Client-centred care means that I am a valued human being

Consensus for a power wheelchair training approach for people with cognitive impairments

PURPOSE

Power wheelchairs (PWCs) can enhance independent mobility. The World Health Organization recommends training PWC users. However, current PWC training approaches do not always meet the needs of PWC users with complex mobility and cognitive impairment. The aim was to co-develop an innovative approach to PWC training for individuals with complex mobility and cognitive impairments.

MATERIALS AND METHODS

A two-phase mixed method research, involving PWC users, clinicians and researchers throughout all aspects of the research, was realized. (1) Interviews and focus groups were used. (2) The Delphi method was followed to refine the PWC training approach.

RESULTS

Phase 1: Twenty-six stakeholders indicated that PWC training should consider the client as a partner, the learning environment, the proposed activities, interactions with the trainer and intervention format. Phase 2: two hundred and seven participants agreed that the PWC training should be goal directed, should be client-centred and occupation-based, should enhance client-therapist relationships and should be realized in a safe and adapted environment.

CONCLUSIONS

Stakeholders on PWC use came to agreement on key components that should be applied when training people with cognitive impairments.

Client-Therapist Relationships: Experiences of Occupational Therapy Clients in Rehabilitation

The relationship between a therapist and his or her client has been recognised to be an important determinant of the success or failure of occupational therapy. The purpose of this qualitative study was to explore clients' perceptions of the relationship that they formed with their occupational therapist in the context of rehabilitation. Twenty clients with varied health problems were interviewed.

The analysis of data revealed three main categories, therapist role, power and connection, as pertaining to the characteristics of the client-therapist relationship. From these categories, seven different relationship dimensions were identified and arranged hierarchically. The dimensions were described as concern, direction, fellowship, guidance, coalition, detachment and rejection. Relationships were generally experienced as positive; however, there were also examples of negative and detrimental experiences.

The findings are discussed in relation to the definition of the therapeutic relationship and to client-centred practice. Occupational therapists are encouraged to consider their own attitudes, needs and boundaries when it comes to establishing close connections and to share power with their clients. Furthermore, therapists must explore which form of relationship and participation each client prefers in order to establish an effective collaborative relationship.

Using Qualitative Research to Inform the Client-Centred Evidence-Based Practice of Occupational Therapy

Demands for increased accountability for health care expenditure, and recognition of clients' rights to interventions and methods of service delivery that are grounded in sound evidence, are compelling occupational therapists to use research findings to inform their clinical decision making. Occupational therapists also state that they embrace a client-centred orientation to practice, yet this espoused ethic seems rarely to influence decisions concerning what research is undertaken and how it is undertaken or what counts as evidence for practice. Given the widely divergent perspectives, priorities and values between health care professionals and their clients, practice based upon therapist-centred research may be neither relevant nor valid.

This paper explores the philosophical underpinning of methods used to develop theory, proposing that occupational therapy's evidence-based practice must be ethically consistent with its espoused client-centred philosophy to avoid a tendency towards hypocrisy. It explores issues concerning client-centred practice and evidence-based practice and suggests that qualitative research methods may be the most appropriate tools to identify and address client priorities. While traditional quantitative research approaches render client voices silent, qualitative methods may enable occupational therapists to explore the complexities of clinical practice and of living with a disability, thereby informing a more client-centred, evidence-based practice of occupational therapy.

A Systematic Review of the Canadian Occupational Performance Measure: A Clinical Practice Perspective

Occupational therapists working to a philosophy of client-centred practice will benefit from a reliable and well reviewed outcome measure to provide an evidence base. A systematic review of the literature was undertaken to evaluate worldwide publications on the use of the Canadian Occupational Performance Measure (COPM) to determine its impact on clinical practice in occupational therapy.

A literature search strategy was deployed which resulted in a review of 64 articles. A themed analysis approach was used to integrate the results into linked and recurring themes. The focus of the systematic review was to concentrate on issues affecting clinical practice and the following were selected as key factors for consideration: negative and positive issues arising from the use of the COPM; impact on practice for the therapist, client, process and clinical work; and change initiatives for the therapist, client, process and clinical practice. A profile of all articles, which identifies where these factors are indicated, is presented as a summary guide to assist the clinician.

The findings of the review indicated that the greatest impact of using the COPM was within clinical practice. Change initiatives indicated the need for further research in different clinical areas, as well as the continual development and need for more training of occupational therapists in the use of COPM as an outcome measure.

A Revised Occupational Therapy Definition of Client-Centred Practice

This paper reports on the second phase of a research project to determine a British occupational therapy definition of client-centred practice. Sixty-seven occupational therapists participated in nine focus groups, structured according to the nominal group technique. These groups involved therapists working in social services, mental health, learning disabilities, paediatrics, neurology, a wheelchair service and with elderly clients and there were two groups in general medicine.

A hundred and sixty-five components of client-centred practice were generated and subsequently analysed to form seven themes. Frequencies and medians of the components ranked in the top five were also calculated. In addition, three questions were asked to solicit opinions on the definition that was created in the first phase of this study and frequencies were also determined from these responses. All these data were used to inform revisions to the definition created in phase one. This revised definition was then reviewed by members of the Council of the College of Occupational Therapists as the final validating group. The resulting final definition will enable therapists to determine whether or not they are using a client-centred approach.

Client-Centred Practice: Is it Compatible with Early Discharge Hospital-at-Home Policies?

Current Government initiatives promote the provision of health care in the community rather than in medical institutions. Over the last decade there has been a growth in the number of early discharge hospital-at-home initiatives which provide a level of nursing and rehabilitation care in the home that previously would have been provided in an acute hospital. Simultaneously, there has been a move away from medical to client-centred models of health care delivery. These new client-centred models of health care emphasise collaboration between client and professional and encourage users of health care services to take greater control over and responsibility for their health care. Some occupational therapists may question whether the principles of client-centred care are compatible with the policy of discharging patients early from hospital while they remain in need of health care.

This paper briefly reviews some of the principles of the Canadian Model of Occupational Performance; discusses some of the barriers to providing client-centred services in the early discharge hospital-at-home setting; and reflects upon whether the principles of client-centredness are consistent with early discharge from hospital policies.

Balancing Challenges and Facilitating Factors when Implementing Client-Centred Collaboration in a Mental Health Setting

This study undertook a replication of the work conducted by Sumsion in 2004 in the United Kingdom regarding the application of a definition of client-centred practice. Twelve occupational therapists employed by a local mental health facility and working with adult outpatients participated in semi-structured interviews. Template analysis and open coding were used to analyse the data. The resulting concept map indicated that collaboration and meaningful goals were at the centre of client-centred practice and formed the two main categories of data. The therapist and the client were the protagonists in these categories, but the family, team and system also played major roles. A table within this paper outlines all the categories and themes that arose from the data. However, space limitations required a focus on only the category of collaboration and the therapist and client facilitators and challenges within this category. The therapists used both attitudes and actions to facilitate the client-centred process and the clients brought strengths to this relationship. Nevertheless, both groups faced many challenges that had to be overcome to enable the successful implementation of client-centred practice.

Informing Client-Centred Practice through Qualitative Inquiry: Evaluating the Quality of Qualitative Research

Occupational therapists are increasingly embracing qualitative research methods yet little published advice exists in the occupational therapy literature to enable readers to gauge the quality and relevance of researchers' work. If qualitative research is to provide convincing evidence with which to inform theory and practice, it must be capable of withstanding critical scrutiny and practitioners must be given sufficient information with which to evaluate the strength and plausibility of the evidence reported. The process of undertaking qualitative research and of writing and critiquing subsequent reports is not about assessing adherence to rigid rules but of ensuring the appropriateness and thoroughness of data collection, analysis and reporting, given the nature and context of the issue. The espousal of a client-centred ethic also demands consideration of research relevance and usefulness to clients and the degree of consumer involvement throughout the research process.

This paper examines an evaluative framework that may be used to assess the quality of qualitative evidence as this is both researched and reported. Recourse to a set of general strategies — used where appropriate – will serve to enhance the quality of qualitative research and assert its potential to inform the client-centred, evidence-based practice of occupational therapy.

Clients' Experience of Partnership with Occupational Therapists in Community Mental Health

The occupational therapy profession is committed to providing services that are client centred. Partnership with clients is seen as central to this way of working. However, there is little published evidence about the types of service and the relationships with therapists that clients value. This qualitative study used in-depth semi-structured interviews with seven clients from three adult community mental health teams to explore the experiences of working in partnership with occupational therapists from the clients' perspective.

The interviews were audio taped and transcribed verbatim by the researcher. The data were analysed by means of content analysis. This established four factors that contributed to partnership: the therapist's personality, the therapist's behaviour, client-centred skills and boundary issues. Five factors described as barriers to partnership were also established: the lack of an individual approach, the lack of communication and knowledge, the lack of confidentiality, the directive therapist and inequality.

The personality and behaviour of the therapist emerged as important, with the participants valuing those occupational therapists whom they perceived as warm, caring, committed and hard working and who appeared to value them as individuals. It was also found that the participants used the language of original writing on client-centred practice to describe their relationships with their therapists: warmth, empathy, trust and acceptance. Further exploration of the barriers to working in partnership with clients is needed, but the implications for practice are clear. Clients wish to be valued as individuals by occupational therapists who are committed to working in partnership with them.

Evaluation of a Prison Occupational Therapy Informal Education Program: A Pilot Study

This pilot study explored the strengths and weaknesses of an informal education program and identified elements of the program valued by participants. Participants were men living in a minimum security prison who had been incarcerated for ten or more years. The outside researcher was joined by three former program participants as co-researchers. Together, they interviewed 27 residents who completed the informal education program. Interviews were transcribed and de-identified. Researchers used the summative content analysis approach to analyze the data. Initial content analysis yielded five concepts: doing (engaging in purposeful activities); information (program handouts and discussions that included data and descriptions of all of the topics discussed); re-entry fears (socialization; making amends with victims and/or reuniting with family and friends); technology (includes, but not limited to, using smartphones, internet and other technology in all areas of occupation); and self-worth as a person. Further interpretation per the summative content analysis method yielded three themes: doing (engaged in purposeful activities), validation of self-worth (confirmation of being a valued human being in spite of having committed a serious crime) and concerns about the future (being able to successfully engage in virtually all occupations). Whilst informal education programs may help people who are incarcerated gain information, gain a sense of self-worth and allay some reentry fears, understanding the long-term affect such programs may have such as preparing them for successful re-entry to society or reducing recidivism rates, will require long-term follow-up. Regardless of the occupational therapy intervention, the practice of occupational therapy in the criminal justice system needs to be client-centred. Because of the small number of participants and limited access to participants, one should not generalize the findings of this study to other situations or populations. Further research to examine the effectiveness of an occupational therapy education program is warranted. Copyright © 2016 John Wiley & Sons, Ltd.

Implementing Client-Centred Practice: Why is it so Difficult to Do?

This paper explores the challenges of implementing client-centred occupational therapy practice. While many occupational therapists believe in the principles of client-centred practice and espouse them, it seems much more difficult to implement these into everyday practice. Findings from three qualitative studies with three different populations (i.e., family-centred care for children and their families, community-based home care, facility-based care for older adults) are used to illustrate the challenges which are divided into three broad categories: challenges at the level of the system, at the level of the therapist and at the level of the client. Suggestions for change at each level are addressed. Organizations, therapists and clients must work together to facilitate these changes and ensure that each occupational therapy client receives respectful, supportive, coordinated, flexible and individualized service.

Enhancing student occupational therapists' client-centred counselling skills

BACKGROUND

Client-centred practice is the cornerstone of the occupational therapy profession. However, there has been little focus on how to teach students to be client-centred practitioners while engaged in counselling.

PURPOSE

The purpose of this study was to examine the impact of the use of a client-completed rating scale on student occupational therapists' client-centred counselling skills.

METHOD

A time-series design was used to measure the changes in students' counselling skills over time. Demographic information was collected prior to time one. An online questionnaire was administered after study completion to explore students' experiences of using the Session Rating Scale.

FINDINGS

The impact of using the Session Rating Scale as a measure of students' client-centred counselling skills performance significantly improved over time. Most students valued using the rating scale and would recommend its use for future students.

IMPLICATIONS

The process of supporting students to learn how to engage clients in providing timely feedback and using this feedback to design treatment sets the stage for integration and application of client-centred practice.

Systematic synthesis of barriers and facilitators to service user-led care planning

BACKGROUND

Service user (patient) involvement in care planning is a principle enshrined by mental health policy yet often attracts criticism from patients and carers in practice.

AIMS

To examine how user-involved care planning is operationalised within mental health services and to establish where, how and why challenges to service user involvement occur.

METHOD

Systematic evidence synthesis.

RESULTS

Synthesis of data from 117 studies suggests that service user involvement fails because the patients' frame of reference diverges from that of providers. Service users and carers attributed highest value to the relational aspects of care planning. Health professionals inconsistently acknowledged the quality of the care planning process, tending instead to define service user involvement in terms of quantifiable service-led outcomes.

CONCLUSIONS

Service user-involved care planning is typically operationalised as a series of practice-based activities compliant with auditor standards. Meaningful involvement demands new patient-centred definitions of care planning quality. New organisational initiatives should validate time spent with service users and display more tangible and flexible commitments to meeting their needs.

The Accountability–Well-Being–Ethics framework: A new philosophical foundation for occupational therapy

Background.

The context that supported occupational therapy’s inception has been replaced with new challenges brought on by globalization and dramatic changes in health care. Thus, the profession’s philosophical grounding needs to be reframed to (a) achieve balance between science-driven and holistic elements, (b) operate within larger contexts on problems brought on by sociopolitical and natural determinants of health, and (c) maintain an ethical identity across all arenas of practice.

Purpose.

This paper presents a brief discussion of the philosophical underpinnings in occupational therapy’s history, outlines new global challenges for the profession, and proposes a new framework to address these challenges through education, practice, and research.

Key Issues.

Occupational therapy finds itself practising in a growing number of middle- and low-income countries where its roles and values need to be context and culture specific.

Implications.

The Accountability–Well-Being–Ethics framework guides the three domains of education, research, and practice to be relevant in an increasingly complex world.

Subject-chosen activities in occupational therapy for the improvement of psychiatric symptoms of inpatients with chronic schizophrenia: a controlled trial

Objective:

To compare the therapeutic effects of subject-chosen and therapist-chosen activities in occupational therapy for inpatients with chronic schizophrenia.

Design:

Prospective comparative study.

Setting:

A psychiatric hospital in Japan.

Subjects:

Fifty-nine patients with chronic schizophrenia who had been hospitalized for many years.

Interventions:

The subjects received six-months occupational therapy, participating in either activities of their choice (subject-chosen activity group, n = 30) or activities chosen by occupational therapists based on treatment recommendations and patient consent (therapist-chosen activity group, n = 29).

Main measures:

The Positive and Negative Syndrome Scale and the Global Assessment of Functioning (GAF) Scale were used to evaluate psychiatric symptoms and psychosocial function, respectively.

Results:

After six-months occupational therapy, suspiciousness and hostility scores of the positive scale and preoccupation scores of the general psychopathology scale significantly improved in the subject-chosen activity group compared with the therapist-chosen activity group, with 2(2) (median (interquartile range)) and 3(1.25), 2(1) and 2.5(1), and 2(1) and 3(1), respectively. There were no significant differences in psychosocial functions between the two groups. In within-group comparisons before and after occupational therapy, suspiciousness scores of the positive scale, preoccupation scores of the general psychopathology scale, and psychosocial function significantly improved only in the subject-chosen activity group, with 3(1) to 2(2), 3(1) to 2(1), and 40(9) to 40(16) respectively, but not in the therapist-chosen activity group.

Conclusions:

The results suggested that the subject-chosen activities in occupational therapy could improve the psychiatric symptoms, suspiciousness, and preoccupation of the inpatients with chronic schizophrenia.

Client-centred practice in occupational therapy: critical reflections

AIMS

The occupational therapy profession has long proclaimed its commitment to a client-centred philosophy of practice and the assumption that occupational therapists consistently practice in a client-centred manner has become central to the profession's self-image and public rhetoric. However, client-centred practice has been subjected to little critical reflection within the occupational therapy profession. The aim of this paper is to foster critical reflection concerning the authenticity and veracity of the profession's commitment to client-centred practices.

MAJOR FINDINGS

Client-centred practice is defined without evident reference to clients' perspectives. Few occupational therapy researchers have sought clients' perceptions of the client-centred nature of their occupational therapy services. Occupational therapy research is neither consistently undertaken in a collaborative manner, nor are the profession's theories developed through explicit reference to a diversity of clients' perspectives. Professional practices and service evaluations do not consistently seek clients' viewpoints. Client-centred rhetoric is politically expedient and may be a professionalizing strategy employed to increase status and entrench power.

PRACTICE CONCLUSION

Although exemplary client-centred occupational therapy practices exist, evidence suggests that the profession does not adhere consistently to its espoused client-centred principle in all its practices. The client-centred practice of occupational therapy should be subjected to assiduous critical reflection.

Improving client-centered brain injury rehabilitation through research-based theater

Traumatic brain injury often results in physical, behavioral, and cognitive impairments perceived by health care practitioners to limit or exclude clients' full participation in treatment decision making. We used qualitative methods to evaluate the short- and long-term impact of "After the Crash: A Play About Brain Injury," a research-based drama designed to teach client-centered care principles to brain injury rehabilitation staff. We conducted interviews and observations with staff of two inpatient neurorehabilitation units in Ontario, Canada. Findings demonstrate the effectiveness of the play in influencing practice through the avoidance of medical jargon to improve clients' understanding and participation in treatment; newfound appreciation for clients' needs for emotional expression and sexual intimacy; increased involvement of family caregivers; and avoidance of staff discussions as if clients were unaware. These findings suggest that research-based drama can effect reflexivity, empathy, and practice change to facilitate a client-centered culture of practice in brain injury rehabilitation.

Patients' experience of groups in outpatient mental health services and its significance for daily occupations

The prevalence of mental health problems such as depression and anxiety in the Swedish population is increasing and individuals' daily occupations are seriously affected. Occupational therapy groups have long been used in mental health services. Now, with the increase in the number of outpatients and the current principle of patients' participation there is a need for further knowledge of this group of patients' perspective on the method. The aim of this study was thus to explore how outpatients in mental health services experience treatment in occupational therapy groups and what significance the treatment has for daily occupations. The focus group method was used. Four groups, with a total of 14 participants, were formed and met on one occasion. A number of factors for positive change in occupational therapy groups were found, i.e. "timing", "belonging", "involvement", "challenge", "meaningful occupation", and "balanced focus on disease". The participants' active use of the treatment and the transfer of experiences and knowledge from treatment to daily life were important for success. The abilities "to manage" and "to dare" developed in occupational therapy groups helped participants in the process of making changes in daily occupations. The findings show how a traditional method in occupational therapy in mental health services can be used to meet current needs and principles.

The experiences of treatment from other people as narrated by people with moderate or severe traumatic brain injury and their close relatives

PURPOSE

The aim of this study was to describe the treatment from other people as experienced by people with moderate or severe traumatic brain injury (TBI) and their close relatives.

METHOD

Twelve people with moderate or severe TBI and eight of their close relatives were interviewed. The interviews were analysed using thematic content analysis.

RESULTS

The results were described by the means of two themes: being excluded and missing confirmation. People with TBI and their close relatives had experiences of being avoided, being ruled by the authorities, being met with distrustfulness and being misjudged. They also searched for answers and longed for the right kind of help. People who listened to them, believed them and tried to understand and help them were appreciated.

CONCLUSIONS

This study showed a lack of treatment which promotes well-being of the people with TBI and their close relatives. They experienced bad treatment also from authorities. Therefore, we emphasize that authorities should continuously reflect on how to make their practice a place which promotes dignity. Treatment of people with TBI and close relatives may be improved by increased knowledge about TBI, living with it and being a close relative to a person with TBI. This is a challenge to health care and rehabilitation professionals.

Clients' experiences of a work rehabilitation process

PURPOSE

The aim of this study was to describe clients' experiences of a work rehabilitation process.

METHOD

Ten clients who had participated in work-related rehabilitation at a rehabilitation centre in the northern parts of Sweden were interviewed using a narrative approach. The interviews were analysed using qualitative content analysis focusing on clients' descriptions of the goals, contents and results of the work rehabilitation process.

RESULTS

At the beginning of the rehabilitation the goal was often to confirm a diagnosis, to become healthy and able to return to work. It was hard to be forced to change the goals. When fortunate the rehabilitation provided more profound guidance and function assessment. It resulted in changes varying from practical alterations to important insights into life. It was important to get support and understanding. When the rehabilitation was not adjusted to clients' needs, feelings of disappointment emerged and life became a struggle with various authorities in order to gain understanding and other forms of rehabilitation.

CONCLUSIONS

This study shows the need to develop truly client-centred practice. Therefore, we emphasized, based on this study, the importance of professionals involved in rehabilitation working on different levels and in various settings having regular discussions about what the term client-centred practice means to them. Integrating individual perceptions is essential to advancing a multidimensional approach in return-to-work research.

From child to adult: An exploration of shifting family roles and responsibilities in managing physiotherapy for cystic fibrosis

Although chest physiotherapy is central to the management of cystic fibrosis many report problems with adherence. Research in other long-term conditions suggests that non-adherence may be exacerbated as the child grows older and self-care responsibilities are transferred to the young person. We explored the nature and variation in roles of family members, how responsibility was transferred from the parent/family to the child, and what factors aided or hindered this process. We conducted in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7-17 years, and with 31 parents attending cystic fibrosis clinics in two Scottish regions. Family responsibilities were primarily focused on mothers. The level and nature of involvement varied along a continuum that separated into six parental and five child roles and changed over time. However, this movement was frequently reversed during periods of illness or mistrust. The day to day experience of such a transfer was not straightforward, linear or unproblematic for any of the family members. Three factors were identified as assisting the transfer of responsibility: parents' perceptions of the benefits of transferring responsibility, children's perceptions of the benefits, and the available physical, social and psychological resources to support such a transfer. The principles and lessons from "concordance" (a therapeutic alliance based on a negotiation between equals and which may lead to agreement on management or agreement to differ) may provide a foundation for newly developing relationships between parents and their children emerging into adulthood. Further research is required to develop more specifically the content and structure of required support, its effectiveness in achieving more concordant relationships, and the resulting impact on adherence, perceived health and well-being from the perspective of the young person and parent.

Experience of rehabilitation following spinal cord injury: a meta-synthesis of qualitative findings

STUDY DESIGN

Meta-synthesis of qualitative research.

OBJECTIVES

To identify, compare and synthesize published qualitative evidence concerning the experience of rehabilitation following spinal cord injury (SCI).

METHODS

Published articles were identified from the Medline, CINAHL and Sociological abstracts databases, a hand search through selected journals published since 1990, and from reference lists. These were assessed for their relevance to the focus of interest and appraised for rigour. The key themes that emerged from the data were summarized, compared and synthesized.

RESULTS

The search located 64 papers and four books, of which eight papers (describing seven studies) met the review criteria for relevance and rigour. Thematic comparison and synthesis resulted in the identification of seven concepts that encapsulate the important dimensions of rehabilitation from participants' perspectives: (1) the importance of specific staff qualities; (2) the need for a vision of future life possibilities; (3) the importance of peers; (4) the relevance of programme content; (5) the institutional context of rehabilitation; (6) the importance of reconnecting the past to the future; (7) the importance of meeting the needs of the real world.

CONCLUSIONS

If rehabilitation services are to be evidence-based, relevant and effective in meeting the needs of people with SCI they must be informed by the perspectives of people with SCI. The findings of this review suggest that the most important dimension of rehabilitation for people with SCI is the calibre and vision of the rehabilitation staff.

Developing empathy as a foundation of client-centred practice: evaluation of a university curriculum initiative

BACKGROUND

The foundation of client-centred practice is the therapist's capacity to view the world through the client's eyes and to develop an understanding of the lived experience of disability.

PURPOSE

This paper describes the evaluation of an educational initiative promoting student empathy to the lived experience of disability.

METHODS

Pairs of first-year occupational therapy students visited adults with disabilities who shared their knowledge and experience of living with a disability. Students reflected on their visits in journals, which were later analyzed using pattern matching.

FINDINGS

Students appeared to appreciate the co-existence of health and disorder and demonstrated a holistic understanding of living with a disability. Little attention was focused on cultural and institutional environments. Students struggled to define the nature of their relationship with their tutors. Practice Implications. The evaluation confirmed our belief that this educational initiative could facilitate student empathy, consistent with critical features of client-centred practice.

Psychometric characteristics of the child occupational self-assessment (COSA), part two: refining the psychometric properties

Self-assessment is an appropriate way to support client-centered practice and promote personal development in young occupational therapy clients. This study, the second study in a series of two, sought to refine the psychometric properties based on previous analysis of the Child Occupational Self-Assessment (COSA), a self-report tool based on the Model of Human Occupation. The COSA comprises 24 statements, which the child rates in terms of personal competence and importance. The Rasch Rating Scale Model was used to evaluate the measurement properties of the Competence and Values scales that result from these self-ratings. The original three-point rating scale was expanded to four response categories in this study, which resulted in improved reliability and sensitivity. In this second study, the items once again coalesced to form measures of competence and values, and the order of items from less to more competence and value was similar to that in the first study, supporting the internal validity of the COSA scales. The results provide evidence that the COSA can be used as meaningful and reliable client-directed assessment tool as well as an outcome measure.

Reflections on power and justice in enabling occupation

BACKGROUND

This descriptive paper offers reflections on power and justice associated with occupational therapy's client-centred practice, now described as the practice of enabling occupation. Framed as a contribution to the sociology of professions, the questions addressed are: How do power and justice work in occupational therapy today? What vision of power and justice guides the profession in implementing the client-centred practice of enabling occupation?

METHOD

The paper opens with an overview of the analytic framework for reflections. Two sources for reflections are highlighted: the development of the Canadian guidelines and, client/consumer and occupational therapy perspectives. To illustrate the discussion of power and justice, two contrasting diagrams are presented, one on late 20th century power relations and the other on potential power relations.

RESULTS

Recommendations for research, education, practice, and guidelines development are offered prior to a conclusion that acknowledges the dissonance facing occupational therapists who struggle to focus on occupations in client-centred practice.

PRACTICE IMPLICATIONS

The paper offers insights and strategies for addressing power and justice as issues in implementing the client-centred practice of enabling occupation. The analysis may be used in raising awareness and guiding the strategic development of institutional change toward social inclusion and enabling occupation.

A framework of strategies for client-centred practice

BACKGROUND

Implementing strategies to overcome barriers to client-centred practice is a challenge encountered by many occupational therapists in their daily practice. The Client-centred Strategies Framework is proposed as a tool to assist occupational therapists to consider barriers and implement strategies from a variety of perspectives.

DESCRIPTION

The framework consists of five categories: personal reflection, client-centred processes, practice settings, community organizing, and coalition advocacy and political action. Within each category are a number of actions that can be taken to facilitate client-centred practice. This paper describes the framework with elaboration of each of the five categories. A case example is used to illustrate how a therapist can use the framework to address client-centred practice issues.

PRACTICE IMPLICATIONS

This framework will assist therapists and students to problem-solve ways to enhance the use of client-centred processes within their own practice environments.

Barriers to client-centredness and their resolution

This research sought to determine which therapist barriers prevent client-centred practice the most, and which methods are perceived as being most effective in resolving therapist barriers. A list of barriers that therapists bring to client-centred practice and methods to resolve these was identified from the literature and formed the basis of a questionnaire sent to 60 occupational therapists in the United Kingdom. The results showed that the therapist and client having different goals was the barrier which most prevented client-centred practice. The high ratings of other statements suggested that the values, beliefs and attitudes of therapists and of the employment culture make client-centred practice uncomfortable to use and hence prevent its implementation. Case examples showing how to practice in a client-centred fashion were rated as the most effective method of barrier removal.