Disclaimer: The opinions expressed in this blog are entirely our own and not necessarily those of our employer or any other occupational therapist.

Wednesday, 26 November 2008

Generic working eroding Occupational Therapy

In my previous position within a mental health assertive outreach team I was required to undertake the roles of occupational therapist and care co-ordinator. As the title suggests, care co-ordinators are compelled to oversee all aspects of a service user’s care, ranging from issues such as housing and benefits, to criminal and legal matters and illicit substance misuse.

The requirements of this role led me and a colleague to reflect on the generic work we were undertaking when acting as a care co-ordinator and how this was seemingly at odds with our role as occupational therapists. Whilst we could bring the philosophy of occupational therapy to care co-ordination, it certainly was not occupational therapy. For a more detailed discussion of occupational therapy and care co-ordination see our recently published article at https://share.acrobat.com/adc/adc.do?docid=b7ddbeb4-4fbc-4238-a169-7095d91c87c2

I understand that this generic way of working is not exclusive to mental health; it occurs in many other areas of occupational therapy practice. So why do managers and policymakers deem it an appropriate use of skills to oblige some occupational therapists to undertake generic working, in some cases on a vast scale? Some occupational therapists report to enjoy and value the variety of being able to work generically. But what could be more varied than occupational therapy? It is such a unique and diverse profession that has the potential to touch every area of human existence. The issue of generic working also raises the question of professional identity and to a broader degree the whole future of the profession. How is occupational therapy expected not only to survive, but thrive as a profession, when it is continually being eroded by generic working?

14 comments:

healthskills said...

An interesting post. Not sure I'm going to be all that supportive, however! Surely occupational therapists are not alone in being asked to undertake 'generic' or broad roles inside many aspects of health care?
Take, for example, nurses. Nurses may be asked to be case coordinators, administrators, managers, educators, quality managers to name just a few.
Similarly, physiotherapists are asked to be case managers, administrators, perhaps manage the equipment pool, be service managers and so on.
Occupational therapists are not alone in fulflling these broad roles!
I guess one thing I'd love to know if I was a manager of a service is whether occupational therapists can point to evidence-based studies to demonstrate that their unique input makes a difference to outcomes. Until then, one view could be that it's great that occupational therapists are considered capable of being asked to do generic roles alongside much more established professions such as social work, nursing, psychology and physiotherapy.
In the end, each occupational therapist needs to recognise what it is about his or her practice that defines it as 'occupational therapy' and hold onto this when being asked to do generic work. If the generic work doesn't fit within the scope of practice of an occupational therapist it could be argued that the therapist should not be doing it.

Cathie said...

Interesting. I recall a discussion with one of my lecturers on a similar subject which left me feeling the same way.

I think that it's the way in which we as OT's don't focus on one specific area of a person's life which makes us ideally suited for the co-ordinating role. As long as it's not to the detriment of our focus on people's occupations. It's an interesting area since there is such a move towards some role blurring at a time where OT is starting to try and really forge an identity for itself.

Anonymous said...

I love being an OT and would never want to lose my specialist role, I have care coordinated and didn't enjoy it but on the other hand should OTs in a community team have the right to exclude themselves from care coordination etc when other team members are expected to do this? I suspect part of the problem is OTs work hard to define their unique skills but in my experience other professionals such as nursing and social work are nowhere near as clear about how to differentiate between their unique skills and generic work. Maybe if all the professions could clearly define their role we could all be fighting for protected time to carry these out? That way maybe we wouldnt run the risk of looking like we're trying to avoid doing the part of the job we don't enjoy.
I agree with 'healthskills' basically we all have to share the tasks that need doing within the MDT and I feel OTs risk damaging their relationship with other professions if we try too hard to set ourselves up as too special to do our share. Alternatively are we saying we want to be seen more like the psychologists who generally seem to avoid care coordination? This would be a significant change from our current position.
If OTs made up a greater % of the teams maybe the problem wouldnt be so apparent as it would then be easier for the team to see how useful OT is. We need more OTs!

Paul said...

Hi there,
thanks for your comments. From feedback I’ve had on the article I’m realising that there seems to be polarising views on the subject!
Occupational therapists are, indeed, not alone in being asked to undertake generic duties, but should this be an argument that we be duty-bound to undertake them? I have yet to hear a compelling argument from any manager, policymaker, or indeed any of my occupational therapy colleagues to square the particular circles that I raised in the case studies in my journal opinion piece.
I think Anonymous raises an interesting point. Psychologists rarely undertake care co-ordination duties. They trained to be psychologists; they provide psychological interventions. We trained as occupational therapists; we provide…? Generic working as a care co-ordinator in mental health is to the detriment of the client, and perhaps that is why I am so vociferous in my opinions – I observe clients missing out on our services. Perhaps it is the extent to which the care co-ordination role dominates our profession within community mental health settings, leaving little scope for occupational therapy, that I feel so strongly.
One more thought - what other industry spends so much time and money providing its workforce with a set of skills, only for those skills to be largely discarded once the worker becomes trained?

Anonymous said...

Hi Paul

In response to the final paragraph of your blog dated 21 December - those of us who have undertaken a role emerging placement may take a slightly different view. As final year students we were asked to look at a job advertisement for a ‘Life Skills Educator’ and encouraged to look at how the wide variety of skills that we had learned whilst at uni would certainly apply to this job. At a time when jobs in occupational therapy were thin on the ground this approach opened up new opportunities for students; I didn’t feel that my skills would be “largely discarded” once trained, rather I celebrated the fact that in applying for a job that would not necessarily have the title of occupational therapist I would, nevertheless, work within the philosophy of occupational therapy whilst promoting our profession.

Sarah Bodell said...

Hi,
A really interesting discussion......
As an educator I feel passionately that Occupational therapists should do Occupational Therapy ( the quick witted amongst you may argue that I am not actually practicing what I preach, but we'll leave that one for another day!)
I agree that care co-ordination is a vital and necessary role however those professionals who undertake the role inevitable have less time to devote to their core skills. Occupational therapy offers a different perspective on the management of people with severe and enduring mental health issues focusing as it does on volition, habituation and performance skills in the context of an individuals multi faceted environment. If occupational therapy is a valued intervention, surely to dilute it should be unacceptable. A healthy, functioning team should recognize the strengths of all of it's members and advocate for these, not insist on generic working as an example of effective teamwork possibly at the expense of the client. This is a management and resource issue. Yes. Anonymous, we do need more OT's.

Perhaps we are also doing a disservice to care co-ordination by assuming that "anyone" can do it. After all, OT's are not trained for this role, and I wonder if other professionals are? Is it a specific role in its own right? Does it need to be a health care professional at all? I have to claim ignorance here, and would bow to the opinion of those with much more knowledge and experience than I have.

And finally, I have no problem with occupational therapists who work in jobs that do not have this title but who practice OT and acknowledge and promote it as such. It's the people who work with the OT title but who do not practice OT that give a highly confusing picture of our profession to clients, colleagues and the general public.

healthskills said...

Curious, in New Zealand, psychologists DO provide case coordination in mental health, along with nurses, social workers, occupational therapists and so on.
I still haven't seen anyone in this set of comments show evidence to suggest that what an occupational therapist provides is so very unique that it should be considered elite and therefore not required to carry out generic duties.
I also don't yet know whether there is evidence that generic care coordination is detrimental for mental health consumers - particularly for long-term consumers, coordination of services seems to be much more important than discipline-specific interventions.
Interestingly, I would think that a whole lot of skills developed at undergraduate level in nursing programmes are lost by postgraduate nurses - especially those who move into administration, education or quality management...and there are more nurses who move into these generic healthcare positions than any other profession, and more who leave that profession than in any other profession. So the question could be asked whether nursing education is simply providing a background for nurses to become generic healthcare workers?

Angela said...

Hello all
I have been following these discussions with great interest and some disappointment that we still as a profession have not identified any clear solutions as it seems we cannot clearly identify the problem. Is the problem:
a) needing to be seen as a valuable team member (and therefore "mucking in" with generic roles)
b) providing value for money for our employers (and being "jack of all trades")
c) providing best care for our service user (and thus bringing our skills to the forefront)
d) others I've not thought of yet (?)
In my previous role as a manager of OT services within mental health I was clearly aware of the compromise that needs to be taken within the health and social care sector in order to meet all three of the above. Within any team the OT is usually a minority figure possibly by 4 nurses, 4 social workers and 1 OT to a team (I know numbers will differ from place to place)and it was upto myself as the manager and clinical supervisor of the Ots to ensure that their caseload was balanced accordingly to ensure that clients who needed OT were receiving it. This meant that we took on the case management role within our active caseload but not for cases we had no therapeutic input to. This allowed us space within our caseload to receive referrals from other team members for OT intervention of their clients as relevant.
I think what was the key thing here is that my role was there - in many areas the OTs do not have an OT manager and therefore do not have the backing to put forward this way of working.
I realise that I am rambling now - but maybe a brief case scenario will illustrate my point:
The majority of the teams at that time took referrals for enduring mental health needs clients, those clients that had been known to the service for some time and were maintained on medication and occasional intervention to reduce admission. Contact was mostly limited to depot clinics, CPA reviews and ward meetings if relevant. The OT was able to work with many of these clients and really consider issues of occupational dysfunction and deprivation and work with the client (using MOHO) to establish clear roles and routines within the scope of their ability and perceived futures. No other profession was able to produce the outcomes achieved by this intervention in terms of client satisfaction (and reduced admission but I'm not sure we could take full credit for that) - evidence of a type that suggests that we made a difference. By doing this and using our unique language and skills (which I strongly believe that we have) we were able to be a valued member of the team without becoming generic. We gained the respect of other team members and the overall managment once they saw what we could do.
It probably goes back to things we ahve discussed before - should OT move out of the health and social care sector which is limiting our scope of practice?

kapil kumar said...

Similarly, physiotherapists are asked to be case managers, administrators, perhaps manage the equipment pool, be service managers and so on.
Occupational therapists are not alone in fulflling these broad roles!
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Angela said...

@Kapil - hello and thanks for your comment - a view shared by healthskills in earlier comments certainly - but my question would be is an activity/role right or justified just because more than one person/profession is expected to engage in it?

Anonymous said...

I am an OT working in USA who trained at Salford many years ago, so this post attracted my attention. l have worked in psych in UK and US and l think the unique contribution OT makes is not in our role in the Team but our approach to the clients problems, which is quite different from the Nurses, SW, and Drs. The ability of OT to break down a task into cognitive and functional components in an automatic way allows us to easily adjust any setting or task to the clients present functional level. I see OTs everyday make their groups and 1:1 interventions look easy because of the nature of their training creating a perpective that looks at any task and automatically breaks it down so we can intercede where the client is coming from in terms of cognitive perceptual ability. Task equivalency and task breakdown are core skills that set us apart from other Team members. Being a Manager or case coordinator doesn't dilute this approach to care. l have been a Manager for many years and can still intercede in a client related issue using these skills.

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Elaine Allan said...

We live in an ever changing world, one which is becoming more multiprofessional (this is for the benefit of the service user-remember them)One of the reasons occupational therapy has been said to struggle with defining its role is our seeming inability to tell others what it is we actually do. I would add that another is the 'Ivory Tower' we appear to operate from. We can do what others do,partly because we are adaptive and partly because we put the service user at the centre of all our interventions, we can put our unique stamp on everything we undertake and use these opportunities to educate others to appreciate our role and we can do it willingly and with respect. Guess what? others can do what we do and unless we become business like and market ouselves effectively other professionals will utilise occupation as a 'technique' and we may find ourselves up a tower without a ladder. It is good to have a strong identity but do it with your head up, looking forward at others not in the sand....or worse!!!

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