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.
