Professional tensions in client-centered practice: using institutional ethnography to generate understanding and transformation

Towards accountability-centred practices: governance in OSCEs subordinating patient and practitioner clinical experience

New public management ideals and standards have become increasingly adhered to in health professions education; this is particularly apparent in high-stakes assessment, as a gateway to practice. Using an Institutional Ethnographic approach, we looked at the work involved in running high-stakes Objective Structured Clinical Exams (OSCEs) throughout an academic year including use of observations, interviews and textual analysis. In our results, we describe three types of 'work'-standardising work, defensibility work and accountability work-summarising these in the discussion as an Accountability Circuit, which shows the organising role of texts on people's work processes. We show how this form of governance mandates a shift towards accountability-centred practices, away from practices which are person-centred; this lens on accountability-centring during high-stakes assessments invites critique of the often-unquestioned emphasis of new public management in health professions education.

The role of therapist-patient relationships in facilitating engagement and adherence in upper extremity rehabilitation

BACKGROUND

Active patient engagement and adherence are essential for successful rehabilitation outcomes, particularly in complex cases such as work-related musculoskeletal injuries. Although the therapist-patient relationship is a significant component of successful care coordination, there has been limited examination of this relationship within upper extremity musculoskeletal rehabilitation.

OBJECTIVE

To explore therapists' perspectives on how the therapist-patient relationship intersects with engagement and adherence in the provision of holistic and collaborative rehabilitation services.

METHODS

Data were collected from four therapists over three months. Descriptive statistics were generated from the Sport Injury Rehabilitation Adherence Scale (SIRAS) and the Rehabilitation Therapy Engagement Scale (RTES) completed by therapists following visits from a sub-sample of patients (n = 14). Weekly semi-structured group interviews (n = 13) were analyzed using an iterative grounded theory-informed process. Emerging themes were identified, refined, and situated within the context of quantitative results.

RESULTS

SIRAS scores averaged 14.4 (SD: 1.0) and RTES scores averaged 42.5 (SD: 3.5), indicating high perceived patient engagement and adherence. Four themes emerged from therapist interviews: (1) dynamic power; (2) co-constructed engagement; (3) emotional states; (4) complementary therapy contexts.

CONCLUSION

In this engaged and adherent setting, therapist-patient relationships were complex and intimate, and extended beyond education and physical interventions. Careful management of this relationship was central to active patient participation and engagement. Incorporating holistic techniques may provide more structure for managing and communicating these aspects of care. These findings provide a preliminary understanding of the impact of therapeutic relationships on engagement and collaborative care.

Disability Orientation of Occupational Therapy Practitioners in Physical Rehabilitation Settings: Tension Between Medical and Social Models in Theory and Practice

IMPORTANCE

To date, little is known about the extent to which occupational therapy practitioners have adopted the core insights of disability studies.

OBJECTIVE

To examine the degree to which occupational therapy practitioners endorse the medical model of disability versus the social model of disability in theory and in practice.

DESIGN

Cross-sectional study.

SETTING

Physical rehabilitation facilities, ranging from hospital to community settings.

PARTICIPANTS

One hundred two Israeli occupational therapy practitioners. Outcomes and Measures: The Orientation toward Disability Scale, constructed for this study, has two dimensions that distinguish between the medical and social models of disability: locus of intervention (the person or environment) and client involvement (extent to which the practitioner fosters the client's autonomy in the rehabilitation process). Each dimension addresses both theoretical and practical endorsements.

RESULTS

Greater support for the social model of disability was mostly evident in the client involvement dimension, whereas support for the medical model of disability was mostly evident in the locus of intervention dimension. Over both dimensions, the medical model of disability was significantly more endorsed in practice than in theory. Work setting and prior exposure to the social model of disability were found to affect practitioners' disability orientation.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners working in physical rehabilitation are still relatively far from fully adopting the critical insights of the social model of disability. This finding is especially relevant when their actual practice, rather than their theoretical views, is considered and when rehabilitation takes place in out-of-home settings. What This Article Adds: This study offers unique insight into the disability orientation of occupational therapy practitioners, showing a need for more training programs to expose students to the social model of disability. These programs should use critical discussions of the challenges that this model presents to the profession and barriers to implementing it in practice.

Observation and Institutional Ethnography: Helping Us to See Better

Observation is a staple data collection method, which is used in many qualitative approaches, including both traditional and institutional ethnographies. While observation is one of the most used data collection methods in traditional ethnography, less is written about its use by institutional ethnographers. Institutional ethnography is an approach to social research where the aim is to explicate how peoples' every activities are coordinated or ruled by different institutions. In this article we explore uses of observation as a data collection method, focusing on its use in institutional ethnography. We use examples from the health care literature to show how observation can be beneficial and help institutional ethnographers see better.

(In/Ex)clusive fitness cultures: an institutional ethnography of group exercise for older adults

Older adults benefit greatly from being physically active yet they are the least active generation. To appeal to older consumers, to reduce barriers older adults experience to becoming physically active and to increase the number of physically active older adults, the exercise market has been divided into mainstream fitness and age-segregated programming that specifically targets older adults. This research employed an institutional ethnography approach to understand better the social discourses and material practices that shape socially (in/ex)clusive physical cultures for older exercisers in both mainstream and older-adult group exercise classes. Textual analyses, interviews and field observations revealed that the material and discursive work practices intended to promote inclusivity in group exercise physical cultures actually engendered age-exclusive markets. Herein, we discuss how the guidelines and policies put forth by these certifying bodies, and the training curricula they publish, govern group exercise practices in a manner that tends to align with dominant ideological discourses conflating age and ability. We conclude by arguing that in order to create more inclusive physical cultures, mainstream fitness providers need to embrace options that appeal to potential group exercise consumers of all abilities, regardless of age.

Exploring stroke survivors' experiences and understandings of occupational therapy

BACKGROUND

Occupational therapists view people with stroke as occupational beings who may experience occupational issues. Concurrently, occupational therapy practice is guided by research evidence that supports predominantly impairment-based practices. There has been limited exploration of how people with stroke experience and understand occupational therapy in the context of the potential tension between the professional philosophy and the research-based evidence.

AIMS/OBJECTIVE

To explore the experience and understanding of occupational therapy with stroke survivors.

MATERIAL AND METHODS

Interpretative phenomenology guided semi-structured interviews with nine participants from five states across Australia.

RESULTS

Three themes emerged: Understanding of occupational therapy grows by 'doing' outlines how participants understood occupational therapy based on their individual experiences over time; Personal factors influence the experience highlights how participants had diverse expectations for recovery that influenced their occupational therapy experience. Context shapes occupational therapy experience identified that the therapeutic relationship and context of occupational therapy were important factors in shaping experiences.

CONCLUSION

Both impairment-based and occupation-based therapy were considered valuable aspects of occupational therapy, representing the proposed tension between the professional philosophy and research-based evidence. Occupation-based and client-centred practice was more often experienced in the outpatient setting, with challenges described for both within the inpatient setting.

Routine use proportion and determining factors of the Canadian Occupational Performance Measure in the real-world setting: A retrospective cross-sectional study in Japan

Introduction

The aim of this retrospective cross-sectional study is to examine the routine use proportion and factors determining the use of the Canadian Occupational Performance Measure in the real-world subacute rehabilitation setting.

Methods

This study retrospectively collected data from all inpatients and occupational therapists at a single Japanese subacute rehabilitation ward during 2017, including Functional Independence Measure motor/cognitive scores, years of experience, and rate of Canadian Occupational Performance Measure administration (that is, Canadian Occupational Performance Measure proportion). Multiple logistic regression analyses were used to identify the determining factors of daily routine Canadian Occupational Performance Measure use/non-use, after which cut-off values were calculated.

Results

Of the 619 included clients, the Canadian Occupational Performance Measure was applied in 232 cases (37%). A multiple logistic regression analysis revealed two significant determining factors of its use: Canadian Occupational Performance Measure proportion (odds ratio, 1.06) and Functional Independence Measure cognitive item (odds ratio, 1.22). The cut-off value, sensitivity, and specificity, respectively, were 35.4%, 0.73, and 0.36 ( p < 0.0001) for the Canadian Occupational Performance Measure proportion and 25.5, 0.84, and 0.45 ( p < 0.0001) for the Functional Independence Measure cognitive score.

Conclusion

The client’s high-level cognitive skill and occupational therapist’s attitude may determine the use of the Canadian Occupational Performance Measure.

A matter of time: grappling with everyday ethical tensions at the confluence between policy and practice in a psychiatric unit

OBJECTIVE

To provide insights on emergent ethical tensions experienced by mental health practitioners during system re-organisation, which is sufficiently grounded in empirical data at the local level to inform policy on recovery at institutional and provincial levels.

METHOD

Ethnographic methods using narrative and critical phenomenological resources over 24 months.

FINDINGS

Everyday ethical tensions emerged at the confluence of different experiences of time, for example, how a context of increasing pressure to decrease patients' length of stay at the hospital (service-defined time) challenged efforts to listen to and advocate for what mattered to patients (personal time) and maintain the integrity of interventions (clinical time). In this context, practitioners drew on clinical language and that of personal recovery to strategically 'push back', 'play with' or 'take back' time.

DISCUSSION

Examining everyday practices through ethnographic methods can illuminate the everyday ethical tensions that arise when mental health professionals and psychiatrists grapple with, often competing, goods. Critical phenomenological resources can help expand the structural considerations in empirical ethics, excavate underground practices and raise questions about the conceptual categories undergirding normative ethics. Experiencing-with practitioners in clinical contexts as they encounter and creatively resolve ethical tensions also propose a normative ethics of possibility, to help bridge the gap between empirical and normative ethics.

CONCLUSION

Focus on the relationship between policy, temporal practices and ethics suggests a reconfiguration of time and re-imagination of ethics in institutional settings in ways that can ultimately benefit patients and professionals alike.

Community-based participatory research remodelling occupational therapy to foster older adults’ social participation

Background.

Occupational therapists who provide community-based services are well positioned to foster older adults’ social participation. However, community occupational therapists rarely address social participation and require support to change their practice.

Purpose.

This study initiated a remodelling of community occupational therapy services by (a) selecting practices fostering older adults’ social participation and (b) identifying factors that could affect their integration.

Method.

A community-based participatory research study was conducted in a large Canadian city. Four focus group meetings and seven individual interviews were held with 28 key informants.

Findings.

A continuum of emerging practices was identified, including personalized, group-based, and community-based interventions. Potential enablers of these practices included clinical support, better communication, and user involvement. Organizational and systemic barriers were related to the institutional culture and performance indicators.

Implications.

These results point to innovative ways to foster older adults’ social participation and identify potential enablers and barriers affecting their integration.

Why institutional ethnography? Why now? Institutional ethnography in health professions education

This 'A Qualitative Space' article takes a critical look at Dorothy Smith's approach to inquiry known as institutional ethnography and its potentiality in contemporary health professions education research. We delve into institutional ethnography's philosophical underpinnings, setting out the ontological shift that the researcher needs to make within this critical feminist approach. We use examples of research into frontline healthcare, into the health work of patients and into education to allow the reader to consider what an institutional ethnography research project might offer. We lay out our vision for potential growth for institutional ethnography research within the health professions education field and explain why we see this as the opportune moment to adopt institutional ethnography to meet some of the challenges facing health professions education in a way that offers informed change.

Linking occupational therapy models and assessments to the ICF to enable standardized documentation of functioning

BACKGROUND.

The International Classification of Functioning, Disability and Health (ICF) can serve as reference for standardized documentation of health in clinical practice.

PURPOSE.

This study aims to bridge the gap between the ICF and occupational therapy specific concepts, represented by occupational therapy models and their derived assessments.

METHOD.

Occupational therapy assessments in relation to their models were systematically linked to the ICF, and a compatibility analysis was conducted. To strengthen reliability of the linkings, feedback from the respective assessment hosts was obtained.

FINDINGS.

Linking tables were developed for the Assessment of Motor and Process Skills, the Canadian Occupational Performance Measure, and the Model of Human Occupation Screening Tool. Similarities and differences between the ICF and the three assessments and their associated models show how they differ from and complement each other.

IMPLICATIONS.

The findings of this study lay the foundation for standardized documentation in occupational therapy and enhance the practicability of the ICF.

Validation of vocational assessment tool for persons with substance use disorders

BACKGROUND

Work-related problems are a serious concern among persons with substance use but due to lack of a standardized tool to measure it; these problems are neither systematically assessed nor appropriately addressed. Most existing measures of work performance cater to the needs of the workplace rather than focusing on the workers' perception of the difficulties at work.

AIM

To develop a standardized instrument to measure work-related problems in persons with substance use disorders.

METHODS

Qualitative data obtained from interviews with substance users were used to develop a scale. The refined list of the scale was circulated among an expert panel for content validation. The modified scale was administered to 150 cases, and 50 cases completed the scale twice at the interval of 2 weeks for test-retest reliability.

RESULTS

Items with a test-retest reliability kappa coefficient of 0.4 or greater were retained and subjected to factor analysis. The final 45-item scale has a five-factor structure. The value of Cronbach's alpha of the final version of the scale was 0.91.

CONCLUSIONS

This self-report questionnaire, which can be completed in 10 min, may help us in making a baseline assessment of the work-related impairment among persons with substance use and the impact of substance use on work.

Supporting children with disabilities at school: implications for the advocate role in professional practice and education

PURPOSE

School settings are a common practice context for rehabilitation professionals; health advocacy is a common and challenging practice role for professionals in this context. This study explored how pediatric practitioners advocate for children with disabilities at school. Specifically, we examined everyday advocacy in the context of school-based support for children with disabilities.

METHOD

Our theoretical framework and methodological approach were informed by institutional ethnography, which maps and makes visible hidden social coordinators of work processes with a view to improving processes and outcomes. We included families, educators, and health/rehabilitation practitioners from Ontario. Of the 37 consented informants, 27 were interviewed and 15 observed. Documents and texts were collected from the micro-level (e.g. clinician reports) and the macro-level (e.g. policies).

RESULTS

Pediatric practitioners' advocacy work included two main work processes: spotlighting invisible disabilities and orienteering the special education terrain. Practitioners advocated indirectly, by proxy, with common proxies being documents and parents. Unintended consequences of advocacy by proxy included conflict and inefficiency, which were often unknown to the practitioner.

CONCLUSIONS

The findings of this study provide practice-based knowledge about advocacy for children with disabilities, which may be used to inform further development of competency frameworks and continuing education for pediatric practitioners. The findings also show how everyday practices are influenced by policies and social discourses and how rehabilitation professionals may enact change. Implications for Rehabilitation Rehabilitation professionals frequently perform advocacy work. They may find it beneficial to perform advocacy work that is informed by overarching professional and ethical guidelines, and a nuanced understanding of local processes and structures. Competency frameworks and education for pediatric rehabilitation professionals may be improved by: encouraging professionals to consider how their practices, including their written documents, may affect parental burden, (mis)interpretation by document recipients, and potential unintended consequences. Policies and texts, e.g. privacy legislation and the Diagnostic and Statistical Manual (DSM), influence rehabilitation professionals' actions and interactions when supporting children with disabilities at school. An awareness of the influence of policies and texts may enable practitioners to work more effectively within current systems when supporting individuals with disabilities.

Participatory citizenship: Critical perspectives on client-centred occupational therapy

BACKGROUND/AIMS

This article aims to discuss client-centred practice, the current dominant approach within occupational therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries on their engagement with clients, while working with complex, multidimensional social realities.

METHODS

The authors present a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and critical engagement with the literature on occupational therapy, occupation, and citizenship.

CONCLUSION

A focus on citizenship suggests reframing professional development based on the participation in public life of people as citizens of their society. While occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term client-centred practice typically represents a particular view of the individual and may sometimes be too limited in application for a more systemic and societal approach.

SIGNIFICANCE

The authors question the individual focus which has, until recently, been typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and practise.

Enacting Occupation-Based Practice: Exploring the Disjuncture between the Daily Lives of Mothers with Rheumatoid Arthritis and Institutional Processes

Introduction:

Occupation-based approaches are a hallmark of excellence in occupational therapy practice. This article focuses on the disjuncture between how women with rheumatoid arthritis go about their daily lives, that is to say their occupations, and what is addressed during routine visits at a specialized rheumatology outpatient clinic.

Method:

Institutional ethnography was employed as a method of inquiry to identify the occupations and related issues that were or were not accounted for in health records and addressed within institutional processes. Interviews and participant observations were conducted with seven women with rheumatoid arthritis who were mothers. Hospital records were analysed as texts mediating between the women's daily lives and the rheumatology outpatient clinic.

Findings:

The analysis revealed that despite the diversity in the ways that the women managed their daily lives, the things that they did were viewed, understood, and addressed only within the boundaries of the standardizing relations that ruled practice in this clinical setting. Institutional processes grounded in biomedical concepts such as functional status or disease activity, as well as clinical assessments that depict these concepts, both shape and limit opportunities for occupational therapists to advance and enact occupation-based practice.

Conclusion:

In this setting, the complexity of the participants' daily lives and the occupations they engage in remain unaddressed.

An institutional ethnography inquiry of health care work in special education: a research protocol

BACKGROUND

Special education for children with chronic health conditions or disabilities requires the integration of health care work with education. This phenomenon occurs in an understudied and challenging context for integrated care despite policies and protocols that outline work processes in this context. We are interested in an approach to inquiry that will allow us to address gaps in current literature and practices in integrated care, and move towards informing policy.

STUDY DESIGN AND DATA COLLECTION METHODS

Institutional ethnography is an approach to inquiry that maps the actualities of what individuals do at an everyday local level, while examining this work activity in relation to the sociopolitical context. It has been used to change policy and local practice by highlighting disjunctures between policy and actuality. We are adopting institutional ethnography and its three common methods of data collection: document collection, interviews, and observation/shadowing. Informants to this inquiry are chosen from school-based teams, family-centred units and constellations of clinical professionals.

METHODS OF ANALYSIS

We are following work processes, verbally and visually mapping what is done and by whom. It is important to note that work includes 'unofficial' work, including the work of families and others who may not be assigned an official work role in a policy or protocol. The mediating role of texts in work processes is also being mapped in order to link the local work to the high-level social coordinators. To begin, analysis focuses on local, or micro-level, work processes; next, analysis identifies and explains the macro-level coordination of the local work (i.e. social and political structures).

CONCLUSION

A primary outcome of this study will be the creation of verbal and visual maps that demonstrate the social organisation of work processes occurring in the health care-special education interface. These maps will make invisible work visible, highlight disjunctures between policy and practice and identify opportunities for change. They will be useful for critical knowledge translation purposes, providing parents and professionals with an awareness of how their individual work fits in to the larger picture of integrating health care work in special education.

Arthritis-Related Occupational Therapy: Making Invisible Ruling Relations Visible Using Institutional Ethnography

Introduction:

Occupational therapists' intention of enabling women with rheumatoid arthritis to participate in everyday life is fraught with challenges in everyday practice.

Method:

Inspired by institutional ethnography, this paper aims to make explicit how the work of occupational therapists in an outpatient rheumatology hospital setting is governed within invisible, ruling relations. An analytical description of the first author's clinical experience was a standpoint from which to explicate how occupational therapy is coordinated to the ruling relations of the Austrian health care system.

Findings:

Occupational therapy practice and research are ruled within a positivist, body-focused, medical apparatus, which renders largely invisible occupational therapists' knowledge of enabling people to engage in occupations that are meaningful to them.

Conclusion:

Occupational therapists have professional power that can be asserted by strategically using occupational therapy specific knowledge and language in textually mediated practices, from assessments and case files to media images, to give greater visibility and influence to the profession's work of enabling occupation.

Exploring the gap between rhetoric and reality in dementia care in Australia: Could practice documents help bridge the great divide?

Quality of care, and indeed, quality of life, for people living with dementia in long-term care is often underpinned by philosophies of care, such as person-centred care and relationship-centred care. The translation of these philosophies into practice is influenced by a range of individual and organizational features, including the context in which such care occurs. Within modern care organizations, the context of care is evidenced through organizational documents.

This study sought to identify the key documents guiding dementia care within one large Australian long-term care organization and to explore points of consistency and tension within the documented system of care. Results highlight a lack of consistency and clarity in the philosophy of dementia care and a disconnection between the key documents guiding practice. This disconnection creates tension for clinicians and carers, and may contribute to the gap between rhetoric and reality in dementia care.

This study suggests that a congruent documented dementia system can help bridge the gap between espoused philosophies of care and everyday care practices.

Self-Identified Occupational Competencies, Limitations and Priorities for Change in the Occupational Lives of People with Drug Misuse Problems

This study investigated self-identified competencies, limitations and priorities for change in the occupational lives of people with drug misuse problems. Thirty people undergoing inpatient drug detoxification completed the Occupational Self Assessment (OSA) version 2.2. Six of these participated in semi-structured interviews focusing on their priorities for change, identified using the OSA.

The OSA results found that the participants identified the greatest occupational limitations with the following OSA items: managing finances; making decisions based on what they think is important; getting done what they need to do; having a satisfying routine; and working towards goals. The items considered most important were taking care of others; being involved as a student, worker, volunteer, and/or family member; and working towards goals. The items prioritised for change were the ability to manage finances; work towards goals; take care of the place where they live; and take care of themselves. The interview participants maintained that a focus on drug use had stopped them from achieving goals and making changes in their lives.

The findings from both the OSA and the interviews drew particular attention to self-care and financial management needs and suggest a rationale for occupational therapy to give meaning, purpose and structure to clients' abstinence-related goals, aimed at reclaiming their lives.

Therapists' Perceptions of how Teamwork Influences Client-Centred Practice

This qualitative study adds to the client-centred literature by focusing on occupational therapists' experience of working on teams that support clients with a severe and persistent mental illness from a client-centred perspective. The paper reports on the second category of data relating to a previously published paper, which replicated the work of Sumsion (2004).

Interviews were conducted with 12 therapists to capture their experience and interpretation of this approach to practice. The multiphased analysis included template analysis and open coding. It resulted in the creation of the category of meaningful goals, which addressed the work done to ensure that the goals towards which everyone was working were meaningful for the client. The facilitators related to these goals included team cohesion, the structure of the system and family collaboration and support. The challenges were differing perspectives and paradigms, competitive frameworks and time.

This study identified the unique contribution that families provided to a client-centred approach. Overall, the study makes a significant contribution to the literature and to therapists' understanding of the factors that influence the therapist's ability to facilitate client-centred practice.

Power is only skin deep: an institutional ethnography of nurse-driven outpatient psoriasis treatment in the era of clinic web sites

We present an institutional ethnography of hospital-based psoriasis day treatment in the context of evaluating readiness to supplement services and support with a new web site. Through observation, interviews and a critical consideration of documents, forms and other textually-mediated discourses in the day-to-day work of nurses and physicians, we come to understand how the historical gender-determined power structure of nurses and physicians impacts nurses' work. On the one hand, nurses' work can have certain social benefits that would usually be considered untenable in traditional healthcare: nurses as primary decision-makers, nurses as experts in the treatment of disease, physicians as secondary consultants, and patients as co-facilitators in care delivery processes. However, benefits seem to have come at the nurses' expense, as they are required to maintain a cloak of invisibility for themselves and for their workplace, so that the Centre appears like all other outpatient clinics, and the nurses do not enjoy appropriate economic recognition. Implications for this negotiated invisibility on the implementation of new information systems in healthcare are discussed.

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.