NIHR Highlight My Signals - Occupational Therapy
Published October 2019
Photo (c) The Royal College of Occupational Therapists
In My Signals, health and social care staff and service users tell us what research is important to them and why they feel others need to know about it.
In this collection, we asked seven occupational therapists to tell us which Signals have interested them most and explain why they feel the findings are worth sharing.
Dr Jenny Preston MBE
Jenny is a Consultant occupational therapist within a neurological rehabilitation service in NHS Ayrshire and Arran. She is also an Honorary Associate Professor at the Nursing, Midwifery and Allied Health Professions, Research Unit, University of Stirling. Jenny has a particular interest in evidence-based practice applied to the wider needs of those living with neurological conditions.
Early, intense rehabilitation helps recovery after serious traumatic head injury
I was drawn to this Signal as it highlights the impact of early, intensive rehabilitation on functional independence, self-care, movement, communication, cognition, and work status further to serious traumatic head injury.
This Signal provides evidence on the timing and intensity of rehabilitation in people with moderate or severe traumatic brain injury and will help inform local and regional clinical pathways through delivery of more intense rehabilitation programmes that are cost-effective. It also acknowledges the key role that family members have to play in providing early multisensory stimulation with instruction.
National quality improvement programmes need time and resources to have an impact
This Signal caught my interest as a large trial evaluating the effectiveness of a UK wide quality improvement programme. Despite the clinical speciality being different to my own area of interest, the outcomes from this study could be applied within any clinical area by highlighting the importance of culture and willingness to change as being key to complex change in clinical practice.
This Signal also illustrates the need for sufficient resources and time required to implement interventions and detect improvements in patient care.
Participation in health research may be linked to better care and performance
Occupational therapists, like many other health and social care professionals, have a professional duty and responsibility to ensure their practice is evidence based. Yet challenges exist for therapists to balance the demands of their clinical roles and engagement in research.
This Signal begins to explore the relationship between research engaged clinicians and better clinical care while acknowledging that there is still considerable gaps in our understanding of how this happens and “which types of research engagement are most beneficial to patient care.”
Ways of integrating care that better coordinate services may benefit patients
This Signal is important because it provides “strong evidence that integrated care models can improve patient satisfaction and perceived quality of care.” However, the evidence from this literature review also confirms that we still do not have sufficient knowledge of the impact on “people’s health, healthcare systems and resources.”
A key strength of this Signal is the acknowledgement that “transformation requires engaging the workforce, addressing incompatible systems, and meaningful engagement of patients and communities.”
Jessica qualified as an occupational therapist in February 2019. She is now working for East Coast Community Healthcare as part of the Waveney Primary Care Network. She works with adults living with a variety of health needs including; dementia, osteoarthritis, parkinson’s disease, and cancer. Her particular areas of interest are long term neurological conditions, hand therapy, and palliative care.
A reflective group activity supports healthcare staff in England
Our service has recently undergone a major restructuring process in order to deliver better integrated, patient-centred care to its users in the community. This has meant that we now work as localised multi-professional teams, rather than a broader occupational therapy service.
This new way of working has come with communication challenges and an increased need to understand alternative approaches to healthcare and treatment.
Reflecting on practice as a multi-disciplinary group, as this Signal promotes, would be a useful way to approach this. It would also enable healthcare professionals to share ideas, debrief and de-stress, which can otherwise be difficult when working in the community.
An end of life strategy probably improved choice of where to die for people with severe respiratory disease
In my experience, most of the hospices and third sector services for those receiving palliative care specialise in supporting people living with cancer. This Signal indicates that greater attention needs to be given to those with conditions other than cancer who are approaching end of life (EOL), such as Chronic Obstructive Pulmonary Disorder (COPD).
Whilst the study focussed on preferred place of death (PPD) as its outcome measure, it is important to consider this alongside the person’s other preferences and not consider this the sole indicator of a ‘good death’. For example, deciding whether a person wishes to receive treatment to prolong life for as long as possible, or to adopt an approach that focusses on reducing pain and symptom control. This Signal emphasises the importance of identifying palliative care needs early, and timely intervention in order to establish these care needs and build them into a care plan. Our service has adopted a standardised form to document people’s wishes. However, I would like to explore whether a tool to enable early identification of palliative care needs could be implemented.
Further, the huge impact and demands on family and carers is very apparent when working with people approaching EOL. As healthcare practitioners, we need to carefully consider the impact that a person being cared for, and dying, at home may have on their family and the ways in which they can be supported to manage this.
Coordinating care for people with long term conditions and dementia: room for improvement
Our community referrals often relate to a single diagnosis, health need or occupational difficulty, which may make holistic treatment difficult. In particular, people living with dementia may be unable to easily communicate their medical history or current symptoms, putting them at greater risk of having additional health needs that are not recognised or treated correctly.
The symptoms of these co-morbidities, such as pain, fatigue or poor vision, may be incorrectly attributed to being a behavioural or psychological symptom of dementia, leading to delayed treatment. This Signal emphasises that better co-ordinated care planning may help reduce delays in correct treatment, and highlights the importance of having regular contact with other healthcare professionals involved in a person’s care.
As community workers, we are often able to talk to family members and carers directly about a person’s medical needs. This Signal highlights that we need to utilise these valuable sources of information more readily in order to address the health inequalities that exist for people living with dementia. As part of our care planning, the Signal highlights the benefits of gaining consent from people with or at risk of dementia to discuss their medical information with families and carers, while they still have capacity.
Toni is an occupational therapist who after 20 years of working in a variety of adult mental health services is undertaking a 3 year programme to become a Consultant Practitioner (Mental Health), working across a variety of clinical areas. Prior to this opportunity she was Trust Lead for Recovery and Clinical Teaching Fellow at a local University. She continues her role as a practising Dialectical Behavioural Therapist.
Peer support may reduce readmissions following mental health crises
This study’s focus on self-management and peer support really interests me. My recent experience working with a crisis team reminded me of the complexity of balancing safety and recovery with someone when they are in crisis. Also, differences may occur in perceptions of readiness for discharge. This study finds those who worked with a peer worker on discharge experienced reduced rates of readmission.
Many services have introduced peer worker roles and this randomised controlled trial offers important evidence to support and guide this practice. As is often the case, the non-statistically significant findings are the ones which grab my curiosity: note the high numbers who independently read a posted self-help manual after discharge and increased social networks at 18 month follow up. It’s really heartening to see robust research in such a complex area.
A third of people with dementia have treatable vision problems
This study really reminded me of the value of the allied health professions when working with people with dementia. My current placement in this area has demonstrated that occupational therapy assessments offer a significant contribution to identifying people’s strengths and limitations and therefore shaping intervention.
This study highlights that visual problems are common, often undetected and correctable. Optometrists were able to assess more than 80% of participants and 44% had easily remedied visual impairment. This raises important questions about membership of the multi-disciplinary team and how we, as a professional group, raise awareness about the importance of optimal sensory function in order to improve quality of life.
Additional therapy helps social recovery from first episode psychosis
Here is a study for occupational therapists to learn a great deal from. This is a robust randomised controlled trial demonstrating that social recovery therapy delivered to adults with first episode psychosis, results in increased time spent in structured activity and constructive economic activity plus reduced positive symptoms of psychosis.
The findings are coherent and convincing, with the study limitations clearly outlined. This study therefore demonstrates the value of carrying out methodologically robust health and care research.
Supported employment helps people with severe mental illness to obtain work
I was drawn to this paper because it highlighted a gap in my own practice. Employment is an area of great importance to the people we work with and to our profession. This Signal looks at a systematic review which examined nearly 50 studies comparing vocational rehabilitation interventions. Augmented supported employment and IPS (Individual Placement and Support) are identified as the most effective interventions to supporting people with severe mental illness into competitive employment.
This paper serves to reinforce my understanding on this subject and leads me to reflect on how differences between evidence and operational practice emerge and persist.
Chrissie qualified as an occupational therapist in 1981 and began her career with a rotational post in Worthing and Shoreham Hospitals. In 2010, Chrissie moved into her present role as a specialist palliative care occupational therapist for Rowans Hospice and Solent NHS Trust. Chrissie completed an MSc in Clinical Leadership in Oncology, Palliative and End-of-Life Care in 2016. She acts as one of three Team Leads for the Portsmouth Specialist Palliative Care Team.
How to improve 'do not resuscitate' decisions in England
‘Do not resuscitate’ conversations are a regular aspect of my work and as this Signal states, advanced communication skills, good timing and a sensitive approach are essential to ensure minimum distress and good understanding for patients and their families.
Meeting patients early in their journey can enable relationships and trust to be built to enhance future conversations, but currently the provision of advanced communication training is insufficient to meet the needs of the number of staff who would benefit.
Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) discussions are not solely the domain of medical practitioners; I recently completed enhanced training to become one of the first occupational therapists to be able to complete and sign uDNACPR forms with patients. This enables me to have the conversation with a patient and complete the form so the patient doesn’t have to have the conversation twice to achieve the same aim.
UK – wide study reveals a pattern of delay in referral to specialist end-of-life-care
This study talks about ‘hospice-based’ specialist palliative care, however specialist palliative care is also delivered via specialist teams who may or may not have access to a hospice.
Patients known to specialist palliative care teams are likely to have a better quality of life in the weeks and months before their deaths, particularly with relation to symptom control and psychological support. Sadly, working within a specialist team, I’m aware that limited resources prevent teams from seeing any but the most complex cases.
Ongoing societal misunderstanding of the role of hospices at end-of-life can prevent patients and their families being open to engaging with hospice services. Many fear if they ‘go in, they won’t come out’. As a team we try to increase early referral for those needing specialist palliative care by running an early referral clinic with access to specialist nurses, occupational therapists and physiotherapists.
There is an ever growing need for increased access and bed availability in hospices, but there is also an ever growing need for enhanced training within the community services to enable patients to receive excellent end of life care earlier, wherever their preferred place of death may be.
Christina works as Urgent Care Lead for Hounslow CCG. Part of this role involves supporting the development and implementation of the integrated care organisation within Hounslow. This includes developing Home First Pathways and alternative pathways for people presenting to urgent care services. Prior to this role she was Head of Therapies for an acute trust. Much of her occupational therapy career has been within an acute setting. Christina has a keen interest in using evidence to ensure that the best services are developed for patients.
People with COPD exacerbations prefer early discharge then treatment at home
This Signal looks at patients’ preferences in terms of where they would prefer to receive treatment. It provides evidence for the ongoing move for more services provided in a community setting.
From an occupational therapy perspective, it highlights the importance of a patient-centred approach as patients said they would prefer to be treated at home in the event of future exacerbations. As more services move out to a community setting this provides a real opportunity for occupational therapists to make the most of their core skills.
Occupational therapists also need to consider their role in teams as well as areas they may need to upskill in to work in a truly inter-disciplinary manner.
Early discharge ‘hospital-at-home’ gives similar outcomes to in-patient care
There is a significant amount of momentum surrounding ensuring patients are discharged home as quickly as possible and the detrimental effects remaining in hospital can have particularly on an older person.
In a previous role as a manager of an acute therapy service I often had discussions with the multidisciplinary team (including occupational therapists) about the perceived level of risk associated with discharging people home, particularly when implementing Home First. Home First is where patients are discharged and receive their assessments within their home environment rather than being assessed before they can be discharged.
This Signal provides evidence that patient outcomes are often better if they are supported to return home with community-based services as soon as they no longer require acute medical care. It should also provide reassurance to those who may be concerned about the risks associated with early discharge.
As an occupational therapist and a commissioner this provides evidence on the importance of working with all healthcare professionals across the system to develop services that enable people to leave hospital as soon as they are medically able to, to enable them to continue their recovery within their own environment.
Ways of integrating care that better coordinate services may benefit patients
I was drawn to this Signal as it links very closely with my current role as a commissioner, a role I recently moved into. Part of the portfolio involves working to improve the integration of services across the system and I was keen to explore the evidence associated with integrated care as well as some of the possible barriers to implementation.
The NHS Five Year Forward View and the Five Year Forward View Next Steps place a significant emphasis on integrated care and this signal provides evidence that integrated care can improve patient outcomes and bring benefits to the health and social care system.
The evidence within this Signal suggests that there are benefits for patients in terms of being able to meet their preferences, improved patient satisfaction and perceived quality of care. The evidence also looks at the factors that influence implementation such as established hierarchies and difficulties with changed boundaries of professional roles.
Occupational therapists are already working across organisational boundaries and integrated care has the potential to bring significant benefits to the profession. However, it is important to ensure the right support and training is provided as services are developed going forward.
The evidence identifies what is needed to support staff as services move to a more integrated approach and this is important both for occupational therapy leaders and commissioners to ensure integrated care is implemented successfully. It is also important to ensure patients are involved in development of integrated care systems as this is also a key driver to success.
Susan Windeatt is a specialist occupational therapist working in the community in Westminster, providing assessment and rehabilitation in people’s homes. She has an interest in older adults, falls and frailty as well as palliative and chronic conditions. With prior experience and masters level research in software development, she also has keen interest in the development of digital technology for therapeutic benefit.
Goal-setting can help people with early-stage dementia improve function
This Signal appealed to me as working toward therapy goals with people in their own homes can be challenging when dementia affects self-directed rehabilitation. As a service we identified this as a challenge and participated in occupational therapy training to better support assessment for people with dementia. This Signal offers an approach to home-based cognitive rehabilitation towards meaningful service-user directed home-based tasks. I liked that carers were included in the research and goal attainment ratings.
The Signal found improvements in ratings of goal attainment over time but there was no significant improvement in participant quality of life. There was also not a cost-effective impact in terms of quality-adjusted life years. This Signal shows promise in that provision of an occupational therapy cognitive rehabilitation home-based intervention can improve person-centred goal attainment. However, there is still work to do on improving other quality of life measures for people with dementia alongside task-based goal completion.
Long-term exercise programmes reduce falls and injuries in older adults
I read this Signal with interest as falls are so common among the older adults I work with.
This Signal followed people working on aerobic, strength or balance training over the course of a year, and combined with the other two Signals I have listed below which support pilates and yoga intervention, demonstrates wide ranging benefits of regular exercise activity, including falls reduction with interventions provided regularly over a number weeks.
Although there was no significant reduction found in rates of admission or fractures there was an overall reduction in falls and injuries, meaning encouraging exercise interventions could potentially impact on reducing the fear of falling and anxiety that so often affect people who have fallen.
Community NHS services are commonly limited by time constraints. This Signal looked at long term exercise participation and makes a case for longer term planning in falls prevention intervention.
Online education, pain coaching and advice by video conference can reduce knee pain
I was interested in this Signal as in the community I see a lot of older adults with pain, particularly knee pain and osteoarthritis. I visit individuals who are unable to leave their homes and therefore have difficulty accessing a pain clinic, and are reliant on home visiting services to encourage self-management. Given the potential benefits of reducing need for admission and surgery, especially in older adults with multiple comorbidities, this seems like a promising intervention.
As the Signal illustrates, the benefits of such a programme are only available to those with access to fast and usable internet technology. In today’s society so many aspects of daily life are increasingly completed online (e.g. shopping, communicating with family, working remotely) and this is a growing area in which occupational therapists are able to support people. I think there is a role for occupational therapists both by providing online interventions, such as that described in this Signal, and in supporting people to access such interventions e.g. by providing accessible technology and guidance in its use.
Hearing aids make communication easier for people with mild hearing loss
Hearing loss affects over 70% of older adults (aged 70+) which is almost three quarters of my occupational therapy caseload. Often this, combined with other sensory impairment (e.g. vision), contributes to an increased sense of isolation and reduced participation in activities. Hearing loss has been linked to increased risk of falls and cognitive decline.
This Signal highlights that encouraging hearing aid use for people with mild-to-moderate hearing loss can make a difference to their ability to communicate as well as overall quality of life. I have found in my work that encouraging people to wear their hearing aids improves assessment and interventions. I think as occupational therapists we can look holistically at improving communication by adjusting our methods, considering sensory assessment and adapting the environment. I also was interested to learn that there were no reports of adverse effects for hearing aids.
This Signal has reassured me that discussing hearing loss and encouraging the use of hearing aids can be beneficial.
Dr Leanne Miller
Leanne is the Operational Lead of an integrated hand therapy team comprising occupational therapists and physiotherapists at the Norfolk and Norwich Hospital. She recently completed an NIHR Clinical Doctoral Research Fellowship looking at the assessment and treatment of sub-acute hand oedema post-trauma or surgery. She has been an occupational therapist for 15 years, specialising in hand therapy for 12 years and pursuing a clinical academic career for the past 10 years.
Outpatient video consultations are feasible but challenging for the NHS
This Signal attracted my attention as I have attended national and international conferences recently where this has been presented as a service development idea.
I am aware that some hand therapy units in London have trialled Skype consultations for patients who struggle to attend outpatient appointments. The challenges for implementing this type of follow-up consultation in a hand therapy setting is identifying the most appropriate patient group who would benefit from this, as those who require splints and physical modalities such as massage, heat treatment or electrotherapy still require face-to-face appointments.
In hand therapy we regularly measure joint range of motion, assess scar tissue pliability and record muscle or grip strength therefore the numbers of suitable patients are reduced to those who may have chronic pain conditions who require longer term follow-up to check progress.
Lack of evidence on whether collagenase or surgery is more clinically or cost effective in managing Dupuytren’s contracture
As an occupational therapist working in hand therapy we regularly assess patients prior to their surgery and post-operatively for Dupuytren’s contracture and I have also been involved with data collection for a research study comparing percutaneous needle fasciotomy with collagenase.
I was surprised by the amount of bruising and swelling patients had to their hand for around 7-10 days after collagenase however, patients reported high levels of satisfaction with the speed of the procedure and recovery process compared with those who undergo a surgical procedure such as fasciectomy or dermofasciectomy.
This Signal calls for a head-to-head comparison between collagenase and surgery for Dupuytren’s and I think it is important that patients are educated about their options and understand the distinction between the different procedures and what is actually happening to the Dupuytren’s tissue in each procedure, and what the prognosis will be in terms of need for future surgery.
Patients may prefer the immediate treatment of a collagenase injection or percutaneous needle fasciotomy, which could be offered in an outpatient clinic, however cost analysis would need to take into consideration the combination of procedures which one patient may undergo over time. Or patients may prefer surgery as the first line treatment where you would need to incorporate aspects such as therapy time and resources, nursing time, visits to hospital, time off work etc.
Royal College of Occupational Therapists
The Royal College of Occupational Therapists (RCOT) is the UK’s only professional body for occupational therapy professionals and students. We work to ensure the profession’s rightful place in health and social care delivery and encourage our members to play an active role as ambassadors for the profession.
This collection, which contains Signals selected by occupational therapists working in a diverse range of settings, illustrates how research has real-world impact. The occupational therapists write about the relevance of the research to their areas of professional interest and practice, reflecting on the findings and wider implications.
The views expressed within this collection are those of the individuals, and do not necessarily reflect the views of RCOT.