Merry Christmas to you all and a Happy 2014 - here's to more blog posts.....

Transitions from unhealthy to healthy behaviour- a personal journey

  "If one does not believe in one's capability to perform a desired action, one will fail to adopt, initiate and maintain it".

Schwazer:  Health Action process Approach

In this blog post I attempt to consider the notion of transition from an unhealthy behaviour to a healthy behaviour using the Model of Human Occupation (MOHO) as a loose frame to focus my personal experience of being diagnosed with Type2 Diabetes. Firstly some very quick definitions to key you into the terminology I am using.

  I thought it best to go to the official site to define MOHO here:

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. 

Type 2 Diabetes, taken from the UK website

Type 2 diabetes develops when the insulin-producing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly (known as insulin resistance).Insulin is a hormone. It works as a chemical messenger that helps your body use the glucose in your blood to give you energy. You can think of it as the key that unlocks the door to the body’s cells. Once the door is unlocked glucose can enter the cells where it is used as fuel.

 

It is said that health is a process through which people become who they want to be (I apologise that I cannot find the original reference for this that came from nursing research). Much of the self-help literature offers the idea (myth?)  that it takes 28 days to adapt to change or 3 weeks to learn, 6 weeks to adopt and 6 months to internalise a new behaviour - but there is little evidence to support this within specific research areas, however, it seems to have worked for me this way. 

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

MOHO seeks to explain how occupation is motivated, patterned, and performed. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Within MOHO, humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity. Volition refers to the motivation for occupation, habituation refers to the process by which occupation is organized into patterns or routines, and performance capacity refers to the physical and mental abilities that underlie skilled occupational performance. MOHO also emphasizes that to understand human occupation, we must understand the physical and social environments in which it takes place. Therefore, this model aims to understand occupation and problems of occupation that occur in terms of its primary concepts of volition, habituation, performance capacity, and environmental context. - See more at: http://www.cade.uic.edu/moho/resources/about.aspx#sthash.Nq8aLYPW.dpuf

When we look at changing health behaviour, Schwazer offers the HAPA framework using  psychological and social sciences to discuss an approach to this which is designed to examine a set of psychological constructs that jointly aim at explaining what motivates people to change and how they take preventive action. In short, the motivation phase (or perhaps we might call this the initiation phase?)  describes how one needs to believe in one's capability to perform a desired action ("I am capable of initiating a healthier diet in spite of temptations"), otherwise one will fail to initiate that action.  In the subsequent volition phase (perhaps we may call this the adoption phase so as not to get tangled up with MOHO language?), after a person has developed an inclination toward adopting a particular health behaviour, the "good intention" has to be transformed into detailed instructions on how to perform the desired action. 

This had some resonance with me and I began to consider these issues in relation to me as an occupational therapist and using the elements of MOHO in the change I asserted. The sections in red refer to the language of the HAPA framework, I have linked them together with where I believe MOHO best fits with these categories and then given some personal reflection as to what this meant to me in my experience.

Volition:

A minimum level of threat or concern must exist before people start contemplating the benefits of possible actions and ruminate their competence to actually perform them 

• In order to consider change in healthy behaviour it was important to address and explore my relationship with food - values held, traditions practiced etc. 

• Food was a social event, a treat, a marker of time, a consolation. A way of sharing an experience and showing care and consideration with friends and family, and a link to the past.

•  This was all under threat and the advantages of change had to be weighed against the perceived effort and skill involved in making changes to all of this.

The message has to be framed in a way that allows individuals to draw on their coping resources and to exercise skills in order to control health threats (fear appeals are limited)

• The current stance by the NHS here in the UK is to approach the issue in a 'soft' way. Everything  in moderation is the message. What I observed through this within an education session with a group of people with a recent diagnosis was that this did not clearly offer the importance of change. There was little consideration of what coping resources or skills might be required 

• Utilising other sources from the internet and books, mainly from Australia (because in my view they seem to have a more well defined approach and attitude to the issue) I was able to find my way through often conflicting and usually complex messages to find a message that spoke to me enough to enable me to draw on coping strategies. The messages I found made me want to exert the effort required and make changes.

• Intrinsic motivation was also impacted by the future requirement of health care professionals to assess and judge my progress - I have never been able to easily accept being judged (I got through 3 driving instructors and 2 tests before I passed my driving test). So to avoid this I needed to adopt healthy behaviours.

 Intention is not enough on its own - it then has to be planned for and instructed within the  development of an internal coping dialogue 

•  Schwazer explains this as outcome expectancies- subjective beliefs on positive and negative outcomes and  perceived capability of a person to implement a certain behavior 

• I had to learn to challenge an internal dialogue that stated such things as "I don't have time to do all that cooking of fresh food", " I couldn't possibly eat that....", "I don't like ....", 

• I had to retrain my thinking on what was a treat, what was sociable, what was consolation etc. This was perhaps one of the hardest things, I had to identify my internal dialogue at each occasion where food was involved, what was I thinking, feeling about this. How did this fit with what I now knew to be "healthy" choice?

 Habituation

Intention has to be transformed into instruction

•  I scoured cookery books and each week I planned exactly what I was to eat every day - breakfast, lunch, dinner and snacks and by doing so learned about the science of food, how different groups work together, understood the concept of low Glycaemic Load (GL) for slow release and complex combinations that slowed sugar release or enhanced insulin effectiveness. And I finally began to understand portion control.

Action plans on how to create and adopt transitional behaviour, then have to be protected by cognitions in order to be maintained and not distracted by competing demands and intentions

•  By doing this I created a new routine for eating incoporating more time for cooking. In this way I began to enjoy making meals, creating an ambient environment (is now the time to admit that my favourite 'goto' music for meal prep is Steps??)

Avoidance of high risk situations

•  This was a bit harder to enforce. At first it was easier to avoid social situations where food would form part of the experience, but friends soon became slightly annoyed with me for this.

• Eventually this was impossible, but taking relearned coping strategies and with the support of friends and family I was able to find the confidence to ask questions of the food others had prepared and could make informed and healthy choices

Prioritise these intentions over other desires and intentions for a specific time period 

• My first HbA1c test would take place 3 months after initial diagnosis, therefore this became my first goal. I intended to keep these new behaviours for this period of time and then re-consider dependent upon the outcome of the test reading.

 Performance

Performing an intended health behaviour is an action, just as is refraining from a risk behaviour. The suppression of health-detrimental actions requires effort and persistence as well.

• As mentioned I learned how to cook healthy food, how to put food together what and how much to eat  

• I developed research skills to find and interpret the information available - there is much that is conflicting and complex in the available literature and learning to navigate through this is very difficult - and not something I have totally mastered to date I'm sure 

• I became so successful at suppressing health-detrimental actions that at the point of trying to 'fall off the wagon' and have treat to celebrate my first 3 months reading - and choose a cream cake - I couldn't do it and actually ..... I didn't want to do it - and I haven't

It is worth recognising, as with MOHO, that I continue to impact  on and be impacted on by the perceived and actual human and non-human environments.

• Human environment of support and personal networks of family friends and colleagues in both real and virtual world. 

• NHS support and advice

 

Outcome: BMI in normal range, HbA1c in non-diabetic range, Cholesterol normal range, weight loss - 3 stone and counting, feeling well :-)

This post is slightly away from the norm here as I feel I am exposing something more personal than I ususally do on this blog. I would welcome your comment and feedback as to whether this post was useful or interesting to your work or even personal circumstance. Any ideas for future posts would also be well received.
Many thanks 
Angela

OT4OT 24Vx 2013

Making the most of placement - a guest post from an anonymous Salford undergraduate.

Being on placement: the placement jitters

For me, placements are source of excitement and trepidation. This strange combination means that at around two weeks before placement I start to feel a little on edge (cue the ‘turning up for exams without doing any revision/going to Alton Towers in my pyjamas’ dreams). This build-up of butterflies usually leads to me saying something daft within the first 10 minutes to my educator. Why am I like this? A question I often ask myself. I think that it’s because I treat every placement as a potential employer, a 1-10 week-long job interview testing my practical skills, knowledge and clinical reasoning. It’s a bit like being on the Apprentice but with bottle-green trousers. When I finish university, I could be applying for a job at that workplace, so as well as passing my placement, I want them to have a positive impression of me.  So, if you feel the anxiety rise as placement creeps ever forward on your timetable. I hereby order that you give yourself a break and let me pass on some things I’ve learned to help you along the way. 

Make yourself useful. 

I thought that educators get extra time to supervise students; I was surprised to find out that this is not always the case. So educators may have a full caseload AND have to find time to make sure students under their charge have learning opportunities and supervision. I feel that if educators are sacrificing their time to help me learn then I should try and pay it back by trying to lighten the load for them. Basic things like answering the phone, taking messages, tidying up after a group, writing in medical notes and even the old favourite of making a cup of tea for staff (if not on the ward) or brewing up for patients (say, in groups) have gone down well in my experience.  I have had feedback that the use of initiative is always welcome (i.e. doing something without being asked). A note of caution here; that what you can do will depend on your placement so always check with your educator first. In my last placement there was a regular routine each morning such as cleaning, setting up the equipment and getting patient notes out for the day. I used to get in early to miss the traffic, so I used to do the morning routine when I first got in.

 Go easy on yourself

Whether it’s initial interviews, mini-mental state inventories, or group works, you are not going to be a superstar at something straight away. Go easy on yourself, it takes practise. It’s important to remember that the Oxford dictionary (2013) defines practise as a “repeated exercise in or performance of an activity or skill so as to acquire or maintain proficiency in it”. If you’re finding something difficult, keep trying, it will get better. It’s when you give up that you don’t improve. If you were amazing at something straight away, I would probably label it ‘talent’ and call Simon Cowell immediately.

People skills.

 Placement can be an overwhelming experience and I have heard of students, through the pressure, being nervous about talking to clients in case they say the wrong thing or worry that they won’t be able to answer client’s questions. In less than three years time, I will be seeing clients every day, so I use placement as the time to practice my interpersonal skills. I found that if I have developed a rapport with the client, then they are forgiving if something doesn’t go quite according to plan (common comments I have heard from patients are: “it’s alright love, you’ve got to start somewhere”, “you’re doing fine!”  and “don’t worry, we’ve all been there”. If I am unsure where to start I have found if I introduce myself, smile, make eye contact, am able to explain to the client the purpose of the intervention, actively listen and am polite that everything else seems to come naturally. Remember that patients may feel more apprehensive about their appointment than you so anything that can put them at their ease is helpful. 

You will be tired!

Even if you are just observing, placement is emotionally and physically draining. So be prepared! Look after yourself, try and get a decent night sleep. Exercise can be a good way of re-energising and shaking away any tension. Make your mornings easy, you don’t need anything else getting you into a flap.  Have your uniform (or work gear) all pressed and ready to go, car filled with petrol, lunch packed and some good music for the journey to placement to put you in the right frame of mind.

And finally, make the most of it, learn as much as you can and build some good contacts. I hope it goes well for you.

If you want to read more you can vist my blog TheOTProcess and also  Charlotte's blog  who diarises her daily experiences of her 3^rd  year OT Erasmus  placement. It's a  really good account of how it feels during placement and I certainly respect anyone getting their work experience through ERASMUS (I thought normal ones are scary enough!) 

What are your top placement tips?