You may have read in our recent newsletter that recently 2 of our undergraduate students had the great opportunity to visit and work in Brazil. On their return they have both been busy reporting back. One of their tasks was to write a reflection on their experience - here is Carrie's

Reflecting on an occupational therapy student visit to Brazil - Carrie Sant

After reading about community occupational therapy practice in South Africa in Occupational Therapy Without Borders (Kronenberg, 2005) I became interested in the concept of how occupational therapists practice around the world under the influence of different cultural and contextual factors such as limited resources and financial funding to implement interventions. With the NHS struggling under tight financial resources (The Kings Fund, 2015) it is essential as a future health care professional that I have an understanding of how to provide a high quality of care with limited resources.  With another student from my cohort I applied for the Santander International Travel Bursary with the intention of experiencing occupational therapy in a different culture and context to which we had previously had opportunity to see. Brazil, a developing country in South America (World Bank, 2015), contrasted in numerous ways with the UK, and provided the ideal opportunity to explore how theory and practice translated across international borders. The World Federation of Occupational Therapists (2011) promotes occupational therapy internationally and refers to the importance of seeking opportunities for continuing professional development. Although we discussed what we hoped to learn and see whilst in Brazil, and had some expectations about ways in which teaching and practice would be different, I think we both found it difficult to comprehend just how different healthcare practice would be.

After taking a few days to adjust to our new surroundings we began working with occupational therapists in a hospital for infectious diseases. Here we spent time in the ICU, on the surgical and paediatric wards and attended both individual and group occupational therapy sessions. The physical environment itself was the most noticeable difference as there was a significant reduction in the numbers of staff working on the wards as well as the quantity and quality of equipment being used. The hospital itself was not the modern, well-resourced and sterile environment we are accustomed to at home and this was worrying at first as we considered the impact this might have on patient care and safety. Initially, the interventions we observed seemed very different to the kind we might expect to see in the UK and we struggled to understand the links with occupational therapy. We observed occupational therapists carrying out lymphatic massages and focussing on providing emotional support to patients experiencing distress or anxiety during their hospitalisation. However, through discussion with the therapists we could see that the goals of treatment remained occupation focussed. Other practice included cognitive stimulation for patients experiencing cognitive deterioration and also mobility rehabilitation, however, there was minimal equipment and resources readily available and most assessment tools and other resources were made by the occupational therapists themselves specific to their patient’s needs.

The most inspiring project we saw was at the State University where students and teachers ran a clinic for children with disabilities providing assessment, treatment and equipment. The project had funding to purchase equipment and so treatment rooms were stocked with touch screen computers and communication aids, specialised seating and desks for children to work at and even a games console room for games therapy, however, there was minimal financial resources to provide equipment for children to use at home and so the project focused on finding low cost alternatives to create mobility equipment and communication aids from. The students were taught how to design and create switch controls, communication books, washing and dressing aids, bathing aids and seating as part of their studies. They also learnt how to make splints using PVC pipes and other orthotics from a range of recycled materials. The project was using the core concepts and skills of occupational therapy (Creek, 2003) to provide much needed equipment to children and their families who would not be able to afford it otherwise. Although the project encountered issues such as long waits for equipment whilst it was made, sporadic attendance from patients who travelled long distances to attend the clinic and risks to themselves in using kitchen cookers to heat the splint material, it demonstrated the valuable role an occupational therapist could have in services running with limited resources and the contribution their skills could make to improve lives. For us this was an ideal example of how the core principles, values and skills of occupational therapy could be used in practice and something we felt was missing from UK training and practice.

It was interesting to note that many of the same difficulties were faced by the therapists, including lack of awareness of occupational therapy from other healthcare professions and conflict over roles and responsibilities. The therapist role was very similar in the sense that they were applying the same concepts and theories with the end goal of maintaining or improving function, however, the selection and implementation of interventions was different due to the environmental restrictions on practice. The role of the occupational therapist in the UK is still undergoing change as the profession diversifies the services and clients with whom they work (COT, 2011). In Brazil, the students and therapists felt they often filled in gaps where other professionals are not meeting patient’s needs and that the role of an occupational therapist in a setting was not always clearly defined. This created difficulties for the therapist in explaining their role to others and knowing exactly where they fit into the healthcare system.

As in the UK, emphasis was placed on the therapeutic relationship (COT, 2006; HCPC, 2012). Whilst in some settings in the UK, therapists work with clients over a number of weeks or months, there are also many occasions where they might meet with a client briefly before discharging them from a service. In Brazil, however, therapists were usually able to develop the relationship much further as they as might see a patient daily over several months, from admission through to discharge. This linked to their role in providing emotional support as they were often the healthcare professional to spend the most time with the patients. Whilst in the UK we claim to offer holistic, client centred care (COT, 2010; HCPC, 2012), our ability to do this is often restricted by time and other environmental constraints and we do not get to spend as much time with each patient as we would often like. Our training teaches us to use advanced communication skills to build effective therapeutic relationships with patients in short periods of time, however, these often lack the depth that we could see in the relationships between therapists and their patients in Brazil.

Systems of working also differed significantly to the UK, an occupational therapist was not dependent on receiving referrals and so could seek out patients they felt were most in need of intervention. Referrals could still be made by other professionals who felt the patient would benefit from occupational therapy but were not essential. This allowed the therapists to identify which patients they felt would benefit the most from their care. Therapists practicing in the healthcare system were not under the same pressures to justify interventions and measure outcomes (Duncan, 2012). The reduced need to document practice in detail allowed more time to spend with patients as well as to plan and prepare activities. It also allowed them more freedom to work with patients on areas they both felt were important and for as long as needed. However, we questioned whether this had an impact on the quality of therapy provided as practice was not driven by the need to prove effectiveness or base interventions on an evidence base as in the UK which is perceived as contributing to a provision of a high standard of care (Heiwe et. al, 2011).

There was also a reduced impact of health and safety legislation and other guidelines on practice which have developed in the UK as a result of increasing litigation and drive to reduce incidents where patient’s safety is compromised (NHS, 2015) Whilst therapists remained aware of protecting patient’s safety and providing a high standard of care, there were many aspects of practice which could be considered to benefit from this, for example, therapists were able to custom make equipment which could not be bought to be provided for patients use in hospital or at home. We were able to identify many benefits to practice of reduced guidelines and legislation such as more freedom in practice and increased time for patient contact due to reduced administrative work, however, it was difficult to see how this practice would work within the UK healthcare system.

As a result of the Santander Travel Bursary I have been able to have the opportunity to experience not just an alternative approach to occupational therapy practice but also a completely different way of life. Our experiences in Brazil were both challenging and rewarding. It provoked difficult emotions to see the conditions in which the patients received treatment and the therapists sometimes had to work, such as having difficult emotional conversations with patients in corridors, running therapy groups from buildings without windows, doors or electricity and therapists not always being able to provide essential equipment to a patient in need. However, it was also inspiring to see how they still strived to maintain a high standard of care for their patients and their families and used their creativity and skills as an occupational therapist to identify alternative ways of meeting patient’s needs that were low cost. The occupational therapists we worked with were passionate about their role and their work and this translated into their practice. Our visit highlighted key assumptions we hold about what is essential to healthcare practice, in particular the resources we have access to and the environment in which we work. I feel much more appreciative of the standards and resources of the healthcare system in the UK, and hope my experiences will make me a more reflective and resourceful practitioner in the future as I challenge myself to put my unique skills and knowledge as an occupational therapist to use in the same way as the therapists I was lucky to work alongside in Brazil. The trip has inspired me to find other opportunities to travel and experience occupational therapy in a range of cultures and contexts to broaden my understanding of the profession and further progress my knowledge and understanding which I hope to transfer to my work here in the UK.