabilitation through tele-care is to ensure that Gladis can access the adequately trained occupational therapists or other healthcare staff and learn to self-manage her condition whilst remaining at home (Yersel 2008).
On the other hand, it is significant to make certain that the healthcare and local authority staff has acquired standardised, competency-based training to support the delivery of pulmonary maintenance learning programs to patients like Gladis and others within the local community on continuous basis (Yersel 2008). The domiciliary tele-pulmonary rehabilitation is meant to facilitate the isolated or serious patients.
4. THEORETICAL REFLECTIONS
The study has significantly outlined the role of occupational therapists that is designed to work in collaboration with local authorities for assessing the healthcare requirements, stipulating equipments for effective treatment and improve the psycho-social well-being of disabled and vulnerable people through adjustment opportunities (Lett, Sackley and Littlechild 2006).
Occupational therapy can substantially help in the development and succession of a society by entrenching drastic measures to improve quality of life, facilitate autonomy and prevent dependency of people (Heywood and Turner 2007). The study also encompasses the extensiveness and richness behind the roles and responsibilities of occupational therapists to work beyond the sector and regional limitations.
It has also been studied that occupational therapists, along with a range of several functions, also facilitate the support workers and home carers to assist and encourage the service users to learn daily living skills and adapt with their changing psycho-social health (College of occupational Therapists 2008).
The utilisation of advanced technological equipments and techniques including tele-care and tele-health is another significant aspect of occupational therapy that is targeted to maximise the potentials for the service users to maintain autonomy whilst remaining within the comfort-zone of their residence (COT 2008).
The role of occupational therapists as vocational rehabilitators is exceptionally dignified as disabled and elderly people are persuaded to penetrate the highly competent employment market thus, providing them a sense of self-assurance and contributing towards building a healthy society by effectively indulging in planning and regeneration of community areas (Nelson and Senker 2006).
Certain promoting factors that enhance the requirement of adapting vocational rehabilitation help the occupational therapists to perform their duties with maximum contentment. The comprehension of the employers with the regulatory framework and their understanding towards economic reform of the society facilitates the occupational therapists to better perform the on-site service to retain the injured or disables employees.
The active participation of a multidisciplinary team including the employee, co-workers, occupational therapist and the employer increases the chances to gain positive results as all of them contribute towards achieving a common goal (Grol and Grimshaw 2003). The vocational rehabilitation becomes more helpful and cost effective when the intervention is introduced in the earliest possible time.
The individual’s willingness towards returning back to normal life also produces positive effects on the rehabilitation therapy. The job of the occupational therapists becomes much easier where individuals are prepared to accept the realities of life and understand the significance of occupation in leading a healthy and active life. Mentally ill or disabled people go through extreme levels of stress and develop an inner fear of being targeted by their co-workers or discriminated by their employers (Seebohm and Secker 2003).
The occupational therapists need to identify the internal fears of the individual and address them in such a manner that their barriers to connect with the other people shatter and they subsequently start to trust their therapist. Once, a trust level between the individual and the occupational therapist is developed; it becomes easier to rehabilitate their employment.
Occupational therapists enable the individuals to take charge and empower them as a result of which increase level of confidence and self-efficacy can be observed which drives them out of apprehension (Clark and Krupa 2002). The positive attitude of co-workers and employers also enables the mentally challenged or disabled people to realize their inner strengths and this would eventually facilitate the treatment procedure in an efficient manner.
Furthermore, young men that unfortunately became mentally ill or disabled can be engaged in productive activities that not only develop within themselves a sense of self-reliance but would also foster hope (McCann 2002), this makes possible for the occupational therapists to retain their physical and mental well-being together with the prevention of dependency.
The legislations imposed by the government along with the policies formulated by the employers both are meant to strengthen the disabled. Integrated grading system within an organization that acknowledges the effort of its employees on equal basis also enables the occupational therapists to utilize it as an effective tool to promote vocational rehabilitation.
The productive occupations that offer increased chances for professional growth are also a vital tool for recovery because it is associated with improved self-concept and identity (Ferguson, 2004). Occupational therapists play a vital role in creating awareness amongst the people to know their rights and responsibilities and thereby, promoting constructive working environment at all times.
There are certain barriers that restrict the occupational therapists to carry out the process of vocational rehabilitation in an effective manner. Sometimes, the psychological well-being of a person has worsened to an extent where he/she may not feel comfortable to seek help and deliberately refuse to continue treatment especially in the presence of co-workers.
There could be many times when occupation therapist may not decide the correct path to intervene espe
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