Occupational Therapy and Arts Therapies
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Item 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, NiamhBackground: 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.Item Incidence rates and multidisciplinary response to delirium in acute stroke: a mixed methods investigation(2018) Carin-Levy, GailDelirium 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.Item Exploring the experience of Dementia from a participatory perspective. From experience to theory and back again: realist explanatory theory building method(2018) Górska, SylwiaBackground: 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.Item Occupational Therapists' Perceptions Of Preterm Children's Academic Difficulties In The Early Years Of Mainstream Schooling(Queen Margaret University, 2011) Giatsi Clausen, MariaPreterm 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 DiscussionsItem The development and testing of the lively later life programme (3lp) for institutionalised elderly people in Malaysia(Queen Margaret University, Edinburgh, 2011) Dahlan, AkehsanChanges 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.Item Being Person Driven In A Service Driven Organisation: A Grounded Theory Of Revisioning Service Ideals And Client Realities(Queen Margaret University, 2010) Breckenridge, JennaThis 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.Item Measuring children's participation from the perspectives of parents and teachers: Rasch analysis of the ACHIEVE assessment(Queen Margaret University, Edinburgh, 2017) Crowe, MiriamBackground - 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.Item Framing occupational therapists' knowledge and beliefs of alcohol misuse in physical health care settings(Queen Margaret University, Edinburgh, 2016) Maclean, FionaBackground: 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.Item 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, BadrPurpose – 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.Item Description and evaluation of arts therapies practice with adults suffering from depression in the UK(Queen Margaret University, Edinburgh, 2013) Zubala, AniaThis 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.