The role of occupational therapists in reablement services a qualitative realist study Lisa Dibsdall

Today.. Background to research Introduction to realism Realist evaluation Case studies Analysing data Findings Implications for practice

Background to research Reablement services have developed with different organisations involved Occupational therapists identified as key professionals No blueprint for the delivery of reablement services The role of occupational therapists in reablement and what influences their effectiveness

Research questions How can we critically understand the role and effectiveness of occupational therapists working in reablement services? What is the experience of occupational therapists working in reablement services, and what contexts and mechanisms affect the outcomes of their practice for service users, carers and members of the reablement team?

Realism Positivism Realism Constructionism Realism is a school of philosophy Aiming for understanding ‘what works, for whom, in what circumstances and why?’ (Pawson, 2006, page 78) Realism is a school of philosophy. It sits between positivism – that asserts that there is one observable reality, that we can test and derive facts from; and constructionism – that the world is constructed by what we make of it through our senses and we cannot know for certain what reality is. Realism considers both the material and the social worlds as ‘real’, in that they can have effects on whether and how intervention or programmes work. All observation is shaped through human brain and therefore no ‘final’ truth or knowledge. Social systems are open systems with flexible boundaries, interacting with one another – families and schools, health and housing Aiming for understanding

Nature of Causation Context Mechanism Outcome Realism considers the influence of context (physical and social factors. Environment, resources) and asserts that it is not the intervention or programme, like reablement, that works per se, but there are mechanisms that cause the intervention to lead to positive or negative outcomes. mechanisms –Power to change. The largely unseen reactions, choices and capacities of people that impact on the success of a programme or intervention. Mechanisms exist whether or not they are operating at that particular moment.

Context-mechanism-outcome configurations There may be many contexts, mechanisms and outcomes and realist research looks for the configurations of those. Programme – Setting up of a choir in Bristol to perform at a charitable concert. Claude, sees the choir advertised, he has experience of singing , he loves performing (context). Mechanism – performance, achievement. Outcome – asset to the choir Abi– context is recently moved to Bristol, she lives alone – mechanism for their attendance is social interaction. Her intended outcome to meet people, make friends.

Realist Evaluation Realist Evaluation is theory driven evaluation Identifying the theory Stakeholders Social services network Realist evaluation is theory driven, it isn’t fixed to one methodology it can be qualitative or quantitative. . Stakeholders – people involved in the intervention or programme that you are looking at. A starting point to consider how a programme is supposed to work. Mine was an email to occupational therapists via the Royal COT social service network. Can see contexts and outcomes, no mechanisms

Realist synthesis review of the literature No hierarchy of evidence Relevance and Rigour Searched for reablement and occupational therapist, restorative care, based in community. Exclusions – mental health, residential based.

If…then statements If occupational therapists provide timely access to equipment (C) and service users and carers accept that equipment (M) then service users can do more for themselves (O) If occupational therapists are involved in training reablement support workers (C), support workers increase their skills and confidence (M), and practice in a reabling way with service users (O)

Programme Theories Recognition of the skills and knowledge of occupational therapists by staff in reablement teams determines the degree to which occupational therapists support service users and carers. Occupational therapists completing holistic assessments, goal setting and reablement plans, support the occupational engagement of service users in all areas of daily life. The timely provision of equipment increases the independence of service users and supports carers in their caring role. Occupational therapists contact with support workers, including involvement in training, increases the skills and confidence of support workers and assists support workers to work in a reabling way.

Testing Theories Three case studies Recruited from initial stakeholder conversations and direct approach Observations of occupational therapists (N=10) Interviews with occupational therapists and managers Focus groups and interviews with support workers (n=16) Questions aimed test and develop theory Ethical Approval Case studies recruited via original email expression of interest and through a published list of Local Authorities that had developed reablement service with another organisation involved. For pragmatic reasons as part time student case studies were within two hour drive of where I live. Median average for observations 1.5 days. Overall 12 days. Ethical Approval – by University as my research part of PhD study. Ambiguous whether needed approval from social care research ethics committee as mostly working with staff. Decided to go through approval as observing service users in their own home. Also gained ethical approval via research governance arrangements – with Local Authorities for each case study

Data Analysis Reading and re-reading established some familiarity Themes coded using NVIVO Coded Contexts, mechanisms and outcomes

Data Analysis Reading and re-reading established some familiarity Themes coded using NVIVO Coded Contexts, mechanisms and outcomes

Findings Original programme theories expanded Occupational therapists were core members of the team, other team members requested their support. Evidence of holistic and person centred practice Provision of equipment was an option amongst others in the occupational therapy ‘tool box’ Training develops trust and confidence in support workers Two new theories identified Regular contact supports working as one team Importance of having shared purpose

An example of restrictions in policy is the focus on ‘the basics’ – personal care and tasks within the home. There was willingness to do more in the wider environment but not the resources. Clinical reasoning – Procedural reasoning – defining the issue and selecting an intervention

Shared Purpose ‘I just feel like the whole ethos of occupational therapy and reablement just sits so well together. I think we can see people’s potential’ (occupational therapist) ‘I think we really need to buy into reablement. I think OT’s time has come with reablement’. (manager) Share purpose if required at all layers of the service. Occupational therapists showed a clear commitment to reablement and it’s links to occupational therapy philosophy Screening and allocation is important to ensure that the ‘right person, at the right time’ sees the service user. A knowledge of each others’ role helped to work as a team for the service users. This included occupational therapists training support workers. There was confidence in support workers’ skills. Service users need to ‘buy in’ or share the purpose of reablement – particularly at points of hospital discharge. Marteau and Weinman (2004) – we process information based on existing schemata, for example if experience of social care has been domiciliary care doing tasks for them, they will start with that impression, need to present information in different ways to increase understanding Legislatively the Care Act supports reablement, policy can restrict provision – both in terms of equipment and meeting all goals, goals tended to focus on personal care and domestic tasks rather than activities outside of the home.

Holistic and person centred practice ‘knowledge base’ ‘tool box of options’ Provision of equipment was an element of reablement support within a range of interventions from the occupational therapists’ tool box of information, advice, demonstration of techniques. Clinical Reasoning skills - Fleming’s work (1991) three track mind – procedural, interactive, conditional. Occupational therapists demonstrate conditional reasoning. Multidimensional thinking process. Considering the meaning of the illness or disability for the service users within their physical and social contexts.

Implications for Practice Reablement needs a shared purpose at all layers of the service. Occupational therapists have skills in assessment and goal setting key to the reablement service Clinical reasoning skills are essential in choosing from a toolbox of interventions Communication and training develops trust between team members Realist research is a useful approach in researching complex interventions Occupational therapy philosophy and the ethos of reablement were keenly linked. Shared purpose needs to occur at all levels of the service. If you are interested in realist research, there are books, and materials including the RAMESES email network that you can link to. Realist and meta-narrative evidence synthesis: evolving standards.

References Useful link for realist research Fleming MH (1991) The Therapist with the Three Track Mind. American Journal of Occupational Therapy. 45(11) 1007-1014 Pawson R and Tilley N (1997) Realistic Evaluation. London: SAGE Publications Ltd Pawson R (2006) Evidence-based Policy: A Realist Perspective. London: SAGE Publications Ltd www.ramesesproject.org Useful link for realist research

Thank you for listening, Any questions? Lisa Dibsdall, PhD Student, University of the West of England Lisa4.Dibsdall@uwe.ac.uk Principal Occupational Therapist, Wiltshire Council Lisa.Dibsdall@Wiltshire.gov.uk