Reflection on Client Interaction and Assessment

The purpose of the client interaction was to conduct an initial assessment (whereby in this hospital, a SSKIN assessment is included) on a newly admitted patient (see Appendix B). This was done the morning after admission within the patients room, thus the patient could settle into their new environment prior to being assessed. The goal of this interaction was to gather as much information about the patients previous/ current function, their goals prior to discharge, their social environment and their current home setup (Hanga, Dinitto, & Leppik, 2016). Prior to entering the patients’ room, I read their handover medical records from the acute hospital to gather as much information as possible (see Appendix A). This was done so as to reduce the concentration time required from the patient, as well as allowed for facts to be checked through following up on the statements in the record. Post-interview, a SSKIN test was conducted with assistance from one of the nurses, this was done to determine the risk of pressure sores as the patient had a Waterlow score of 17. A stage 2 pressure sore was present thus, with assistance from my supervisor, I prescribed a low profile ROHO cushion to reduce the stage of the sore. I was unclear of the differing types of equipment, therefore lacked confidence in making an independent decision.

As mentioned in Appendix A, the purpose of this assessment was to establish the rehabilitation outcomes for the patient, with the major goals being mobility and selfcare with limited/ no assistance required. It was important to identify if there would be benefit for the patient post-rehabilitation, this is the idea that if they were not functioning independently prior to admission then rehabilitation is less likely to have a significant effect. This was unclear to the patient, as they believed they could improve on their baseline mobility prior to admission (approx. 10m – see Appendix B). This had to be addressed through explaining the purpose of the rehabilitation program, which is the concept of improving the quality of life of the patient through attempting to reach the baseline they had prior to admission.

During the interaction, it became clear that the patient was from a non-English speaking background (NESB) however had learnt the basics required for communication. This was unclear to me prior to the interview, as there were no medical notes suggesting they were from a NESB. This posed not only a communication barrier, as I had to rely more on non-verbal cues to gather information, but also posed the issue of the lack of understanding between the crucial relationship between poor language proficiency, culture and patient safety (difference in treatment and care desires) (Garrett, Dickson, Whelan, & Whyte, 2010).

At this hospital, the Person, Environment and Occupation (PEO) Model was used, the health professionals found it was a simple tool to emphasise the occupational performance shaped by the interaction between the patient, environment and occupation (Metzler, & Metz, 2010).

Based on the PEO Model, the facilitators of the interaction were the social support (from the multidisciplinary team), patients’ psychological status (self-aware and optimistic personality) and the patients’ spirituality (able to identify what has meaning to them).  As stated in Appendix A, rehabilitation for older adults is most effective when there is coordination between a team of health professionals as well as when a person has a positive mental status. Prior to the assessment, a case conference was held to establish the respective goals the health professionals had for the patient. This ensured each person was on the same page with regards to the plan for discharge. It aided in gathering accurate information about the patient’s current status within biomechanical (physiotherapists), cognitive (doctor, occupational therapist), sensory (psychologist, speech pathologist) and social performance (social worker) areas. The patient was self-aware and was engaged in conversation, which facilitated gathering rich responses to the questions asked such as able to identify potential hazards within the patients’ home environment due to the descriptions given. The patient, although from NESB, tried their best to understand and interpret the verbal and non-verbal cues. The patient was spiritually connected to what contributes to their well-being, therefore was able to easily identify what was important to them which guided the goals that were established at the end such as identified that being able to independently dress is important.

These intrinsic and extrinsic factors contributed to the occupation of conducting the interview, as they increased the participation of the patient which aided in significant information being gathered which proved useful in establishing the final goals.

The barriers were the built infrastructure design (nurses station near patients room), hospital technology (nurses alarms/ patient bed alarms), patients cognition (reduced sustained attention – could be associated to the unfamiliar environment and/or NESB), economic systems (limited options for patient as they are unable to financially afford certain interventions; unable to find a place in a high care aged care home due to increased pressure on health system), and culture (NESB; Greek culture therefore family traditions are that the other family members become the patients primary carer).

The design of the ward hindered the interview as it caused the patient to become distracted by the noise coming from the nurses’ station. The hospital technology caused reduced attention to the interview, as the patient become distracted by identifying where the alarms were coming from. The patient was unfamiliar with the presence of bed alarms which reduced her sustained attention, as they were more focused on understanding the purpose of the alarms rather than answering my questions. The economic systems limited the options of effective interventions, this was due to financial constraints of the patient which resulted in limited options for interventions, such as the option to move to a high care aged care facility was not viable. The patient was from a Greek background whereby their ability to speak English was limited, as well as the family tradition was that another family member (in this case the eldest son) would become the primary carer. This posed a patient-student conflict as the patient was unable to comprehend that their care needs were too high for an unqualified person to provide sufficient care.

Prior to the assessment I was nervous, however was able to rely on my strengths that were developed in the previous semester. I was able to concisely explain the purpose of the assessments as well as ask consent to conduct the interview and SSKIN assessment with my supervisor present. I had good non-verbal communication, which proved useful as I needed to gesture many words to aid in the patient understanding my questions. I appropriately closed the interview by giving warning through saying I was asking one final question, then allowed for the patient to complete their answer fully before concluding the interview. I was able to reflect well on the content by asking the patient clarifying questions as well as able to write up the report post-assessment. I was able to provide clear non-verbal cues and maintained SOLER (Sit squarely, open posture, leaning in, eye contact, relax) throughout the duration of the interview (Stickley, 2011). I was dependent on my non-verbal communication skills due to the language barrier, therefore relied on the SOLER model to build rapport with my client whilst gathering necessary information. I showed I was actively listening and engaged with what the client had to share. My information gathered prior to placement proved useful in my understanding of the role the OT (Occupational Therapist), therefore enabled me to clearly and concisely explain what was being done and who I was relative to what I contribute to the patient (see Appendix A).

During the interview, I experienced feelings of doubt and being overwhelmed. This was due to my inability to simplify concepts enough to aid in the patients understanding such as explaining why the OT conducts the SSKIN Assessment with nurses. I struggled with overcoming the differing views with regards to a safe discharge plan, this was due to my lack of knowledge of the patients’ culture as well as my problem-solving abilities are not fully developed. For future placement, I need to ensure I am more culturally competent by researching the demographics of the surrounding areas as these are where most patients will be coming from. Further reading of how to overcome differing views with regards to treatment/ intervention opens will be useful in my future placement, as well as learning more broad evidence-based interventions other than the common ones.

I thoroughly enjoyed being able to build rapport with the patient, as the interview progressed, they became more comfortable opening up to me. The experience helped me identify my strengths and weaknesses which has contributed to my development as a future OT student as well as my own personal skills. The negative of the experience was my lack of sufficient knowledge of practical application of the OT role, this caused feelings of stress to build up as I had to learn on the job. To address this negative, I ensured I asked many questions to my supervisor as well as other health professionals to aid in my knowledge of specific topics.

This could have been a more positive experience had I spent more time prior to placement learning about the practical applications of the OT role within this setting. My focus was misdirected, as the plan was too focused on what rehabilitation is rather than what the OT does within the rehabilitation setting. If I were faced with the same situation again, I would be able to more effectively handle it as I have already learnt from my previous errors. I learnt from them through debriefing with my supervisor, asking questions and completing suggested readings. To further develop my skills to ensure my handling of these situations is successful, I can continue to challenge myself in learning and understanding various evidence-based practice techniques which will then improve my problem-solving skills (due to a broader range of knowledge of intervention options).

My short-term SMART goal for the remainder of this academic year (2 months) is to increase my evidence-based practice knowledge (interventions/ assessments/ recommendations) through reviewing literature and mixed media (O’Neill, Conzemius, Commodore, & Pulsfus, 2006).

The placement helped me analyse my performance, planning, presentation of approach to development, correction and improvement for future placement, thus overall leading to solidifying my current and future learning goals (Pianpeng, & Koraneekij, 2016).

References:

• Garrett, P., Dickson, H., Whelan, A., & Whyte, L. (2010). Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications.(Research)(Report). Australia and New Zealand Health Policy, 7.
• Hanga, K., Dinitto, D., & Leppik, L. (2016). Initial assessment of rehabilitation needs using the WHODAS 2.0 in Estonia. Disability and Rehabilitation, 38(3), 260–267. https://doi.org/10.3109/09638288.2015.1036172
• Metzler, M., & Metz, G. (2010). Analyzing the Barriers and Supports of Knowledge Translation Using the PEO Model. Canadian Journal of Occupational Therapy, 77(3), 151–158. https://doi.org/10.2182/cjot.2010.77.3.4
• O’Neill, J., Conzemius, A., Commodore, C., & Pulsfus, C. (2006). The Power of SMART goals : using goals to improve student learning . Bloomington, IN: Solution Tree.
• Pianpeng, T., & Koraneekij, P. (2016). Development of a Model of Reflection Using Video Based on Gibbs's Cycle in Electronic Portfolio to Enhance Level of Reflective Thinking of Teacher Students. International Journal of Social Science and Humanity, 6(1), 26.
• Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11(6), 395–398. https://doi.org/10.1016/j.nepr.2011.03.021

Appendices:

Appendix A:

Skills: 

Conducting a functional as well as cognitive assessment are a significant factor that contribute towards the potential rehabilitation intervention plans. Raising the patients ability to mobilise as well as complete basic ADL’s (activities of daily living) with limited assistance are the goals of many rehabilitation programs.

Rehabilitation is most effective when methods of coordination between a team of health professionals is put in place. This generally includes formal case discussion meetings whereby the patient and their significant others (ie. family) are actively engaged in goal setting and program design. This requires effective communication skills between professionals as well as older adults, whereby word choice will have to be adjusted depending on who you are talking to.

Communication, outside of a rehabilitation setting, is most commonly conducted with the family and patient present. Thus, ensuring family and health professionals are on the same page with regards to current and future goals within the patients’ rehabilitation.

Knowledge:

As people age, the rate of physical impairment diagnoses’ increases at a significant pace, thus resulting in an increased pressure on rehabilitation services. Most patients within the rehabilitation setting have an impairment of recent onset, such as but not limited to: stroke, hip fracture or other fracture, a fall-related injury, ongoing osteoarthritis, Parkinson’s disease, or a major illness. These recent onsets result in an impaired ability for patients to perform their ADL’s and IADL’s. Thus, potentially resulting in reduced independence.

The major consideration given to the selection of rehabilitation programs is the potential to positively gain ability from the rehab, rather than age being a factor. More important factors include the timespan of pre-existing comorbidities, previous and/or current cognitive impairments and the extent of damage caused by the diagnosis. For more minor disabilities, patients can benefit from outpatient rehabilitation programs. Rehabilitation programs are specific to the differing patients that require them, in other words each patient has their own unique program set to address issues relating to their current impairments with mobility and self-care.

Comorbidities in the age are of significant relevance to participation in rehabilitation programs as they are unpredictable and may reduce effectiveness of the program. Thus, programs are often not given specified timelines as they are not always a reliable measure of the effectiveness of the program.

Techniques:

In order to establish the suitability of rehabilitation for a client, a holistic approach to examining the patient is required. Interviews with the patient as well as family members is an integral first step in assessing the client, followed by examining their medical history. The Barthel Index is a useful tool in measuring the patients functional status prior to creating a rehabilitation program. If the person was not independently functioning prior to impairment, interventions may have a reduced effect on this post-impairment.

A cognitive assessment should also be performed as it is an important factor in assessing the readiness of the patient to undergo intense rehabilitation. The Mini-Mental State Examination (MMSE) is the most widely used cognitive measurement tool used in Australia. This is used to screen for possible impairments, however, does not provide a definitive diagnosis therefore caution should be applied to interpreting the reliability of results. An example of this is poor language ability may produce a lower score, thus a therapist should account for this prior to providing the test. Cognitive impairment appears to be linked to reduced benefit from interventions in the aged population, however, it is not a factor that should prevent a person from being able to receive a personalised program.

Depression is of significant importance to therapists as it is one of the prevalent mental health issues associated with the aged. Therefore, it is necessary to evaluate the level of mood disturbance through the Geriatric Depression Scale. This tool allows for information to be gathered about the extent of mental health assistance required for the patient whereby they can receive basic medical treatment or further psychiatric assistance.

A good measure of the success of a rehabilitation program is the rate at which patients achieved the previously determined specified goals. These tasks are often achieved within a specific order as well as timeframe, such as feeding is completed prior to being able to walk up an incline. The Barthel Index can be continuously used to re-score the patient throughout the therapy program, thus providing a statistical reference for improvement. Providing the patient with assistance on understanding the extent of the impact of their conditions is essential to improve the effectiveness of the program. This can be done through actively listening and addressing their thoughts/ feelings and providing a safe space for discussion. Palliative care is offered to patients prior to being included into the therapy programs. Palliative care is a patient and family-centred care provided for a patient with a disease that adherers to one or more of the following criteria: active, progressive, advanced disease, has little or no prospect of cure and/or is expected to die. The primary treatment goal is to optimize a patient’s quality of life. It becomes mandatory in late stages of incurable cancers or other illness/ conditions.

References:

• Cameron, I.D., & Kurrle, S.E. (2002). Rehabilitation and older people. The Medical Journal of Australia, 177(7), 387-391. Retrieved from https://www.mja.com.au/journal/2002/177/7/1-rehabilitation-and-older-people
• Young, J., Robinson, J., & Dickinson, E. (1998). Rehabilitation for older people. The BMJ, 316(1), 1108-1109. Retrieved from https://www.bmj.com/content/316/7138/1108.short