Occupational Therapy and Arts Therapies

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An inquiry into the relationship between the visual arts and psychotherapy in post revolutionary Cuba
(Queen Margaret University College, 2006-03) Hills de Zárate, Margaret
This thesis focuses on the relationship between the visual arts and psychotherapy in post Revolutionary Cuba. The material on which it is based was collected over a fourteen month period and three visits to Cuba between April 1999 and August 2001. The study opens with the presentation of two brief histories, that of Cuban Art and Art Education and that of Cuban Mental Health Care. In this context the Revolution is taken as a useful reference point in terms of thinking about change and historical developments in both fields. Naturalistic Inquiry and Grounded Theory respectively were used to collect and analyse the data presented. These approaches allowed the researcher the degree of flexibility necessary to undertake research in a potentially delicate situation full of unknowns and to be able to modify and develop the course of inquiry as new evidence emerged. The main descriptive themes emerging from an analysis of the data pertain to the relationship between artists and mental health care professionals. These are (1) therapeutic work undertaken by artists, (2) artists working collaboratively with mental health professionals and (3) psychologists working with art as a therapy. The story which emerges pertains to a series of largely unrecorded histories spanning a forty year period. It begins with the work of Antonia Eiriz, who emerges as a key figure in the early development of art as a therapy and concludes with the work of the psychologist, Aurora García Morey, who takes centre stage in its continued development. This snapshot of Cuban art therapy is specific and unique and demonstrates the development of a very particular Cuban practice. However an analysis of the analytic themes which emerge from the data suggests that certain concepts such as responsiveness and pragmatism resound within a wider picture. These themes are discussed in chapters 7 and 8 with reference to the wider international context and specifically to the development of the profession in the United Kingdom. In my conclusions I suggest that these themes may be applicable to other areas of research and practice outwith and beyond Cuba and that while the concept of art therapy cannot be narrowly defined when it is applied to understanding practices in other, social, economic and cultural contexts, there are common factors which can be identified.
An interpretive description of the patterns of practice of arts therapists working with older people who have Dementia in the UK
(Queen Margaret University, 2009) Burns, Jane
In recent years there has been growing interest in arts therapy work with older people who have dementia. This has happened despite a paucity of UK research and writing on the aims of practice. Furthermore, there is little knowledge about the professional background of practitioners, the client group, care settings, theories and methods underpinning their work. This qualitative mapping study employs a methodology from nursing called interpretive description (Thorne et al. 2004). Interpretive description advocates a pluralistic approach for understanding the complex dialogue between clinical and research knowledge. The research design involved thirty-one semi-structured interviews with arts therapists from art therapy, music therapy, dramatherapy and dance movement therapy, participant observations of thirteen care settings and formal and informal interviews with ten medical/care staff who work with the arts therapists. The descriptive map was analysed using template analysis (King, 1998) and was interpreted using an integrative interpretive analysis (Heidegger, 1927; Smith et al.1999) The findings suggest that many arts therapists are pioneers in terms of being the first from their profession to work in the care setting. Issues around the arts therapists being unheard and staying unheard relate to their newness within these established settings. In terms of therapy work, theory and practice were being adapted in order to accommodate the temporal nature of the work. Despite distinctions in the art form, the study found that there is reciprocity of experience in terms of the arts therapists' feelings about the work and some in-session practices. These united the disciplines beyond the norms of mainstream practice.
Community-based creative dance for adolescents and their feelings of social wellbeing
(Queen Margaret University, 2009) Oliver, Sue
The thesis contextualises creative dance as art in a community setting. The participants were teenage members of a community-run creative dance company. The aim was to explore any links young people make between their creative dance experience in a community class and their feelings of social well-being. The literature gives a brief historical overview of dance as a performing art and of the nature of aesthetics and creativity. It considers the art of dance as a form of communication, and the conditions for creativity to flourish. It looks at Bourdieu‘s (2005) theory of ‗habitus‘ and ‗field‘ in understanding the social experience which the dancers derived through creative dance. Consideration is given to theories and accounts of adolescent development and how community interaction can affect the dancers‘ feelings of social wellbeing. The methodological approach is hermeneutic phenomenology, with influences from ethnomethodology and social constructionism. The ontological principle is that personal meaning is socially constructed. Epistemologically the study is informed by the belief that knowledge is generated through the creative dance experience. The main data collection method was semi-structured interviews with the dancers (n=10), supported by observation of dance classes (n=7; filmed: n=4), group discussions (n=3) and graffiti walls (n=8, completed by the dancers). The data were organised and analysed thematically using a method of presentation inspired by Bourdieu‘s concept of a ‗social trajectory‘ - a lifetime journey of social encounters – offering headings under which the data were loosely organised. Selected observations are presented on DVD. The responses suggested a dance ‗journey‘ from preparation to performance, which allowed further organisation of data. The emergent themes included the dancers‘ motivation for dancing, their feelings about the creative process, experiences of social interaction and of taking control of one‘s own identity, through all the stages of experimenting with movement, refining the dances and performing. The main findings are: the dancers attached importance to company membership because it offered a means to clarifying self-identity through physical and artistic endeavour; the creative dance context gave them freedom to explore their movement capabilities and to interact socially, and thus gave them a means of negotiating their ‗habitus‘, i.e. adopting and adjusting social norms and values on their own terms. Performing was a celebration of achievement and confirmation of identity as a dancer. The study contributes to the understanding of how adolescents make sense of their identity in their social context through their creative dance experience and how that influences their feelings of social wellbeing.
Being Person Driven In A Service Driven Organisation: A Grounded Theory Of Revisioning Service Ideals And Client Realities
(Queen Margaret University, 2010) Breckenridge, Jenna
This thesis presents a classic grounded theory study of Condition Management Programmes, which form part of the UK Government Initiative Pathways to Work. Condition Management Programmes provide short, work focused interventions to help people claiming incapacity benefits to return to employment. Delivered jointly between Jobcentre Plus and the NHS, or by providers within the private and voluntary sectors, health care practitioners working in Condition Management Programmes are often faced with competing priorities. This thesis has identified practitioners' concern with being person driven in a service driven organisation, and presents the emergent grounded theory of Revisioning Service Ideals and Client Realities which explains conceptually the means through which this concern is continually resolved. Practitioners are conceptualised as 'revisioning' or making thoughtful, situational adaptations to their practice which either deviate from or retreat within service boundaries. By cycling iteratively between deconstructing and reinstating service ideals, practitioners are able to create a reverberating equilibrium between the expectations and realities of practice, negotiating a person driven approach without compromising service structures completely. The theory has been developed using the full complement of classic grounded theory procedures and is based on interviews with 35 practitioners and observations of 26 practitioner-client sessions. Additional informal observations, programme documentation, client case notes and extant literature were also included as data. The theory adds to current Condition Management literature by explaining the differences across and within programmes, highlighting some important considerations for future development and evaluation within welfare to work. Furthermore, the theory of Revisioning Service Ideals and Client Realities, on account of its conceptual nature, also demonstrates relevance outwith its substantive area. Most notably, offering contributions to current research on treatment fidelity, theories of organisations and bureaucracy, and professional and clinical reasoning by offering a conceptual explanation of the behaviour of practitioners in daily practice.
Occupational Therapists' Perceptions Of Preterm Children's Academic Difficulties In The Early Years Of Mainstream Schooling
(Queen Margaret University, 2011) Giatsi Clausen, Maria
Preterm infants born before 37 weeks of gestation constitute up to 10% of all births, and can display development that, frequently, differs from those of full- term infants. Studies indicate that school children born preterm present with a, generally, higher incidence of performing poorly academically. The present study investigated the perceptions of paediatric OTs regarding the type of difficulties with which children born preterm present, and explored the role of OT. In the first, quantitative part of this study, paediatric OTs completed a postal questionnaire (N=353). The second, qualitative part, used asynchronous, online discussions (N=13), by utilising the virtual environment of WebCT, to further explore the topic. The survey was also designed to capture: • information on the extent of this paediatric population within OT services, and how identifiable and accessible it is • OT practices when working with these children • what informs therapists’ clinical decision making. The discussion groups provided a forum for OTs’ “reflexive comment” on the issues emerging from the questionnaire analysis. Despite sensorimotor and attentional difficulties reaching the highest frequencies, the findings revealed rather a combination of problems in most developmental domains. Writing emerged as the predominant problematic area within the school curriculum. A “persistence” of sensorimotor difficulties throughout the preschool years also emerged. More frequent and/or severity difficulties, more medical issues, a higher co morbidity of SLD with other conditions for the preterm group, were other findings. These insights could lead to a further exploration of the need for differentiating assessment and treatment practices for this group. Occupational therapy was highlighted as particularly “advantageous” for this population due to a number of OTspecific contributions e.g. ability to “detect “subtle” difficulties at a young age. The implications of a “shift” of more OTs into the area of early intervention, are discussed. The findings of the study constitute tacit, professional knowledge, and they are based on subjective clinicians’ views. They could, however, help frame hypotheses to be further explored verified with the use of empirical research. KEYWORDS: Prematurity; Specific Learning Difficulties; Early Intervention; Paediatric Occupational Therapy; School; Clinical Decision Making; Assessment; Intervention; Survey; WebCT; Asynchronous Online Discussions
The development and testing of the lively later life programme (3lp) for institutionalised elderly people in Malaysia
(Queen Margaret University, Edinburgh, 2011) Dahlan, Akehsan
Changes in demographic characteristics and modernisation in Malaysia have contributed to relocation of many elderly people to an elderly institution which is rapidly growing in number in Malaysia in spite of traditional cultural values and the personal beliefs towards elderly people. Living in elderly institutions is often associated with deterioration in well-being as a result of negative issues in institutions such as occupational injustice, loss of meaningful relationships, loss of autonomy and individuality which lead to psychological problems such as depression. Subsequently these issues affect several domains in life including future orientation towards ageing (ERA), general self-efficacy (GSE) and quality of life (QoL). Various lifestyle redesign programmes based on occupational therapy have been conducted to prevent such deterioration. However, such programmes are conducted in Western countries and were design for elderly people in the community. To date, there is no substantial work exploring the applicability of such programmes to elderly people in institutions and in different sets of cultures, values and beliefs such as in Malaysia. This provides justification for the need for such a study. The aim of this concurrent embedded experimental mixed methods study was to explore the effect, and identify the ideographic experience, of forty-six elderly people living in a public funded elderly people institution in Malaysia before and after participated in a new lifestyle redesign programme known as the Lively Later Life Programme (3LP) on ERA, GSE and QoL. Another thirty-six elderly people in a control group participated in an 'in-house' programme. After six months of taking part in the 3LP, there were statistical significant changes in the scores of the study measures for the participants in the experimental group. In addition, the participants provided ideographic experiences exemplified in various themes relating to the experience of taking part in the 3LP which supported and elaborated the changes in the scores of the study measures. Findings from this study contribute to evidence based practice in occupational therapy, validate and expand previous lifestyle redesign programmes. In addition, the findings demonstrate that a lifestyle redesign programme based on occupational therapy can be successfully transferred to a different setting, transcend cultural barriers and philosophies of life.
Description and evaluation of arts therapies practice with adults suffering from depression in the UK
(Queen Margaret University, Edinburgh, 2013) Zubala, Ania
This thesis contributes new knowledge to the field of arts therapies and their relevance in the treatment of depression in adults. The global burden of depression means that available treatments do not address all areas within the complexity of the condition and arts therapies may potentially present a relevant alternative by offering opportunities for non-verbal expression and exploration of creativity. Literature up to date does not offer comprehensive enough description of arts therapies practice and therefore establishing of credible evidence has not been possible. This thesis addresses the gap by exploring the nature of arts therapies practice and its value in the treatment of depression. The research consists of two phases: phase 1 provides a description of arts therapies practice with depression in the UK based on data collected from 395 survey respondents, while phase 2 evaluates group brief art therapy for adults experiencing mild to moderate depression. The project employs mixed methodologies within a creative research design incorporating surveys, interviews, arts-based inquiry and a pilot clinical study to examine multiple perspectives and offer findings meaningful to diverse audience. This project establishes that depression is a common condition among arts therapists' clients while some of the practitioners consider work with depression their main area of professional interest. It further finds that the therapists address depression through the use of humanistic, psychodynamic and integrative approaches and discovers that certain areas of the therapy process have particular relevance in the treatment of depression (e.g. time, group work, motivation, reconnecting). The pilot clinical study concludes with decrease of depression levels and increase of subjectively perceived wellbeing in all participants immediately after nine sessions of art therapy and in the follow-up. Participants' experiences, researcher's observations and arts-based reflections on the therapy process highlight the potential value of arts therapies in areas relating to, among others: connection and sharing, awareness of others and self, sense of achievement, self-expression and regain of meaning. The findings are integrated in the final discussion, which proposes a set of concepts particularly relevant to the treatment of adult depression through arts therapies. This research provides the first comprehensive description of arts therapists' work with depression in the UK and confirms the potential of this practice to be effective, which is relevant to health professionals and may lead to increased involvement of arts therapies in mainstream healthcare. The particular value of this project lies in shaping the basis for further explorations in the form of larger RCTs as well as demonstrating relevance and superiority of creative research designs in evaluating arts therapies.
Framing occupational therapists' knowledge and beliefs of alcohol misuse in physical health care settings
(Queen Margaret University, Edinburgh, 2016) Maclean, Fiona
Background: Research exploring occupational therapists' knowledge, beliefs and practice associated with alcohol misuse in physical health care settings is scarce, despite the recognition that professionals are likely to work with people who misuse alcohol irrespective of practice context. Furthermore, the relationship between pre-registration occupational therapy education and practice in the area of alcohol misuse is currently poorly understood. Aims: This critical appraisal aims to (a) frame the knowledge gaps and existing knowledge of occupational therapists related to alcohol misuse in physical health care settings, through the findings of five prima facie case papers and; (b) align this framed knowledge to wider professional literature in order to extend professional understanding of the relationship between education and practice, associated with alcohol misuse in physical health care settings. Methodology: A gap analysis approach was selected and modified to provide a way of critically introspecting and occupationally classifying the gaps in, and existing knowledge of, student occupational therapists, practitioners and educators linked to physical health care settings and alcohol misuse, as reported in the five papers. The introspective data linked to gaps and existing knowledge was unified and general inductive qualitative analysis undertaken. One practitioner working in physical assessment for older people in an acute hospital, and one occupational therapy educator provided stakeholder feedback of the tentative themes generated, further refining the analysis of data. Findings: Two themes emerged from the analysis of data; delimiters of professional education and conceptual contradictions. These indicate there is a need to educate 'educators' concerning the value of teaching alcohol-related policy as part of educational programmes, and in raising the visibility of alcohol as a topic. Therapists valued the Person Environment Occupation Model (PEO Model), however the essence of 'transaction' fundamental to this model, lacks fidelity in practice. Practitioners appear to separate out the entities of person and environment, placing greater emphasis on the observable aspects of the environment rather than the person, to support timely discharge. Thus, current practice in physical health care supports a process of occupational evaporation connected to alcohol misuse. Conclusion: These findings help to inform the future direction of educational and practice developments connected to patients' alcohol misuse in physical health care settings, and in so doing, advance and re-emphasise the importance of the centrality of occupation to service delivery.
Developing and evaluating an arts therapies programme for children with Attention Deficit Hyperactivity Disorder (ADHD) in primary schools in the Kingdom of Saudi Arabia (KSA)
(Queen Margaret University, Edinburgh, 2016-05) Alrazain, Badr
Purpose – The overall aim of the research is to develop a culturally sensitive arts therapies programme for children with Attention Deficit Hyperactivity Disorder (ADHD) in primary schools in the Kingdom of Saudi Arabia (KSA). This research adapted the UK arts therapies practice to fit these cultural requirements. Design/methodology – The study is a mixed methods design, carried out in two stages. The first stage was to identify the current provision and cultural issues in conducting arts therapies intervention for children with ADHD in KSA. Data was collected using interviews from twelve arts therapists from the UK and nine informants from KSA. The information obtained assisted in the development of culturally sensitive guidelines for the delivery of an arts therapies programme, which was conducted in stage two of the study. The second stage involved a pilot randomised control trial design that took place in an identified school in KSA. This stage involved 12 children aged 6-12, randomly allocated to either the intervention or the control group, with six participants in each group. The programme was carried out three times a week over a period of eight weeks. Data was collected using pre and post-tests (SDQ and ADHD scales) and from interviews of the parents and teachers of the children from both the experimental and control groups. Findings – The findings demonstrate that art therapists in KSA focus on behaviour modification while arts therapists in the UK focus on improving emotional wellbeing. Art therapists in KSA used more structured approaches which are less effective for children with ADHD. There may be cultural problems in using arts therapies in KSA, particularly music and dance. Safety, routine activities and ground rules were adopted from the current practices in the UK and adapted to be appropriate for the cultural context in KSA. A culturally sensitive arts therapies programme may be an appropriate and valuable intervention for children with ADHD. Qualitative and quantitative findings indicate that the intervention of this study achieved specific benefits such as; decreasing hyperactivity/ impulsiveness and inattention. Moreover, this intervention improves relationship/social skills and emotional wellbeing. Practical implications – This programme is found to be beneficial and it may have a significant impact on the treatment of ADHD in KSA. Understanding cultural issues by the therapist increases the value of arts therapies interventions. Value – This study has many benefits as a contribution to knowledge and for the development of services in KSA for this client population. Since children with ADHD currently have minimal access to therapy of any sort, and very limited access to arts therapies, this research has a key role in developing culturally sensitive arts therapies programme for children with ADHD.
Measuring children's participation from the perspectives of parents and teachers: Rasch analysis of the ACHIEVE assessment
(Queen Margaret University, Edinburgh, 2017) Crowe, Miriam
Background - One of the most significant changes within healthcare practice and research is a shift from ‘treating’ disability at the level of body function to an ecological approach that addresses the children’s involvement in everyday life, conceptualised as participation. Participation encompasses children’s involvement across home, school and community settings. A complex interaction of personal characteristics, performance skills and environmental factors influence children’s participation. Therefore, assessments that comprehensively and ecologically capture children’s participation and contributory factors are important. Gathering information from parents and teachers may enhance the accuracy of information. Of the currently available assessments, few include multiple informants and provide an overarching portrait of the child’s participation across all settings. The ACHIEVE Assessment is one that does and forms the focus of this work. Methods - Services from across Scotland agreed to participate in the research by implementing the ACHIEVE Assessment and inviting parents to consent to use of their child’s information. Rasch modelling was used to analyse the ACHIEVE Assessment. Parent and teacher questionnaires were also compared. Results – The study includes a large clinical sample ranging in age from 4-17 years old, with an average age of 8 years. The results from the study demonstrate that the ACHIEVE Assessment provides unidimensional measurement of children’s participation and contributory factors. The environment items measure a separate latent trait and are too easy for respondents to endorse. Parent and teacher questionnaires fit on the same dimension. However, self-care and social skills items differ in function between respondents. In addition, there is a low correlation between parent and teacher questionnaires. Overall, items relating to children’s participation in activities are easier than items about contributory factors. Process skills items are the hardest to endorse, despite the sample predominantly including children referred for reasons related to motor difficulties. Items about children’s school activities are relatively harder than items about community activities. Finally, item function differs for children in the youngest age group. Conclusion – Using Rasch analysis allowed exploration of the complexity of factors that interact to influence children’s participation as captured by the ACHIEVE Assessment. The study demonstrates the measurement qualities of the participation items on the ACHIEVE Assessment, however the environment items require further development as a separate measure. The item hierarchy emphasises the importance of further investigating the association between children’s process skills and their participation, in addition to research in the area of school participation. As there are only weak associations between parent and teacher reports, one is not substitutable for the other and multi-informant assessment will be an important strategy for gathering comprehensive information about children’s participation.
Exploring the experience of Dementia from a participatory perspective. From experience to theory and back again: realist explanatory theory building method
(2018) Górska, Sylwia
Background: The way dementia is understood shapes public attitudes towards those living with the condition and professional approaches to treatment. This has implications for the experiences of those living with dementia. Theoretical models currently guiding care and informing public perceptions are limited and incomplete, reflecting professional rather than personal experience. They fail to capture the complexity of this experience, potential for adaptation and role of participation relative to health and wellbeing. Research presented in this thesis contributes towards bridging this gap through developing a conceptualisation grounded in the first-hand accounts, reflecting the complexity of living with dementia and exploring factors and processes impacting upon adaptation and participation. Methods: A modified realist explanatory theory building method was used. This included triangulation of subjective perspectives of people living with dementia with complexity- consistent theories, identification of factors contributing to the overall experience, as well as causal mechanisms and processes involved. The first phase used qualitative meta- synthesis of 34 studies on first-hand experience and informed the development of a tentative model of dementia experience. During the next phase, this initial model was examined against concepts and ideas from 11 complexity-consistent theoretical frameworks. In the final phase, a model was scrutinised against narrative data of 12 people living with dementia and 19 family members. Results: The experience of living with dementia is conceptualised as “adaptation through participation”, emerging from ongoing, dynamic and non-linear interactions between multiple contributory factors and causal mechanisms, both personal and environmental. The model identifies and explains causal dynamics and adaptive processes shaping outcomes in dementia. Possible trajectories of these outcomes are explored, with the model indicating that these should be considered in terms of a spectrum rather than distinct stages of dementia progression. “A tree and a forest” metaphor is used to depict the proposed model and further explain findings. Diverse understandings of the model’s key conceptual domains are captured and explored relative to implications for the “adaptation through participation” process in dementia. Finally, findings are discussed in the context of the relevant theory and research evidence. Conclusions: By emphasising and explaining the potential for adaptation and enduring participation in dementia, the conceptualisation proposed in this thesis can contribute towards a shift in current policy and practice from the management of deficits to proactive support for continuity of participation throughout the dementia spectrum. However, before this is realised, additional work aiming at validation of the proposed model, further clarification of conceptual domains and causal relationships between them, and exploration of the role of multiple accounts of dementia experience, representing perspectives of people living with dementia and the important others; is required to establish the practical utility of the proposed model.
Incidence rates and multidisciplinary response to delirium in acute stroke: a mixed methods investigation
(2018) Carin-Levy, Gail
Delirium is a serious medical condition affecting up to 30% of hospital in-patients and associated with significant negative consequences such as increased mortality, morbidity as well as an increased long term risk of cognitive impairment. Delirium is difficult to identify due to its fluctuating course and the various subtypes, which are not well recognised by hospital staff. Stroke patients display a number of the precipitating and predisposing factors for delirium, yet the incidence of delirium in this population is not well documented. It is not known how best to identify delirium in this population and the ways in which multidisciplinary healthcare staff understand the condition. This thesis outlines the mixed methods of investigation which set out to answer these questions, utilising a systematic review and meta-analysis, an online survey, and online focus groups. The thesis makes a novel contribution to the field of stroke research in identifying the incidence of delirium as 28.1% (95% CI: 22.9 to 33.2), as well as synthesising research on the specific risk factors and outcomes associated with delirium in this population. The thesis also highlights the inconsistent practice of delirium identification in acute stroke, in both research and clinical practice. A further contribution is in the response of various healthcare professionals when it comes to identifying delirium in stroke patients: more doctors than nurses identify delirium, nurses have a recognised role in highlighting physiological changes associated with the condition and allied health professionals may lack confidence in their knowledge of the condition, as seen in their use of tentative language to discuss delirium. Despite this, the data suggest that the appropriate management of the condition takes place. The thesis argues that more education and organisational recognition of delirium as a diagnostic priority needs to take place in order to potentially improve outcomes for this population.
REALISING AUTHENTIC OCCUPATIONAL THERAPY THROUGH PROFESSIONAL ARTISTRY: UNCOVERING THE NATURE AND CONTEXT OF PRACTICE FOR PERSONS LIVING WITH DEMENTIA
(Queen Margaret University, Edinburgh, 2018) Kinsella, Niamh
Background: All occupational therapists in the UK are expected to engage in and develop evidence-based, person-centred practice in order to provide therapy that facilitates well-being through occupation. There has been recognition in occupational therapy literature that differences often exist between the values the underpin research evidence and occupational therapists’ professional values, and that practice culture and context influence the way research evidence is used in practice. However, current research into practice with persons living with dementia suggests that the contextual influences on practice have not been adequately considered. This has resulted in research and practice examples that reflect a compliance-orientated model of evidence-based practice. In such examples research guidelines and protocols are applied directly to practice, despite recognition that consideration of contextual factors and other forms of evidence enable creative practice that is meaningful for both persons living with dementia and occupational therapists. This study set out to explore the components of context that facilitate evidence-based practice congruent with professional values, and the values of the person living with dementia, as well as the nature of such practice. Approach and methods: This research is underpinned by a theory of critical creativity, which facilitates understanding, and guides deconstruction, of context through use of creative expression, imagination, and ancient wisdom and traditions. Creativity acts as a vehicle to transform embodied knowledge about the nature of practice to language, through reflection. It also enables blending of worldviews for the purpose of developing research praxis. A critical creativity methodology facilitated exploration of context and foregrounding of the issues that were influencing occupational therapists’ practice. Observation, critical creative reflection, and critical creative dialogue were layered to develop an understanding of the interplay between context and practitioners’ values and action, and the nature of their actions in practice. ii Findings: The findings of the exploration of practice context revealed that occupational therapists appeared to feel fear and anxiety about exploring and sharing their practice as a consequence of conflicting understandings about the way research evidence should be used in practice. Occupational therapists’ engagement in evidence-based practice and intervention ‘roll-out’, which are underpinned by learning that is often removed from practice context, resulted in practice that was often compliance-orientated and devoid of critical reflection. These contextual influences limited occupational therapists’ ability and opportunity to embody person-centred values that they hold, namely to make autonomous decisions about their practice with person(s) living with dementia and their families. Additionally, their engagement in developing professional artistry and creative practice was hindered, and their energy for practice development depleted. Conclusions and implications: Occupational therapists require contexts that are conducive to human flourishing to facilitate exploration, dialogue and development of creative, reflective practice. Such contexts consist of psychologically safe spaces, facilitative leadership, and researchers and practice developers that support all ways of knowing, being and doing in practice, to encourage contextually appropriate learning and practice enquiry. Facilitation of practice development in such contexts should be done in collaboration with practitioners. In such contexts, the contextual relevance of practice policies and guidelines that are heavily informed by technical-rational research evidence should be closely and critically considered. Development of such contexts and developmental approaches could result in authentic practice, in which occupational therapists can embody their values and blend research evidence with other ways of knowing, being and doing, and realise their professional identity. Keywords: occupational therapy, dementia, professional artistry, critical creativity, authentic, context, person-centred, compliance.
Improving outcomes in autism spectrum disorder through effective service provision: diagnostic assessment pathways and parent focussed interventions [PhD by publication]
(Queen Margaret University, Edinburgh, 2020) Rutherford, Marion
Introduction: This thesis on the topic of autism spectrum disorder presents six publications focussed on research about improving outcomes through effective service provision, together with a critical appraisal, which adds depth and breadth to the reasoning and decision making involved in this work. The work follows an iterative process and is positioned from a pragmatist philosophical standpoint, using mixed methods to clarify shared language, concepts and meanings and to ensure translation of research findings into real world practice. The thesis provides evidence of the urgent need for research to inform services as to how they might address the issue of delays in ASD assessment and diagnosis, alongside better understanding of which interventions improve wellbeing outcomes. Aims: This portfolio of published research has arisen from three related research programmes, with the unifying objectives of: 1. Adding to clinical and research knowledge of current ASD service provision across the lifespan and how that might be improved through adherence to ASD clinical guidelines; 2. Reducing family stress associated with ASD by reducing delays in diagnosis through identification of factors which influence efficiency and quality in a diagnostic pathway, and; 3. Developing understanding of the effectiveness of parent focused interventions to inform future research and practice. The critical appraisal aims to: (a) Explore key areas for debate that have arisen in the work, which transcend the individual publications; (b) Position this debate within the context of international literature, research evidence and theory in relation to autism, implementation science and pragmatist epistemology underpinning the work; (c) Highlight the contribution of this research to the advancement of clinical practice and research knowledge, and the potential for further clinical reach and informing evidence based practice through diffusion of innovation. Methods: Research aims, methods and outcomes are presented within a series of publications, using mixed methods to seek to address these. Findings: Through this research, it was identified that the wait for diagnosis in child and adult services, from referral to diagnosis shared, exceeds the recommended 119 day time standard in 74% of child and 59% of adult services. There was a significant difference in mean age of referral and diagnosis for girls compared to boys and this delay occurred prior to referral through delayed recognition rather than through delays in the assessment process. Findings provide strong evidence of the need to address the way we collectively deliver ASD services. This research identified factors which influence waiting times in child and adult services. These included the availability of relevant pre-referral information at first appointment, consideration of the number of contacts or appointments used to reach a conclusion and complexity of the case. Mixed methods were used to further identify a broader range of factors affecting wait times in each service and to develop child and adult action plans as proposed solutions that could be applied by local service providers. Plans developed were then successfully applied in a 12 month service improvement intervention with 11 adult services, resulting in a statistically significant reduction in duration of assessment (b=-0.25, t(136) = -2.88, p=0.005), taking the duration to within the recommended timescale. In child services, this model also led to a statistically significant reduction in waiting times for diagnostic assessment and increased identification of girls with ASD. Systematic review and meta analysis of parent focused intervention for older children and adults found that a) parent training and education and b) mindfulness interventions provide measureable improvements in family wellbeing, which in turn are known to have a reciprocal effect on the individuals with ASD. A number of recommendations for future research arise from this work. These include the aspiration for an ASD specific wellbeing measure which can be applied with greater consistency across ASD intervention studies; and the need for consensus on theoretical models to underpin evaluation of complex interventions in ASD, which in turn may lead to deeper understanding of which elements of interventions are most effective in which circumstances. Conclusion: In a field where research evidence has been lacking, this body of work applies a range of research methods, in order to add to the evidence base and provide practical steps, which clinical service providers could apply, to reduce the delays in diagnosis. Earlier access to ASD specific interventions, as a result of earlier diagnosis, has the potential to improve wellbeing for individuals with ASD and their families. Despite limitations of the research on ASD parent focused interventions for older children and adults, findings reported here add further support to the ASD clinical guideline recommendations to use such interventions.
The resilience of older adults receiving hospital care: Validation of the Making it CLEAR questionnaire, and an exploration of protective and vulnerability factors
(Queen Margaret University, Edinburgh, 2020) Whitehall, Lucy
Background ‘Resilience’ is the process by which individuals adapt to and manage adversity. Through the identification of older adults who may struggle to ‘adapt well’ following health difficulties, resilience research may support health improvement. As resilience is influenced by an individual’s personal characteristics, resources, and physical and social environment, resilience measures that comprehensively capture resilience are important. Furthermore, due to the contextual nature of resilience, research findings should not be generalised across populations who experience unique adversities. Despite this, most resilience measures used with older adults assess resilience at the individual level, and current resilience research has largely recruited community-dwelling older adults, preventing the findings from being generalised to those receiving hospital care. The Making it CLEAR (Community Living, Enablement and Resilience) (MiC) questionnaire was designed to measure the individual and environmental determinants of an older adult’s resilience. This work focuses on assessing its validity with a population of older adults receiving inpatient care and uses the data to investigate the protective and vulnerability factors of this population. Methods The study analyses data collected from older adults recruited during acute hospital admission across three Medicine of the Elderly wards. Exploratory factor analysis and item analysis was used to assess the validity of the MiC questionnaire, while item response analysis identified the key ‘resilience needs’ of the population. Regression analyses identified the protective and vulnerability factors of the sample and investigated the mediatory effect of self-efficacy on the relationship between frailty and resilience. Results Exploratory factor analyses and item analysis demonstrated acceptable construct validity, internal consistency, discriminant validity, and item difficulty for each subscale of the MiC questionnaire. Multiple regression analysis found that gender, marital state, perceived physical and mental health, and receipt of a daily care package predicted individual determinants of resilience. Religion, frailty status, perceived physical and mental health, and visual impairment predicted environmental determinants of resilience. Self-efficacy was found to mediate the relationship between frailty and resilience; and low self-efficacy, poor person-environment fit, and a lack of social support from friends were identified as the most common resilience needs. Conclusion The results demonstrate that the MiC questionnaire is a valid measure of both the individual and environmental determinants of resilience of older adults during hospital admission, thus supporting the use of the MiC questionnaire with this population. In addition, the regression analyses suggest potential characteristics of older adults with low resilience, while the identified resilience needs are suggested as potential priorities for targeted intervention.
THE CHARACTERISTICS AND COMMUNITY-BASED PARTICIPATION OF CHILDREN WITH DISABILITIES AGED 10-12 YEARS IN THE UNITED KINGDOM
(Queen Margaret University, Edinburgh, 2020) Arakelyan, Stella
Introduction: Participation is a key therapy and health promotion outcome for children with disabilities. This thesis contributes to childhood disability participation literature by (a) synthesizing evidence on family factors consistently associated with the participation of children with disabilities, (b) providing evidence on characteristics, family circumstances and community-based participation of a nationally representative sample of children with and without disabilities, and (c) identifying factors associated with participation frequency of children with disabilities in community-based social and physical activities. Methods: A systematic review focusing on family factors consistently associated with participation was completed. This was followed by a quantitative analysis of data from the fifth sweep of the Millennium Cohort Study (MCS5) (2012-2013) which supplied evidence on 1,073 children with disabilities and 11,122 children without disabilities aged 10-12 in the United Kingdom. Chi-squared and logistic regression analyses were used. Results: Thirty studies included in the review provided evidence on non-modifiable family “status” factors and modifiable family “process” factors. “Status” factors consistently associated with participation were parental ethnicity, parental education, family type and family socio-economic status. Family “process” factors with consistent associations were parental mental and physical health functioning, parental self-efficacy beliefs, parental support, parental time, family preferences, and activity orientation. Quantitative data suggested that children with disabilities were more likely to be boys, have psychosocial and behavioural problems, live in single-parent households and have a parent with a longstanding illness compared to peers without disabilities. They also had greater restriction in community-based participation, especially in social and physical activities. Child psychosocial and behavioural problems, ethnicity, parental education, family income, parental physical activity, parental play of physically active games with a child and parental social support had independent effects on participation frequency of children with disabilities in social and physical activities. Conclusion: Support services for children with disabilities and their families should be strengthened. Interventions targeting child psychosocial and behavioural functioning and immediate social environment are required to promote children’s participation in community-based social and physical activities. Revisions to the “immediate family” component of the WHO’s conceptual framework for functioning, disability and health of children and youth are proposed. Keywords: children, disability, characteristics, participation, family factors, environment, community activities
Exploring the benefits and challenges of volunteering: Participatory action research with people with lived experience of mental illness
(Queen Margaret University, Edinburgh, 2020) Hunter, Heather M.
Volunteering is associated with a range of health and employability benefits. However, there is limited evidence of the collective experience of volunteering for people recovering from mental illness. This thesis presents a participatory action research project in collaboration with a group of ten working age adults comprising four men and six women of white British ethnicity, predominantly Scottish and all living in the same Scottish city. All had lived experience of mental illness; many had significant experience of volunteering and all were actively engaged at the time of the research in unpaid volunteering in the community through personal choice as part of their recovery journey. The aim of the project was to hear about the benefits and challenges of volunteering including the positives and negatives of sociopolitical and welfare systems that support people with lived experience of mental illness to volunteer, with a view to producing something through action that would be of benefit to the group and/or the wider community. Participants took part in a preliminary interview and attended a series of five participatory action research groups. Thematic data analysis of the interviews was carried out by the researcher. Data generation and analysis of the PAR groups was combined and followed Freire’s (1970, p. 80; p. 104) process of “problem posing” and “conscientization” or critical consciousness raising where participants by asking critical questions about their situation recognised the potential for transformation. Data analysis of the PAR groups was collaborative, iterative, cumulative and coconstructed with themes revisited and revised by participants. Findings revealed factors that supported and hindered a positive volunteering experience including challenges from the socio-political impact of welfare reform. Participants produced a briefing paper to inform newly devolved powers supporting the Social Security (Scotland) Bill to support change at policy level and resolve the problem of mandatory volunteering in Scotland. This project has generated a new understanding of the experience of volunteering for people with lived experience of mental illness proposing an original theory of five conditions for successful volunteering that are necessary to support recovery namely: readiness and support to volunteer; synergy between volunteer and experience to ensure volunteering is meaningful; flexibility to stay well; opportunity to meet needs for identity and connectedness; and opportunity for influence and activism. Findings have also highlighted the negative effects of neoliberal welfare policies on the experience of volunteering for out-of-work disabled welfare recipients; demonstrated how PAR contributes to positive socio-political change with findings supporting Scottish Government policy development; and exposed how at a practice level the hegemony of paid work dominating occupational therapy vocational services limits an understanding of volunteering to one viewed solely through a work lens, with limited critique.
AN EXPLORATORY SECONDARY DATA ANALYSIS OF THE IMPACT OF HETEROGENEITY ON ASSISTIVE TECHNOLOGY TO REDUCE SAFETY AND WANDERING RISKS FOR PEOPLE WITH DEMENTIA LIVING AT HOME
(Queen Margaret University, Edinburgh, 2020) Curnow, Eleanor
Introduction: There is an acknowledged gap between the potential and achieved benefit of assistive technology in the care of people with dementia. In order to make better use of this resource, this research aimed to investigate the heterogeneity of population characteristics of people with dementia living at home who have safety and wandering risks and how this is related to assistive technology recommended and installed to meet their needs. Methods: This research consisted of two studies; a systematic review and secondary data analysis. Initially, published quantitative data describing the needs of people with dementia living at home was subjected to meta-analysis in order to explore the prevalence of needs reported by people with dementia and their caregivers and associated heterogeneity. Following univariate analyses, ordinal models were developed using secondary data which described the needs of people with dementia, and their level of wandering and safety risk, to explore the relationship between needs and risks in this population. The possibility of grouping participants according to data describing multiple needs, predisposing characteristics and enabling resources was investigated using cluster analysis. Associations between these groups and recommended and installed Assistive Technology were investigated. Results: Prevalence estimates for twenty-four needs reported by people with dementia and their caregivers were provided for the first time. Heterogeneity was associated with the person reporting the needs and age of onset. Level of need was often not recorded in the dataset indicating limited assessment. Wandering risks were shown to be associated with posture and mobility, routine and cognition needs, whilst safety risks were associated with posture and mobility, and problem-solving needs. Partitioning Around Medoids cluster analysis demonstrated that robust clustering solutions could be created from data describing participants. Clustering solutions were then validated through exploring their association with recommended and installed Assistive Technology data and the published literature. Caregiver support and living situation impact Assistive Technology installed for people with dementia. Discussion: This research advances understanding of the impact that needs, safety and wandering risks, caregiver support and the living situation of the person with dementia have on variation in the assistive technology interventions recommended and installed for people with dementia. Results have implications for needs assessment and for the tailoring of Assistive Technology for this population. Keywords: dementia, assistive technology, community dwelling, meta-analysis, cluster analysis, ordinal regression, wandering, safety, risk, needs.
The relevance of cultural arts practices to the psychosocial well-being of adolescents affected by violence in Trinidad and Tobago
(Queen Margaret University, Edinburgh, 2021) Soo Hon, Sarah A.
This research focuses on the relevance of cultural arts practices to the psychosocial wellbeing of adolescents affected by violence in Trinidad and Tobago. Previous research identified the need for further inquiry into the use of sustainable interventions with youth in communities affected by poverty and violence (Ryan et al., 1997), since adolescents exposed to violence experience cumulative negative effects, and often display violence and delinquency themselves (Benedini & Fagan, 2018; Foote, 2010; Office of the SRSG on Violence against Children, 2016; Savahl et al., 2013). This research seeks to understand the psychosocial effects of community violence on the wellbeing of adolescents as well as the therapeutic value of cultural arts practices for affected adolescents. It explores the development of approaches to art as therapy, to understand how the psychosocial wellbeing of adolescents might be enhanced. This participatory ethnography utilizes mixed qualitative methods of data collection with students and teachers at a school affected by community and school violence. The relevance of cultural arts practices to the psychosocial wellbeing of adolescents is a complex area of inquiry, given the diversity of the population and the historical and social context of a community affected by violence. Findings that impact the psychosocial wellbeing of adolescents and any implications of these for the fields of art therapy and research on community violence are discussed.
An Investigation of Adolescent Psychosocial Factors and Disengagement from Education and Employment Among Individuals with Common Mental Health Problems
(Queen Margaret University, Edinburgh, 2022) Tayfur, Sumeyra N.
Background: Participation in employment and education have been highlighted as key to health and wellbeing. Adolescents with common mental health problems are at risk of being “not in education, employment or training” (NEET) in young adulthood which negatively influences their life chances. Therefore, it is important to address the determinants of education and employment outcomes for this population. Methods: A systematic review and meta-analyses focusing on adolescent psychosocial factors associated with participation in education and employment in young adulthood was completed. This was followed by a quantitative analysis of data from the Next Steps cohort study using waves 2 and 8 which supplied evidence on 2,224 adolescents with common mental health problems in England, United Kingdom. Different statistical techniques were used to examine associations. Results: Fourteen articles were included in the systematic review providing evidence on adolescent psychosocial factors that mapped into seven domains, namely, behavioral problems, peer problems, substance use, prosocial skills, self-evaluations, aspirations, and physical activity. Secondary data analysis suggested that adolescents with common mental health problems who were disengaged as young adults were more likely to be female, have lower socioeconomic status, live in single/no parent households, and have caring responsibilities. Lower self-esteem, external locus of control, no job aspirations, and low/no physical activity increased the likelihood of becoming NEET whereas more positive attitudes to school and avoiding being bullied decreased the likelihood after adjustment for background characteristics. Conclusion: Psychosocial factors play an important role in disengagement from education and employment after compulsory education for adolescents with common mental health problems. School-based interventions during secondary school focusing on psychosocial factors, particularly physical activity could be helpful. The findings encourage provision of targeted mental health support at school, community, and clinical settings to prevent undesired educational and employment outcomes and improve life chances for at-risk youth.