Interprofessional Education Faculty of Health Science Development team Botma Y School of Nursing Butler M School of Allied Health Professions Coetzee D School of Nursing Hattingh R School of Allied Health Professions Labuschagne M School of Medicine Van Wyk R School of Medicine This document is an output of a project funded by the National Research Foundation – Education Grant Developed June 2014 Revised November 2014 Printed by Xerox, Bloemfontein 1 Contents Introduction ........................................................................................................................... 4 Competence ......................................................................................................................... 5 Programme ........................................................................................................................... 5 Assessment .......................................................................................................................... 6 Outcome 1: ........................................................................................................................... 7 Activity 1.1: Completion of the questionnaire [5 minutes] ...................................................... 7 Activity 1.2: Get to know your group members [15 minutes] .................................................. 7 Activity 1.3: Orientation [10 minutes] ..................................................................................... 7 Activity 1.4: Visual representation of IPP [30 minutes] ........................................................... 7 Activity 1.5: Value clarification [20 minutes] ......................................................................... 10 Outcome 2: ......................................................................................................................... 11 Pre-reading ......................................................................................................................... 11 Barthel Index of Activities of Daily Living ............................................................................. 13 Activity 2.1: Role clarification (25 minutes) .......................................................................... 14 Activity 2.2: Briefing [10 minutes] ........................................................................................ 14 Activity 2.3: SP simulation [15 minutes] ............................................................................... 14 Activity 2.4: Debriefing [45 minutes] .................................................................................... 14 Outcome 3: ......................................................................................................................... 16 Activity 3.1: Peer evaluation [10 minutes] ............................................................................ 16 Pre-reading ......................................................................................................................... 16 Activity 3.2: Briefing [10 minutes] ........................................................................................ 19 Activity 3.3: SP simulation [15 minutes] ............................................................................... 19 Activity 3.4: Debriefing [45 minutes] .................................................................................... 19 Outcome 4 .......................................................................................................................... 21 Activity 4.1: IPP plan [60 minutes] ....................................................................................... 21 Activity 4.2: Completion of the RIPLS questionnaire [5 minutes] ......................................... 21 Activity 4.4: Peer evaluation [5 minutes] .............................................................................. 21 Addendum A HPCSA 2014 ................................................................................................. 23 Addendum B Alberts & Easton 2004 ................................................................................... 37 Addendum C Stroke care Ontario ...................................................................................... 53 Addendum D Rowland, Cooke & Gustafsson 2008 ............................................................. 59 Addendum E Ballinger, Ashburn, Low & Roderick 1999 .................................................... 109 Addendum I ...................................................................................................................... 119 2 Addendum II ..................................................................................................................... 121 Addendum III .................................................................................................................... 122 Addendum IV .................................................................................................................... 123 3 Interprofessional Education Introduction Dear Student Welcome to the four interprofessional education sessions. It is our pleasure to introduce you to collaborative practice as it is seen internationally. We as educators strive to provide you with the relevant information and learning experiences so that you can make meaning of the experience and construct your own knowledge for future use in different settings. As collaborative practice is all about working in a team, your team is composed of the various health professions in our Faculty of Health Sciences. You will remain in the team for the duration of the Interprofessional Education sessions. Teamwork is the core of collaborative practice and therefore it is essential that you are honest and just when you evaluate team member’s contribution and participation in this module. Poor teamwork is often the result of communication breakdowns (Anderson, Manek & Davidson 2006). Olenick and Allen (2013) confirm these findings by ascribing the lack of interprofessional collaboration and lack of communication as the cause of as many as 98 000 preventable deaths in the USA per year. Up to 10% of patients admitted to hospitals in Australia may suffer adverse events due to poor teamwork (Armitage, Connolly & Pitt 2008). No similar data could be found for South Africa, but it stands to reason that it might be much worse due to the multiple languages (11) and the inability of most healthcare professionals to express themselves fluently in more than two or three of the eleven languages. Poor patient outcomes, for example, delays in patient care, wasted staff time, and serious adverse events result from poor interprofessional communication (Olenick & Allen 2013). Interprofessional education and collaborative practice can improve:  access to and coordination of health services offered by the spectrum of healthcare providers, individuals and their families;  appropriate use of specialist clinical resources;  health outcomes for people with chronic diseases (World Health Organisation 2010);  patient care and safe health systems that are responsive to the needs of the population (Craddock, O’Halloran, McPherson, Hean & Hammick 2013); and  job satisfaction with reduced stress and compassion fatigue of health professionals (World Health Professions Alliance 2013). The World Health Professions Alliance (WHPA) (2013) that speaks on behalf of the International Council of Nurses, the International Pharmaceutical Federation, the World Confederation for Physical Therapy, the World Dental Federation and the World Medical Association supports interprofessional collaborative practice that builds on interprofessional education. Healthcare reform initiatives drive the redesign in education of the health professions to integrate the concepts of interprofessional care (Casimiro, MacDonald, Thompson & Stodel 2009). In South Africa, the re-engineered Primary Healthcare (PHC) strategy (2011) emphasises a team approach to healthcare and states that the education should be relevant. Leadership, specifically in PHC, depends on circumstances and frequently shifts from one 4 member to another, consequently causing ambiguities regarding tasks, roles, leadership and decision-making. Baldwin and Baldwin (2007) are of the opinion that interprofessional relationships should not be left to chance; they should be an integral part of the curriculum. Interprofessional education takes place when “members or students of two or more professions associated with health or social care, engage in learning with, from and about each other” (Bridges, Davidson, Odegard, Maki & Tomkowiak 2011: online). The contact details of the educators that are responsible for IPE per school are listed below. Please feel free to contact the educators, should you experience any challenges with regard to IPE. Please make an appointment, as the educators might not be able to see you immediately due to other academic commitments. School Name Office e-mail Telephone no SoN Prof Yvonne Botma Idalia Loots 18 botmay@ufs.ac.za 051 401 3476 Mrs Desiree Coetzee Idalia Loots coetzeeD1@ufs.ac.za 0825561262 SoM Dr Mathys Labuschagne Simulation Unit labuschagneM@ufs.ac.za 051 401 3869 Mr Riaan van Wyk Simulation Unit Vanwykr3@ufs.ac.za 051 401 9307 SoAH Mrs Michelle Butler Chris de Wet butlermd@ufs.ac.za 051 401 3302 Mrs Rialda Hattingh Chris de Wet hattinghRP@ufs.ac.za 051 401 9768 Competence At the end of the four Interprofessional Education (IPE) sessions, you will be able to develop a plan to promote collaboration among healthcare professionals based on the six key domains of collaborative practice in order to improve health outcomes. Programme Table 1 shows the learning outcomes with their deliverables, as well as the dates and venues. Table 1: Timetable with outcomes and deliverables Date Outcome Deliverable Venue 25 Feb Clarify collaborative practice and Visual Please check the group establish shared values representation of allocation to find out in collaborative which venue you should practice convene Shared value statement 4 March Demonstrate shared decision-making Role establishment Please check to which and shared power through effective Footage of simulation laboratory your communication and collaboration simulation group is allocated to among all healthcare professionals 18 Demonstrate shared decision-making, Self-evaluation March shared power, collaborative leadership (footage previous through effective communication and session) collaboration among all healthcare Footage of professionals, patient and significant simulation others 8 April Compile a plan to establish a Self-evaluation Same venue as on 25 Feb collaborative practice according to the (footage previous underpinning principles in a session) 5 Date Outcome Deliverable Venue multidisciplinary healthcare setting Assignment Assessment Formative assessment will take place throughout the four sessions by means of peer/self- assessment. You will assess the teamwork at the beginning of session three. The summative assessment is a group assignment and individual peer assessment. The mark for each individual will be based on the average of the group assignment and the peer assessment. Full instructions for the assignment are provided under session four. 6 Session 1 Outcome 1: Clarify collaborative practice and establish shared values. Activity 1.1: Completion of the questionnaire [5 minutes] Please complete the Readiness of Interprofessional Learning Scale (RIPLS) questionnaire (Addendum IV) anonymously. It will not take more than 5 minutes and will be used for research purposes. Completion of the questionnaire is voluntarily. There will be no retribution if you decide not to complete the questionnaire. We shall disseminate findings by means of conference papers and articles in professional journals. You will be asked to complete the questionnaire on completion of the IPE sessions again. Therefore, two copies of the questionnaire are at the back of the workbook. Thank you in advance for completing the questionnaire. It is much appreciated. On completion, remove the page from this study guide and hand it to the facilitator. Activity 1.2: Get to know your group members [15 minutes] All group members sit in a circle. We are having a party and everyone has to bring something that begins with the same first letter as their name to the party. For example, a person will say, “My name is JANINE, and I am bringing a bag of JELLYBEANS." The person to his/her right says his/her name and item, and then repeats the leader’s name and item, "My name is ERIK, I am going to bring EGG SALAD. This is JANINE, who is bringing JELLYBEANS." Each person in turn introduces himself/herself, announces his/her item, and repeats the name and item of everyone who preceded them. This means that the last person has to remember everyone’s names in the group, or at least try. You may help with verbal or pantomimed clues if participants get stuck on someone’s name or item. Activity 1.3: Orientation [10 minutes] Now that you know with whom you are going to develop a collaborative practice, a facilitator will give you an overview of Interprofessional Education and Interprofessional Collaborative Practice. He/she will also orientate you regarding the workbook and inform you about your responsibilities and the expectations of the educators. Activity 1.4: Visual representation of IPP [30 minutes] Discuss Figures 1, 2 and 3 and draw a single visual representation of collaborative practice. It is important to keep this information, as it will come in handy for the summative assignment. Also read Addendum A on the core competences as formulated by the HPCSA (2014) Use the page from the flip chart and crayons provided to create the visual representation collaboratively. 7 Figure 1: Framework for Action on Interprofessional Education and Collaborative Practice (Adopted from WHO 2010) Professional/ Occupational components Figure 2: Core competences for students in healthcare (Adopted from HPCSA 2014) Quality & safety continuous improvement/enhancement 8 Healthy work environment Policy/Physical/ Structural Competent communication Cognitive /Psycho/ components  Is clear, focused, transparent and respectful Social/Cultural  Constructively manage conflict components  Maintains and enhances the relationship Care Expertise Patient/clients are full participants in their care Encompasses specific contributions and collective knowledge as dictated by the complexity of the patient/client needs Greater complexity may dictate a need for coordination of Effective group functioning specialised expertise Shared power  Group members assess, practice and  Creating balanced power relationships reflect upon effective group processes  Leveraging for all team members to  Collaborate to formulate, implement participate and evaluate care  Contributes to healthy work environment Professional/  Intentionally engage to formulate Goal: implement and evaluate care L Professional/ Occupational Exemplary Occupational components Shared decision-making Interprofessional care for client/patient & their components  Develop structures and processes to Collaborative leadership support shared decision-making support network  Reflects shared accountability that  Reflect the priorities addresses power and hierarchy  Communicate and implement with  Utilises structures and processes to respect of the context and advance exemplary care contributions of each team member Optimizing profession/role/scope within and across the team  Demonstrate knowledge application of of care own profession/role/scope  Exploring and integrating roles of others  Optimising interface to result in enhance care Cognitive/Psycho Social/Cultural Policy/Physical/ components Structural components Quality and safety continuous Improvement/Enhancement Figure 3: Conceptual model for developing and sustaining interprofessional care (RNOA 2013) 9 Activity 1.5: Value clarification [20 minutes] 1.5.1 Each one tear an A4 page in 5 equal sized horizontal strips. Think for 2 minutes on the values that guide healthcare professionals. Write one value per strip of paper during the next minute. Put all the small pieces of paper in the middle of the group and mix them thoroughly. Use Round robin to discuss all the values. Compile value statements for the group. 1.5.2 Watch the video on professional attributes (CANMED) and evaluate your statements against the information in the video. Read the best practice guidelines and the patient status 10 Session 2 Outcome 2: Demonstrate shared decision-making and shared power through effective communication and collaboration among all healthcare professionals. Pre-reading Read the Evidence Best Practice guidelines (Addenda B-E) as well as the information on the patient. Patient information A 65-year-old Caucasian patient who lives in Brandfort was seen at the National District Hospital Casualty Department 48 hours ago and was admitted to the high-care unit. The patient is a pensioner and was accompanied by a significant other who has stayed with the patient since admission. He/She was transferred to the ward where you meet him for the first time during your grand round. Current history Patient developed a sudden onset right hemiplegia and an inability to speak while gardening. The patient was rushed to the National District Hospital. Previous medical history Known with atherosclerosis and previous atheroma with left carotid endarterectomy done in 2007 Ischemic heart disease complicated by coronary artery bypass graft (CABG) done 12 years ago and metal stents in 2007 Essential hypertension Smoker 20 cigarettes per day from the age of 20 years Diabetes Mellitus non-insulin dependent on Metformin oral treatment Current findings on examination Vital signs Blood pressure 130/74 mmHg Pulse rate 72/minute, PO2 92% on low flow oxygen, Respiratory rate 18 breaths/minute, Serum glucose 6.5 mmol/l Temperature 36.3˚C Cardio-vascular System Regular, regular pulse palpated Normal heart sounds 11 No bruits heard over carotid arteries Respiratory system Coarse crepitations bilateral basal segments No diaphragmatic breathing present Gastro Intestinal System The abdomen is soft with no distension No organomegaly Neurological examination Global dysphasia is present with a Glasgow Coma Scale (GCS) of e-4 m-5 V-1 (e=eye opening response; m=motor response; v=verbal response) Cranial nerves Pupils are reactive and equal with no disc swelling Gaze palsy to the right is present Right upper motor neuron Cranial Nerve VII palsy is present Cranial N IX affected – (Cannot swallow, no gag reflex, tongue weak to the left) Motor examination: The tone is decreased in the right arm and leg The power in the right arm is 1/5 and leg 3/5 Decreased reflexes right with a neutral plantar response Sensory examination: Moves all limbs on pain stimulation – see motor fallout above Cerebellar examination: No nystagmus, rest could not be tested Diagnosis Left middle cerebral artery infarction Management in ward Intravenous Saline 1l 8-hourly Nasogastric tube in situ (free drainage) Urinary catheter in situ – intake 2 400 ml/24 hours – output 1 800 ml/24 hours Metformin 1 tab 2 x day per os Enalapril 5 mg/d per os 1/2 Disprin daily per os Zocor 20 mg nocté per os Chest X-ray done, showed bilateral infiltrates Augmentin 1.2g 8-hourly intravenous Glucose monitoring q 6-hourly 12 Barthel Index of Activities of Daily Living Instructions: Choose the scoring point for the statement that corresponds the closest to the patient’s current level of ability for each of the following 10 items. Record actual, not potential functioning. Information can be obtained from the patient’s self-report, from a separate party who is familiar with the patient’s abilities (such as a relative), or from observation. Refer to the guidelines section on the following page for detailed information on scoring and interpretation. Bowels Bladder 0 = incontinent (or need to be given enemata) 0 = incontinent, or catheterised and unable to 1 = occasional accident (once/week) manage 2 = continent 1 = occasional accident (max once/24 hours) 2 = continent (for over 7 days) Patient’s score: 1 Patient’s score: 1 Grooming Bathing 0 = needs help with personal care 0 = dependent 1 = independent face/hair/teeth/shaving (equipment 1 = independent or in shower provided) Patient’s score: 0 Patient’s score: 0 Toilet use Dressing 0 = needs help with personal care 0 = dependent 1 = needs some help, but can do something alone 1 = needs help but can do almost half unaided 2 = independent (on and off, dressing, wiping) 2 = independent (including buttons, zips, laces, etc.) Patient’s score: 0 Patient’s score: 0 Transfer Mobility 0 = unable – no sitting balance 0 = immobile 1 = major help (1 or 2 people, physical) can sit 1 = wheelchair independent, including corners, etc. 2 = minor help (verbal or physical) 2 = walks with help of 1 person (verbal /physical) 3 = independent 3 = independent (but may use aid, e.g. stick) Patient’s score: 0 Patient’s score: 0 Feeding Stairs 0 = unable 0 = unable 1 = needs help cutting, spreading butter, etc. 1 = needs help (verbal, physical, carrying aid) 2 = independent (food provided within reach) 2 = independent up and down Patient’s score: 0 Patient’s score: 0 Total score: 2 Scoring: sum the patient’s scores for each item. Total possible scores range from 0 to 20, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, while change on one item from fully dependent to independent is also likely to be reliable. Sources Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988:10(2):61-63 Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J. 1965:14:61-65 Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988:10(2):64-67 13 Activity 2.1: Role clarification (25 minutes) Because it is the first time that all of you are working collaboratively it is important to identify the professional roles and responsibilities of each one. The group will conduct team interviews with representatives of a profession until the group has interviewed everybody. Steps 1. The topic is the role and responsibilities of the profession. 2. The representatives of the profession stand ready to be interviewed by the teammates. 3. Teammates interview the standing participants, asking open- ended and true questions. 4. After three (3) minutes, the teammates thank the participants who may then sit down. 5. In turn, remaining professions stand and are interviewed by the teammates for three minutes. Activity 2.2: Briefing [10 minutes] Your group constitutes a healthcare team that is doing a grand round. Your next patient is a standardised patient representing a patient who lives in Brandfort and was seen at the National District Hospital Casualty Department 48 hours ago. The patient was hospitalised in the high-care unit. The patient is a pensioner and a significant other accompanied him to the hospital. This person stayed with the patient since admission. The patient was transferred to the ward this morning. A standardised patient with a stroke will be lying in the bed. The patient is conscious but unable to speak. Some of the professionals may have met the patient but others have not met the patient yet. You have read the most recent information pertaining to the patient. Additional information i.e. results of investigations, is in the file at the patients’ bedside. It is not necessary to perform a physical examination. A person representing each of the professions has to present their findings (provided under patient information) and proposed treatment plan (your own). Develop a collaborative treatment plan for the patient. Activity 2.3: SP simulation [15 minutes] You should demonstrate the application and integration of the core elements of collaborative practice while developing a collaborative treatment plan for the patient. Activity 2.4: Debriefing [45 minutes] Steps to follow during the debriefing 1. Each participant briefly states how he/she felt during and directly after the simulation. Please explain why you think you experienced that specific emotion. 2. What was the simulation all about? 3. Do you think you achieved the outcome? 14 4. How did the patient experience the simulation and what would he/she advise? 5. What went well 6. What do you want to improve? 7. What do you need to do to improve on your performance? Please note that the SP will give feedback specifically from the patient’s perspective, with emphasis on communication between the healthcare providers and patient/family. Read about the progress of the patient 15 Session 3 Outcome 3: Demonstrate shared decision-making, shared power, collaborative leadership through effective communication and collaboration among all healthcare professionals, patient and significant others. Activity 3.1: Peer evaluation [10 minutes] Complete Addendum III while you reflect on your practice in session 2. Pre-reading It is the same patient two weeks later. Patient information Diagnosis: Left middle cerebral artery infarction Current findings on examination Blood pressure 125/65 mmHg Pulse rate 85/minute, Respiratory rate 16 breaths/minute Serum glucose 6.2 mmol/l Temperature 36.0 ˚C Cardio Vascular System Regular, regular pulse palpated Normal heart sounds. No bruits heard over carotid arteries Respiratory system Normal breathing sounds Gastro Intestinal System The abdomen is soft with no distension No organomegaly Gastrostomy for feeding Nappies used for excretion Neurological examination Global dysphasia is present with a Glasgow Coma Scale (GCS) of e-4 m-6 V-2 (e=eye opening response; m=motor response; v=verbal response) 16 Cranial nerves: Pupils are reactive and equal with no disc swelling Gaze palsy to the right is present. Right upper motor neuron Cranial Nerve VII palsy is present Cranial N IX affected – swallow small amounts of fluid Motor aphasia Motor examination: The tone is increased in the right arm and leg The power in the right arm is 3/5 and leg 3/5 Limited active movement on the right side Sensory examination: Intact Skin Reddish area under R buttock and R heel (Braden score) Management in ward: Gastrostomy tube in situ Metformin 1 tab 2 x day per os Enalapril 5 mg/d per os 1/2 Disprin daily per os Zocor 20 mg nocté per os Glucose monitoring q 6-hourly Rehabilitation Physiotherapy Walks with a quadropod Short distances only (+10 m) Still struggling with a step Able to bridge, roll and sit up Occupational therapy Needs assistance with toilet transfer Full assistance with hygiene Able to do basic self-care functions with the left hand Still needs assistance with dressing Still uses a communication board Dietetics Gastrostomy in situ (PEG) Bolus feeding with standard formula for diabetics Wife has been trained to administer feeds 17 Barthel Index of Activities of Daily Living Instructions: Choose the scoring point for the statement that most closely corresponds to the patient’s current level of ability for each of the following 10 items. Record actual, not potential, functioning. Information can be obtained from the patient’s self-report, from a separate party who is familiar with the patient’s abilities (such as a relative), or from observation. Refer to the guidelines section on the following page for detailed information on scoring and interpretation. Bowels Bladder 0 = incontinent (or need to be given enemata) 0 = incontinent, or catheterised and unable to 1 = occasional accident (once/week) manage 2 = continent 1 = occasional accident (max once/24 hours) 2 = continent (for over 7 days) Patient’s score: 1 Patient’s score: 1 Grooming Bathing 0 = needs help with personal care 0 = dependent 1 = independent face/hair/teeth/shaving (implements 1 = independent or in shower provided) Patient’s score: 0 Patient’s score: 0 Toilet use Dressing 0 = needs help with personal care 0 = dependent 1 = needs some help, but can do something alone 1 = needs help but can do almost half unaided 2 = independent (on and off, dressing, wiping) 2 = independent (including buttons, zips, laces, etc.) Patient’s score: 1 Patient’s score: 1 Transfer Mobility 0 = unable – no sitting balance 0 = immobile 1 = major help (1 or 2 people, physical) can sit 1 = wheelchair independent, including corners, etc. 2 = minor help (verbal or physical) 2 = walks with help of 1 person (verbal /physical) 3 = independent 3 = independent (but may use aid, e.g. stick) Patient’s score: 1 Patient’s score: 0 Feeding Stairs 0 = unable 0 = unable 1 = needs help cutting, spreading butter, etc. 1 = needs help (verbal, physical, carrying aid) 2 = independent (food provided within reach) 2 = independent up and down Patient’s score: 0 Patient’s score: 0 Total score: 5 Scoring: sum the patient’s scores for each item. Total possible scores range from 0 to 20, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable. Sources Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988:10(2):61-63 Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J. 1965:14:61-65 Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988:10(2):64-67 18 Home assessment Patient comes from a low socioeconomic environment. He lives with his wife who is 70 years old. She is very involved in the patient’s care and is healthy. They live in a 3 bedroom house with 1 bathroom that only has a bath. Loose carpets cover the wooden floors. There is one step to the front door. The patient enjoys gardening and enjoys working in his vegetable garden. Once a month the patient sells his vegetables at the town market. They are both pensioners and their children both work overseas. The patient was functionally independent before this incident and still drove his car. His wife cleans the house but they have a domestic worker who comes in once a week to help with the ironing. The patient is diabetic and hypertensive and has a history of heart disease. The patient wants to go back home as his wife can help him with easy tasks (not transfers). His name has however been put on the waiting list for the Old age home in Brandfort. His wife assists with feeding. They are encouraged to make contact with the community service OT and Physiotherapist in Brandfort to determine the need for assistive devices. He can walk short distances (20 m) only with a quadripod as his exercise tolerance is reduced. Activity 3.2: Briefing [10 minutes] You have read the updated patient information. The same patient, as in the previous session, is in a bed in a private hospital. It is now two weeks later and the patient is haemodynamically stable. The patient’s medical aid requested the hospital to discharge the patient because he is stable. Each profession has to either support or reject the proposal for discharge. As a collaborative practice group, you must reach consensus on the way forward. Activity 3.3: SP simulation [15 minutes] You should demonstrate the application and integration of the core elements of collaborative practice while reaching consensus on the way forward with the patient. Compile a conclusive document to include in the patient’s file. Activity 3.4: Debriefing [45 minutes] Steps to follow during the debriefing 1. Each participant briefly states how he/she felt during and directly after the simulation. Please explain why you think you experienced that specific emotion. 2. What was the simulation all about? 3. Do you think you achieved the outcome? 4. How did the patient experience the simulation and what would he/she advise? 5. What went well 6. What do you want to improve? 7. What do you need to do to improve on your performance? 19 Please note that the SP will give feedback specifically from the patient’s perspective, with emphasis on communication between the healthcare providers and patient/family. 20 Session 4 Outcome 4: Compile a plan to establish a collaborative practice according to the underpinning principles in a multidisciplinary healthcare setting. Activity 4.1: IPP plan [60 minutes] You are all working at the same healthcare institution and want to improve the collaboration among yourselves. Design a plan on the page from the flip chart on how you should go about developing a collaborative practice. Use the knowledge gained from the previous IPE sessions. You may want to consult the work you did during the first session. Hand the final product to the facilitator for marking. The mark obtained for this assignment in combination with the peer evaluation of performance and participation will be used in your profession specific module. The calculated mark will be recorded per student as explained in the specific module guide. Activity 4.2: Completion of the RIPLS questionnaire [5 minutes] Please complete the Readiness of Interprofessional Learning Scale (RIPLS) questionnaire in Addendum II anonymously. It will not take more than 5 minutes. Completion of the questionnaire is voluntarily. There will be no retribution if you decide not to complete the questionnaire. Data will be used for research purposes such as dissertations, articles and conference proceedings. Thank you in advance for completing the questionnaire. We appreciate your collaboration. On completion, remove the page from this study guide and hand it to the facilitator. Activity 4.4: Peer evaluation [5 minutes] The facilitator wrote the names of the group on pieces of paper. Each student draws a name from the container. Ask the facilitator to put your name back into the pool should you per chance take the piece of paper with your own name on it. Complete the form in Addendum I in which you evaluate the member’s participation and contribution. Tear the completed form from the book and hand it to the facilitator before departure. Thank you for your participation. We hope you have enjoyed the Interprofessional education sessions and that you will reap the benefits of having attended these sessions in future. We wish you success with your studies and professional endeavours. 21 Reference List Anderson, E., Manek, N., & Davidson, A. (2006). Evaluation of a model for maximising interprofessional education in an acute hospital. Journal of interprofessional care, 20(2), 182–94. Armitage, H., Connolly, J., & Pitt, R. (2008). Developing sustainable models of interprofessional learning in practice--the TUILIP project. Nurse education in practice, 8(4), 276–82. Baldwin, D. C., & Baldwin, M. A. (2007). Interdisciplinary education and health team training: a model for learning and service. 1979. Journal of interprofessional care, 21 Suppl 1(October), 52–69. Bridges, D. R., Davidson, R. A, Odegard, P. S., Maki, I. V, & Tomkowiak, J. (2011). Interprofessional collaboration: three best practice models of interprofessional education. Medical education online, 16(6035), 1–10. Casimiro, L., MacDonald, C. J., Thompson, T. L., & Stodel, E. J. (2009). Grounding theories of W(e)Learn: a framework for online interprofessional education. Journal of interprofessional care, 23(4), 390–400. Craddock, D., O’Halloran, C., McPherson, K., Hean, S., & Hammick, M. (2013). A top-down approach impedes the use of theory? Interprofessional educational leaders’ approaches to curriculum development and the use of learning theory. Journal of interprofessional care, 27(1), 65– 72. Interprofessional Education Collaborative Expert Panel. (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an expert panel. Washington, D.C. Olenick, M., & Allen, L. R. (2013). Faculty intent to engage in interprofessional education. Journal of Multidisciplinary Healthcare, 6, 149–161. World Health Organisation. (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva. World Health Professions Alliance. (2013). WHPA statement on interprofessional collaborative practice. 22 Addendum A MEDICAL AND DENTAL PROFESSIONS BOARD OF THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA Core competencies* for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in South Africa Developed by the Undergraduate Education and Training Subcommittee of the Medical and Dental Professions Board in collaboration with training institutions and the South African Committee of Medical and Dental Deans. Version: February 2014 *Adapted from the CanMEDS Physician Competency Framework, with permission of the Royal College of Physicians and Surgeons of Canada. Copyright 2005. 23 24 1 ROLE: HEALTHCARE PRACTITIONER As healthcare practitioners, healthcare professionals integrate all of the graduate attribute roles, applying profession-specific knowledge, clinical skills and professional attitudes in their provision of patient/client - centred care. The healthcare practitioner is the central role in the framework of graduate attributes. 1 . 1 KE Y CO M P E T E N CY Function effectively as entry-level healthcare practitioners, integrating all graduate attribute roles to provide optimal, ethical, comprehensive and patient/client-centred care in a plurality of health and social contexts. 1 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Perform a consultation or facilitate a structured clinical encounter effectively, including thorough documentation of assessments and recommendations. b) Identify and respond appropriately to relevant ethical issues arising in patient/client care and clinical decision-making. c) Prioritise professional duties effectively and appropriately when caring for multiple patients/clients and being challenged to address their healthcare needs holistically. d) Provide compassionate, empathetic and patient/client-centred care. e) Demonstrate a commitment to work in primary healthcare settings (urban and rural), and find professional and personal satisfaction in it. 1 . 2 K E Y C OM P E T E N CY Acquire and maintain knowledge, skills, attitudes and character appropriate to their pactice. 1 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Reflect on, integrate, apply and evaluate core knowledge, skills, attitudes and character acquired during undergraduate training in:  the application of appropriate academic literacy, numeracy and information technology skills;  natural sciences;  normal human structure;  normal biological, psychological, social and spiritual development and functioning of the individual in the context of family and community;  the pattern, aetiology and history of common human disease processes and mechanisms;  physical, psychological, social and spiritual determinants of health and disease;  the principles of drug action and use; 24 25  the efficacy of various therapies;  the holistic management of functional and structural impairment, activity limitations and participation restrictions, all with reference to personal and environmental risk factors;  the interdependence between health and education systems; and  the ethical, human rights and legal principles embedded in healthcare. b) Apply life-long learning skills to keep up to date and to enhance professional competence. 1 . 3 K E Y C OM P E T E N CY Perform comprehensive assessments of patients/clients. 1 . 3 .1 E N A B L I NG C OM P E T E N CIE S a) Effectively identify and explore issues to be addressed in a patient/client encounter, including the patient/client’s context and preferences. b) Elicit a history of the patient/client that is relevant, concise and accurate to context, for the purposes of disease prevention, health promotion, diagnosis and/or management. c) Perform a holistic and focused examination that is relevant and accurate, for the purposes of disease prevention, health promotion, diagnosis and/or management. d) Select appropriate investigative methods in a resource-effective and ethical manner. e) Demonstrate effective problem-solving and judgement to address patient/client problems, including interpreting data and integrating information to make differential diagnoses and propose holistic management plans. f) Demonstrate increasing proficiency in clinical decision-making. 1 . 4 K E Y C OM P E T E N CY Use preventive, promotive, therapeutic and rehabilitative interventions effectively. 1.4.1 ENABLING COMPETENCIES a) Demonstrate effective, appropriate and timely application of therapeutic interventions. b) Include prevention and health promotion in the management plan. c) Consider the range of solutions that have been developed for treatment and prevention of health problems, taking into consideration all ages and diverse communities. d) Formulate and implement appropriate holistic, cost-appropriate and effective management plans in collaboration with patients/clients and their families, emphasising the importance of healthy behaviour and the patient/client’s right to choice. e) Ensure that appropriate informed consent is obtained for interventions and that patients/clients’ needs and rights are respected. 25 26 f) Appropriately utilise clinical-care and patient-care guidelines and protocols, and demonstrate the ability to adapt these to local settings. g) Develop and deliver appropriate follow-up and ongoing care beyond the immediate onsultation and short-term management plan. h) Recognise acute life-threatening emergencies, and initiate appropriate treatment and referral. i) Take cognisance of the structure, organisation and functioning of the South African healthcare system in compiling the patient/client care plan. 1 . 5 K E Y C OM P E T E N CY 1 .5 Demonstrate efficient and appropriate use of procedural skills, both diagnostic and therapeutic. 1 . 5 .1 E N A B L I NG C OM P E T E N CIE S a) Demonstrate effective, appropriate and timely performance of diagnostic, therapeutic and rehabilitative procedures. b) Appropriately document and disseminate information related to procedures performed and their outcomes. c) Ensure adequate follow-up care and care continuity for procedures performed. 1 . 6 K E Y C OM P E T E N CY 1 .6 Seek appropriate consultation from other healthcare professionals, recognising the limits of their own and others’ expertise. 1 . 6 .1 E N A B L I NG C OM P E T E N CIE S a) Demonstrate insight into own limitations of expertise. b) Demonstrate effective, appropriate and timely consultation of other healthcare practitioners as needed for optimal patient/client care. 26 27 2 ROLE: COMMUNICATOR : As communicators, healthcare professionals effectively facilitate the carer-patient/carer-client relationship and the dynamic exchanges that occur before, during and after interventions. 2 . 1 K E Y C OM P E T E N CY 2 .1 Develop rapport, trust and ethical therapeutic relationships with patients/clients, families and communities from different cultural backgrounds. 2 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Demonstrate a both patient/client-centred and community-centred approach in interactions with patients/clients and their families. b) Practise good communication as a core clinical skill, recognising that effective communication between the healthcare professional and the patient/client can foster patient/client and professional satisfaction, as well as adherence and improved clinical outcomes. c) Establish positive therapeutic relationships with patients/clients and their families characterised by understanding, trust, respect, honesty, integrity and empathy. d) Respect patient/client confidentiality, privacy and autonomy. e) Motivate patients/clients and their families and communities to take personal responsibility for their health. f) Demonstrate flexibility in the application of communication skills. 2 . 2 K E Y C OM P E T E N CY 2 .2 Accurately elicit and synthesise relevant information and perspectives of patients/clients and families, communities, colleagues and other professionals. 2 . 2 .1 E N A B L I N G C O M P ET E N C IE S a) Gather information about health conditions and functioning, as well as about a patient/client’s beliefs, concerns, expectations and illness experience. b) Seek and synthesise appropriate information from relevant sources, such as a patient/client’s family, community, caregivers and other professionals. c) Communicate effectively by listening, clarifying uncertainties, probing sensitively, and being aware of, and responsive to, non-verbal cues. 2 . 3 K E Y C OM P E T E N CY 2 .3 Convey relevant information and explanations accurately and effectively to patients/clients, families, communities, colleagues and other professionals as well as statutory and professional bodies. 27 28 2.3.1 ENABLING COMPETENCIES a) Retrieve patient/client-specific information from a clinical data system. b) Deliver information to a patient/client and family, communities, colleagues and other professionals in a humane manner and in such a way that it is understandable, and encourages discussion and participation in decision-making. c) Present well-documented assessments and recommendations effectively in written and/or verbal form in response to a request from another healthcare professional. d) Compile accurate reports as needed and required for statutory and professional purposes. 2 . 4 K E Y C OM P E T E N CY 2 .4 Develop a common understanding of issues, problems and plans with patients/clients, families, communities, colleagues and other professionals, to develop a shared plan of care/action. 2 . 4 .1 E N A B L I NG C OM P E T E N CIE S a) Identify and explore problems to be addressed effectively from a patient/client encounter, including the patient/client’s functioning, context, responses, concerns and preferences. b) Respect diversity and difference and the influence of ethnicity, gender, religion, education and culture on decision-making. c) Encourage discussion, questions and interaction. d) Engage patients/clients, families, communities and relevant healthcare professionals in shared decision- making to develop a plan of care/action. e) Effectively address challenging communication issues, such as obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding. f) Communicate effectively with patients/clients and their families about costs and risks implicit in clinical interventions and care, in order to minimise potential medico-legal issues. 2 . 5 K E Y C OM P E T E N CY 2 .5 Convey effective and accurate oral and written information about a clinical encounter. 2 . 5 .1 E N A B L I NG C OM P E T E N CIE S a) Maintain clear, accurate and appropriate records (written or electronic) of all clinical encounters and plans, within systems that allow for the dependable and rapid retrieval of such information. b) Present effective oral and written reports of clinical encounters and plans, using language, visual, information technology and numeracy skills. c) Recognise ethical and legal issues in compiling patient/client documentation. 28 29 3 ROLE: COMMUNICATOR As collaborators, healthcare professionals work effectively within a team to achieve optimal patient/client care 3 . 1 KE Y CO M P E T E N CY 3 .1 Participate effectively and appropriately in multicultural, interprofessional and transprofessional teams, as well as teams in other contexts (the community included). 3 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Describe their own roles and responsibilities to other professionals. b) Recognise and respect – irrespective of profession, status, age, gender, race, class or beliefs – the diversity of roles, responsibilities and competencies of other team members. Appreciate diversity, and demonstrate the ability to adapt. (Healthcare team members may include other professionals, community workers and practitioners of alternative, complementary and cultural/traditional healthcare practice). c) Work interdependently and share tasks with others to assess, plan, provide and integrate quality care for individual patients/clients (or groups of patients/clients). d) Collaborate with others, where appropriate, to assess, plan, provide and review other tasks, such as research problems, educational work, programme review or administrative responsibilities. e) Participate effectively in interprofessional team meetings, respecting team ethics, including confidentiality, resource allocation and professionalism. f) Demonstrate appropriate leadership in a healthcare team. 3 . 2 K E Y C OM P E T E N CY 3 .2 Work effectively with other healthcare professionals to promote positive relationships and prevent, negotiate and resolve interpersonal conflict. 3 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Demonstrate a respectful attitude towards other team members, and work with other professionals to promote positive relationships and prevent conflict. b) Employ collaborative negotiation skills to achieve consensus and/or resolve conflict. c) Recognise differences, misunderstandings and limitations in other professionals, and acknowledge their own differences, misunderstandings and limitations that may contribute to interpersonal tension. d) Reflect on improving interprofessional and transprofessional team function. 29 30 4 ROLE: LEADER & MANAGER As leaders and managers, healthcare practitioners are integral participants in healthcare organisations, organising sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system. 4 . 1 K E Y C OM P E T E N CY 4 .1 Participate in activities that contribute to the effectiveness of the healthcare organisations and systems in which they work. 4 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Work with others in their organisations, understanding the structure and functioning of the healthcare systems as these relate to their practice. b) Demonstrate the competence to work in home and community-based care settings, with insight into the potential contributions of community support groups. c) Participate in the quality process evaluation and improvement of systems, such as practice audits, mortality and morbidity meetings and patient/client safety initiatives, integrating the available best evidence and practice. d) Demonstrate problem-solving enterprise and creativity in improving and managing a healthcare system, and by providing advice to relevant authorities, with support from superiors. 4 . 2 K E Y C OM P E T E N C Y 4 .2 Manage their practice and career effectively. 4 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Set priorities and manage time to balance patient/client care, practice requirements, outside activities and personal life. b) Manage their professional practice, including finances, human resources and effective record keeping. c) Implement processes to ensure personal practice improvement. d) Use information technology effectively in managing healthcare environments. 4 . 3 K E Y C OM P E T E N C Y 4 .3 Utilise finite healthcare resources appropriately. 4 . 3 .1 E N A B L I NG C OM P E T E N CIE S a) Utilise healthcare resources under their control carefully and fairly. b) Apply evidence and good management to achieve cost-appropriate care. 30 31 4 . 4 KE Y CO M P E T E N CY 4 .4 Serve in administration and leadership roles, as appropriate. 4 . 4 .1 E N A B L I NG C OM P E T E N CIE S a) Participate effectively in committees and meetings, as the need arises. b) Participate in implementing change, where necessary, in the healthcare organisation in which they are serving. c) Plan relevant elements of healthcare delivery (e.g. duty rosters). 4 . 5 K E Y C OM P E T E N C Y 4 .5 Provide effective healthcare to geographically defined communities. 4 . 5 .1 E N A B L I NG C OM P E T E N CIE S a) Play a constructive, critical and creative role in the organisation, management and provision of healthcare, in the community, hospital and other facilities where profession-specific services are rendered. b) Evaluate the burden of disease within the community using local, regional, national and global data. c) Identify the health determinants of the population, such as genetic, demographic, environmental, socio- economic, psychological, cultural and lifestyle-related determinants. d) Evaluate existing primary healthcare practice and community health programmes. e) Evaluate the elements of the local health system, taking into consideration the economic and practical constraints within which the service is delivered and the audit process to monitor its delivery. f) Collaborate with other professionals, relevant organisations and the community to draw up a plan to manage the identified health priorities and to collectively promote health. g) During planning, take cognisance of the functional links between primary healthcare and public health, the interface between hospital and home-based care, and the principles of ethics and human rights in community-oriented healthcare. 31 32 5 ROLE: HEALTH ADVOCATE As health advocates, healthcare professionals responsibly use their expertise and influence to advance the health and well-being of individuals, communities and populations. 5 . 1 K E Y C OM P E T E N CY 5 .1 Respond to individual patient/client health needs and related issues as part of holistic care. 5 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Identify the health needs of an individual patient/client, taking into consideration his/her culture. b) Identify and use opportunities for health promotion and disease prevention with individuals to whom they provide care, incorporating ethical and human rights principles. c) Act as advocates for patient/client groups with particular health needs (including the poor and marginalised members of society). 5 . 2 K E Y C OM P E T E N CY 5 .2 Respond to the health needs of the communities that they serve. 5 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Familiarise themselves with the communities they serve by obtaining insight into the functioning of the local health system, barriers to access care and resources, and other factors not directly part of healthcare., b) Identify vulnerable or marginalised populations and respond appropriately, with a commitment to equity through access to care and equal opportunities. c) Identify opportunities for health promotion and disease prevention within the context of promoting a healthy environment and lifestyle. d) Communicate effectively with communities, and enable them to identify, prioritise and address healthcare needs specific to them. e) Recognise and respond to competing interests within the community being served by reporting these to the relevant stakeholders in the community. f) Apply the ethical and professional principles inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism, appreciating the possibility of conflict inherent in the role of health advocate. 32 33 6 ROLE: SCHOLAR As scholars, healthcare professionals demonstrate a lifelong commitment to reflective learning as well as the creation, dissemination, application and translation of knowledge. 6 . 1 K E Y C OM P E T E N CY 6 .1 Maintain and enhance professional competence through ongoing learning, both as healthcare professionals and as responsible citizens, locally and globally. 6 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Reflect on and acknowledge the strengths and limitations of their knowledge and skills. b) Commit to maintaining and enhancing knowledge and skills using a personal development plan. c) Use appropriate strategies and utilise opportunities for continued professional development and lifelong learning. d) Be able to maintain comprehensive, complete and accessible records for the purposes of good practice and the facilitation of audits and healthcare research. e) Reflect on, and learn from, challenges that are experienced in practice by posing appropriate questions, accessing and interpreting relevant evidence, integrating new learning with practice, evaluating the impact of change in practice, and documenting the learning process. f) Know the requirements of the regulations regarding continuous professional development (CPD), as specified by the Health Professions Council of South Africa. 6 . 2 KE Y CO M P E T E N CY 6 .2 Ask questions about practice, locate relevant evidence, critically evaluate and interpret information and sources, and consider the application of the information. 6 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Phrase clear, answerable, relevant questions related to practice. b) Utilise knowledge gained through the critical evaluation of health-related literature to keep up to date with new developments. c) Use appropriate techniques to effectively and efficiently access relevant research findings from reliable sources. d) Critically appraise retrieved evidence for quality and relevance, and interpret the findings. e) Consider the applicability of research findings to own setting. f) Understand the basic principles of quantitative and qualitative research design and analysis as well as research ethics. g) Respect and comply with laws pertaining to plagiarism, confidentiality and ownership of intellectual property when accessing and using information and conducting research. 33 34 6 . 3 K E Y C OM P E T E N CY 6 .3 Facilitate the learning of patients/clients, families, students, other healthcare professionals, the public, staff and others, as appropriate. 6 . 3 .1 E N A B L I NG C OM P E T E N CIE S a) Identify collaboratively the learning needs and desired learning outcomes of others. b) Select effective teaching strategies and content to facilitate others’ learning. c) Reflect on teaching encounters and seek feedback to guide their development as effective facilitators of learning. d) Create an enabling and supportive learning environment that is sensitive to issues that can influence learning. e) Listen and provide feedback. f) Seek and utilise opportunities to develop their skills as facilitators of learning and as mentors. 34 35 6 ROLE: PROFESSIONAL As professionals, healthcare professionals are committed to ensure the health and well-being of individuals and communities through ethical practice, profession-led self-regulation and high personal standards of behaviour. 7 . 1 K E Y C OM P E T E N CY 7 .1 Demonstrate commitment and accountability to their patients/clients, other healthcare professions and society through ethical practice. 7 . 1 .1 E N A B L I NG C OM P E T E N CIE S a) Exhibit and promote appropriate professional behaviour, including honesty, integrity, commitment, compassion, respect for life, accessibility and altruism. b) Demonstrate a commitment to delivering the highest quality care and maintenance of professional competence according to the values of the profession. c) Recognise and appropriately respond to ethical, legal and human rights issues and dilemmas encountered in practice and not be influenced by political pressure. d) Recognise and appropriately manage conflict of interest in practice. e) Recognise the principles and limits of patient/client confidentiality as defined by professional practice standards and law. f) Maintain appropriate professional relations with patients/clients, healthcare professionals and communities. 7 . 2 K E Y C OM P E T E N CY 7 .2 Demonstrate a commitment to their patients/clients, healthcare professionals and society through participation in profession-led self-regulation. 7 . 2 .1 E N A B L I NG C OM P E T E N CIE S a) Adhere to the appropriate professional, legal and ethical codes of practice of the profession. b) Recognise and interrogate public health policy in terms of ethics and human rights. c) Demonstrate accountability and fulfil the regulatory and legal obligations required by the regulatory bodies of the health professions. d) Recognise, address and report unprofessional behaviour encountered in healthcare training and practice. e) Maintain professional competence through ongoing self-reflection and peer review. 35 36 7 . 3 K E Y C OM P E T E N CY 7 .3 Demonstrate a commitment to own health and sustainable practice. 7.3.1 E N A B L I N G C O M P E T E N C Y a) Make informed choices for their own future career development based on an understanding of the nature and scope of various professions. b) Recognise and balance personal and professional priorities to achieve personal health and a sustainable and effective practice. c) Demonstrate insight into personal and professional problems, and develop strategies to address them effectively with the aim to maintain own physical, psychological, social and spiritual well- being. d) Recognise other professionals in need, and respond appropriately. 36 Addend3u7 m B 37 38 38 39 39 40 40 41 41 42 42 43 43 44 44 45 45 46 46 47 47 48 48 49 49 50 50 51 51 52 Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 Adde5n3d um C Stroke Assessment Ac ross The Continuum Of Care Summary of recommendation RECOMMENDATION *1 LEVEL OF EVIDENCE Practice Recommendations Secondary prevention 1.0 Nurses in all practice settings should screen clients for risk IV factors related to stroke in order to facilitate appropriate secondary prevention. Clients with identified risk factors should be referred to trained healthcare professionals for further management. Stroke recognition 2.0 Nurses in all practice settings should recognise the new onset IV of the signs and symptoms of stroke as a medical emergency to expedite access to time dependent stroke therapy, since “time is brain”. Neurological 3.0 Nurses in all practice settings should conduct a neurological IV assessment on admission and as soon as there is a change in assessment client status. This neurological assessment, facilitated with a validated tool (such as the Canadian Neurological Scale, National Institutes of Health Stroke Scale or Glasgow Coma Scale), should include at minimum: ■ Level of consciousness; ■ Orientation; ■Motor (strength, pronator drift, balance and coordination); ■ Pupils; ■ Speech/Language; ■ Vital signs (TPR, BP, SpO2); and ■ Blood glucose. 3.1 Nurses in all practice settings should recognise that signs of IV decline in neurological status might be related to neurological or secondary medical complications. Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management. Practice Recommendations Complications 4.0 Nurses in all practice settings should assess the client’s risk IV for pressure ulcer development, which is determined by the combination of clinical judgement and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability (such as the Braden Scale for Predicting Pressure Sore Risk) is recommended. 4.1 Nurses in all practice settings should assess the stroke client’s fall Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neuro logy - Supplement 2008 54 RECOMMENDATION *1LEVEL OF EVIDENCE Practice Recommendations fall risk on admission and after a fall, using a validated tool (such as the STRATIFY or timed “Up and Go”). Pain 5.0 Nurses in all practice settings should assess clients for pain IV using a validated tool (such as the Numeric Rating Scale, the Verbal Analogue Scale or the Verbal Rating Scale). Dysphagia 6.0 Nurses should maintain all clients with stroke NPO (including IIa oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert. 6.1 Nurses in all practice settings, who have appropriate IV training should administer and interpret a dysphagia screen within 24 hours of the stroke client becoming awake and alert. This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. This screening should include: ■ Assessment of the client’s alertness and ability to participate; ■ Direct observation of signs of oropharyngeal swallowing difficulties (choking, coughing, wet voice); ■ Assessment of tongue protrusion; ■ Assessment of pharyngeal sensation; ■ Administration of a 50 ml water test; and ■ Assessment of voice quality. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management. Nutrition 7.0 Nurses in all practice settings should complete a nutrition IV and hydration screen within 48 hours of admission, after a positive dysphagia screen and with changes in neurological or medical status, in order to prevent the complications of dehydration and malnutrition. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management. Practice Recommendations Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 55 RECOMMENDATION *1LEVEL OF EVIDENCE Cognition/ 8.0 Nurses in all practice settings should screen clients for IV Perception alterations in cognitive, perception/perceptual and / Language language function that may impair safety, using validated tools Language (such as the Modified Mini-Mental Status Examination and the Line Bisection Test). This screening should be completed as follows: Within 48 hours of regaining consciousness: ■ Arousal, alertness and orientation; ■ Language (comprehensive and expressive deficits); and ■ Visual neglect. In addition, when planning for discharge: ■ Attention; ■ Memory (immediate and delayed recall); ■ Abstraction; ■ Spatial orientation; and ■ Apraxia. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management. Activities of daily 9.0 Nurses in all practice settings should assess stroke clients’ IV living ability to perform the activities of daily living (ADL). This assessment, using a validated tool (such as the Barthel Index or the Functional Independence Measure™), may be conducted collaboratively with other therapists, or independently when therapists are not available. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management. Bowel and bladder 10.0 Nurses in all practice settings should assess clients for IV function faecal incontinence and constipation. 10.1 Nurses in all practice settings should assess clients for urinary incontinence and retention (with or without IV overflow). Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RECOMMENDATION *1LEVEL OF EVIDENCE 56 Depression 11.0 Nurses in all practice settings should screen clients for IV evidence of depression, using a validated tool (such as the Stroke Aphasia Depression Questionnaire, Geriatric Depression Scale, Hospital Anxiety and Depression Scale or the Cornell Scale for Depression in Dementia) prior to discharge throughout the continuum of care. In situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management. 11.1 Nurses in all practice settings should screen stroke clients for suicidal ideation and intent when a high index of suspicion for depression is present, and seek urgent medical referral. Practice Recommendations Caregiver strain 12.0 Nurses in all practice settings should assess/screen caregiver III burden, using a validated tool (such as the Caregiver Strain Index or the Self Related Burden Index). In situations where concerns are identified, clients should be referred to a IV trained healthcare professional for further assessment and management. Sexuality 13.0 Nurses in all practice settings should screen stroke IV clients/their partners for sexual concerns to determine if further assessment and intervention is necessary. In situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management. Client and Caregiver 14.0 Nurses in all practice settings should assess the stroke client IV readiness to learn and their caregivers’ learning needs, abilities, learning preferences and readiness to learn. This assessment should be ongoing as the client moves through the continuum of care and as education is provided. Documentation 15.0 Nurses in all practice settings should document IV comprehensive information regarding assessment and/or screening of stroke clients. All data should be documented at the time of assessment and reassessment. Education Recommendations Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RECOMMENDATION *1LEVEL OF EVIDENCE 57 16.0 Basic education for entry into practice should include: IV ■ Basic anatomy and physiology of the cerebrovascular system; ■ Pathophysiology of a stroke; ■ Risk factors of a stroke; ■ Signs and symptoms of a stroke; ■ Components of a client history and assessment specific to stroke; ■ Common investigations (tests); and ■ Validated screening/assessment tools. 16.1 Nurses working in areas with a focus on stroke should have enhanced stroke IV assessment skills. Organisation & Policy Recommendations 17.0 Organisations should develop a plan for implementation that includes: IV ■An assessment of organisational readiness and barriers to education. ■Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ■Ongoing opportunities for discussion and education to reinforce the importance of best practices. ■Dedication of a qualified individual to provide the support needed for the education and implementation process. ■Opportunities for reflection on personal and organisational experience in implementing guidelines. Nursing best practice guidelines can be implemented successfully only where there are adequate planning, resources, organisational and administrative support, as well as appropriate facilitation. In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the HSFO-RNAO best practice guideline Stroke Assessment Across the Continuum of Care. 18.0 Organisational policy should clearly support and promote the nurses’ role in stroke IV assessment, either independently or in collaboration with other members of the interdisciplinary team. Interpretation of evidence Levels of Evidence Ia Evidence obtained from meta-analysis or systematic review of randomised controlled trials. Ib Evidence obtained from at least one randomised controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomisation IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomisation. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 IV Evidence obtained from expert committee reports or opinions and/or clinical experien5c8e s of respected authorities. Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 Addendum D Review Article 59 Role of occupational therapy after stroke Tennille J. Rowland, Deirdre M. Cooke1, Louise A. Gustafsson2 Department of Occupational Therapy / Acute Stroke Unit, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, 1Mater Private Rehabilitation Unit, Brisbane, Queensland, 2Division of Occupational Therapy, University of Queensland, Brisbane, Queensland, Australia. abstract Internationally recognized best practice care in the early management and rehabilitation of individuals following stroke includes multidisciplinary assessment and treatment by a coordinated team of health care professionals that includes occupational therapists. Occupational therapists assess the impact of changes in motor function, sensation, coordination, visual perception, and cognition on a person’s capacity to manage daily life tasks. Intervention improves participation in meaningful roles, tasks, and activities; remediates deficits; minimizes secondary complications; and provides education and support to the patient and caregivers. Occupational therapists’ focus on independence and function, individual goal-setting, and their specialist skills in task adaptation and environmental modification underpin the profession’s contribution to the multidisciplinary stroke rehabilitation team. The aim of this paper is to provide an overview of occupational therapy practice in stroke patients. Keywords Assessment, intervention, occupational therapy, role, stroke For correspondence: Ms Tennille Rowland, Department of Occupational Therapy, Royal Brisbane and Women’s Hospital, Level 2 James Mayne Building, Butterfield Street, Herston, Queensland, Australia, 4006. E-mail: tennille_rowland@health.qld.gov.au Ann Indian Acad Neurol 2008;11:S99-S107 Atfter stroke, occupational therapists work to facilitate and There are 15 occupational therapy education centers in improve motor control and hand function in the stroke-aff India that are recognized by the All India Occupational ected upper limb; to maximize the person’s ability to Therapists ’ Association (AIOTA) and the World undertake his or her own personal self-care tasks and domestic Federation of Occupational Therapy (WFOT). The tasks; to help the patient learn strategies to manage the International Journal of Occupational Therapy is an offi cognitive, perceptual, and behavioral changes associated cial publication of AIOTA.[4] with stroke; and to prepare the home and work environment for the patient’s return. Occupational Therapy Assessment after Stroke Internationally recognized best practice care in the early Assessment is conducted to understand the impact of management and rehabilitation of individuals following changes in motor function, sensation, coordination, visual stroke includes multidisciplinary assessment and treatment perception, and cognition on the stroke victim’s capacity to by a coordinated team of health care professionals, manage daily life tasks. Assessment is used to identify including occupational therapists.[1] Occupational areas of individual and environmental difficulties and therapists work collaboratively with the patient to to enable patient-centered goal- seting with the establish the impact of stroke on the performance of daily participation of both the patient and the family members. tasks, including personal cares, domestic tasks, and work and leisure activities, and develop a goal-focused program to Table 1 lists the core areas of occupational therapy develop the required skills for participation in daily life. The assessment, summarized according to the International 5] aim of this paper is to provide an overview of ClassiÞ cation of Functioning (ICF) terminology.[ occupational therapy practice in stroke. Occupational therapists endeavor to set rehabilitation goals related to activity and participation that are speciÞ c, The Clinical Guidelines for Acute Stroke Management[2] and measurable, at ainable, realistic, and relevant to the Stroke Rehabilitation and Recovery[3] provides a individual person. framework that is based on the best available evidence. There is a growing research evidence base in support of the benefits of occupational therapy management following stroke. Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RSo1w0l0an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n0al Table 1: Core areas of occupational therapy assessment ICF dimension Body function and Activity Participation Environment structure Occupational Therapy Occupational Performance Occupational Performance Occupational Performance Environments and Contexts Terminology Assessment Components Roles Areas  Vision  Upper limb function  Occupational roles  Physical (e.g. home work)  Visual perception  Personal self care tasks  Community integration  Social  Memory  Domestic or instrumental  Cultural  Cognition activities of daily living  Executive function  Leisure activities  Sensory motor changes  Driving  Psychosocial adjustments Activities of Daily Living (ADL) therapists routinely screen for visual-perceptual impairments such as agnosia; visuospatial relations problems, eg, Þ gure- The initial process of occupational therapy assessment ground, body scheme disorders, depth perception, and involves interviews with the patient and the carer to unilateral neglects, and impairments in constructional establish previously held life roles and the tasks and [14] skills. Other neurobehavioral changes, including praxis activities that were completed within these roles. and acalculia, are commonly assessed in conjunction Observational assessment is undertaken of personal self- with visual-perceptual screening following both right and letf care tasks, including showering, dressing, toileting, grooming, hemisphere stroke. A more detailed summary of the visual- and eating, and domestic or instrumental tasks, including perceptual and motor planning changes that are screened for meal preparation, shopping, cleaning, laundry, and by occupational therapists is shown in Table 2. management of Þ nances and medications. Standardized measures may include the Functional Independence Memory and Cognition Measure (FIM),[6] the ModiÞ ed Barthel Index (MBI),[7] the The occupational therapist conducts initial screening, and Assessment of Motor and Process Skills (AMPS),[8] the more detailed assessments if indicated, in the areas of Assessment of Living Skills and Resources (ALSAR),[9] and memory, cognition, and executive functioning to determine the Reintegration to Normal Living Index.[10] Understanding the impact of changes in these areas on the ability to the level of assistance needed in each of these areas and the resume daily function. The occupational therapist uses priorities of the individuals helps the occupational therapist standardized measures in addition to structured target rehabilitation interventions appropriately and to observational techniques, and the results are then used in measure progress towards individual goals. Observation of treatment planning and outcome measurement. These activity limitations allows the occupational therapist to identify the measures may include the Mini Mental State Examination impairments that underpin these limitations, including the motor, [18](MMSE), the Cognitive Assessment of Minnesota sensory, cognitive and/or perceptual sequelae of stroke. These [19] [20] (CAM), the Rivermead Behavioral Memory Test (RBMT), will now be described in more detail. [8] and the Assessment of Motor and Process Skills (AMPS). Vision and Visual Perception Unless identiÞ ed and addressed, impairments in memory, cognition, and executive skills can impact signiÞ cantly upon a Screening of primary visual skills, including visual acuity, visual Þ person’s ability to participate in a rehabilitation program and to elds, and visual tracking are undertaken by the occupational complete personal, domestic, leisure, and work-related therapist before examining for changes in visual tasks.[21] Diffi culty in initiating regular tasks such as perception.[11] Routine occupational therapist assessment for preparing breakfast, impaired capacity to plan in advance impairments of perception are integral to the rehabilitation to a t end an appointment or take medication appropriately, of patients following stroke[12] and are prerequisites to the reduced a t entional capacity to at end to a task such as overall goal of optimizing functional independence.[13] using the computer, or impulsiveness that poses safety risks Standardized assessment tools used in this area include the for the individual are practical examples of the eff ects of Occupational Therapy Adult Perceptual Screening Test (OT- these impairments. APST),[14] the Rivermead Perceptual Assessment Bat ery Sensory, Motor, and Upper Limb Function [15] (RPAB), the Behavioral Ina t ention Test (BIT),[16] and the Ontario Society of Occupational Therapists Perceptual Occupational therapists conduct detailed assessment of the Evaluation (OSOT).[17] Following stroke, occupational motor and sensory changes following stroke, with Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RSo1w0l1an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n1al Table 2: Classification of terminology for visual perceptual impairments and apraxia.[14] Areas of Impairment Specific Impairments Agnosias Visual object agnosia (visual perceptual impairments, visual discrimination Defective visual analysis and synthesis  Figure-ground discrimination  Simultanagnosia  Visual closure Shape and size constancy (form constancy) Facial agnosia (prosopagnosia)  Recognition of familiar and unfamiliar faces Color agnosia Alexia 2. Visuospatial Impairments (spatial perception, spatial Judgment of direction, distance, position in space and the disorientation, visuospatial agnosia, spatial relations perception of depth Topographical disorientation syndromes Unilateral neglect  Sensory, motor, or representational neglect  Personal or spatial neglect (peripersonal or extrapersonal) Body scheme disorders  Somatognosis  Finger agnosia  Left / right discriminatin  Anosognosia Line orientation 3. Constructional skill impairments (visuoconstructional Defective assembling performance on two and three-dimensional ability visuoconstructional praxis, visuomotor  Two-dimensional constructional impairments integration*) tasks  Three-dimensional constructional impairments Defective graphomotor performance (agraphia) 4 Apraxias Buccofacial/oral apraxia  Ideational apraxia  Ideomotor apraxia  Gait apraxia Dressing apraxia 5 Acalculia *Alternative terms included in parentheses particular emphasis on upper limb and hand function. Occupational and the choice of the method may be inß uenced by the level and pa t therapy interventions then address changes in motor power, ern of motor control available to the patient, the clinical se t ing, the muscle tone, sensory loss, motor planning/praxis, Þ ne motor time available to administer the test, the resources available, and the coordination, and hand function, with the aim of regaining upper intended use of the results. limb control and function. Standardized assessment methods may [22] include Manual Muscle Testing , grip and pinch Home Assessment [23,24] [25] strengths, Nine Hole Peg Test, ModiÞ ed Ashworth Scale During the rehabilitation phase of stroke, and close to the time [26] [27] (MAS), and ModiÞ ed Tardieu Scale (MTS). Functional upper of hospital discharge, the occupational therapist will examine the limb ability measures are taken throughout the rehabilitation patient’s capacity to complete their usual activities, to manage program to assess progress towards individual goals and for safely in their own home environment, and to access the further treatment planning. These measurements supplement the community. The occupational therapist will evaluate the need for a measures of impairment by identifying how stroke- related deÞ cits home assessment, taking into consideration the environmental impact on the ability to use the upper limb in activities of daily living. barriers, speciÞ c impairments, risk of falls, and the needs of the Measures of upper limb ability may include the Action Research Arm patient/carer. The purpose of the assessment is to establish [28] ), [29] whether it is safe for the stroke patient to return to their pre-stroke Test (ARAT Wolf Motor Function Test (WMFT), Arm [30] environment or if alternate accommodation will be required. A Motor Ability Test (AMAT), Upper Limb-Motor Assessment Scale home assessment involves the occupational therapist (UL-MAS),[31] Chedoke Arm and Hand Activity Inventory (CAHAI),[32] observing the patient’s ability to physically negotiate their environment Motor Activity Log (MAL),[33] and ABILHAND.[34] Currently, there is no and perform their usual activities. For instance, the occupational [35] single upper limb assessment method that is universally accepted, therapist may assess the patient’s ability to safely transfer from their Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RSo1w0l2an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n2al bed or toilet. The occupational therapist will also assess a patient’s ability to plan, implement, and problem-solve tasks like making a simple meal, safely administering medications, using the telephone to call for assistance, or paying bills . Illustrative Case Study A 69-year-old retired male with a middle cerebral artery stroke on CT scan presented with a dense lef t hemiplegia, severe lef t -sided neglect, and cognitive changes. During the initial ADL shower assessment, Mr S required prompting to locate and identify the items needed for showering, cueing and physical assistance to dress, one- person assistance for all transfers, and cueing to sequence the tasks. Mr S achieved a score of 48/135 using the Functional Independence Measure (FIM) (26/91 motor and 22/35 cognitive scores), indicating moderate to full assistance with self-cares. Figure 1a: Mr S OT-ASPT clock drawing item on admission Initial cognitive screening using the MMSE revealed impairment of basic level cognition (score of 22/30). The CAM identiÞ ed moderate deÞ cits in the areas of a t ention, visual and auditory memory and sequencing, mental manipulations relating to money use, foresight/ planning, concrete problem-solving, and severe visual neglect. On the ward Mr S needed signiÞ cant cueing to locate items. His poor problem-solving skills and planning were evident in the incorrect use of switches in the kitchen to turn on/off appliances and inability to recognise an item burning on the stove top,along with inability to problem-solve how to correct this. He was also unsafe at empting to cross the road, and slow and inaccurate in handling Figure 1b: Mr S OT-ASPT house copy item on money. admission Visual perceptual screening using the OT-APST revealed agnosia, Treatment, including individually selected and graded tasks and unilateral neglect, impairments in constructional skills, and impairment on activities, involves retraining motor, sensory, visual, perceptual, the functional skills subscale of this assessment. Figure 1 shows the and cognitive skills within the context of functional activities; OT-APST items on initial assessment, where Mr S at empted to draw a minimizing secondary complications; and providing education and clock and copy the picture of a house. He lacked insight into the [11] errors of performance that he made on the OT-APST and his speed of support to the patient and caregivers. information processing was slow. Occupational therapy interventions may include methods aimed at Upper limb assessment revealed weak active movement in le ft maintaining or improving sof t tissue properties of the upper limb. For shoulder elevation and internal rotation, mild increase in tone in Þ example, techniques that may be used to reduce spasticity include nger and elbow ß exors, and absent protective and discriminative [37] [38]stretching and static or dynamic splinting, either alone or in sensation. combination with the use of medically administered botulinum [39 Occupational Therapy Intervention after Stroke toxin therapy. ] Other methods employed to prevent contracture or dependant edema may include education for the patient and family in Rehabilitation following stroke should begin as soon as the medical ways to support and position the stroke-aff ected upper limb. For condition is stable. Occupational therapy intervention improves patients who have developed contractures, management may [40] [41] participation in meaningful roles, tasks, and activities. A recent include electrical stimulation or casting. The occupational systematic review of randomized trials found that stroke patients who therapist may prescribe a Þ rm support device to reduce the risk of receive occupational therapy focused on personal activities of daily 42-45]shoulder subluxation or prevent further subluxation.[ Upper living, as opposed to no occupational therapy, are more likely to [38] [36] limb positioning, bandaging, compression garments , be independent in those activities. [46] retrograde massage, and electrical stimulation are some of the techniques that may be employed by the occupational therapist Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 RSo1w0l3an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n3al to prevent or reduce the hand edema that may occur af t er a Occupational therapists will establish how tasks can be adapted stroke. Active therapy and graded task selection is used to or the environment changed to improve the patient’s level of encourage sensorimotor return; the therapy may include muscle independence. For the physical environment, the occupational facilitation and strengthening, in conjunction with everyday therapist may prescribe assistive equipment or home modiÞ cations to activities to develop reach, grasp, and object manipulation skills. enable task performance with greater ease or safety.[59] For SpeciÞ c techniques include functional electrical stimulation,[47] example, installing grab rails near steps, raising the chair height, or constraint- induced movement therapy,[48] progressive resistive prescribing a wheeled mobility tray for transporting meals. exercise[49] and sensory-related training,[50] and avoidance of The occupational therapist liaises with the discharge planner, movements that reinforce the synergistic movement pat erns of the patient, and caregivers to establish the anticipated frequency, upper limb that limit function. Patients are encouraged to continue duration, intensity, and type of carer support required for return activities outside of therapy time and are prescribed a task-speciÞ home.[33] For instance, the patient may need supervision with c[51-53] rehabilitation program, encouraging as much practice as medications because of memory diffi culties, assistance for dressing possible.[54] This is achieved by loaning therapy kits to enable because of dyspraxia, or help with the laundry because of balance self- directed practice. Examples of practice tasks include: using problems. The occupational therapist may train carers to use a keyboard, mobile phone, television remote, or calculator to assistive equipment or modiÞ cations safely with the patient.[60] practice Þ ne motor skills; opening a range of jars and containers of When a patient returns home without the capacity to get out of bed varying sizes and weights and with diff erent types of lids; turning the themselves, the occupational therapist trains relatives to safely pages of books, magazines, and newspapers; and managing operate an electric hoist or wheelchair. Continual education of the fastenings of clothing items with diff erent-sized but ons, zippers, patient and family, and participation of the family in a treatment Velcro, clips, and laces. The occupational therapist reviews program, is essential for the smooth transition to discharge, carry- and upgrades the therapy program on a daily basis. over of skills learnt to the home environment, and for facilitating psychosocial adjustment. Visual and perceptual impairments are minimized by retraining in speciÞ c skills, teaching compensation techniques, Case Study Continued substitution of unimpaired skills, or adapting the task or environment.[1] Methods include visual scanning training[55] to Daily occupational therapy treatment involved improving awareness of assist a person with a hemianopia or neglect to locate items more the impact of lef t neglect on daily tasks, systematic visual accurately in their environment. A person with depth perception scanning training, and practical strategies for daily task problems may be encouraged to hold the handrail for completion to overcome the impact of neglecting behavior. additional proprioceptive cues to safely negotiate stairs, as well as These included tasks and strategies of graded complexity including to pace themselves and go more slowly down a ß ight of stairs. A dressing, meal preparation, money management and, eventually, crossing the road and shopping. Feedback was provided continually person with praxis[56] or motor planning problems aff ecting one upper and consistently by occupational therapy and other staff to facilitate limb may initially practice a range of remediation techniques increased insight and awareness of deÞ cits and to facilitate involving feedback, cueing, and functional repetitive practice to anticipatory use of left -sided visual scanning to help achieve ‘over overcome the impairment. If the impairment of the stroke-aff ected learning’ of this skill. Perceptual and cognitive retraining was hand is resistant to remediation methods, the occupational therapist undertaken to achieve a level of safety and independence in may teach the patient to compensate by using the other, unaff the personal care tasks of dressing, showering, toileting, ected, upper limb for tasks requiring greater precision such as shaving, grooming, and eating, as well as in the domestic tasks of meal thus increasing the patient’s level of independence. preparation and shopping. Cognitive therapy may be used in rehabilitation of at ention and Daily upper limb movement facilitation and positioning, massage, concentration impairments.[57] For patients with memory diffi culties, elevation, and compression were employed to address muscle external cues may help prompt their memory,[58] for example, weakness and edema of the lef t upper limb. Education was provided using a diary, visual prompts, or an alarm. An external cue, for for safety in the care of his arm and practical training in one- [58] handed methods of completing daily tasks, including dressing, example a pager, may help patients with impaired executive grooming, and eating. functioning to initiate tasks. Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 SRo1w0l4an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n4al Occupational Therapy Post-discharge control vehicle with a driving instructor.[72] Examples of recommendations from this assessment include the need for Intervention after Stroke specialist equipment or vehicle modiÞ cations, need for rehabilitation or retraining, review of license conditions, or need for reassessment. Outpatient services When patients are unable to return to driving, they are commonly When patients return home, referral to outpatient or provided with information regarding transport subsidies or their local community transport schemes. community occupational therapy is sometimes required.[61] Either hospital or center-based rehabilitation services or therapy Return to work services provided in the home can be used; the aim is to enable independence in the activities of daily living.[62] Rehabilitation is equally eff ective if For the patient in paid employment before their stroke, assessment delivered in the hospital as an outpatient, in a day hospital, or in the regarding return to work commences in the acute se t ing. The community, and should be off ered to all stroke patients as occupational therapist gathers a history of the patient’s occupation, i.e., [61-63] job duties (frequency and duration) and work conditions (hours, needed. Economic evaluations of community rehabilitation environment, etc.). Using the results of assessment of the are limited to cost description studies.[3] In India, community-based sensorimotor, cognitive, visual-perceptual, and psychological abilities rehabilitation is described as a strategy within general community of the patient, the occupational therapist considers the feasibility of development for rehabilitation, equalization of opportunities, and return to work. Of t en the patient is referred to an occupational therapist social inclusion of people with disability.[64] specializing in occupational rehabilitation[70] to conduct a workplace assessment and negotiate a graded return to work hours and Residential care duties.[68] If a stroke patient is unlikely to beneÞ t from active rehabil itat ion and requires residential care, the occupational Case Study Continued therapist may be involved in training the carer of the facil i ty An occupational therapy home assessment wa s to manage the patient ’s functional diffi culties and enabling conducted prior to discharge. Recommendations included maximum patient participation.[65] For instance, this may involve the installation of grab rails in the shower and toilet, removal of a proper positioning for eating tasks or visual scanning strategies for shower screen that limited safe access, purchase of a shower stool reading. The occupational therapist may suggest equipment to for seated showering as his balance remained impaired, and enable the patient to participate in their cares or return to leisure purchase of a lounge chair of a suitable height. activities.[66] For instance, custom clothing[67] for easier toileting or modifying the television on-off switch to assist the patient regulate Mr S’s functional improvements included independence with dressing, [68] showering, toileting, mobilizing with a single stick, and preparing their environment. The occupational therapist may provide advice breakfast. His performance on standardized cognitive and on pressure-relieving mat resses and cushions for patients perceptual assessments improved; however, he continued to managed in bed and seated in wheelchairs, or education regarding require close supervision for outdoor mobility, kitchen tasks requiring positioning for comfort and prevention of deformity.[69] use of electrical appliances, and management of his medications and Þ nances. Safety concerns in the kitchen at time of discharge Return to driving services included the need for cueing to turn off the hot plate of the stove af t er use, turning off the tap before the sink overß owed if distracted by For patients who drove before their stroke, the occupational another task, and shut ing cupboards and drawers a ft er use. His wife therapist provides information and advice on their post-stroke participated in many occupational therapy sessions to gain an driving responsibilities.[70] In Australia, it is recommended that the understanding of the type of supervision and assistance her patient should not drive for a minimum of 1 month af t er stroke husband would need upon return home. or transient ischemic a t ack (TIA), and perhaps longer if there is signiÞ cant neurological, perceptual, or cognitive deÞ cit, depending on Cognitive reassessment on discharge revealed an MMSE score of medical advice.[71] In addition to a medical examination, the patient 27/30 (which is within the normal range for his level of education), may be referred to an occupational therapy driver assessor for off - and Montreal Cognitive Assessment (MoCA) score of 25/30 road and on-road driving assessment.[72] Off-road assessment (normal = 26 and above), revealing ongoing impairment, includes an evaluation of skills such as scanning, attention, particularly in the areas of executive functioning. The OT-APST on visual perception, hazard perception, executive function, discharge continued to show evidence of agnosia and neglect and reaction time, and knowledge of road law. This assessment is also impairment of constructional skills and functional skills, designed to identify patients not suitable for on-road assessment. On-road assessment evaluates driving performance in a dual- Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 SRo1w0l5an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n5al although gains were made in each of these areas since admission. function, individual goal-set ing, and specialist skills in task adaptation Figure 2 demonstrates changes in his visual perceptual abilities at and environmental modiÞ cation underpin the profession’s contribution the time of discharge and also the presence of ongoing visual to the multidisciplinary stroke rehabilitation team. Assessment of neglect. His discharge FIM score of 94/135 (68/91 motor, 26/35 important roles and stroke deÞ cits such as sensorimotor, cognitive) also revealed improvement since admission in his level of musculoskeletal changes (biomechanical), cognition, perception, functioning, but reß ects an ongoing need for supervision and and psychosocial adjustment assist with planning restorative and assistance from his wife in daily living tasks. Mr S was not able to compensatory intervention plans and measuring the patient return to driving due to the impact of his perceptual and cognitive outcomes. Occupational therapists’ treatment contributes to both impairments on safety and judgment and therefore disability parking the quality of life for survivors of stroke and their families and to and transport subsidies were organized. timely evaluation of clinical outcomes for the multidisciplinary rehabilitation team. Mr S did not regain functional use of his lef t upper limb and continued to use the one-handed dressing and daily living Acknowledgments techniques. Community-based occupational therapy and physiotherapy was organized for follow-up care. The authors would like to thank Dr Stephen Read and Dr Robert Henderson from the Neurology Department, Royal Brisbane and Summary Women’s Hospital. The occupational therapist’s focus on independence and References 1. Gresham GE, et al. Post-stroke rehabilitation: Assessment, referral, and patient management. Clinical practice guidelines. 1995, 2. Rockville: U.S Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. 3. National Stroke Foundation, Clinical guidelines for acute stroke management. Australia: National Health and Medical Research Council; 2007. 4. National Stroke Foundation, Clinical guidelines for stroke rehabilitation and recovery. 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Williams R, Tafts L, Minuk T. Evaluation of two support methods 57. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for for the subluxed shoulder of hemiplegic patients. Phys Ther attention deÞ cits following stroke. Cochrane Database Syst Rev 1988;68:1209-14. 2000;4:CD002842. 45. Zorowitz RD, Idank D, Ikai T, Hughes MB, Johnston MV. Shoulder 58. Wilson BA, Emslie HC, Quirk K, Evans JJ. Reducing everyday subluxation after stroke: A comparison of four supports. Arch memory and planning problems by means of a paging system: Phys Med Rehabil 1995;76:763-71. A randomised controlled control crossover study. J Neurol Neurosurg Psychiatry 2001;70:477-82. 46. Faghri PD. The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA 59. Corr S, Bayer A. Occupational therapy for stroke patients after patients. J Hand Ther 1997;10:29-34. hospital discharge: A randomized controlled trial. Clin Rehabil 1995;9:291-6. 47. Glanz M, Klawansky S, Stason W, Berkey C, Chalmers TC. Functional electrical stimulation in poststroke rehabilitation: A 60. Kalra L, Evans A, Perez I, Melbourn A, Patel A, Knapp M, et al. meta-analysis of the randomized controlled trials. Arch Phys Training carers of stroke patients: Randomised controlled trial. Br Med Rehabil 1996;77:549-53. Med J 2004;328:1099. 48. Van Peppen RP, Kwakkel G, Wood-Dauphinee S, Hendriks HJ, 61. Forster A, Young J, Langhorne P. Medical day hospital care for Van der Wees PJ, Dekker J. The impact of physical elderly versus alternative forms of care. Cochrane Database Syst therapy on functional outcomes after stroke: What’s the Rev 2000;2:CD001730. evidence? Clin Rehabil 2004;18:833-62. 62. Trialists OS. Therapy-based rehabilitation services for stroke 49. Morris SL, Dodd KJ, Morris ME. Outcomes of progressive patients at home. 2002. resistance strength training following stroke: A systematic review. Clin Rehabil 2004;18:27-39. 63. Britton M, Andersson A. Home rehabilitation after stroke: Reviewing the scientiÞ c evidence on effects and costs. Int J 50. Carey J, Matyas T. Somatosensory discrimination after stroke: Technol Assess Health Care 2000;16:842-8. Stimulus speciÞ c versus generalisation training. in 3rd annual perception for action. Melbourne: Cleveland Digital 64. Mishra S. Occupational therapy in community based rehabilitation. Printing; 2000. Indian J Occup Ther 2003;35:13-6. 51. Duncan P, Studenski S, Richards L, Gollub S, Lai SM, Reker 65. Winkler D, Farnworth L, Sloan S. People under 60 living in aged D, et al. Randomized clinical trail of therapeutic exercise in acre facilities in Victoria. Aust Health Rev 2006;30:100-8. subacute stroke. Stroke 2003;34:2173-80. 66. Walker MF, Leonardi-Bee J, Bath P, Langhorne P, Dewey M, Corr 52. Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen S, et al. Individual patient data analysis of randomized controlled SP. A randomized controlled comparison of upper-extremity trials of community occupational therapy for stroke patients. Stroke rehabilitation strategies in acute stroke: A pilot study of 2004;35:2226-32. Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 SRo1w0l8an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o0n8al 67. Huck J, Bonhotal B. Fastener systems on apparel for hemiuplegic stroke victims. Appl Ergon 1997;28:277-82. 68. Trombly CA, Radomski MV. Occupational therapy for physical dysfunction. 5th ed. Baltimore: Lippincott Williams and Wilkins; 2002. 69. Carr E, Kenney F. Positioning of the stroke patient: A review of the literature. Int J Nursing Studies 1992;29:355-69. 70. Royal College of Physicians, National clinical guidelines for stroke. 2nd ed. Royal College of Physicians; 2004. 71. Ausroads, Assessing Þ tness to drive: For commercial and rivate vehicle drivers. Sydney: Ausroads; 2003. 72. Unsworth CA. Review of tests contributing to the occupational therapy off road driver assessment. Aust Occup Ther J 2005;52:57-74. Received: 12-11-2007, Revised: 20-03-2008, Accepted: 29-04- 08 Source of Support: Nil, Confl ict of Interest:NIl Annals of Indian Academy of Neurology - Supplement 2008 Annals of Indian Academy of Neurology - Supplement 2008 Clinical Rehabilitation 1999; 13: 301–309 SRo1w0l9an d, et al.: Role of occupational Rowland, et al.: RoAle odf odcceupnaSti1od0n9aul m E Unpacking the black box of therapy – a pilot study to describe occupational therapy and physiotherapy interventions for people with stroke C Ballinger School of Occupational Therapy and Physiotherapy, A Ashburn University Rehabilitation Research Unit, J Low and P Roderick Wessex Institute for Health Research and Development, University of Southampton, Southampton, UK Received 27th July 1998; returned for revisions 12th November 1998; revised manuscript accepted 13th January 1999. Objective: To describe the components used in the practice of occupational therapy and physiotherapy for people with stroke and to examine variability between services. Design: A time-sampling strategy in which therapists recorded their face-to- face interventions with stroke patients during 12 weeks over a total of 17 months. Settings and subjects: Six occupational therapists and seven physiotherapists from four services (three day hospitals and one domiciliary stroke rehabilitation service) recorded interventions with 89 stroke patients recruited to a larger randomized controlled trial. Main outcome measures: Frequencies of use of interventions, together with other details about delivery of therapy, were recorded using a data collection booklet and coding system designed by the participating therapists. Results: The median treatment time for a session was 45 minutes. The most frequently recorded components of physiotherapy intervention were ‘walking’, ‘standing balance’ and ‘upper limb movement pattern’, and of occupational therapy ‘physical function’, ‘social and leisure activities’ and ‘other’. There was variability between the services in terms of median treatment time, use of intervention codes, frequency of treatment sessions, amount of time spent working with assistance and amount of group work. Conclusions: The findings support the view that occupational therapy and physiotherapy with people with stroke are not homogeneous activities, and vary between therapists and services. Recommendations include further development of the tool, and use of other methodologies to explore the process and nature of stroke rehabilitation. Address for correspondence: Claire Ballinger, School of Occupational Therapy and Physiotherapy, University of Southampton, Highfield, Southampton SO17 1BJ, UK. e-mail: cbl@soton.ac.uk © Arnold 1999 0269–2155(99)CR260OA SRo1w1l0an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o1n0al Introduction patient sessions varied from 30 minutes in the day hospital to 90 minutes in the outpatient depart- Treatment of people with stroke forms a large ment for physiotherapy and from 60 minutes in proportion of the workload of occupational ther- the day hospital to 120 minutes in the outpatient apists and physiotherapists working in rehabilita- department for occupational therapy. tion settings. Whilst the majority of patients The study described in this paper was consid- admitted to hospital with stroke receive physio- ered to be exploratory and the aims were: therapy and occupational therapy,1,2 there is lit- 1) to design a tool for recording interventions of tle information available about what constitutes occupational therapists and physiotherapists optimum treatment, skill level and experience of with people with stroke; therapists providing treatment or detail about components of treatment.3 2) to examine variability of therapy input There is a growing between centres; and body of literature suggesting that programmes of 3) to reflect critically on both the recording tool focused stroke rehabilitation may improve func- and process of data collection. tional performance for some patients,3–5 and that improvement may be related to early initiation of treatment, but there are inconclusive findings Method about where rehabilitation should take place6–9 and which characteristics are important to the This small-scale study (referred to hereafter as success of treatment. To date, no single therapy the ‘Therapy inputs’ study) took place within the approach has been identified as preferable3,10 and context of a larger randomized controlled trial, the description of therapy content has received designed to compare domiciliary treatment for scant attention. people with stroke with that provided in day hos- Methodological weaknesses of research studies pitals, along similar lines to the study described have been highlighted as key contributors to the by Young and Forster.6 lack of clear findings from efficacy studies in this field. In many studies neither the aims nor the Participants components of treatment are documented, with Entry criteria for patients were as follows: the outcome measures being poorly linked to the aims.3 The content of therapy input needs to be • diagnosed with stroke understood before outcomes can be truly inter- • need further rehabilitation in day hospital preted and measured. The complexities and vari- • able to attend day hospital • resident in area of study ability of therapy input have added to the • over 55 years of age problems of unravelling the process of interven- • no advanced dementia tion. • no barriers to rehabilitation from previous In recent times there has been a growing inter- disabilities. est in exploring the nature of therapy and the mapping of patient activity. The solitary behav- The participating therapists and services are iour of patients in hospital units has been note- profiled briefly below: worthy with long periods of inactivity.11–13 • Service A: A day hospital where staff treat Observation studies have shown that formal ther- around 20 patients with varied diagnoses apy occupies a small proportion of inpatient time. daily. Staffing comprised a full-time senior Researchers have found that the lengths of ther- physiotherapist, two assistants and two part- apy sessions have varied. Newall et al.14 recorded time senior occupational therapists plus a a mean of 43 minutes, Lincoln et al.15 found that helper. patients on medical wards received on average 21 • Service B: A day hospital providing rehabili- minutes while those on the stroke unit received tation for around 15 patients per day, with a 36 minutes of therapy and Wade et al.16 recorded variety of diagnoses. The full-time physio- 45 minutes as the mean time for a therapy therapist was also the day hospital manager. session per day. Gladman et al.17 found that out- The senior occupational therapist worked vir- Unpacking the black box of therapy 303 RSo1w1l1an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o1n1al tually full-time and there were four ber of patient, whether the intervention was with whole- time equivalent generic helpers. a group or individual, whether the therapist was • Service C: The full-time head working with assistance and if the treatment was occupational therapist was also the carried out in the home. manager at this day hospital that provided for around six patients each day, Procedure with different diagnoses. Other staff Participating therapists recorded details of included a healthcare assistant. There their face-to-face contacts with stroke patients was access to an occupational therapy involved in the main trail for a total of six two- helper and part-time senior physiotherapy week periods over a 17-month period. Informal cover. interviews focusing on patient load, referral rates • Service D: A domiciliary stroke and service policies were carried out with the rehabilitation service comprising a full- therapists at their place of work towards the end time senior physio- therapist and a part- of the data collection period to add depth to the time senior occupational therapist was set interpretation of the results. up specifically for the pur- poses of the main trial. Results During the 17-month project there were changes in staff and organization of the In the following presentation of results, all fre- service. These changes mean that it is hard quencies are in multiples of 15 minutes because to describe the sample with absolute accuracy of the way in which the data were collected. but it does reflect the reality of clinical practice. Sample characteristics Design Eighty-nine out of 138 patients with stroke A time-sampling strategy was employed, recruited to the main randomized controlled trial in which two-week periods were identified were recorded as receiving rehabilitation either within each three-month block for the in the day hospitals (services A, B and C) or at purposes of data collection. Whilst these weeks home (service D) during the study period. The were not selected randomly, they were average age of these patients was 78 years (range considered to reflect ther- apy delivered 60–94, SD 7.0); 36 were right hemispheric and 47 throughout the year, thus preclud- ing the need left hemispheric (six unknown); 39 were male and to collect data continuously over the 50 female. Forty-six patients (average age 77 17 months of this project. years, SD 6.5) were treated by the domiciliary service and 43 (average age 79 years, SD 7.5) Measures were treated in the day hospitals. Thirteen The data collection tool was designed therapists were involved in treatment, ranging specifi- cally for this study, and the from senior II to head/superintendent III. participating thera- pists were closely involved Total treatment time recorded by physiothera- in the design of the booklet used, and the pists was 235 hours, and by occupational thera- identification of the coding system. Each pists, 153 hours and 15 minutes. therapist received one booklet for each two- Table 1 illustrates the median time of treat- week period of data collection, com- prising ment sessions for patients seen during the study brief instructions for completion, codes plus in the different services. The median duration of definitions and one page per day from Mon- combined occupational therapy and physiother- day to Friday over the two-week period apy given in a day was 60 minutes. for recording (totalling 10 sheets). Each daily As can be seen from Table 1, the median treat- sheet was broken down into 15-minute ment time of an occupational therapy session in periods between the hours of 8.00 am and service C was 210 minutes, over three times that 6.00 pm, and the therapist was required to of the second highest ranked duration. This was allocate one code to each period of 15 minutes face-to-face contact with stroke patients. The occupational therapists identified 12 codes and the physiotherapists 14 codes (see Appendix 1). This tool was piloted by the therapists over a two-week period, and the final version included space to record trial num- 304 C Ballinger et al. RSo1w1l2an d, et al.: Role of occupational Rowland, et al.: Role of occupaSti1o1n2al Table 1 Median physiotherapy and occupational therapy treatment time in minutes per patient per day Time (min) Therapy Service A Service B Service C Service D Physiotherapy Median 30 45 45 60 Range 15–75 15–90 15–75 30–105 Occupational therapy Median 30 45 210 45 Range 15–60 15–90 120–270 15–105 explained by the fact that in describing her prac- minute periods during which the main treatment tice, this therapist tended not to view therapy as component was recorded. Sixty-three physiother- occurring in discreet sessions, but saw it extend- apy sessions of 45 minutes were identified and ing into activities such as tea breaks and travel- ling to and from the unit, accompanying patients Table 2 Frequencies and percentages of occupational on the transport provided. Hence the lengthy therapy intervention codes duration of occupational therapy sessions in this service. When the extreme data for occupational Code no. Frequency Percentage of (15-min periods) total therapy in service C were removed, the median combined treatment time was 45 minutes. 1 73 12 Therapy provided in the day hospitals was 2 32 5 3 159 26 often divided into more than one session in a day. 4 7 1 Thirty-seven per cent of patients receiving phys- 5 11 2 iotherapy and 49% receiving occupational ther- 6 9 1 7 141 23 apy had their treatment divided into more than 8 23 4 one session during the day. This did not occur in 9 13 2 the domiciliary service. 10 3 1 11 25 4 Tables 2 and 3 show the overall frequencies 12 117 19 and percentages of use of the 12 occupational therapy and 14 physiotherapy intervention codes. The ‘home visit’ code was not used by the domi- Table 3 Frequencies and percentages of physiotherapy ciliary therapists, as all their interventions were intervention codes carried out in the patients’ homes. (See Appen- Code no. Frequency Percentage of dix 1 for descriptions of codes.) (15-min periods) total The three most frequently recorded activities 1 53 6 for occupational therapy were ‘physical function’, 2 15 2 ‘social/leisure activities’ and ‘other’, whilst for 3 66 7 physiotherapy the most frequently used codes 4 177 19 5 70 7 were ‘walking’, ‘standing balance’ and 6 205 22 ‘upper limb movement patterns’. 7 22 2 8 21 2 Forty-five minute treatment sessions Individual treatment were examined more 9 161 17 closely to investigate the content of treatment 10 75 8 11 8 1 sessions of similar length. The therapy 12 25 3 components uses in all 45-minute occupational 13 0 0 therapy and physiotherapy sessions were 14 42 4 extracted. In each 45 minute session there were three 15 recl Unpacking the black box of therapy 305 out of RS to1hw1ol3asn ed,, e t3 a6l. : hRoalde o f docicfufpearteionat l combinations of an exception being the occupational therapisRto winla nd, et al.: Role of occupaSti1o1n3al treatment components, suggesting different service B, who spent just over half the recorded objectives and goals. For example, one combina- treatment time working with assistance. tion indicated 30 minutes were spent primarily on Most of the patients received treatment indi- the control of pain and 15 minutes on upper limb vidually and services A and D did not use group activities while another combination indicated 15 activities at all during the data collection period. minutes were spent primarily on positioning and Group work tended to occur more in occupa- passive movements, 15 minutes on sitting to tional therapy, with just over half of the occupa- standing and 15 minutes on walking. Interestingly tional therapy interventions in service C being more than half of the sessions were different in delivered in group settings. A small percentage content although similar in length. The remain- of treatment time was not categorized as within- ing sessions were repetitions of 15 of the differ- group or individual settings by the occupational ent combinations of components. therapists, primarily in service C. Forty-three occupational therapy sessions of 45 minutes were identified and 21 of those sessions had different combinations of treatment compo- Discussion nents. For example, one combination indicated that 15 minutes were spent on patient education Eighty-nine patients were seen during the sam- and 30 minutes on carer education, while another pling period. The average age of the patients was combination indicated that for 45 minutes the 78 years (domiciliary group 77 years, day hospi- prime activity was domestic activities of daily liv- tal group 79 years) which meant that the sample ing. The remaining half of the 40 sessions were was older than that reported by Young and made up of repetitions of four combinations of Forster6 and Gladman et al.17 In the former study treatment components. One combination was used 14 times and represented social or leisure activities carried out in a group. Clinical messages Variability of treatment delivery • The data collection tool developed for this Table 4 illustrates findings relating to fre- study was simple and practical to use. quency of therapy, and mode of working. Most • Stroke rehabilitation varies according to patients received therapy once a week in the day setting, and cannot be described in terms hospitals. This was also true for the patients of duration of treatment. receiving domiciliary occupational therapy. How- • The data collection tool alone does not ever, 66% of patients receiving domiciliary phys- reflect the complexity of rehabilitation or iotherapy were seen more than once a week. the process of therapy. Qualified therapy staff primarily worked alone, Table 4 Percentages of patients receiving therapy once a week, time therapists spent working alone and interventions delivered in group settings Service A Service B Service C Service D % of patients receiving physiotherapy once a week 63 60 83 33 % of patients receiving occupational therapy once a week 90 74 66 98 % of time physiotherapists spent working alone 97 92 78 100 % of time occupational therapists spent working alone 96 44 89 94 % of physiotherapy interventions delivered in group settings 0 46 12 0 % of occupational therapy interventions delivered in group settings 0 38 57 0 306 C Ballinger et al. those SRtro1ew1al4atn edd, e t ianl. : Rthole o fd oaccyu p ahtionsapl ital averaged 72 ‘standing balance’ and ‘upper limb movemRoewnlatn d, et al.: Role of occupaSti1o1n4al years whilst those treated at home had an aver- pattern’) reflect those found by others.5,18 How- age age of 70 years. In the study by Gladman et ever, the most frequently used occupational ther- al.,17 those treated in the day hospital were on apy interventions were more unexpected average 75 years while those treated in the out- (‘physical function’, ‘social/leisure activities’ and patient department, 60 years. There were slightly ‘other’), and the relatively small amount of time more women than men and slightly more indi- devoted to activities of daily living and equip- viduals with left than right hemispheric lesions. ment provision was interesting, and in contrast to The median duration of a treatment session in other findings.18,19 Similarly, the low frequency of the study was 45 minutes which reflects that perceptual activity warrants further investigation. found by previous researchers who have investi- The occupational therapists commented that they gated day hospital, outpatient and domiciliary had included assessment, transfers and handwrit- rehabilitation.14,16,17 The overall treatment times ing in the ‘other’ category, perhaps suggesting recorded by the day hospital therapists were that further refinement and piloting of the occu- smaller than those by the domiciliary therapists. pational therapy categories would be useful. In addition most patients were treated once a It is noteworthy that physiotherapists in the week in the study, except patients receiving phys- day hospitals did not use the intervention ‘edu- iotherapy at home. This finding conflicts with cating carers’. The absence of this component those of Young and Forster6 who reported that could reflect the difficulties carers can experience day hospital patients received more total hours in travelling to hospitals, the need to plan such of treatment in their study than domiciliary events or the limitations of the time-sampling patients and Gladman et al.17 who found most strategy. The lack of the use of ‘social/leisure patients in their study received treatment twice a activities’ by the occupational therapist in the week in day hospitals. However, Gladman et al.17 home was also of note. This therapy may best be found that day hospital patients received a lower delivered through group work in which case the average treatment time than those individuals individual sessions of the domiciliary service who were treated in the outpatient department. could be a deterrent. Alternatively such input One reason for the contrast in findings could be may be considered inappropriate in the home. the exclusive nature of the domiciliary service in The examination of all 45-minute treatments the present study. It was created for the main revealed a wide variation in the content of occu- randomized controlled trial and so the therapists pational therapy and physiotherapy sessions. had no other workloads or demands to compete These findings suggest that duration of therapy with the needs of patients with stroke. The dif- alone is inadequate in determining equity of ference between the frequencies of occupational treatment and highlights the error in assuming therapy and physiotherapy treatment sessions in that objectives of therapy sessions for people the domiciliary service may be explained by the with stroke are the same. Knowledge of the com- fact that the physiotherapist was full-time whilst position of the treatment session is essential. the occupational therapist was part-time. Thera- The majority of patients in the day hospital pists in the day hospitals continued to work with received treatment once a week, although this patients with other diagnoses and disabilities was sometimes split into two or more sessions attending the day hospitals during the study peri- during the day’s attendance. The majority of ods, although this activity was not recorded for patients receiving physiotherapy were treated the purposes of this study. more than once a week, although this was not the The number and type of intervention cate- case for the domiciliary occupational therapy ser- gories identified in the study (12 for occupational vice, perhaps explained by the fact that the occu- therapists and 14 for physiotherapists) seemed pational therapist was part-time. appropriate: all occupational therapy codes and It was more common for therapists to work all but one physiotherapy code were used during alone than with assistance during the study. the study. The interventions carried out most Occupational therapists worked with help more frequently by the physiotherapists (‘walking’, often than physiotherapists. The physiotherapist Unpacking the black box of therapy 307 in serviSRceo1w 1lC5an da, netd a l.o: cRcolue pofa otcicounpaatlio ntahl erapist in service components of therapy intervention in strRookwlea nd, et al.: Role of occupaSti1o1n5al B appeared to be more reliant on additional help rehabilitation. This study has demonstrated that in carrying out their work than other therapists. stroke rehabilitation is not a homogeneous activ- No other study could be found describing thera- ity and varies according to the service and ther- pists working with assistance during treatment apists providing the treatment. It may be sessions. influenced by such factors as individual patient Group work was used in two of the day hospi- needs and goals, ethos of unit, constraints on tals and more so by occupational therapists than therapists and interests and expertise of thera- physiotherapists. Researchers such as Young and pists. The authors believe that an understanding Forster6 have reported on group work in day hos- of therapy and collaboration with therapist par- pitals before, but because their methodology dif- ticipants is both important and necessary in any fered, it is difficult to compare the findings to study attempting to describe or measure therapy those in this current study. intervention. The challenge of representing 15 minutes of Recommendations for further work arising treatment by just one code was an issue. In real- from this study include the following: further reli- ity, both therapists and patients may be working ability testing and refinement of the data collec- on combinations of different activities to meet tion tool; repeated use of the tool and method multiple goals (e.g. in working with a patient to across a greater number of services providing make a cup of tea, the therapist could be focus- stroke rehabilitation, to include more hours of ing on perceptual, physical, activities of daily liv- treatment time; use of qualitative methodology ing and social objectives simultaneously). For the and complementary methods such as semi-struc- purposes of the study, the therapists were tured interviews, observation and single-case directed to record the primary activity or goal for experimental design to explore other aspects of the 15-minute period, although it is recognized stroke rehabilitation; focus on patient perspective that this may not adequately capture the com- and understanding of therapy intervention and plexity of the intervention. comparison of therapy interventions with people The tool designed for this study is crude, and with stroke with interventions with other people provides a simplistic picture of the work that with other conditions/impairments. therapists do, but it is in the first phase of devel- opment. Whilst the therapists participating in this Acknowledgements study found the method and procedure feasible, We wish to thank the occupational therapists it may be that in simplifying practice to such an and physiotherapists from each of the services extent, the complexity of stroke rehabilitation who worked consistently with us on this project. and the skill required to facilitate it are misrep- We would not have been able to complete this resented. This tool does not, for example, record work without their important contributions. The the processes that are involved in treatment, such main randomized controlled trial was funded by as assessment, problem solving, clinical reasoning the South and West NHS Executive Research and decision making. Whilst this tool and study and Development Directorate. make a contribution to the understanding of ther- apy for people with stroke, this needs to be sup- plemented with studies utilizing methods which References explore other dimensions of stroke rehabilitation. 1 Wade D, Wood V, Langton-Hewer R. Recovery after stroke – the first three months. J Neurol Neurosurg Psychiatry 1985; 48: 7–13. Conclusions and recommendations 2 Brocklehurst J, Andrews K, Richards B, Laycock P. How much physical therapy for patients with stroke? This paper describes an opportunistic pilot BMJ 1978; 1: 1307–10. study designed to explore the content of stroke 3 Ashburn A, Partridge C, De Souza L. Physiotherapy in the rehabilitation of stroke: a review. Clin Rehabil rehabilitation. The tool developed for this study 1993; 7: 337–45. provides a practical and simple way of recording 4 Ottenbacher K, Jannell S. The results of clinical 308 C Ballinger et al. trialsSR oi1nw1 l6asnt rdo, keet a rl.e: hRaoblei loift aotcicounpa rtieosneala rch. Arch Neurol 13 Lincoln N, Gamlen R, Thomason H. BehaviouralR owland, et al.: Role of occupaSti1o1n6al 1993; 50: 37–44. mapping of patients on a stoke unit. Int Disabil Stud 5 Kalra L. The influence of stroke units rehabilitation 1989; 11: 149–54. on functional recovery from stroke. Stroke 1994; 25: 14 Newall J, Wood V, Langton-Hewer R, Tinson D. 821–25. Development of a neurological rehabilitation 6 Young JB, Forster A. The Bradford Community environment: an observation study. Clin Rehabil Stroke Trial: results at six months. BMJ 1992; 304: 1997; 11: 146–55. 1085–89. 15 Lincoln N, Willis D, Philips S, Juby L, Berman P. 7 Gladman JRF, Lincoln NB, Barer DM. A Comparisons of rehabilitation practice on hospital randomised controlled trial of domiciliary and wards for stroke patients. Stroke 1996; 27: 18–23. hospital-based rehabilitation for stroke patients after 16 Wade D, Skilbeck C, Langton-Hewer R, Wood V. discharge from hospital. J Neurol Neurosurg Therapy after stroke: amounts, determinants and Psychiatry 1993; 56: 960–66. effects. Int Rehabil Med 1984; 6: 105–10. 8 Walker FM, Drummond A, Lincoln NB. Evaluation 17 Gladman J, Lomas S, Lincoln N. Provision of of dressing practice for stroke patients after physiotherapy and occupational therapy in discharge from hospital: a crossover design trial. Clin outpatient departments and day hospitals for stroke Rehabil 1996; 10 : 23–32. patients in Nottingham. Int Disabil Stud 1991; 13: 9 Drummond A, Walker FM. A randomised 38–41. controlled trial of leisure rehabilitation after stroke. 18 Gladman JRF, Juby LC, Clarke PA, Jackson JM, Clin Rehabil 1995; 9: 283–90. Lincoln NB. Survey of a domiciliary stroke 10 Ernst E. A review of stroke rehabilitation and rehabilitation service. Clin Rehabil 1995; 9: physiotherapy. 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Unpacking the black box of therapy 309 Appendix 1 – Details of occupational therapy and physiotherapy intervention codes Occupational therapy codes 1) Personal activities of daily living, e.g. washing, dressing, feeding, toilet. 2) Domestic activities of daily living, e.g. cooking, cleaning, bedmaking. 3) Physical function, e.g. mobility, balance, grip, muscle tone (i.e. priority over functional application). 4) Perception, i.e. perceptual assessment and treatment. 5) Cognition/mood, e.g. memory, raising mood. 6) Home visit, i.e. general home assessment with patient and carer present. 7) Social activities/leisure, e.g. social groups, hobbies. 8) Education of patient, i.e. rather than treatment. 9) Education of carer. 10) Wheelchair/seating, e.g. assessment, practise with patient. 11) Aids and equipment (when used with patient). 12) Other. Physiotherapy codes 1) Positioning/passive movements, i.e. for normalizing position and range of movement. 2) Bed mobility, e.g. bridging and rolling. 3) Sitting balance, i.e. static and dynamic. 4) Standing balance, i.e. static and dynamic. 5) Sit to stand/transfers, i.e. practising skill. 6) Walking, i.e. all aspects of skill acquisition. 7) Stairs, i.e. patient practise. 8) Control of pain, e.g. handling, ultrasound. 9) Movement patterns of upper limb, i.e. relearning movement. 10) Movement patterns of lower limb, i.e. relearning movement. 11) Aids and equipment, e.g. walking aids, wheelchair use. 12) Education of carer. 13) Home visit. 14) Other. Addendum I Peer Evaluated: ________________________________________ Date: __________________ Rate a team member on a 4 point scale on the following items. For each item, select the score that fairly represents that person’s efforts and contributions to the project. Cooperative Learning Peer Assessment Rubric Seldom or Sometimes Frequently Always Never Demonstrates Demonstrates Demonstrates Score Demonstrates 2 3 4 1 Responsibilities Does not perform Performs all Fulfils Team any duties of Performs some Performs all duties & helps Role & Duties assigned team duties duties others role Does not Participates in Participates in participate in Participates in Participates in planning planning & planning even planning after Action Planning without encourages after encouragement encouragement others encouragement Does not fulfil Fulfils Shares responsibilities & Fulfils some Fulfils responsibilities Responsibilities relies on others responsibilities responsibilities & helps others to do their work Contributions Collects some Collects Collects very basic Collects a lot of Researches & information that little information information information that Gathers does not relate to which relates to which mostly relates to the Information the topic the topic relates to the topic topic Share Information Follows the team action Doesn't follow Follows the Follows the Upholds Team plan & helps the team action team action plan team action Action Plan others stay on plan some of the time plan track Interactions with Teammates Listens to Always talks & Usually does Listens to Listens to Others does not listen to most of the other's ideas, others' ideas & Seldom or Sometimes Frequently Always Never Demonstrates Demonstrates Demonstrates Score Demonstrates 2 3 4 1 other's ideas talking & listens but sometimes speaks when to some talks too much appropriate teammates ideas Cooperates Cooperates Does not sometimes & with Cooperates Cooperates with cooperate & argues with teammates & well with others Others argues with some sometimes & never argues teammates teammates argues Usually does not Usually sides Usually Respects respect opinions with someone respects Respects opinions of or decisions of who has a opinions of Others' Opinions teammates & others & wants similar opinion teammates & or Decisions supports their things his/her or decision as supports their decisions way his/her own decisions Asks & Asks & Does not ask or Asks & Asks questions discusses Discusses discuss discusses to some questions with Questions with questions with questions with teammates some Team Members teammates all teammates teammates Comments: Total Score: ____________________ Created and Modified using www.rubistar.4teachers.org Addendum II Readiness for Interprofessional Learning Scale (post) You are consenting to participate in the research by completing this questionnaire Tick the professional group you belong to: Medicine 1 Nursing 2 Physio 3 Dietetics 4 OT 5 Optom 6 Biokinetics 7 Please indicate the degree to which you agree or disagree with the statement by drawing a circle around the number of the response that best expresses your feeling. The scale is as follows: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree 1. Learning with other students will help me become a more effective member of a 1 2 3 4 5 healthcare team 2. Patients would ultimately benefit if healthcare students worked together to solve 1 2 3 4 5 patient problems 3. Shared learning with other healthcare students will increase my ability to 1 2 3 4 5 understand clinical problems 4. Learning with healthcare students before qualification would improve relationships 1 2 3 4 5 after qualification 5. Communication skills should be learned with other healthcare students 1 2 3 4 5 6. Shared learning will help me to think positively about other professionals 1 2 3 4 5 7. For small-group learning to work, students need to trust and respect each other 1 2 3 4 5 8. Teamwork skills are essential for all healthcare students to learn 1 2 3 4 5 9. Shared learning will help me to understand my own limitations 1 2 3 4 5 10. I do not want to waste my time learning with other healthcare students 1 2 3 4 5 11. It is unnecessary for undergraduate healthcare students to learn together 1 2 3 4 5 12. Clinical problem-solving skills can only be learned together with students from my 1 2 3 4 5 own department 13. Shared learning with other healthcare students will help me to communicate better 1 2 3 4 5 with patients and other professionals 14. I would welcome the opportunity to work on small-group projects with other 1 2 3 4 5 healthcare students 15. Shared learning will help to clarify the nature of patient problems 1 2 3 4 5 16. Shared learning before qualification will help me become a better team worker 1 2 3 4 5 17. The function of nurses and therapists is mainly to provide support to doctors 1 2 3 4 5 18. I am not sure what my professional role will be 1 2 3 4 5 19. I have to acquire much more knowledge and skills than other healthcare students 1 2 3 4 5 Addendum III Interprofessional care Complete the questionnaire by ticking the appropriate box next to the statement indicating the frequency of the occurrence of the statement Indicator Care Expertise 1. Di scipline specific care was provided in collaboration with the patient 2. Di scipline specific care was provided in collaboration with the healthcare team 3. Sp ecialized care was well coordinated 4. Ro le differentiation was clear 5. Pe rform own roles in culturally respectful way 6. Ac cess others’ skills and knowledge appropriately through consultation 7. De monstrate knowledge application of own profession/role/scope Shared power 8. Al l team members contributed to the treatment 9. A psychological safe environment existed where you could voice diverse opinions Collaborative leadership 10. Re flected shared accountability 11. W ork with others to enable effective patient/client outcomes 12. Fa cilitation of team processes occurs spontaneously 13. Ut ilize structures and processes known to team members to advance exemplary care Shared decision making 14. Co mmunicate with respect with team members 15. Gr oup agrees on care priorities 16. Re cognize and respect each other’s knowledge and expertise, regardless of occupation and formal position 17. Cr eate common understanding of care decisions Quality of care 18. Du plication of work has been reduced 19. Pa tient experience was positive 20. Ho listic care that addressed all facets of a human being was rendered 21. A positive work environment exists We did best at _______________________________________________________________ Next time we could improve at___________________________________________________ NA Almost always Sometimes Rarely Never Addendum IV Readiness for Interprofessional Learning Scale (pre) By completing this questionnaire, you are consenting to participate in the research Tick the professional group you belong to: Medicine 1 Nursing 2 Physio 3 Dietetics 4 OT 5 Optom 6 Biokinetics 7 Please indicate the degree to which you agree or disagree with the statement by drawing a circle around the number of the response that best expresses your feeling. The scale is as follows: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree 1. Learning with other students will help me become a more effective member of a 1 2 3 4 5 healthcare team 2. Patients would ultimately benefit if healthcare students worked together to solve 1 2 3 4 5 patient problems 3. Shared learning with other healthcare students will increase my ability to 1 2 3 4 5 understand clinical problems 4. Learning with healthcare students before qualification would improve relationships 1 2 3 4 5 after qualification 5. Communication skills should be learned with other healthcare students 1 2 3 4 5 6. Shared learning will help me to think positively about other professionals 1 2 3 4 5 7. For small-group learning to work, students need to trust and respect each other 1 2 3 4 5 8. Teamwork skills are essential for all healthcare students to learn 1 2 3 4 5 9. Shared learning will help me to understand my own limitations 1 2 3 4 5 10. I do not want to waste my time learning with other healthcare students 1 2 3 4 5 11. It is unnecessary for undergraduate healthcare students to learn together 1 2 3 4 5 12. Clinical problem-solving skills can only be learned together with students from my 1 2 3 4 5 own department 13. Shared learning with other healthcare students will help me to communicate 1 2 3 4 5 better with patients and other professionals 14. I would welcome the opportunity to work on small-group projects with other 1 2 3 4 5 healthcare students 15. Shared learning will help to clarify the nature of patient problems 1 2 3 4 5 16. Shared learning before qualification will help me become a better team worker 1 2 3 4 5 17. The function of nurses and therapists is mainly to provide support to doctors 1 2 3 4 5 18. I am not sure what my professional role will be 1 2 3 4 5 19. I have to acquire much more knowledge and skills than other healthcare students 1 2 3 4 5