SIS Quarterly Practice Connections

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SIS Quarterly Practice Connections

A Supplement to OT Practice

Published by The American Occupational Therapy Association, Inc.

Table of Contents Children & Youth............................................................................. 2

ӹӹ Use of Assistive Technology With Transition-Aged Youth, Andrea D. Fairman, PhD, OTR/L, CPRP; Roxanna Bendixen, PhD, OTR/L; Haley Younkin; & Julie R. Krecko ӹӹ Paradigm Transitions in Pediatric Practice: Tools to Guide Practice, Patricia Laverdure, OTD, OTR/L, BCP; Francine M. Seruya, PhD, OTR/L; Pam Stephenson, OTD, MS, OTR/L; & Joanna Cosbey, PhD, OTR/L

Health & Wellness........................................................................... 8

ӹӹ The Impact of Occupational Therapy Services for Individuals Transitioning Through Neuro-Oncology Care, Ni He-Strocchio, OTD; & Sheila M Longpré, MOT, OTR/L ӹӹ When an Adult Child With a Developmental Disability Goes to College: A Transition for Parents, Varleisha D. Gibbs, OTD, OTR/L; & Adele Breen-Franklin, OTD, JD, OTR/L

Mental Health.............................................................................. 14 ӹӹ Support Models to Enhance Community Transitions, Margaret Swarbrick, PhD, OT, FAOTA

Transition The theme of this issue of SIS Quarterly Practice Connections reflects both client transitions and professional transitions for occupational therapy practitioners. As the only profession that addresses all aspects of a client’s life from a strengths-based perspective, occupational therapy practitioners are instrumental in facilitating successful transitions. These can include transitioning to a new school, a new rehab facility, back to the community, or among levels of care. It also includes helping other members of the care team, including family members, support and adjust to changes. The same skills used to help clients and families can be used by practitioners themselves when changing practice areas or moving to new roles. A pdf of this issue is on AOTA’s website in the Publications section, and individual articles are posted within the appropriate SIS pages. What do you think? Please let us know at [email protected] or join the discussions at OTConnections.org.

Donna M. Costa, DHS, OTR/L, FAOTA Special Interest Section Council Chairperson

Productive Aging.......................................................................... 17

ӹӹ Fostering Health-Related Quality of Life in Community-Based Stroke Survivors, Lynne Clarke, OTD, MS, OTR/L; & Rachel Prewitt, MOT, OTR/L

Rehabilitation, Disability, & Participation...................................... 20

ӹӹ The Meaning of Context: Connecting the Home Environment and Outpatient Occupational Therapy, Emily C. Burgard, OTD, OTR/L; Dory Sabata, OTD, OTR/L, SCEM, FAOTA; & Andy J. Wu, PhD, OT ӹӹ Transitioning from Clinician to Manager, Penny Rogers, DHA, MAT, OTR/L, CEAS I; Catherine Killian, MEd, OTR/L; Ellen Hudgins, OTD, OTR/L; & Terry Polland, MA

Work & Industry........................................................................... 26

ӹӹ Returning to Work After Traumatic Brain Injury, Amanda Acord-Vira, MOT, OTR/L, CBIS; Steven Wheeler, PhD, OTR/L, CBIS; & Diana Davis, MA, OTR/L ӹӹ Addressing Sensory Integration for Work Participation, Beth Pfeiffer, PhD, OTR/L, BCP

Education .................................................................................... 31

ӹӹ Transitioning From Clinician to Fieldwork Educator, Lynne Margaret Chapman, MS, OTR/L, LICDC, Instructor, AOTA Fieldwork Education Certificate Program

May 2016, Volume 1, Issue 2 ISSN 1084-4902

Special Interest Section Guide AM

Administration & Management

MH

Mental Health

DD

Developmental Disabilities

PD

Physical Disabilities

Education

SI

Sensory Integration

Early Intervention & School

T

Technology

E EIS G HCH

Gerontology Home & Community Health

WI

Work & Industry

Full Page Ad Space - inside front cover 45p0 x 59p0 7.5in x 9.833in

Congratulations!

Managing Editor: Stephanie Shaffer Production Manager: Gary Furton Marketing, Graphic Design: Jennifer Folden SIS Council Chairperson: Donna M. Costa, DHS, OTR/L, FAOTA AOTA Liaison to SIS: Deborah Yarett Slater, MS, OT/L, FAOTA

Congratulations to Stacy Smallfield, DrOT, OTR/L, BCG, FAOTA, and Sarah Guarglia, MA, OTR/L, on being awarded the AOTA Special Interest Section Quarterly Writer's Award for their article "The Role of Occupational Therapy in Medication Management and Acute Care."

Special Interest Section Chairpersons and Editors Administration & Management Chairperson, Ellen Hudgins, OTD, OTR/L Editor, Penny Rogers, DHA, MAT, OTR/L Developmental Disabilities Chairperson, Wanda J. Mahoney, PhD, OTR/L Editor, Susan M. Cahill, PhD, OTR/L Early Intervention & School Chairperson, Patricia Laverdure, OTD, OTR/L, BCP Editor, Francine M. Seruya, PhD, OTR/L Education Chairperson, Tina M. DeAngelis, EdD, OTR/L Editor, Michael Roberts, OTD, OTR/L

Special Interest Section Election Results

Gerontology Chairperson, Jeannine Nonaillada, MA, OTR/L, BCG Editor, Stacy Smallfield, DrOT, MSOT, OTR/L, BCG, FAOTA

Congratulations to the 2016 AOTA election winners whose terms of office will begin July 1, 2016:

Home & Community Health Chairperson, Marnie Renda, MEd, OTR/L, CAPS, ECHM Editor, Emily Somerville, MSOT, OTR/L

ӹӹ

Mental Health Chairperson, Susan Noyes, PhD, OTR/L Editor, Elizabeth Griffin Lannigan, PhD, OTR/L, FAOTA

ӹӹ

Physical Disabilities Chairperson, Lauro A. Muñoz, MOT, OTR Editor, Claudine Campbell, MOT, OTR/L

ӹӹ

Special Interest Section (SIS) Council Chairperson-Elect: Andrew Persch, PhD, OTR/L, BCP Education SIS Chairperson: Lenin Grajo, PhD, EdM, OTR/L Physical Disabilities SIS Chairperson: Elena Espiritu, OTD, OTR/L, BCPR

Sensory Integration Chairperson, Annie Baltazar Mori, OTD, OTR/L Editor, Beth Pfeiffer, PhD, OTR/L, BCP Technology Chairperson, Jana Cason, DHS, OTR/L, FAOTA Editor, William E. Janes, OTD, MSCI, OTR/L Work & Industry Chairperson, Julie Dorsey, OTD, OTR/L, CEAS Editor, Denise Finch, OTD, OTR/L, CHT

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Mission Statement SIS Quarterly Practice Connections focuses on the role and application of research and other evidence to occupation-centered practice in areas of interest to members. It reflects the applicability and value of collaboration across specialty areas and settings.

Send comments or submissions to [email protected]. For more information on the Special Interest Sections, visit www.aota.org/sis.

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Children & Youth Sponsored in part by

Use of Assistive Technology With Transition-Aged Youth T

education, self-management, and employment. These examples are by no means comprehensive, but are meant to illustrate possibilities.

Secondary Education

Andrea D. Fairman, PhD, OTR/L, CPRP; Roxanna Bendixen, PhD, OTR/L; Haley Younkin; and Julie R. Krecko

The Individuals with Disabilities Education Improvement Act of 2004 mandates that all individualized education teams must consider the AT needs of students; additionally, they must address transition needs by age 16. Although challenges exist in providing AT for students (e.g., cost, training, complexity, maintenance, upgrades), research suggests that AT may improve students’ post-school outcomes and assist in their preparation for employment and other adult roles after high school (Bouck & Flanagan, 2015). Most students with disabilities can and do benefit from technology in the classroom (Jaeger, 2012), yet receipt of AT varies greatly within and among schools, as well as by disability and severity of disability (Kagohara et al., 2013). It is crucial that occupational therapy practitioners seek adequate training to serve in this role and remain up to date not only with regard to AT but also with funding technology and services (Long, Woolverton, Perry, & Thomas, 2007). As important members of the multidisciplinary transition team, occupational therapy practitioners can help to ensure not only that individuals’ AT needs are met, but also that the AT selected will actually be used by the individual in all the necessary contexts. In addition, they may also educate other providers regarding principles of universal access

Occupational therapy practitioners help children and youth successfully transition through the stages of childhood and beyond. One of the supports often provided is assistive technology (AT) to increase participation and independence (American Occupational Therapy Association [AOTA], 2008). The National Longitudinal Transition Study-2 (Newman, Wagner, Cameto, & Knokey, 2009) indicated that one of the most difficult and complex transitions for many persons with disabilities is passing from childhood to the roles and activities of adulthood, such as postsecondary education, employment, productive engagement, social involvement in the community, and residential and financial independence. For many youth with disabilities or chronic conditions, technology can be an important component of enhancing functional participation. This article explores a sampling of technologies that hold promise for improving outcomes in three primary environments associated with physical and social contexts in which major changes are occurring for young persons of transition age: secondary

1/2 p Ad Space 45p0 x 28p8 7.5in x 4.778in

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and the wide variety of AT devices, systems, and services available to help support participation. When used correctly, mainstream digital technology (e.g., tablets, applications [apps], smartphones) can motivate students to participate in activities. It also allows the therapist to make the activities more individualized to students’ needs and abilities, increasing their potential to learn (Bouck, Maeda & Flanagan, 2012; FernándezLópez, Rodríguez-Fórtiz, Rodríguez-Almendros, & Martínez-Segura, 2013). Important, but often less emphasized, is the potential of technology to lessen stress and anxiety for students who need academic support to be successful in the traditional classroom (Jaeger, 2012). Digital-assisted learning offers students benefits such as visual presentation, highly motivating graphics and sound, immediate feedback, and the opportunity to learn and participate at their own pace (Fernández-López et al., 2013). For high school students with disabilities, increased graduation rates and success in transitioning to post-secondary education or employment has been linked to the presence of, access to, and use of adequate and appropriate technological supports and accommodations (Bouck & Flanagan, 2015; Garrison-Wade & Lehmann, 2009; Stodden, Whelley, Chang, & Harding, 2001). Occupational therapy practitioners play a key role in determining the best AT for each individual (e.g., a smart phone with a recording app may be a better option than a tape recorder for a high school student).

Self-Management Technology may also be effective in assisting children and adolescents who have chronic conditions to manage their self-care (White, Liberatos, O’Hara, Davies, & Stock, 2015). Self-managing triggers, symptoms, and control of conditions such as asthma, diabetes, cystic fibrosis, epilepsy, and spina bifida have all been studied in interventions involving web-based health technology. A benefit of technology is the ability to track information over time, such as physiological data, adherence to routines, and quality of life data. Web-based and mobile health technology can be a powerful tool. Among the users of Sweet Talk, a text messaging service for young people with diabetes, 82% reported improved self-management and self-efficacy after receiving messages containing goal-setting prompts and insulin reminders, along with exercise, healthy eating, and carbohydrate counting prompts (Franklin, Waller, Pagliari, & Greene, 2006). Telehealth technology may also involve clinicians through messaging, phone calls, or videoconferencing. Clinician support can be effective for direct goal-setting advice, counseling, and care guidance. While policies for insurance coverage and licensure vary from state to state, telehealth can also be beneficial for hard-to-reach youth residing in rural communities, or those with disabilities who have difficulty traveling to medical appointments (AOTA, 2013). Another novel self-management system, Interactive Mobile Health and Rehabilitation, uses a suite of modules within a smartphone app to guide individuals with complex health care regimes in their self-care routines. The app involves reminders for medication management, self-catheterization, bowel programs, skin checks, and mood checks. Initial users had spina bifida and were able to record and track problems with any of these tasks, while being monitored by health care professionals, including occupational therapists, who assisted them as needed through an online portal and secure messaging system (Parmanto et al., 2013).

Explore the Children & Youth section of AOTA's apps database http://aota.org/Practice/Children-Youth/ CY-Apps.aspx

Employment Training/Vocational Supports Recent data indicate that 38% of people with disabilities are employed 8 years after graduation compared with 66% of their peers without disabilities (Newman et al., 2009). Technology can support vocational participation at every level: seeking employment (e.g., web-based career exploration, virtual reality job interview training), maintaining employment (e.g., task instruction or cueing, electronic reminder systems), and monitoring and follow-up (e.g., real-time phone or video support). Job interviews can present a challenge to persons with social and cognitive impairments. Virtual Reality Job Training has been studied in persons with autism and psychiatric conditions (Smith, Ginger, Wright, Wright, Humm, et al., 2014; Smith, Ginger, Wright, Wright, Taylor, et al., 2014). The software is commercially available and provides didactics in a variety of job search and interview skills, along with diverse interview practice with extensive feedback. After employment is obtained, executive functioning skills frequently present challenges for workers with cognitive impairments in integrated settings (i.e., following step-by-step directions, remembering tasks, completing tasks in a required sequence, transitioning between tasks; Mechling & Ortega-Hurndon, 2007). Interventions for these cognitive deficits can include setting text reminders; providing a paper checklist; video, audio, or pictorial prompting; and modeling task components. Several studies have found user and employer preference for computerized modeling and reminder systems (Furniss et al., 2001). Occupational therapists can easily access apps like HowToDoIt Therapy (to create task sequencing cues and instructions) or Visual Schedule Planner (to create a customizable schedule with audio and visual representations of events). Beyond executive functioning skills, social skills are an important factor in maintaining employment (Savage, 2005). There is growing support for using virtual reality environments to teach social skills, primarily with young adults with autism spectrum disorder (Georgescu,

About the Technology SIS The Technology Special Interest Section (TSIS) encompasses the use of assistive technologies, telehealth, health application “apps,” virtual reality, and gaming technologies used to enhance occupational performance, participation, role competence, and quality of life. It also provides a forum for learning about technologies specific to individuals with disabilities— seating, positioning and mobility, reasonable accommodations, augmentative communications, and adaptive computer access—as well as for exploring technologies for program administration and client evaluation and treatment. ӹӹ Meet the TSIS committee members at www.aota.org/TSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/20.aspx.

Children & Youth ••• 3

Kuzmanovic, Roth, Bente, & Vogeley, 2014; Tsiopela & Jimoyiannis, 2014). The SIMs© is a commercially available option that simulates everyday life and has the potential to be used for developing problem solving and social skills (LoPresti, McCue, Sporner, & Schutte, 2015).

Conclusion As technology expands and evolves at an ever-increasing rate, so do the opportunities to support young persons of transition age using AT. Occupational therapy practitioners are well positioned to support the integration and use of AT in transition planning. Technology supports the goals of independence and participation by shifting the locus of control to the individual and decreasing stigma by harnessing ubiquitous and socially accepted tools. From setting an alarm clock to using a way-finder app to get to work, school, or social engagements, occupational therapy practitioners break down the activity demands of life’s occupations across the user’s environments and determine how AT can be implemented effectively. References American Occupational Therapy Association. (2008). Transitions for children and youth: How occupational therapy can help. Retrieved from http://www. aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/ Fact-Sheets/Transitions.pdf American Occupational Therapy Association. (2013). Telehealth. American Journal of Occupational Therapy, 67(Suppl.), S69–S90. http://dx.doi.org/10.5014/ ajot.2013.67S69 Bouck, E. C., & Flanagan, S. M. (2015). Exploring assistive technology and post-school outcomes for students with severe disabilities. Disability and Rehabilitation: Assistive Technology. Advance online publication. http:// dx.doi.org/10.3109/17483107.2015.1029537 Bouck, E. C., Maeda, Y., & Flanagan, S. M. (2012). Assistive technology and students with high-incidence disabilities: Understanding the relationship through the NLTS2. Remedial and Special Education, 33, 298–308. Fernández-López, Á., Rodríguez-Fórtiz, M. J., Rodríguez-Almendros, M. L., & Martínez-Segura, M. J. (2013). Mobile learning technology based on iOS devices to support students with special education needs. Computers & Education, 61, 77–90. Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial of Sweet Talk, a text‐messaging system to support young people with diabetes. Diabetic Medicine, 23, 1332–1338. Furniss, F., Lancioni, G., Rocha, N., Cunha, B., Seedhouse, P., Morato, P., & O’Reilly, M. F. (2001). VICAID: Development and evaluation of palmtop-based job aid for workers with severe developmental disabilities. British Journal of Educational Technology, 32, 277–287. Garrison-Wade, D. F., & Lehmann, J. P. (2009). A conceptual framework for understanding students’ with disabilities transition to community college. Community College Journal of Research and Practice, 33, 417–445. Georgescu, A. L., Kuzmanovic, B., Roth, D., Bente, G., & Vogeley, K. (2014). The use of virtual characters to assess and train non-verbal communication in high-functioning autism. Frontiers in Human Neuroscience, 8, 807. http:// dx.doi.org/10.3389/fnhum.2014.00807 Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108446, 20 U.S.C. §§ 1400–1482.

Jaeger, P. T. (2012). Disability and the internet: Confronting a digital divide. Boulder, CO: Lynne Rienner. Kagohara, D. M., van der Meer, L., Ramdoss, S., O’Reilly, M. F., Lancioni, G. E., Davis, T. N. … Sigafoos, J. (2013). Using iPods® and iPads® in teaching programs for individuals with developmental disabilities: A systematic review. Research in Developmental Disabilities, 34, 147–156. Long, T. M., Woolverton, M., Perry, D. F., & Thomas, M. J. (2007). Training needs of pediatric occupational therapists in assistive technology. American Journal of Occupational Therapy, 61, 345–354. http://dx.doi.org/10.5014/ajot.61.3.345 LoPresti, E. F., McCue, M. P., Sporner, M., & Schutte, J. (2015). Therapeutic use of life simulation games for people with cognitive impairments. Manuscript submitted for publication. Mechling, L. C., & Ortega-Hurndon, F. (2007). Computer-based video instruction to teach young adults with moderate intellectual disabilities to perform multiple step job tasks in a generalized setting. Education and Training in Developmental Disabilities, 42(1), 24–37. Newman, L., Wagner, M., Cameto, R., & Knokey, A. M. (2009). The post–high school outcomes of youth with disabilities up to 4 years after high school. A report from the National Longitudinal Transition Study-2 (Publication No. NCSER 2009-3017). Menlo Park, CA: SRI International. Parmanto, B., Pramana, G., Yu, D. X., Fairman, A. D., Dicianno, B. E., & McCue, M. P. (2013). iMHere: A novel mHealth system for supporting self-care in management of complex and chronic conditions. JMIR mHealth and uHealth, 1(2), e10. Savage, R. C. (2005). The great leap forward: Transitioning into the adult world. Preventing School Failure, 49(4), 43–52. Smith, M. J., Ginger, E. J., Wright, M. A., Wright, K., Humm, L. B., Olsen, D. E., … Fleming, M. F. (2014). Virtual reality job interview training for individuals with psychiatric disabilities. Journal of Nervous and Mental Disease, 202, 659–667. http://dx.doi.org/10.1097/NMD.00000000000000187. Smith, M. J., Ginger, E. J., Wright, K., Wright, M. A., Taylor, J. L., Humm, L. B., … Fleming, M. F. (2014). Virtual reality job interview training in adults with autism spectrum disorder. Journal of Autism and Developmental Disabilities, 44, 2450–2463. http://dx.doi.org/10.1007/s10803-014-2113-y Stodden, R. A., Whelley, T., Chang, C., & Harding, T. (2001). Current status of educational support provision to students with disabilities in postsecondary education. Journal of Vocational Rehabilitation, 16, 189–198. Tsiopela, D., & Jimoyiannis, A. (2014). Pre-vocational skills laboratory: Development and investigation of a web-based environment for students with autism. Procedia Computer Science, 27, 207–217. White, A., Liberatos, P., O’Hara, D., Davies, D. K., & Stock, S. E. (2015). Promoting self-determination in health for people with intellectual disabilities through accessible surveys of their healthcare experiences. Journal of Human Development, Disability, and Social Change, 21(1), 29–38. Andrea D. Fairman, PhD, OTR/L, CPRP, is an associate professor in the Depart-

ment of Occupational Therapy at MGH Institute of Health Professions in Boston. She can be reached at [email protected].

Roxanna Bendixen, PhD, OTR/L, is an assistant professor in the Department

of Occupational Therapy at the University of Pittsburgh in Pennsylvania.

Haley Younkin is an occupational therapy student at MGH Institute of Health

Professions.

Julie R. Krecko is a student and research assistant at the University of Pittsburgh.

Join the Conversation! Andrea D. Fairman, Roxanna Bendixen, Haley Younkin, and Julie R. Krecko will join Technology SIS Editor Bill Janes for a virtual chat about this article at XXXX ET on XXXXXX. AOTA members are invited to listen in and submit your questions during the chat. Join us at http://www.talkshoe.com/tc/138131 to participate or listen to the recorded call. (Log in first) Children & Youth ••• 4

Paradigm Transitions in Pediatric Practice: Tools to Guide Practice EIS

Patricia Laverdure, OTD, OTR/L, BCP; Francine M. Seruya, PhD, OTR/L; Pam Stephenson, OTD, MS, OTR/L; and Joanna Cosbey, PhD, OTR/L

Pediatric occupational therapy practitioners often work in two or more systems simultaneously and fill numerous roles. Hospitals, private clinics, schools, and family homes all represent contexts where practitioners may fill roles such as evaluator, service provider, case manager, collaborative consultant, administrator, leader, and scholar. Effective transitions between these systems and roles require understanding the characteristics of the systems and shifting the way that practitioners think about their practice within the systems. An understanding of systems and roles can be facilitated by professional reflection, which is a practice used by a range of health practitioners to facilitate effective professional engagement and support professional development (Birney, Beckmann, & Wood, 2012). Professional reflection is a process of considering thoughtprovoking questions to develop a deeper understanding of contexts and the actions that take place within them, then identifying areas for professional learning and growth. Reflection enables occupational therapy practitioners to examine the effects of interventions and interactions across systems, and to use these observations to influence practice change (McConnell, Regehr, Wood, & Eva, 2012). When approached systematically and intentionally, the reflective process can support learning from complex clinical contexts; streamline the time required for effective professional reasoning; and lead to improved client outcomes (Bannigan & Moores, 2009). All these outcomes serve to better promote client engagement in occupation and participation within each system.

Systems in Pediatrics Pediatric occupational therapy practitioners typically practice within either a medical or an educational system, each of whose missions and priorities must be understood to provide appropriate and highquality services. Medical systems are largely governed by health care policy, managed care organizations, or corporations, and often use curative and/or palliative models of intervention (Muhlenhaupt, 2010). In contrast, early intervention and public education systems in the United States are governed by federal, state, and local education agencies. For students with disabilities, the Individuals with Disabilities Education Improvement Act of 2004 addresses not only academic outcomes but also functional outcomes; therefore, occupational therapy practitioners need to gear intervention specifically to an educational system that supports both aspects of occupational performance. Rather than tapping into other practice models, however, evidence indicates that school practitioners primarily use medical models of practice within educational settings, working on foundational skills such as handwriting and sensory processing to promote educationally relevant tasks (Benson, 2013; Seruya & Ellen, 2015).

Reflective Practice To meet national and state educational mandates, practitioners who transition between medical and educational systems must understand the characteristics of their practice settings and have a dynamic view of the client that includes not only the student, but also family

members, the school community, and community partners. They must be able to focus outcomes simultaneously on student development, achievement, and participation, as well as family and teacher collaboration and client satisfaction. Several factors are critical for practitioners who successfully transition between practice contexts: strong occupation-focused practice foundations; clinical and ethical reasoning and decision making; and a commitment to ongoing personal reflection (Holmes & Scaffa, 2009). Gleeson (2010) suggested that reflective practices increase the retention of new learning and its application across practice contexts. In this way, reflection is thought to bridge the theory-to-practice gap and ensures that the care remains client-centered and based in the client’s experience. In a study conducted by Lowe, Rappolt, Jaglal, and Macdonald (2007), practitioners who engaged in professional reflection were more successful in translating complex learning into practice and implementing and monitoring change across systems. General questions practitioners may consider when transitioning between systems include: ӹӹ What is unique about the practice context? Are there distinctive

regulatory, policy, and guidance requirements (i.e., licensure requirements, funding requirements, educational legislation, state and local policies and regulations, standards of learning, professional association guidance) that influence the development of professional roles and the provision of safe and ethical services?

ӹӹ Is the role of the occupational therapy practitioner clear? Are

there ambiguities about the nature and purpose of the services and the service provision? Are the roles and responsibilities encumbered by variability in identifying the client (i.e., child, family member, teacher, school division); practice contexts; ages, functional levels, and disabilities of clients; varied team dynamics; and social, economic and political structures?

ӹӹ What is the nature of collaboration among professionals within

and outside of the system? What resources are available for developing collaborative relationships to improve case coordination and student outcomes?

ӹӹ How do occupational therapy services help children, families,

school teams, and other health care providers?

Using Reflection as a Tool to Facilitate Professional Transitions and Improve Client Outcomes Bulman and Schultz’s learning-by-doing model (2013) identified six steps of a cyclical reflective process. This model enables practitioners to challenge assumptions, explore new ideas and approaches,

About the Early Intervention & School SIS The Early Intervention & School Special Interest Section (EISSIS) provides resources to support the practice, leadership, and advancement of practitioners serving youth, families, and teams in early intervention and school programs. It promotes the meaningful participation of youth and families in their everyday lives where they live, learn, and play. ӹӹ Meet the EISSIS committee members at www.aota.org/EISSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/17.aspx.

Children & Youth ••• 5

promote practice improvement, and link practice to theory. The model’s process involves: ӹӹ Describing the system and the ways in which the system influ-

ences clinical scenarios. Practitioners consider what happened in specific situations. What were the notable features of the systems that influenced the occurrence, and what were the intended outcomes? Are there research or practice guidelines that influence clinical reasoning?

ӹӹ Describing one’s reactions to the specific situations within the

system. Practitioners consider what feelings and reactions were evoked by the event.

ӹӹ Evaluating the outcomes of the specific situations within the

system. Practitioners consider what went well and what did not work. How was the experience different from what might have occurred in another system or from what was expected? Is there theory or research that might explain the outcome?

ӹӹ Critically analyzing the occurrence and the system influences.

Practitioners evaluate the emerging patterns. They consider the causes and/or consequences of the things that went well and those that did not go as expected.

ӹӹ Identifying what was learned. Practitioners consider their contri-

butions and what they learned about the system and its influences on practice in that setting.

ӹӹ Establishing an action plan. Practitioners consider what is needed

to be better prepared. They consider the areas they can improve and how they might prioritize a professional development plan. They consider the research and resources that can guide knowledge and skill acquisition.

When transitioning between systems, practitioners using this reflective model can more effectively identify the unique character-

istics and influences of the system; increase the efficiency of service provision; and improve the outcomes of service (Driscoll & Teh, 2001). Common reflective practices and ways to use them to support transitions to varying systems are described in Table 1.

Case Example Jenny is a registered occupational therapist who has worked in a pediatric outpatient clinic for 2 years. One month ago, she transitioned to a large urban school district with a wide range of occupational therapy practitioners, and she is unsure about this new practice context and whether her skills are a good fit. After completing the American Occupational Therapy Association (AOTA) Professional Development Tool (2003) and the National Board for Certification in Occupational Therapy Self-Assessment Tool for Pediatrics (n.d.), Jenny identified that although her core clinical skills provided a strong foundation to support a range of diagnoses, she had limited knowledge of educational law and the provision of services in school-based settings. She scanned the AOTA website for guidance documents addressing the role of occupational therapy in educational settings and collected and annotated articles addressing regulator mandates. She began a reflective journal in which she recorded new experiences such as collaborating with teachers and family members, aligning interventions with educationally relevant expectations and occupations, and attending individualized education program meetings, and reflected on what she learned from them. She also sought an experienced school-based practitioner as a mentor to help her navigate the transition to the new setting. Jenny noted that her service delivery became more focused and appropriate for student success in the school setting through engaging in the self-reflective process. References American Occupational Therapy Association. (2003, May). Professional development tool. Bethesda, MD: Author. Retrieved from http://www.aota.org/pdt.

TABLE 1. STRATEGIES TO SUPPORT REFLECTIVE PRACTICE Strategy

Examples

Self-assessment

Competency assessments, such as the AOTA Professional Development Tool (2003) or the NBCOT Self-Assessment Tools (n.d.), can help identify current skills, strengths, and areas for further professional development.

Transitioning practitioners might use these tools to assess learning needs and transferable skills when transitioning between practice areas. Portfolios

Portfolios involve “collection, reflection and selection” (Simmons, 1996) of items and resources that illustrate the development of knowledge, skills and achievements over the course of a career. Reflection helps practitioners to make connections between experiences and new learning and to develop plans to fill gaps in knowledge and skills.

Practitioners may include artifacts such as articles, handouts, curriculum vitae, letters of recommendation, reflection on education opportunities, and AOTA practice guidance documents. Reflective journals

Guided reflective journaling can facilitate thinking about theoretical and clinical concepts and can lead to enhanced understanding of performance and outcomes. Practitioners are encouraged to write and reflect about what happened (positive and negative), why it happened (what it means, how successful it was), and what was learned from the experience.

Practitioners may address the differences between systems (e.g., funding mechanisms, guiding mandates, outcome measures). Interactive journal

By using an interactive journal as a reflection tool, the practitioner engages in a mentoring relationship and shares his or her reflective journal with another, who responds to the reflective writing. Interactive journaling may help practitioners reflect on new clinical experiences, explore changes in settings, and foster deeper understanding of new roles.

Practitioners may want to choose a mentor in the new practice system to support their transition and application of new knowledge. Peer review, professional supervision, and mentoring

In the peer review process, supervisors or mentors provide feedback that assist in navigating transitions between varying systems.

Practitioners may choose a trusted colleague to serve as peer mentor or build a collaborative relationship with a supervisor and seek feedback to support understanding of the practice context and the clinical skills required.

Children & Youth ••• 6

Bannigan, K., & Moores, A. (2009). A model of professional thinking: Integrating reflective practice and evidence based practice. Canadian Journal of Occupational Therapy, 76, 342–350. Benson, J. (2013). School-based occupational therapy practice: Perceptions and realities of current practice and the role of occupation. Journal of Occupational Therapy, Schools & Early Intervention, 6, 165–178. Birney, D. P., Beckmann, J. F., & Wood, R. E. (2012). Precursors to the development of flexible expertise: Metacognitive self-evaluations as antecedences and consequences in adult learning. Learning and Individual Differences, 22, 563–574. Bulman, C., & Schultz, S. (Eds.) (2013). Reflective practice in nursing (4th ed.). New York: Wiley-Blackwell. Driscoll, J., & Teh, B. (2001). The potential of reflective practice to develop individual orthopaedic nurse practitioners and their practice. Journal of Orthopaedic Nursing, 5, 95–103. Gleeson, C. (2010). Education beyond competencies: A participative approach to professional development. Medical Education, 44, 404–411. Holmes, W. M., & Scaffa, M. E. (2009). An exploratory study of competencies for emerging practice in occupational therapy. Journal of Allied Health, 38, 81–90. Individuals with Disabilities Education Improvement Act of 2004, Pub. L. 108446, 20 U.S.C. §§ 1400–1482. Lowe, M., Rappolt, S., Jaglal, S., & Macdonald, G. (2007). The role of reflection in implementing learning from continuing education into practice. Journal of Continuing Education in the Health Professions, 27, 143–148. McConnell, M. M., Regehr, G., Wood, T. J., & Eva, K.W. (2012). Self-monitoring and its relationship to medical knowledge. Advances in Health Sciences Education, 17, 311–323. Muhlenhaupt, M. (2010). The perspective of context as related to frame of reference. In P. Kramer & J. Hinojosa (Eds.), Frames of reference for pediatric occupational therapy (pp. 67–95). Baltimore: Lippincott Williams & Wilkens. National Board for Certification in Occupational Therapy. (n.d.). Occupational therapist registered OTR® domain, task, and skill statements for the OTR® certificant pediatric practice area. Gaithersburg, MD: Author.

Explore AOTA's Children & Youth transition resources http://aota.org/Practice/Children-Youth/ Transitions/Resources.aspx Seruya, F. M., & Ellen, K. M. (2015, June). Role of the middle school occupational therapist: An initial exploration. Early Intervention & School Special Interest Section Quarterly, 22(2), 1–3. Simmons, J. (1996). Control the purpose, not the contents: Coaching the creation of teaching portfolios. Action in Teacher Education, 18(1), 71–81. Patricia Laverdure, OTD, OTR/L, BCP, is program manager of physical and oc-

cupational therapy services at Fairfax County Public Schools in Virginia. She serves as the chairperson for the Early Intervention & Schools Special Interest Section (EISSIS) and can be reached at [email protected].

Francine M. Seruya, PhD, OTR/L, is clinical associate professor of occupational

therapy and director of the Post Professional Occupational Therapy Doctorate Program at Quinnipiac University, School of Health Sciences, in Hamden, Connecticut. She is also the Quarterly editor for the EISSIS.

Pam Stephenson, OTD, MS, OTR/L, is assistant professor, Doctor of Occupational

Therapy, at Murphy Deming College of Health Sciences, Mary Baldwin College, in Fishersville, Virginia. She is also the professional development coordinator for the EISSIS forums.

Joanna Cosbey, PhD, OTR/L, is assistant professor, Occupational Therapy

Graduate Program, Department of Pediatrics, at the University of New Mexico in Albuquerque, New Mexico. She is the education and research professional development coordinator for the EISSIS.

Increase your evidence-based practice knowledge base in school setting Cahill, Egan, Wallingford, Huber-Lee, and Dess-McGuire’s (2015) article featured in the March/ April 2015 issue of the American Journal of Occupational Therapy demonstrates the effectiveness of a 17-month evidence-based practice (EBP) initiative to significantly improve EBP knowledge and skills for school-based occupational therapy practitioners. To learn more about the initiative and how it can be used to build your own EBP skills, visit www.ajot.aota.org. For more school-based practice EBP resources, visit http://www.aota.org/Practice/Children-Youth/Evidence-based. Children & Youth ••• 7

Health & Wellness Sponsored in part by

The Impact of Occupational Therapy Services for Individuals Transitioning Through Neuro-Oncology Care PD

prevention, restorative care, supportive care, and palliative care. An individual receiving cancer treatment may transition among all four stages, and it is important that the rehabilitation needs of the client are addressed on a continuing basis to promote quality of life throughout this process (Rankin & Gracey, 2008).

Ni He-Strocchio, OTD, and Sheila M. Longpré, MOT, OTR/L

The Effect on Cognitive and Motor Function Brain tumors occupy space within the cerebrum, cerebellum, and brainstem, which can cause swelling and intracranial pressure (Giordana & Clara, 2006). Depending on the location and the size of the tumor, individuals with brain cancer typically experience numerous neurological deficits that may affect their physical, emotional, and psychological functions (Campbell, Pergolotti, & Blaskowitz, 2009). Dysfunction in motor, neuromuscular, sensory, speech, cardiovascular, respiratory, and mental functions, as well as the performance skills necessary to complete desired occupations, are characteristic of this client population. Cognitive and motor disturbances can be a direct or secondary result of the tumor, medical treatment, or medication prescribed for symptom management (Taphoorn, Sizoo, & Bottomley, 2010). Although medical treatments are intended to alleviate neurological and cognitive deficits and increase survival, they can also disrupt surrounding brain tissue. Some of the potential deficits include seizures, headaches, fatigue, sleep and mood disturbances, and

According to the National Cancer Institute (2015), approximately 40% of the U.S. population will be diagnosed with cancer at some point in their life. Individuals with brain tumors make up a small percentage of those who are newly diagnosed and have one of the lowest survival rates among all types of cancer, which is approximately 5 years (Ellor, Pagano-Young, & Avgeropoulos, 2014). A brain tumor has the potential to affect daily function and occupational engagement by causing cognitive, emotional, psychological, and physical impairments. Occupational therapy practitioners possess an important role with clients diagnosed with a brain tumor: to promote wellness, quality of life, and occupational performance, in addition to making recommendations for supportive environmental adaptations and activity modifications as the individual transitions through the continuum of cancer care. Dietz (1980) described four distinct stages of cancer rehabilitation throughout the continuum of care:

1/2 p Ad Space 45p0 x 28p8 7.5in x 4.778in

8

weakness (Klein et al., 2003; Taphoorn & Klein, 2004; Taphoorn et al., 2010; Vargo, 2011).

The Role of Occupational Therapy in Neuro-Oncology While not all clients with a brain tumor will require intensive rehabilitation, those who develop neuromuscular and functional impairments will need some rehabilitation to achieve optimal function (Stubblefield, Schmitz, & Ness, 2013). Clients may require services from multiple occupational therapy providers throughout the course of their cancer treatment, beginning at the time of the cancer diagnosis through the palliative care stage. Occupational therapy can be customized to address each client’s activity engagement limitations to achieve the best functional outcome at any stage. Appropriate occupational therapy interventions are based on the client’s current level of cognitive and physical function, prior and ongoing cancer treatment, and current disease status or progression. The goal of occupational therapy intervention is to promote engagement in meaningful activities (Campbell et al., 2009). Occupational therapy service options can be provided at each stage of the cancer care continuum (See Table 1).

The Benefits of Occupational Therapy Services As a client with a brain tumor transitions through the continuum of cancer care, occupational therapy interventions help the individual gain control and dignity (Penfold, 1996), adapt to the illness, and manage pain (Cooper & Littlechild, 2004). This may be accomplished by facilitating physical performance with adaptive equipment to enhance participation in activities of daily living (ADLs), and engagement in instrumental ADLs, role-related tasks, or leisure activities. In addition, relaxation and stress management may be used to increase a client’s coping skills (Cooper & Littlechild, 2004). As a result of the common side effects of cancer and subsequent medical and/or supportive treatments, occupational therapy practitioners provide valuable client education on how to modify activities, use energy conservation skills, and prioritize tasks to participate in meaningful activities in all contexts throughout the course of treatment (Penfold, 1996). A lack of good health care before diagnosis, limited resources, and the individual’s prognosis may affect access to occupational therapy services. Other barriers include limited occupational therapy practitioners who are familiar with oncology rehabilitation principles, and lack of knowledge among oncologists regarding the value of occupational therapy for clients throughout the cancer care continuum (Chan, Xiong, & Colantonio, 2015). A recent study analyzing the use of occupational therapy services across various types of cancer found that those with stage IV cancer were least likely to receive

occupational therapy services because of poor prognosis (Pergolotti, Cutchin, Weinberger, & Meyer, 2014). Considering these findings, it is important for occupational therapy practitioners to educate oncologists and primary health care team members on the value of occupational therapy services as clients with cancer transition from diagnosis to possible end-of-life care. Occupational therapy practitioners assist clients in engaging in meaningful occupations in any setting and stage of the continuum to promote physical and psychological well-being. For example, a client with a grade III astrocytoma receiving services in a skilled nursing facility may identify the desire to crotchet again, but have limited head movement because of the location of the tumor. The occupational therapist can provide an adjustable-height tilted table so the client can have a better view, or the client can be taught to use touch instead of vision to crochet.

Case Example: Occupational Therapy Along the Continuum of Care Michael was a 55-year-old man newly diagnosed with a glioblastoma in the left prefrontal lobe. He was eager to return to work as a dentist. He was on medical leave while undergoing cancer treatment. Michael had a spouse and two sons who he enjoyed vacationing with. Michael had undergone his first tumor resection and was being evaluated by Lacey, an occupational therapist in an acute care setting. Lacey first created Michael’s occupational profile. Michael shared that he would like to return to work and become as independent as he was before his surgery. Lacey assessed Michael’s safety and cognition based on the location of the tumor. She used the Árnadóttir OT-ADL Neurobehavioral Evaluation (Árnadóttir, 1990) to assess Michael, and he performed well. Lacey noticed that Michael’s attention was slightly decreased during grooming and he required verbal cueing throughout self-care tasks to maintain safety. Because of Michael’s anticipated short stay in the hospital, Lacey developed goals that targeted independence with self-care activities, improving attention with functional activities, and family education. When he was discharged from the hospital, Michael was able to return to home with his family. He was fully independent with basic self care, and he was using compensatory strategies to maintain adequate attention and concentration during tasks like reading, watching television, and carrying on conversations. Two years after his initial diagnosis, Michael underwent a second resection in the same area and was receiving home health care services. At this time Michael was being seen by his occupational therapist, Kim. Kim and Michael discussed that he would not be able to return to his career as a dentist because of the disease progression and the

Table 1. Treatment Considerations Stage

Preventive

Occupational therapy interventions

ӹӹ Complete baseline cognitive and functional ӹӹ Address cognitive and physical ӹӹ Empower the client to self- ӹӹ Educate the client, family, and caregivers about strategies to advocate regarding medical impairments as related to daily assessment when a client is initially diagminimize pain. treatment options. occupations. nosed to help prevent or minimize potential deficits that may result from multi-modal ӹӹ Modify activities to promote suc- ӹӹ Incorporate relaxation strate- ӹӹ Promote participation in selfcancer treatment. care and leisure activities, with gies, guided imagery, or yoga to cessful participation in occupations modifications as needed. address anxiety. (i.e., energy conservation prinӹӹ Educate about preventing future injuries ciples, compensatory strategies to ӹӹ Educate about compensatory as a result of impared cognition, vision, or remember appointments). balance. strategies to combat fatigue, loss of cognition, visual impairӹӹ Promote safe occupational engagement ӹӹ Progress toward previous level of ments, and muscle weakness. function when feasible and/or safe. and education about lifestyle modifications.

Restorative

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Supportive

Palliative

functional impact of his decreased executive functions. Michael now exhibited signs of depression and anxiety that affected successful engagement in his daily occupations. He reported that his illness and limitations had affected his relationships with his wife and sons. Kim administered the Canadian Occupational Performance Measure (Law et al., 2014) during the initial evaluation, and Michael identified that he would like to take a trip with his family. To help manage his anxiety, Kim educated Michael on how to incorporate breathing techniques and guided imagery. In addition, Kim assisted Michael with planning a local day trip in collaboration with his wife and sons to involve the family in the plan of care. Kim has also provided resources for community support groups for Michael and his family.

Conclusion

The Physical Disabilities Special Interest Section (PDSIS) addresses the needs of practitioners who serve individuals with physical dysfunction resulting from a wide range of conditions. The PDSIS also includes the Hand Rehabilitation Subsection for those who address dysfunction of the hand and upper extremity, and the Driving/Driver Rehabilitation Network to educate and support therapists to provide pre-driving screens or driver assessments and training, or to serve as referral sources to appropriate agencies. ӹӹ Meet the PDSIS committee members at www.aota.org/PDSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/16.aspx.

Individuals with brain cancer may develop a broad spectrum of neurological and cognitive deficits resulting in altered life roles and decreased occupational engagement. An interprofessional team approach that includes occupational therapy is essential for providing comprehensive client-centered care to improve quality of life for the client and caregivers. Occupational therapy practitioners make a difference in the lives of clients with brain cancer in each distinct treatment setting by considering the unique needs of each individual at various stages of the disease trajectory, and implementing interventions that promote occupational engagement to maximize independence and function. References Árnadóttir, G. (1990). The brain and behavior: Assessing cortical dysfunction through activities of daily living. St. Louis, MO: Mosby. Campbell, C., Pergolotti, M., & Blaskowitz, M. (2009). Occupational therapy utilization for individuals with brain cancer following a craniotomy: A descriptive study. Rehabilitation Oncology, 27(1), 9–13. Chan, V., Xiong, C., & Colantonio, A. (2015). Patients with brain tumors: Who receives postacute occupational therapy services? American Journal of Occupational Therapy, 69, 6902290010. http://dx.doi.org/10.5014/ajot.2015.014639 Cooper, J., & Littlechild, B. (2004). A study of occupational therapy interventions in oncology and pallitative care. International Journal of Therapy and Rehabilitation, 11, 329–333. Dietz, J. H. (1980). Adaptive rehabilitation in cancer: A program to improve quality of survival. Postgraduate Medicine, 68(1), 145–153. Ellor, S., Pagano-Young, T., & Avgeropoulos, N. (2014). Glioblastoma: Background, standard treatment paradigms, and supportive care considerations. Journal of Law, Medicine & Ethics, 42, 171–182. Giordana, M. T., & Clara, E. (2006). Functional rehabilitation and brain tumour patients. A review of outcome. Neurological Sciences, 27, 240–244. http:// dx.doi.org/10.1007/s10072-006-0677-9

When an Adult Child With a Developmental Disability Goes to College: A Transition for Parents DD

About the Physical Disabilities SIS

Varleisha D. Gibbs, OTD, OTR/L; and Adele BreenFranklin, OTD, JD, OTR/L

Adults with developmental disabilities (DD) are entering into college and living outside of the family home more than any time in history (Lee, McCoy, Zucker, & Mathur, 2014; Shah, 2011). Parents of children with DD go through the same “empty nest” feelings that parents of typically developing children go through. However, for

Klein, M., Engelberts, N. J., van der Ploeg, H. M., Kasteleijn-Nolst Trenité, D. A., Aaronson, N. K., Taphoorn, M. J. B., & ... Heimans, J. J. (2003). Epilepsy in low-grade gliomas: The impact on cognitive function and quality of life. Annals of Neurology, 54, 514–520. Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H. J., & Pollock, N. (2014). Canadian Occupational Performance Measure (5th ed.). Ottawa, Ontario: CAOT Publications. National Cancer Institute. (2015). Cancer statistics. Retrieved from http://www. cancer.gov/about-cancer/what-is-cancer/statistics Penfold, S. L. (1996). The role of the occupational therapist in oncology. Cancer Treatment Reviews, 22, 75–81. Pergolotti, M., Cutchin, M., Weinberger, M., & Meyer, A. (2014). Occupational therapy use by older adults with cancer. American Journal of Occupational Therapy, 68(5), 597–607. http://dx.doi.org/10.5014/ajot.2014.011791 Rankin, J., & Gracey, J. (2008). The role of rehabilitation in oncology and palliative care. In J. Rankin, K. Robb, N. Murtagh, J. Cooper, & S. Lewis (Eds.), Rehabilitation in cancer care (pp. 24–46). West Sussex, England: John Wiley & Sons. Stubblefield, M. D., Schmitz, K. H., & Ness, K. K. (2013). Physical functioning and rehabilitation for the cancer survivor. Seminars in Oncology, 60, 784–795. Taphoorn, M. J. B., & Klein, M. (2004). Cognitive deficits in adult patients with brain tumours. The Lancet Neurology, 3, 159–168. Taphoorn, M. J. B., Sizoo, E., & Bottomley, A. (2010). Review on quality of life issues in patients with primary brain tumors. The Oncologist, 15, 618–626. Vargo, M. (2011). Brain tumor rehabilitation. American Journal of Physical Medicine & Rehabilitation, 90(5), S50–S62. http://dx.doi.org/10.1097/ PHM.0b013e31820be31f Ni He-Strocchio, OTD, is a recent graduate of an entry-level doctor of occu-

pational therapy from Nova Southeastern University in Fort Lauderdale, Florida. She can be reached at [email protected].

Sheila M. Longpré, MOT, OTR/L, is an assistant professor and director of Clini-

cal and Community Relations at Nova Southeastern University, Tampa Campus. She is also a PhD candidate.

parents of children with DD there is often an uneasy realization that their children may not be prepared to leave home and that the patterns of support they’ve provided their child on a daily basis are no longer needed (Todd & Jones, 2005). Consequently, such change presents new considerations. We explore the impact of this “new transition,” defined as the period of post-secondary life for parents after their adult child with DD leaves the home, and the potential role of occupational therapy practitioners in supporting them.

Parent Self-Identified Roles, Responsibilities, and Rituals Parents of children with a DD become devoted to the care of their children, often to the exclusion of other things (Crowe & Florez, 2006). Some parents estimate spending up to 6 hours a day Monday

Health & Wellness ••• 10

through Friday providing direct care for their school-age children with disabilities and spending considerably more time engaged in caregiving tasks during the weekend (Sawyer et al., 2010). Other parents report that they engage in caregiving tasks for their child with disabilities “all the time” and believe that the needs of their children prohibit them from fully engaging in other activities, including paid employment and even sleep (Rupp & Ressler, 2009). As a departure from the experiences of other parents, the time spent caring for a child with a disability does not decrease considerably as the child ages (Crowe & Florez, 2006; Crowe & Michael, 2011). With such dedication to performing child care activities, parents may experience difficulty maintaining their own identities (Crowe & Florez, 2006; Donovan, VanLeit, Crowe, & Keefe, 2005). Socialization often becomes limited as the parental roles become shaped and full of responsibilities and rituals are entrenched over several years (Crowe & Florez, 2006; Todd & Jones, 2005). Such transitional changes can affect parents’ self-esteem and self-concept, as well as interrupt routines, habits, and the pattern of everyday life (Blair, 2000). The occupational therapy literature describes mothers of children with DD as experiencing “occupational marginalization” because of the loss of discretionary occupations (Donovan et al., 2005). Jane Case-Smith (2004) noted that parents of children with DD tend to lose their self-identity. The child’s disability becomes the prominent aspect of the family’s identity and their social-emotional selves. To this end, when an adult child leaves the family home, the loss the parent experiences may be detrimental to his or her occupational identity. Further, the parent may experience a deepened sense of social isolation (Keller & Honig, 2004).

A Gap in the Transition Process Post-secondary transitioning for the child with DD traditionally emphasizes providing services to the adolescent and moving him or her to another classification of support as a young adult (Lee et al., 2014). Job training and coaching, community integration, and transit training introduce real-life experiences. Yet support for the parents is often lacking when the child with DD transitions out of the home.

Case Example Sarah and Will have an 18-year-old son diagnosed with high functioning autism, attention deficit hyperactivity disorder, generalized anxiety disorder, and depression. They constantly worry about him entering adulthood and leaving home. Since the age of 2, their son has received home- and school-based services, and Sarah has attended countless meetings with therapists and other providers.

About the Developmental Disabilities SIS The Developmental Disabilities Special Interest Section (DDSIS) focuses on how occupational therapy assessment and intervention can facilitate the inclusion of individuals with developmental disabilities across the lifespan in home, school, work, and community life. The DDSIS provides a forum for practitioners, educators, students, and researchers to exchange information and strategies and to network by highlighting best practice, current trends, and research updates.

As Sarah and Will’s son exited high school, his transition plan provided ample support for his entrance to college. The transition team did not include an occupational therapy practitioner and at no time did the team discuss how entering college would affect Sarah and Will’s roles as parents. Sarah and Will were confident that their son was prepared, and they expressed to the team their concern about the unique transition that they would experience as their son left home for the first time. They were disappointed when they did not receive support for this enormous transition. What Sarah and Will experienced during the transition process is common. Sarah and Will supported their son’s move to college but were bewildered by entering a stage of their own lives in which their roles as primary caretakers were going to be notably reduced. Sarah and Will had an awareness of role loss and found it difficult to relate to parents whose typically developing children were also leaving for college. In contrast with previous experiences, Sarah and Will found a very limited support system.

Expanding Traditional Services The first step to supporting parents like Sarah and Will is for occupational therapy practitioners to be included on high school transition teams (see Figure 1). Occupational therapy practitioners have reported minimal use of their expertise and knowledge during post-secondary education transitioning (Kardos & White, 2005). Indeed, occupational therapy services are often underused in the post-secondary transition process, with occupational therapy practitioners providing more ancillary services in the areas of assistive technology, and task or environmental modifications (Spencer, Emery, & Schneck, 2003). Describing the ways occupational therapy can support students and their families can expand practitioners’ presence on these teams. The next step is for practitioners to share with teams the distinct value that occupational therapy has in the transition planning process. For example, occupational therapists can use occupational therapy–specific assessments to evaluate independence with self-care and instrumental activities of daily living and identify leisure and social participation interests. The Assessment of Motor and Process Skills (Fisher & Bray Jones, 2010) and the Children’s Assessment of Participation and Enjoyment and Preferences for Activities of Children (King et al., 2004) are some examples of tools that can be used by occupational therapists during post-secondary transition, and the information gained from the tools can play an integral part in clearly identifying the unique needs of the student and family (Kardos & White, 2006). Occupational therapy practitioners can then identify specific and individualized strategies related to daily occupations such as preparing meals, doing laundry, completing

FIGURE 1. STEPS OCCUPATIONAL THERAPY PRACTITIONERS CAN TAKE TO EXPAND TRANSITION SERVICES 1. Briefly describe the role of occupational therapy with families and ask key stakeholders in your school district whether you can join the transition team. 2. Once on the team, educate members on the distinct value occupational therapy provides in supporting students’ transition goals. 3. Conduct occupation-based and focused assessments to clearly identify the needs of the students and their families.

ӹӹ Meet the DDSIS committee members at www.aota.org/DDSIS.

4. Identify specific and individualized strategies to support students and families.

ӹӹ Join the OT Connections discussion at

5. Monitor progress associated with specific and individualized strategies and report back to transition team.

http://otconnections.aota.org/sis_forums/f/11.aspx.

Health & Wellness ••• 11

homework, and communicating regularly, to support students and parents as they enter this new time in their lives. Parents should be reminded that they can continue to request that occupational therapy be on the team and advocate for this expanding role. Occupational therapy practitioners should begin thinking about post-secondary transition early. As soon as a child with a DD begins to transition from early childhood education to elementary school, occupational therapy practitioners can work with families to develop long-range goals focused on adult life and based on the student’s strengths and interests. Further, a plan can be mapped out so that these goals are achievable and support the student’s self-determination. Sarah and Will were feeling uncomfortable with not having direct daily contact with their son, and Will in particular was unhappy that his son would no longer be able to partake in the daily meals that he prepared for the family. An occupational therapist working with Sarah and Will could explore different means of daily communication that fit into both the parents’ and their son’s daily routines (e.g., texting, emailing, Skyping, talking over the phone) and that also provide a means of supporting their son. In addition, the occupational therapist could have discussed with Will ways that he could still cook for his son, such as preparing non-perishable snacks that could be easily transported and stored in a college dorm (e.g., granola, trail mix). This could also provide an opportunity for the occupational therapist to facilitate ways for their son to socialize by sharing his care packages with other students.

Emerging Areas for Occupational Therapy Practitioners Some parents who are exp eriencing the transition of their child with DD to post-secondary life may get their occupational needs met by an occupational therapist who is part of a school transition team. However, other parents may need more support. Given the constraints of school practice, there is a need for enhanced occupational therapy services in nontraditional settings and outpatient community programs (Kardos & White, 2005). Individuals with DD who leave high school shed their role as “high school student” in exchange for “college student,” and their parents shed their role as “constant caretaker” to become “coach” or “distant supporter.” We propose an intensive process for supporting parents through this transition (Figure 2). First, the occupational therapist should be prepared to thoroughly evaluate the parents’ needs. During this process, the therapist should engage them in reflective activities such as narrative-type inquiry (Todd & Jones, 2005). This will allow the parents to define their identity and fully express their sense of loss. Then, the occupational therapist may work with them to develop new and fulfilling habits and routines that are supportive of both them and their child, such as making care packages, using technology to keep in touch, and planning visits to their child’s college campus. Finally, the therapist will coach the parents on ways to expand their own social participation by evaluating their interests, and finding community and other opportunities that are a good match. When children with DD are transitioning from high school to college, many parents struggle with occupational identity and how to fulfill their parental role from a distance. Occupational therapy practitioners can collaborate with transition teams to support parents, as well as the students, during this transition. References Blair, S. E. E. (2000). The centrality of occupation during life transitions. British Journal of Occupational Therapy, 63, 231–237. Case-Smith, J. (2004). Parenting a child with a chronic medical condition. American

Figure 2. Redefining the Parental Role Awareness of "Self" New Parental & Non-Parental Responsibilities Participation in Occupation Within One's Community New Occupational Identity

Journal of Occupational Therapy, 58, 551–560. http://dx.doi.org/10.5014/ ajot.58.5.551 Crowe, T. K., & Florez, S. I. (2006). Time use of mothers with school-age children: A continuing impact of a child’s disability. American Journal of Occupational Therapy, 60, 194–203. http://dx.doi.org/10.5014/ajot.60.2.194 Crowe, T. K., & Michael, H. J. (2011). Time use of mothers with adolescents: A lasting impact of a child’s disability. OTJR: Occupation, Participation and Health, 31, 118–126. Donovan, J. M., VanLeit, B. J., Crowe, T. K., & Keefe, E. B. (2005). Occupational goals of mothers with children with disabilities: Influence of temporal, social, and emotional contexts. American Journal of Occupational Therapy, 59, 249–261. http://dx.doi.org/10.5014/ajot.59.3.249 Fisher, A. G., & Bray Jones, K. (2010). Assessment of Motor and Process Skills. Vol. 2: User manual (7th ed.). Fort Collins, CO: Three Star Press. Kardos, M., & White, B. P. (2005). The role of the school-based occupational therapist in secondary education transition planning: A pilot survey study. American Journal of Occupational Therapy, 59, 173–180. http://dx.doi. org/10.5014/ajot.59.2.173 Kardos, M. R., & White, B. P. (2006). Evaluation options for secondary transition planning. American Journal of Occupational Therapy, 60, 333–339. http:// dx.doi.org/10.5014/ajot.60.3.333 Keller, D., & Honig, A. S. (2004). Maternal and paternal stress in families with school-aged children with disabilities. American Journal of Orthopsychiatry, 74, 337. King, G., Law, M., King, S., Hurley, P., Rosenbaum, P., Hanna, S., …Young, N. (2004). Children’s Assessment of Participation and Enjoyment and Preferences for Activities of Children. San Antonio: Harcourt Assessments. Lee, C., McCoy, K., Zucker, S., & Mathur, S. (2014). ASD academic transitions: Trends in parental perspective. Education and Training in Autism and Developmental Disabilities, 49, 576–593. Rupp, K., & Ressler, S. (2009). Family caregiving and employment among parents of children with disabilities on SSI. Journal of Vocational Rehabilitation, 30, 153–175. Sawyer, M., Bittman, M., La Greca, A., Crettenden, A., Harchak, T., & Martin, J. (2010). Time demands of caring for children with autism: What are the implications for maternal mental health? Journal of Autism & Developmental Disorders, 40, 620–628. http://dx.doi.org/10.1007/s10803-009-0912-3 Shah, N. (2011). After special education, students turn to college. Education Week, 31(14), 14–15. Spencer, J. E., Emery, L. J., & Schneck, C. M. (2003). Occupational therapy in transitioning adolescents to post-secondary activities. American Journal of Occupational Therapy, 57, 435–441. http://dx.doi.org/10.5014/ajot.57.4.435 Todd, S., & Jones, S. (2005). Looking at the future and seeing the past: The challenge of the middle years of parenting a child with intellectual disabilities. Journal of Intellectual Disability Research, 49, 389–404. Varleisha D. Gibbs, OTD, OTR/L, is an associate professor and director of

graduate programs in occupational therapy at Wesley College in Dover, DE. She can be reached at [email protected].

Adele Breen-Franklin, OTD, JD, OTR/L, is an assistant professor for the Depart-

ment of Occupational Therapy at University of the Sciences in Philadelphia.

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AOTA Critically Appraised Topic Series: Cancer A Product of the American Occupational Therapy Association’s Evidence-Based Practice Project This Critically Appraised Topic (CAT) is one in a series of systematic reviews summarizing the evidence related to cancer. For more information on the methodology and to read additional CATs in the series, visit http://www.aota.org/Practice/RehabilitationDisability/Evidence-Based.aspx#cancer.

and promoting health and well-being. The purpose of this CAT is to provide occupational therapy practitioners with the evidence supporting the use of cancer rehabilitation programs to address the activity and participation needs of adult cancer survivors at all stages of the cancer continuum.

Focused Question

Summary of Key Findings:

What is the effectiveness of multidisciplinary cancer rehabilitation programs addressing the activity and participation needs of adult cancer survivors in ADLs, IADLs, work, leisure, social participation, and rest/sleep?

Clinical Scenario:

As of January 2012, the United States had nearly 14 million cancer survivors, with 59% ages 65 years or older (Mariotto, Yabroff, Shao, Feuer, & Brown, 2011). The number of survivors is projected to grow to 18 million by 2022 (Howlader et al., 2012). An estimated 65% of these individuals will survive at least 5 years following their diagnosis (Reis et al., 2007). Cancer can cause impairments, activity limitations, and participation restrictions (Fialka-Moser, Crevenna, Korpan, & Quittan, 2003; Hewitt, Rowland, & Yancik, 2003). Many cancer survivors report declines in their physical functioning, including basic body mobility and engagement in work and leisure activities (Kroenke et al., 2004). Across cancer diagnoses and types of treatment, many adult survivors report that they have not fully regained their precancer levels of physical functioning or engagement in social, work, or leisure activities (Ganz et al., 2004). This review was designed to explore the research focused on cancer rehabilitation from an occupational therapy perspective. Occupational therapy practitioners can help cancer survivors improve their participation by remediating skills, modifying activities and environments, educating on prevention,

Summary of Levels I, II, and III A total of 20 articles met the criteria and were included in the review. Two of the articles were Level 1 systematic reviews, and 12 were Level 1 randomized control trials. There were 4 with Level 2, 1 with Level 3 and 1 with Level 4 evidence. Findings ӹӹ Strong evidence shows that rehabilita-

tion programs benefit multiple types of cancer. The programs do not need to focus on specific types of cancer, and multidisciplinary rehabilitation programs are beneficial for improving function and participation regardless of stage of cancer or age of the cancer survivor (Level I: Cinar, 2008; Khan, Amatya, Pallant, Rajapaksa, & Brand, 2012; Lapid et al., 2007; Scott et al., 2013; Smeenk, Van Haastregt, de Witte, & Crebolder, 1998; ; Level II: Gordon, Battistutta, Scuffham, Tweeddale, & Newman,, 2005; Level III: Hanssens et al., 2011).

ӹӹ Moderate evidence shows that rehabili-

tation in advanced, progressive, recurrent cancer is cost effective and increases quality of life (Level I: Jones et al., 2013).

ӹӹ Moderate evidence shows that rehabili-

tation can be beneficial pre- and posttreatment in many cases (LevelI: Benzo et al., 2011).

ӹӹ Moderate evidence suggests that cogni-

tive rehabilitation can improve attention

and overall quality of life (Level I: Cherrier et al., 2013). ӹӹ Moderate evidence suggests that aquatic

therapy and exercise is beneficial for breast cancer survivors (Level I: CuestaVargas. Buchan, & Arroyo-Morales, 2014).

ӹӹ Limited evidence indicates that single

domain or outcome focus appeared more successful than programs with multiple aims (Level III: Hanssens et al., 2011).

ӹӹ Limited evidence, due to a feasibility

study that needs to be replicated with a larger population, is available that shows that occupational therapist telephonedelivered, problem-solving skills provided to rural breast cancer patients undergoing chemotherapy has a positive effect on function and quality of life (Level I: Hegel et al., 2011).

ӹӹ Insufficient evidence has addressed par-

ticipation limitations among cancer survivors (Egan et al., 2013).

Bottom Line for Occupational Therapy Practice:

Overall, the evidence indicates that multidisciplinary rehabilitation programs are beneficial for cancer survivors. The benefits exist regardless of cancer type or stage of cancer. Cancer rehabilitation may be beneficial before cancer treatment of some types of cancer and is beneficial during and post-treatment. A lack of research exists that addresses participation limitations among cancer survivors. This work is based on the evidence-based literature review completed by Elizabeth G. Hunter, PhD, OTR/L, Mariana D’Amico, EDD, OTR/L, BCP, FAOTA, & Robert Gibson, PhD, MSOTR/L, FAOTA. References can be found at http://www.aota.org/ P r a c t i c e / R e h a b i l i t at i o n - D i s a b i l i t y / Evidence-Based.aspx#cancer

Keep up on evidence-based practice with AOTA's Journal Club Toolkit Interested in keeping you and your colleagues up-to-date on the latest evidence best practices for health and wellness? AOTA’s Journal Club Toolkit has everything you need to plan and implement a journal club including sample fliers, worksheets, references, critical appraisal guides, a statistical reference sheet, and continuing education documentation. To learn more, visit www.aota.org/Practice/ Researchers/Journal-Club-Toolkit.aspx. Health & Wellness ••• 13

Mental Health Sponsored in part by

Support Models to Enhance Community Transitions MH

positioned to help individuals pursue living, working, and learning goals, leading to improved wellness and quality of life. Each model uses a person-centered approach, empowering individuals to build on strengths that can be reinforced and enhanced rather than solely addressing deficits that must be corrected. Each support model assumes that individuals recognize their personal goals and strengths; and can access professional supports including occupational therapy as well as unpaid natural supports (e.g., friends, family, community members) to be successful transitioning to community environments. Supported employment (SE) and supported education are ideally tailored for young adults (though middle age and older adults also benefit) to pursue employment or academic goals. Supported housing can assist adults with serious mental illness and chronic substance use disorders after long-term hospitalizations to transition to the community of their choice and become productive and contributing community members.

Margaret Swarbrick, PhD, OT, FAOTA

The Community Mental Health Centers Act (1963) recognized the recovery potential of people with serious mental health and substance use disorders. However, funding and policy did not support occupational therapy roles in community practice. This changed with the Excellence in Mental Health Act of 2014, which led to the creation of the Certified Community Behavioral Health Centers (CCBHC) demonstration project. CCBHCs are coordinated, fully integrated comprehensive community-based providers serving people with behavioral health challenges across the lifespan, while focusing on the needs of those with serious mental illness and chronic substance use disorders facing life transitions. CCBHC staffing standards identified occupational therapy as optional staff, and the American Occupational Therapy Association is working on advocacy efforts to include occupational therapy in every state. This article highlights three support models (supportive housing, supportive employment, and supportive education) congruent with occupational therapy practice, enabling occupational therapy to assume an important role in community mental health practice helping people manage life transitions. Occupational therapy is well

Supportive Housing In Olmstead v. L.C., the U.S. Supreme Court ruled that public entities must provide community-based services to persons with disabilities, mandating that all live in the least restrictive settings possible and be afforded opportunities to be involved in all aspects of community life (U.S. Department of Justice Civil Rights Division, 2013). Supportive housing combines help for independent housing with flexible mental

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health interventions and other services, such as case management, employment assistance, substance abuse treatment, and daily living supports (Chilvers, Macdonald, & Hayes, 2006; Substance Abuse and Mental Health Services Administration, 2010). Supportive housing is based on the notion that housing positively affects health and should be part of the treatment and recovery process (Rog et al., 2014). These authors identified that service providers offer ongoing support and collaborate with property managers to preserve tenancy and assist with resolving crisis situations and other issues. The authors identified seven randomized controlled trials that demonstrated that supported housing model components reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization (Rog et al., 2014). Individuals participating in these models consistently rate supportive housing more positively than other housing models. Occupational therapy practitioners are ideal members of supportive housing teams as team leaders or consultants. Evaluating strengths and skill challenges of persons with serious mental illness and chronic substance use disorders is needed to assist with the acquisition of skills to manage home cleaning and tenancy (Nolan & Swarbrick, 2002). Occupational therapists should be in lead roles supervising supportive housing teams, with occupational therapy assistants providing direct skills training. When conducting home management evaluations, occupational therapists determine what level of support may be needed. Supports may include task set up (preparing task materials and environment), standby support (in room close to resident during activities of daily living [ADLs] performance, intervening as needed), intermittent support (checking resident performance, intervening if needed), and/or verbal or written cues (instructions about ADLs). Required level of support is determined collaboratively with the clients to develop short- and long-term home management goals. Occupational therapy practitioners can help these individuals and their mental health teams establish recovery plans, including developing the occupational skills of shopping, making and keeping health care appointments, obtaining public benefits, paying bills, preparing meals, and/or keeping clean and safe homes (Nolan & Swarbrick, 2002). Dependence is a central challenge within supported housing services. Caution is needed to prevent persons with serious mental illness and chronic substance use disorders from becoming accustomed to extensive assistance, and/or from staff finding it easier to do tasks rather than to teach occupational skills. Occupational therapy practitioners can perform important roles mentoring other mental health and psychiatric rehabilitation professionals for effective skills training, enhancing independence through empowerment approaches, and focusing on self-sufficiency.

Supported Employment SE helps persons with serious mental illness and chronic substance use disorders to attain and succeed in competitive jobs (Swanson & Becker, 2013). The Individual Placement and Support (IPS) model of SE (Dartmouth College, 2015) is the only nationally and internationally recognized evidence-based approach to vocational rehabilitation for this population and has a clear procedural manual and fidelity scale, and defined training procedures (Swanson & Becker, 2013). Extensive research, including 15-plus randomized controlled trials and many other studies, demonstrated that about two thirds of clients enrolled in IPS achieved competitive employment within 12 to 18 months (Becker, Drake, & Bond, 2014). In long-term follow-up studies, clients tended to remain employed and be steady workers

for many years. Current research aims at examining compensatory cognitive enhancement strategies to enhance employment success (McGurk et al., 2015), which presents an ideal role for occupational therapy practitioners within the IPS model. IPS SE is a team-based model in which employment staff join one or more multi-disciplinary teams (e.g., case management, assertive community treatment, intensive case management, supportive housing). Employment staff galvanizes other team members to consider work as an essential part of the recovery process for persons with serious mental illness and chronic substance use disorders. Both occupational therapists and occupational therapy assistants may provide direct services as job coaches and in other SE roles, assisting all phases of vocational services: assessing, planning, developing, acquiring, mastering, retaining, and changing jobs. Occupational therapy’s client-centered approach engages persons with serious mental illness and chronic substance use disorders in shared decision making for all work-related decisions (e.g., choosing a job type, finding the job, determining how many hours to work, considering disclosure, evaluating types of support). A distinct role of occupational therapy is ensuring that these people also have transportation to and from the job, have needed accommodations at the job site, and have methods to organize their day. Occupational therapy practitioners can learn about developing their role and skills in the IPS model of SE through Dartmouth training courses, videos, books, and fidelity tools (Dartmouth College, 2015) and refine their role through mentoring with IPS supervisors.

Supported Education Pursuing higher education is a means of transition from the patient role to other roles, such as student or worker (Knis-Matthews, Bokara, DeMeo, Lepore, & Mavus, 2007). However, symptoms of and stigma associated with mental illness often create additional challenges in school settings given that many students may be experiencing their first psychosis and first need for mental health services (Melton et al., 2013). Supported education services within integrated post-secondary schools are individualized and flexible, emphasizing student choice, self-determination, and career development to manage postsecondary education, achieve academic goals, and gain meaningful employment (Knis-Matthews et al., 2007). Occupational therapy services in supported education may begin before students enter the college environment and continue for as long as they benefit from occupational therapy support. Supports are highly variable but may encompass occupational therapy assistance to apply to school,

About the Mental Health SIS The Mental Health Special Interest Section (MHSIS) focuses on occupational therapy practice in traditional mental health settings as well as in emerging practice areas, such as forensics/corrections, school mental health, early intervention for psychosis, and primary care. The MHSIS addresses services to benefit the psychosocial needs of individuals in all practice areas and engages members to work on initiatives promoting the role of occupational therapy in mental health care systems. ӹӹ Meet the MHSIS committee members at www.aota.org/MHSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/22/aspx.

Mental Health ••• 15

gain financial support, plan classes, interact with teachers, complete assignments, manage test anxiety, compensate for cognitive problems, and learn how to cope socially. Examples include developing skills to adjust to dorm life, successfully commuting, negotiating places like cafeterias, managing time, organizing homework and papers, and preparing for tests. For example, a supported education and employment program titled The Bridge led by occupational therapy students has addressed these many of these supports to assist with transition for persons with mental illnesses, learning disabilities, and autism-spectrum disorders (Schindler & Kientz, 2013; Schindler & Sauerwald, 2013). Occupational therapy practitioners assume a variety of roles to help students with serious mental illness and chronic substance use disorders access supports required on campus, obtain legal supports as needed, and explore the pros and potential cons of disclosing (or not) to take advantage of these supports. Many newly developed supported education services are offered in team environments, using occupational therapy practitioners to ensure that students have seamless services. Models vary widely in terms of where students attend classes, where they receive supports, who provides supports, what types of supports are available, the amount of supports, and the linkage with mental health services. Current worldwide emphasis on early intervention for first episode psychosis involves working with younger people, many of whom have had their education threatened or interrupted by early phases of mental health problems (Melton et al., 2013). Early episode teams, typically now including occupational therapy, offer preferred integration of supported education and SE (Nuechterlein et al., 2008).

Conclusion The occupational therapy profession needs to be a notable force in offering services and supports to enhance community transitions, leading to improved wellness and quality of life for people with serious mental health and chronic substance use disorders across the lifespan. Having occupational therapy assume a key role in implementing these support models enabling persons to achieve independent housing, employment, and education is essential to the recovery process. Occupational therapy practitioners should begin with the person’s perception of needs, goals, and preferences, through a collaborative evaluation of strengths, challenges, needs, and priority focus to enhance transition. Each approach empowers individuals to link to natural supports rather than become dependent on providers to meet their needs over the short and long term. References Becker, D., Drake, R., & Bond, G. (2014). The IPS supported employment learning collaborative. Psychiatric Rehabilitation Journal, 37(2), 79–85.

Chilvers, R., Macdonald, G. M., & Hayes, A. A. (2006). Supported housing for people with severe mental disorders. Cochrane Database of Systematic Review, 4. http://dx.doi.org/10.1002/14651858.CD000453.pub2 Community Mental Health Centers Act of 1963, Pub. L. 88-164, Stat. 77. Dartmouth College. (2015). Dartmouth supported employment center. Retrieved from http://www.dartmouthips.org/ Excellence in Mental Health Act. H.R.1263, 113 Cong., (2014) (enacted). Knis-Matthews, L., Bokara, J., DeMeo, L., Lepore, N., & Mavus, L. (2007). The meaning of higher education for people diagnosed with a mental illness: Four students share their experiences. Psychiatric Rehabilitation Journal, 31, 107–114. McGurk, S., Mueser, K., Xie, H., Welsh, J., Kaiser, S., Drake, R.,… McHugo, G. (2015). Cognitive enhancement treatment for people with mental illness who do not respond to supported employment: A randomized controlled trial. American Journal of Psychiatry, 172, 852–861. http://dx.doi.org/10.1176/ appi.ajp.2015.14030374 Melton, R. P., Roush, S. N., Sale, T. G., Wolf, R. M., Usher, C. T., Rodriguez, C. L., & McGorry, P. D. (2013). Early intervention and prevention of long-term disability in youth and adults: The EASA model. In K. Yeager, D. Cutler, D. Svendsen, & G. Sills (Eds.), Modern community mental health: An interdisciplinary approach. New York: Oxford University. Nolan, C., & Swarbrick, M. (2002, June). Supportive housing occupational therapy home management program. Mental Health Special Interest Section Quarterly, 25(2), 1–3. Nuechterlein, K. H., Subotnik, K. L., Turner, L. R., Ventura J., Becker, D. R., & Drake, R. E. (2008). Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31, 340–349. Rog, D., Marshall, T., Dougherty, R., George, P., Daniels, A., Ghose, S., & DephinRittmon, M. (2014). Permanent supportive housing: Assessing the evidence. Psychiatric Services, 65, 287–294. http://dx.doi.org/10.1176/appi. ps.201300261 Schindler, V. P., & Kientz, M. (2013). Supports and barriers to higher education and employment for individuals diagnosed with mental illness. Journal of Vocational Rehabilitation, 39, 39–41. http://dx.doi.org/10.3233/JVR-130640 Schindler, V. P., & Sauerwald, C. (2013). Outcomes of a 4-year program with higher education and employment goals for individuals diagnosed with mental illness. Work: A Journal of Prevention, Assessment and Rehabilitation, 46, 325–336. http://dx.doi.org/10.3233/WOR-121548 Substance Abuse and Mental Health Services Administration. (2010). Permanent supportive housing: Evidence-based practice kit. Rockville, MD: Author. Swanson, S. J., & Becker, D. R. (2013). IPS supported employment: A practical guide. Lebanon, NH: Dartmouth Psychiatric Research Center. U.S. Department of Justice Civil Rights Division. (2013). Olmstead: Community integration for everyone. Retrieved from http://www.ada.gov/olmstead/ olmstead_about.htm Margaret Swarbrick, PhD, OT, FAOTA, is the director of the Collaborative Support

Programs of New Jersey Wellness Institute in Freehold, New Jersey, and associate professor at Rutgers University School of Health Related Professions in Scotch Plains, New Jersey. She can be reached at [email protected].

Evidence Supports Techniques for Depression in Adults With Stroke A recent systematic review reveals moderate evidence to support the effectiveness of problem-solving techniques and motivational interviewing to address depression in adults with stroke. To find out more and learn about other key evidence recommendations to guide and justify mental health services for those who have suffered a stroke, check out the Critically Appraised Topic, the Practice Guidelines, the American Journal of Occupational Therapy systematic review article at www.aota.org/ Practice/Rehabilitation-Disability/Evidence-Based.aspx. Mental Health ••• 16

Productive Aging Sponsored in part by

Fostering Health-Related Quality of Life in Community-Based Stroke Survivors G

informed consent, and were physically able to complete a 60- to 75-minute interview. We developed and used a semi-structured interview guide to elicit discussion on participants’ views of their health. Line-by-line coding was used to analyze the data, and six themes were identified. Study procedures were approved by Rockhurst University’s Institutional Review Board. The interviews revealed the following common themes among the survivors: A “can do” attitude; renewed purpose in life; volatility, negative emotions, and the belief that they were being unfairly judged by others; feeling like a burden because of needing daily support; a need for daily activity, exercise, and education; and a loss of valued occupations and roles, including the ability to work. These themes are all areas addressed by occupational therapy, and they demonstrate the value of the profession’s holistic perspective. While most post-stroke therapy focuses on physical changes, the study results suggest the equal importance of psychosocial factors. Some examples of occupational therapy interventions for stroke survivors that align with the themes include the therapeutic use of self to elicit clients’ strengths and needs (American Occupational Therapy Association [AOTA], 2010), creating support groups for stroke survivors and family members (AOTA, 2013), using motivational interviewing when stroke survivors experience depression (Watkins et al., 2007), and using therapeutic occupations to encourage mastery experiences (AOTA, 2010).

Lynne Clarke, OTD, MS, OTR/L; and Rachel Prewitt, MOT, OTR/L

Stroke survivors experience a decrease in health-related quality of life (HRQOL) compared with the general population (Kwok et al., 2006). HRQOL is a multidimensional concept that includes physical and mental health perceptions and their correlates, including health risks and conditions; functional status; social support; and socioeconomic status (Centers for Disease Control and Prevention, 2011). In this article, we describe how to apply evidence to practice to help improve specific aspects of HRQOL deemed important to community-dwelling stroke survivors. To provide a descriptive understanding of what aspects of HRQOL are important to stroke survivors, we conducted a qualitative research project. Stroke survivors from the American Stroke Foundation were recruited to participate in focus group interviews to allow us to understand their perceptions of physical health, mental health, and current involvement in community activities, leisure interests, and socialization. The 15 adult participants were all stroke survivors who lived in the community, were cognitively able to give

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The focus group interviews showed that the stroke survivors value taking responsibility for their health and wellness. In line with the profession’s role in health promotion and prevention (AOTA, 2013), practitioners may provide interventions and programs that focus on health and well-being. Providing education and training on eating habits, activity levels, and prevention of secondary disability to enhance function are examples. In addition, practitioners may refer clients to social support groups within the community. The themes identified in this research project are consistent with those of Corr, Phillips, and Walker (2004), who found that a pilot day-service program for stroke survivors improved occupational performance and satisfaction with performance. They are also consistent with previous research with stroke survivors suggesting that occupational therapy practitioners include meaningful and occupation-focused interventions that align with clients’ goals (Egan, Kessler, Laporte, Metcalfe, & Carter, 2007), incorporate interventions that address social support and community participation (Beckley, 2006), and include interactive education and exercise (Harrington et al., 2010). Interventions that focus on activities of daily living (ADLs) and instrumental ADLs are perhaps most commonly seen within the traditional, medical-model approach of rehabilitation. Consistent with this approach, some key strategies to support occupational performance include providing adaptive techniques to promote engagement in household management, work tasks, and community mobility; modifying routines; and creating schedules to maintain participation in meaningful occupations (Wolf & Nilsen, 2015).

Case Example Saul, a 79-year-old man, experienced a right-sided stroke, which resulted in left-sided weakness, along with depression, frustration, fatigue, and minor confusion. He was admitted to a skilled nursing facility (SNF) after hospitalization. Before the stroke, Saul lived with his wife in a first-floor apartment in a metropolitan city, was independent with daily activities, and used the bus for transportation. As a retired kosher baker and devout Orthodox Jew, Saul baked challah, a ceremonial Jewish bread, every week for his synagogue to share during Sabbath. After his stroke, Saul’s goal was to return home with his wife’s support and resume the meaningful and spiritual activities of daily life. As part of the evaluation process, the occupational therapist used the Canadian Occupational Performance Measure (Law et al., 2014) for Saul to identify problem areas in his daily occupations. Saul was able to pinpoint his goals, which included increasing independence

About the Gerontology SIS The Gerontology Special Interest Section (GSIS) provides resources and support for clinicians, researchers, educators, and students who are addressing the complex needs of older adults along the continuum of care. It highlights new and innovative intervention approaches for older adults with physical, psychosocial, and developmental needs, as well as relevant policy impacting current geriatric practice. ӹӹ Meet the GSIS committee members at www.aota.org/GSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/14.aspx.

with his morning routine (i.e., shaving, and buttoning his shirt), improving his endurance, and decreasing his frustration with trying to complete tasks he used to do at home and in the community. The occupational therapist used a modified approach to facilitate Saul’s participation in his morning routine. Preceding the stroke, Saul had been accustomed to using a standard razor with his left dominant upper extremity; the occupational therapist suggested that he use an electric razor, which he could manipulate more easily with his right hand. Saul liked the clean appearance of a button-up shirt; however, he was no longer able to manipulate the buttons and lacked the motor control for using a button hook. As such, the occupational therapist suggested lining his shirts with Velcro so Saul could don and doff them with less effort and frustration. Using the therapeutic use of self, the occupational therapist elicited Saul’s strengths and values. Saul expressed that baking for his social group at the synagogue gave him a great sense of pride and satisfaction, and that he hoped to resume this volunteer role. The occupational therapist tapped into Saul’s motivation and “can-do attitude” by engaging him in baking activities. In the therapy kitchen, the occupational therapist simplified the activity demands by placing all the necessary items on the counter, having Saul sit down to work on the dough, and incorporating rest breaks as needed. Discussions were held on how similar modifications could be made at Saul’s home and in the synagogue kitchen. The occupational therapist facilitated role-play vignettes in which Saul practiced social participation and baking for other SNF residents. As Saul progressed, the occupational therapist suggested that Saul bake the challah to share with the residents, which incorporated social participation skills in a community environment. As Saul continued with baking activities, it was noted that he had increased confidence, strength, and tolerance for daily tasks. Additionally, he became more social and interactive with other residents, and he reported feeling less depressed. The occupational therapist coordinated a community outing incorporating the activity demands of bus transportation and shopping individualized to Saul’s community. For this outing, the occupational therapist worked with Saul to prepare a short grocery list, ride the public bus to a neighborhood market, select and pay for items at the store, and interact with the bus driver and cashier. As part of this intervention, Saul practiced problem-solving and emotional coping skills during the outing. As a result, Saul expressed increased confidence and decreased frustration in his ability to navigate the bus system and to shop for groceries at the market. In preparation for discharge, the occupational therapist found a local support group for stroke survivors that offered a variety of educational, exercise, and socialization opportunities. Based on evidence that participation in community-based exercise and educational classes can increase physical and psychological well-being in stroke survivors (Harrington et al., 2010), the occupational therapist recommended that Saul attend the support group on a weekly basis. Saul met all of his occupational therapy goals and expressed that he was ready to be a part of the community again.

Identifying Occupational Therapy’s Role in Stroke Rehab Research consistently shows that stroke survivors want to return to their previous roles. Doing so involves addressing their physical, cognitive, social, environmental, and work goals. Occupational therapy is the only profession that addresses all of these aspects during rehabilitation. Occupational therapy can reduce costs and

Productive Aging ••• 18

promote the overall health, quality of life, and daily participation in clients (Arbesman, Lieberman, & Metzler, 2014). Enhancing independence, facilitating aging in place, and reducing rehospitalization are all important outcomes of occupational therapy. Evidence suggests a larger and continuing role for occupational therapy at all stages of stroke recovery to achieve peak outcomes in home, community, work, and other life arenas (Arbesman et al., 2014). By using evidence-based and person-centered interventions incorporating client-directed aspects of HRQOL, occupational therapy practitioners can provide effective, high-quality, and costefficient interventions and demonstrate the profession’s distinct value to clients, administrators, third-party payers, and policy makers. References American Occupational Therapy Association. (2010). Occupational therapy services in the promotion of psychological and social aspects of mental health. American Journal of Occupational Therapy, 64(Suppl.), S78–S91. http://dx.doi.org/10.5014/ajot.2010.64S78 American Occupational Therapy Association. (2013). Occupational therapy in the promotion of health and well-being. American Journal of Occupational Therapy, 67(Suppl.), S47–S59. http://dx.doi.org/10.5014/ajot.2013.67S47 Arbesman, M., Lieberman, D., & Metzler, C. A. (2014). Health policy perspectives—Using evidence to promote the distinct value of occupational therapy. American Journal of Occupational Therapy, 68, 381–385. http://dx.doi. org/10.5014/ajot.2014.684002 Beckley, M. N. (2006). Community participation following cerebrovascular accident: Impact of the buffering model of social support. American Journal of Occupational Therapy, 60, 129–135. http://dx.doi.org/10.5014/ajot.60.2.129

Centers for Disease Control and Prevention. (2011). Health-related quality of life (HRQOL). Retrieved from http://www.cdc.gov/hrqol/concept.htm Corr, S., Phillips, C. J., & Walker, M. (2004). Evaluation of a pilot service designed to provide support following stroke: A randomized cross-over design study. Clinical Rehabilitation, 18, 69–75. http://dx.doi.org/10.1191/0269215504cr703oa Egan, M., Kessler, D., Laporte, L., Metcalfe, V., & Carter, M. (2007). A pilot randomized controlled trial of community-based occupational therapy in late stroke rehabilitation. Topics in Stroke Rehabilitation, 14(5), 37–45. Harrington, R., Taylor, G., Hollinghurst, S., Reed, M., Kay, H., & Wood, V. A. (2010). A community-based exercise and education scheme for stroke survivors: A randomized controlled trial and economic evaluation. Clinical Rehabilitation, 24, 3–15. http://dx.doi.org/10.1177/0269215509347437 Kwok, T., Lo, R. S., Wong, E., Wai-Kwong, T., Mok, V., & Kai-Sing, W. (2006). Quality of life of stroke survivors: A 1-year follow-up study. Archives of Physical Medicine and Rehabilitation, 87, 1177–1182. Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H. J., & Pollock, N. (2014). Canadian Occupational Performance Measure (5th ed.). Ottawa: CAOT Publications. Watkins, C. L., Auton, M. F., Deans, C. F., Dickinson, H. A., Jack, C. I., Lightbody, C. E., … Leathley, M. J. (2007). Motivational interviewing early after acute stroke: A randomized, controlled trial. Stroke, 38, 1004–1009. http://dx.doi. org/10.1161/01.STR.0000258114.28006.d7 Wolf, T. J., & Nilsen, D. M. (2015). Occupational therapy practice guidelines for adults with stroke. Bethesda, MD: AOTA Press. Lynne Clarke, OTD, MS, OTR/L, is an associate professor of Occupational

Therapy Education at Rockhurst University. She can be reached at Lynne. [email protected].

Rachel Prewitt, MOT, OTR/L, is an occupational therapist at Quincy Medical

Group in Quincy, Illinois.

Occupational Therapy's Distinct Value in Addressing Driving What is the distinct value of occupational therapy to address driving and community mobility? In the latest AOTA Everyday Evidence Podcast, Wendy Stav, PhD, OTR/L, SCDCM, FAOTA, explains how occupational therapy services help older adults stay safe on the road and access the community despite age-related changes. To listen to the podcast and learn more about the evidence for driving and community mobility, visit www.aota.org/Practice/ Researchers/Evidence-Podcast/safe-driving-any-age-older-driver-safety.aspx Productive Aging ••• 19

Rehabilitation, Disability, & Participation Sponsored in part by

The Meaning of Context: Connecting the Home Environment and Outpatient Occupational Therapy HCH

increased safety and efficiency of daily occupations and activities (i.e., proper placement of grab bars, stair rails, other environmental modifications [Lysack & Neufeld, 2003]). Research emphasizes the safety benefits of home modifications and the significance of predischarge hospital-based home evaluations (Lannin et al., 2007; Nygard, Grahn, Rudenhammar, & Hydling, 2004; Petersson, Lilja, Hammel, & Kottorp, 2008). During outpatient occupational therapy, the therapist assists patients to develop and refine additional skills that will enhance their level of performance at home and in the community. While outpatient occupational therapists are able to assess accurately the person and task demands in the clinic, challenges often arise when evaluating the context in which these activities naturally occur. This missing component can have a profound effect on performance and participation in valued activities.

Emily C. Burgard, OTD, OTR/L; Dory Sabata, OTD, OTR/L, SCEM, FAOTA; and Andy J. Wu, PhD, OT

Stroke is a leading cause of disability worldwide (Sumathipala, Radcliffe, Sadler, Wolfe, & McKevitt, 2012). Approximately two thirds of stroke survivors exhibit residual neurological deficits that impair function and require rehabilitation (Staines, McIlroy, & Brooks, 2009). Common deficits include hemiplegia, vision problems, behavioral changes, and cognitive changes, which can affect participation, independence, and performance with everyday occupations. The rehabilitation process focuses on remediating these deficits and compensating for functional loss. Participation in inpatient rehabilitation helps stroke survivors to develop skills that will enhance their level of performance with self-care activities, sitting, standing, walking, and functional use of affected limbs. Individuals who discharge home from the hospital with strokerelated impairments may discover that their home environment impedes optimal performance. Typically, home evaluations help therapists identify potential environmental changes that would enable

Occupational Therapy and the Ecology of Human Performance Framework The Ecology of Human Performance (EHP) is a framework that uniquely the relationship between context and occupational performance. A particularly unique feature of EHP is the idea that “performance cannot be understood outside the context” (Dunn, Brown, & McGuigan, 1994, p. 598). Therapists can use a variety of interventions reflective of task-specific training (Hubbard, Parsons,

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Neilson, & Carey, 2009), but are often unable to recreate the contextual supports and cues pertinent to the authentic home environment (Dunn et al., 1994). For example, completing the movement of reaching for an item on a shelf in the clinic may evoke different movement patterns than reaching for a cup while standing at the kitchen counter at home. Many of the environmental differences (i.e., the height of the counter, cabinet door weight, cabinet handle size) can influence the performance skills necessary to complete the task. EHP recognizes the value of the “interaction between person and the environment, and how each can affect human behavior and performance” (Dunn et al., 1994, p. 598), which challenges practitioners in outpatient rehabilitation to consider how the environment and context influence performance. Environmental barriers can affect participation, as the person, task, and environment are dependent on and interact with each other (Dunn et al., 1994). When a person who has sustained a stroke has reached a relatively stable skill level through outpatient rehabilitation, the therapist is able to use the adapt approach from the EHP model to modify or enhance the environment or task to support occupational performance.

Home Evaluations and Outpatient Occupational Therapy While outpatient occupational therapy improves patient outcomes (Teasell, Foley, Richardson, Allen, & Speechley, 2013), the current rehabilitation structure offers little consideration and opportunity for conducting home evaluations within the outpatient rehabilitation setting, which could be most beneficial for individuals who demonstrate prolonged functional deficits after a stroke. Thus, a home visit during the course of outpatient occupational therapy treatment is essential to understand challenges within the authentic context.

Case Example Annie is a 45-year-old woman with an acute left basal ganglia stroke resulting in right-sided hemiparesis. She was treated in an acute inpatient rehabilitation setting, and upon discharge was referred directly to an outpatient neurorehabilitation clinic for further occupational and physical therapy. Her goal was to use her right-dominant hand more efficiently to engage in many daily occupations. Annie is a single mother who worked full time cleaning and packaging dental equipment and was solely responsible for the household chores. She does not drive and relies on family or public transportation. She wanted to return to her prior level of functioning in all these areas. Initial range of motion and strength assessments revealed below functional limits in Annie’s right arm, wrist, and fingers. Annie could use her right hand to stabilize objects using a rudimentary grasp but demonstrated difficulty with isolated finger movements. Annie reported that she was independent with grooming and dressing activities but had adapted the tasks to use primarily her left (nondominant) hand for manipulating items and fasteners. Annie used a cane and wore an ankle-foot orthosis on her right leg when walking outside of the home. The occupational therapist used the EHP framework to understand Annie’s performance of her daily activities and as a guide for the therapy process. The occupational therapist completed a home visit with Annie, and during the visit, the occupational therapist administered the Canadian Occupational Performance Measure (COPM; Law et al., 2014). Through the COPM assessment, Annie identified four occupational performance issues—bathing and shower transfer, entering and exiting the home, cooking and kitchen activities, and cleaning

and laundry management—that became the focus of the entire home evaluation. Annie completed several tasks in each room, allowing the therapist to perform detailed task analysis within the authentic context. When completing kitchen activities, the therapist noticed that Annie was using her left hand instead of her right to open drawers, cabinets, and the refrigerator. Annie could practice opening the refrigerator in the clinic, but the handle on her refrigerator was in a different position. She could practice opening the kitchen drawers in the clinic, but in her home, the drawers are heavier and at a different height. As therapists, we design interventions that are functional and encourage using the affected arm, but at times overlook the importance of the authentic context. The occupational therapist recognized that if Annie continued to use her left arm and hand for all activities, she would decrease her opportunities to re-educate her right arm (Morris & Taub, 2001). By using an establish/restore intervention approach, the therapist worked with Annie to restore the necessary skills to be successful in her home environment (Dunn et al., 1994). The occupational therapist explained to Annie that with repetitive, concentrated practice and intentional integration of her right arm and hand into her daily activities, she would improve motor performance and decrease learned nonuse behaviors (Morris & Taub, 2001). The therapist asked Annie to go back through the house and try to use her right arm for various tasks such as opening doors, retrieving clothing from the dresser, and folding laundry. After observation, the therapist educated Annie on how to use, orient, or place her arm in more optimal positions. A traditional home evaluation would yield more adapt interventions, whereas this evaluation in the home resulted in establish/restore interventions (see Table 1). With outpatient therapy, Annie learned how to integrate her right upper extremity into functional tasks and demonstrated improved motor performance. Unfortunately, Annie was unable to attend the final outpatient therapy visit because of financial hardship, during which final outcome scores would have been obtained. However, she did make clinically noticeable gains in her functional performance.

Making Outpatient Therapy More Meaningful When the health care system allows occupational therapists to provide services in the authentic environment, they should capitalize on the opportunity. Because of the current health care model, Annie was prescribed outpatient occupational therapy services and did not qualify for home health services. However, it is important to practice evidence-based medicine at all times. Thus, it is advisable for practicing therapists to seek out resources available in their setting

About the Home & Community Health SIS The Home & Community Health Special Interest Section (HCHSIS) provides resources and support for occupational therapists and occupational therapy assistants who provide services in the home and community. Examples include home health, adult day services, senior housing, wellness programs, community mental health centers, home modification, and accessibility consultation. The HCHSIS also includes the Home Modification Network. ӹӹ Meet the HCHSIS committee members at www.aota.org/HCHSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/15.aspx.

Rehabilitation, Disability, & Participation ••• 21

Table 1. Modifications & Recommendations for Annie's Home Problem Area

Adapt Modifications and Establish/Restore Recommendations

Bathing & shower transfer

Adapt intervention: Install two horizontal grab bars on the tub or shower walls mounted on the front and side walls at Annie’s waist height. Establish/Restore intervention: When transferring in and out of the shower, place both right and left hands on the grab bar to facilitate and reinforce motor learning on the right side. Adapt intervention: Install at least one handrail to increase safety with climbing and descending the stairs.

Entry & exit into home

Establish/Restore intervention: Position right hand on the railing when ascending the stairs and entering your home. Cooking & kitchen activities

Adapt intervention: Add handles on the upper-level cabinets to increase ability to open with right hand. Arrange regularly used, lighter kitchen materials on lower shelves or on the counter. Establish/Restore intervention: Retrieve items from lower shelves or counter with right hand to encourage carryover.

Cleaning & laundry management

Adapt intervention: Keep laundry detergent lower down on top of the dryer, to maintain proper balance and safety when reaching and managing soap. Establish/Restore intervention: Incorporate your right upper extremity when transferring clothes from washer to dryer, grasp laundry with right hand, use both hands to carry laundry basket to stairs.

to be able to complete a home visit. This can include advocating to management staff for permission to do so by using evidence that supports improved outcomes. In Annie’s case, the home evaluation yielded results that allowed the therapist to obtain the most accurate assessment of Annie’s actual performance and make specific recommendations to improve her function. The therapist was able to use the COPM to create meaningful interventions and individualized goals, which encouraged Annie to use her right hand throughout her home when participating in everyday activities. The ability to practice her actual daily activities would help Annie to understand more easily how to integrate her right arm into these activities at home. As professionals focused on participation in daily life, it is our responsibility to understand the value of performance within the authentic context and be more mindful of the constraints within

a traditional outpatient therapy clinic. Regardless of the practice setting, we need to remember that “occupational therapy is most effective when it is imbedded in real life” (Dunn et al., 1994, p. 602) and much of real life exists outside of therapy. References Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology of human performance: A framework for considering the effect of context. American Journal of Occupational Therapy, 48, 595–607. http://dx.doi.org/10.5014/ajot.48.7.595 Hubbard, I. J., Parsons, M. W., Neilson, C., & Carey, L. M. (2009). Task-specific training: Evidence for and translation to clinical practice. Occupational Therapy International, 16, 175–189. Lannin, N. A., Clemson, L., McCluskey, A., Lin, C. C., Cameron, I. D., & Barras, S. (2007). Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits. BMC Health Services Research, 7(42). http://dx.doi.org/ 10.1186/1472-6963-7-42 Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollack, N. (2014). The Canadian Occupational Performance Measure (5th ed.). Ottawa: CAOT Publications. Lysack, C. L., & Neufeld, S. (2003). Occupational therapist home evaluations: Inequalities, but doing the best we can? American Journal of Occupational Therapy, 57, 369–379. http://dx.doi.org/10.5014/ajot.57.4.369 Morris, D. M., & Taub, E. (2001). Constraint-induced therapy approach to restoring function after neurological injury. Topics in Stroke Rehabilitation, 8(3), 16–30. Nygard, L., Grahn, U., Rudenhammar, A., & Hydling, S. (2004). Reflecting on practice: Are home visits prior to discharge worthwhile in geriatric inpatient care? Scandinavian Journal of Caring Sciences, 18, 193–203. Petersson, I., Lilja, M., Hammel, J., & Kottorp, A. (2008). Impact of home modification services on ability in everyday life for people ageing with disabilities. Journal of Rehabilitation Medicine, 40, 253–260. Staines, W. R., McIlroy, W. E., & Brooks, D. (2009). Functional impairments following stroke: Implications for rehabilitation. Retrieved from http://www. cacr.ca/information_for_public/documents/article3.pdf Sumathipala, K., Radcliffe, E., Sadler, E., Wolfe, C., & McKevitt, C. (2012). Identifying the long-term needs of stroke survivors using the international classification of functioning, disability and health. Chronic Illness, 8, 31–44. Teasell, R., Foley, N., Richardson, M., Allen, L., & Speechley, M. (2013, October). Outpatient Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/ default/files/Chapter7_Outpatients_FINAL_16ed.pdf Emily C. Burgard, OTD, OTR/L, is an occupational therapist at St. Luke’s Hospital

in Kansas City, Missouri. She can be reached at [email protected].

Dory Sabata, OTD, OTR/L, SCEM, FAOTA, is a clinical assistant professor at

the University of Kansas Medical Center’s Occupational Therapy Education Department.

Andy J. Wu, PhD, OT, is a research assistant professor at the University of

Kansas Medical Center’s Occupational Therapy Education Department.

Evidence Connection Helps to Inform, Guide Clinical Decision-Making A new American Journal of Occupational Therapy (AJOT) series, Evidence Connection, provides a clinical application of systematic reviews developed in conjunction with AOTA’s Evidence-Based Practice Project. Using a clinical case format, Evidence Connection articles illustrate how the research evidence from the reviews can inform and guide clinical decision-making. The inaugural article on stroke can be found in the September/October 2015 issue of AJOT. To read the article, visit www.ajot.aota.org. For more EBP resources on stroke, visit www.aota.org/Practice/Rehabilitation-Disability/Evidence-Based. Rehabilitation, Disability, & Participation ••• 22

Transitioning from Clinician to Manager AM

Penny Rogers, DHA, MAT, OTR/L, CEAS I; Catherine Killian, MEd, OTR/L; Ellen Hudgins, OTD, OTR/L; and Terry Pollard, MA

Have you ever envisioned becoming a manager? Because by definition most occupational therapy practitioners do not train for managerial roles, the demand for strong occupational therapy managers could exceed the supply. How do you make the smooth transition from therapist to manager? It should come as no surprise, given our growing baby boomer population and increased life expectancy, along with dynamic changes in the health care system’s policies, that those in the rehabilitation fields of occupational, physical, and speech therapy are finding themselves tasked with taking on more substantial administrative roles or developing enhanced problem solving skills (Canadian Institute for Health Information, 2011). In fact, the 2015 American Occupational Therapy Association (AOTA) Salary and Workforce Survey, completed by 13,000 occupational therapy practitioners, found that occupational therapists spend 24% of their time allocation toward administrative tasks and occupational therapy assistants spend 16%. One way to address these challenges is to channel that additional work into an acknowledged management role. In addition to traditional areas, management opportunities exist for occupational therapists in areas such as primary care, developing independent practices, advocating for underserved populations, and researching avenues to advance occupational therapy.

Is Management Right for You? Bondoc, Kroll, and Herz (2008) found that the essential skills and attributes of occupational therapy practitioners who moved from clinician to manager included enhanced knowledge regarding the service area, a good understanding of reimbursement mechanisms, proficiency with budget planning, and the ability to manage people. Other important traits included past experience, a strong work ethic, being ready to take on the tasks at hand, communication and organizational skills, and flexibility. Effective managers empower and engage people, understand technology, lead by example, embrace vulnerability, and believe in sharing responsibilities (Morgan, 2013). Many clinicians worry that becoming a manager will sidetrack their occupational therapy careers. Yet being a manager provides the opportunity for you to be an advocate for your patients and occupational therapy practitioners, and other staff who are improving outcomes. A manager may have increased opportunity to advance in the health care industry, including sitting at the table with administrators and chief executive officers to provide input for how occupational therapy can contribute to changing systems. This role can provide a higher salary, and it can also allow clinicians to discover hidden talents such as participating in the development of strong health care entities and expanding the organization’s programmatic scope. For example, many practitioners express concern that they are relegated to specific, narrow roles in their facility. As a manager you have the ability to demonstrate enhanced outcomes when occupational therapy services expand to address all aspects of clients’ occupations. With the emphasis on outcomes in health care, a good starting point is to refer to evidence that supports the inclusion of occupational therapy. The Evidence-Based Practice and Research section of AOTA’s website (aota.org) is a great resource, as it con-

tains evidence by topic area. Occupational therapy practitioners who become managers will gain increased visibility among stakeholders, including other health professionals and potential clients. This visibility can provide opportunities to have a voice in policy change and patient advocacy, and offer a personal presence throughout an organization. The more visible occupational therapy is, the more opportunity for advocacy and education to others. This in turn could bring about increased opportunity such as initiating occupational therapy roles in primary care and mental health practices as well as community-based settings.

Getting Started People become managers in different ways. Some actively seek the position, but some are persuaded by a current or retiring manager (Spehar, Frich, & Kjekshus, 2012). A reflection on the path to occupational therapy manager is provided by Catherine Killian, MEd, OTR/L, faculty member at the University of Illinois at Chicago and longtime occupational therapy department and rehabilitation services manager. Killian notes: I had only been out of [occupational therapy] school for 2 years when I was presented with my first management opportunity. I had already worked in behavioral health, rehab, and outpatient settings when my spouse was offered a job promotion in a part of the U.S. distant from the Midwest. He accepted the job, we moved, and I found a position as a director of occupational therapy in an acute care hospital. Suddenly, my responsibilities included not only some patient care, but also management of an entire department. I was fortunate to receive comprehensive training from the hiring organization, which set me up for initial success. In addition, I had a great [occupational therapy] mentor, who was encouraging, upbeat, committed to excellence, and provided me with both positive and constructive feedback as appropriate. She took the time to teach me the basics of health care finance/budgeting, human resources management, program development, and other areas as needed. I was encouraged to practice these new skills, knowing that my mentor was just a phone call away to provide support and/ or advice. As I progressed in my position and new opportunities presented themselves, I was provided with training in marketing and advertising in order to grow the programs I had helped develop. The training and empowerment received in that initial management position I carried with me to subsequent positions. Certain aspects of the management position changed over the years due to health care advancements; focus on evidence-based practice; significant changes in reimbursement, human resource practices, and the roles

About the Administration & Management SIS The Administration & Management Special Interest Section (AMSIS) includes occupational therapists and occupational therapy assistants who are engaged in administrative or managerial responsibilities as part of their daily occupations, or who wish to gain knowledge and skills in these areas. The AMSIS has a designated Private Practice and Entrepreneurs Subsection to meet the needs of practitioners who are business owners, entrepreneurs, or in private practice. ӹӹ Meet the AMSIS committee members at www.aota.org/AMSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/10.aspx.

Rehabilitation, Disability, & Participation ••• 23

and scope of various health care professions; as well as the advent of computers and the Internet. Fortunately, in each of my subsequent management positions, I received the training I needed in order to maintain current with the expected management skills. Although the amount of mentoring and encouragement I received in subsequent management positions varied, its value in the initial position was significant in that it substantiated my suitability as a manager.

Sometimes entering a managerial role can be daunting. It can be filled with long days, increasing workloads, and other challenges such as delegating tasks and lack of organizational support (Spehar et al., 2012). An important component of Killian’s success was the support and training she received as she transitioned to this role. When considering a management position, ask whether training and/or mentorship is included. Mentorship can facilitate a transformational process because it encompasses mentoring as its practice, mentor and mentee as its people, storytelling-listening as its communication tools, and applied learning as the outcome (Gilfoyle, Grady, & Nielson, 2011). Although mentorship is ideal, sometimes there’s neither the time nor the resources for it. Try connecting with other new or experienced managers. This can provide support from someone in a similar position and also provide someone to share your ideas with. You can also educate yourself through leadership books and teleconferences, or take a course on management skills. The American Management Association (2009) provides seminars to build and improve on management skills, and AOTA’s forums on OT Connections can be a place to ask questions and get support, including the Administration & Management and Leadership forums. AOTA also offers volunteer leadership positions through the Volunteer Leadership Development Committee, as well as Continuing Education courses, and resources like The Occupational Therapy Manager (Jacobs & McCormack, 2010).

Going Beyond Management: Leadership Qualities Bennis and Nanus (2007) portrayed the difference between leadership and management by saying that a manager does things right, whereas a leader ensures that he or she does the right thing. A transformational leader is willing to help team members reach goals by developing rapport, trust, and respect among the entire team. Transformational leaders foster growth in others and are valuable to organizations as they help each member of their staff meet their individual needs (Redman, 2006). Those with a strong capacity to build relationships usually have leadership potential. Competent leadership will always be in demand in the health care milieu. Occupational therapy practitioners are well positioned to take on leadership roles, even if they don’t have management titles, because relationship building, communication capacity, professional competency, and vision are integral to day-today clinical practice (Heard, 2014). According to Dr. Earl Suttle (2011) of Leadership Success International, LLC, you must be able to understand how to lead yourself before you can lead others. Leaders make decisions daily whether they are aware of it or not. Leaders are truly visionaries. A visionary is one who embraces new directions and is forward thinking, projecting into the future (Phipps, 2015). This person thinks outside of the traditional confines of the profession to predict and propose how to meet future societal needs. A visionary can see past traditional boundaries to new possibilities at all levels of personal and societal

life. A visionary has the capability to translate vision into a reality as he or she is able to see ahead.

Conclusion Occupational therapy practitioners already have the skills needed to thrive in a changing health care environment. When provided with leadership or management opportunities, practitioners can use these skills to facilitate positive outcomes for both clients and the profession across practice areas. Not only does occupational therapy leadership help broaden society’s understanding of the profession, but it also aids in demonstrating the distinct value to clients, other health care professionals, payers, and legislators. References American Management Association. (2009). Professional training solutions. Retrieved from http://www.amanet.org/Individual-Solutions.aspx American Occupational Therapy Association. (2015). 2015 AOTA salary and workforce survey executive summary. Retrieved from http://www.aota. org/-/media/corporate/files/secure/educations-careers/salary-survey/2015aota-workforce-salary-survey-low-res.pdf Bennis, W., & Nanus, B. (2007). Leaders: The strategies for taking charge (2nd ed.). New York: Harper and Row. Bondoc, S., Kroll, C., & Herz, N. (2008, September). Managerial competencies for the occupational therapy practitioner, part I. Administration & Management Special Interest Section Quarterly, 24(3), 1–4. Canadian Institute for Health Information. (2011). Occupational therapists in Canada, 2011: National and jurisdictional highlights. Retrieved from https:// www.cihi.ca/en/ot2011_highlights_profiles_en.pdf Gilfoyle, E., Grady, A., & Nielson, C. (2011). Mentoring leaders: The power of storytelling for building leadership in health care and education. Bethesda, MD: AOTA Press. Heard, C. P. (2014). Choosing the path of leadership in occupational therapy. The Open Journal of Occupational Therapy, 2(1), Article 2. Retrieved from http://dx.doi.org/10.15453/2168-6408.1055 Jacobs, K., & McCormack G. L. (Eds.). (2010). The occupational therapy manager (5th ed.). Bethesda, MD: AOTA Press. Morgan, J. (2013). 5 must-have qualities of the modern manager. Retrieved from http://www.forbes.com/sites/jacobmorgan/2013/07/23/5-must-havequalities-of-the-modern-manager/#4acbffa160d5 Phipps, S. (2015, August 24). Transformational and visionary leadership in occupational therapy management and administration. OT Practice, 20, CE-1–CE-7. Redman, R. (2006). Leadership succession planning: An evidence-based approach for managing the future. Journal of Nursing Administration, 36, 292–297. Spehar, I., Frich, J. C., & Kjekshus, L. E. (2012). Clinicians’ experiences of becoming a clinical manager: A qualitative study. BMC Health Services Research, 12. Retrieved from http://bmchealthservres.biomedcentral.com/ articles/10.1186/1472-6963-12-421 Suttle, E. L. (2011). How to lead, motivate, and keep your best employees. Presentation for Neshoba County General Hospital Ancillary Leaders in Philadelphia, MS. Penny Rogers, DHA, MAT, OTR/L, CEAS I, is an assistant professor in the

University of Mississippi Medical Center’s School of Health Related Professions Master of Occupational Therapy Program and the Administration & Management Special Interest Section (AMSIS) Quarterly editor. Her contact information is [email protected].

Catherine Killian, MEd, OTR/L, is a faculty member at the University of Illinois

at Chicago and longtime occupational therapy department and rehabilitation services manager.

Ellen Hudgins, OTD, OTR/L, is founder and president of Progressive Therapy

in Farmville, Virginia, and AMSIS chairperson.

Terry Pollard, MA, is an assistant professor of Health Sciences at the University

of Mississippi Medical Center in Jackson. He teaches courses in writing and health education. As the director for Instructional Development and Distance Learning, he consults with faculty in the development, design, and evaluation of online programs. 

Rehabilitation, Disability, & Participation ••• 24

AOTA Critically Appraised Topic Series: Traumatic Brain Injury A Product of the American Occupational Therapy Association’s Evidence-Based Practice Project This Critically Appraised Topic (CAT) is one in a series of systematic reviews summarizing the evidence related to traumatic brain injury. For more information on the methodology and to read additional CATs in the series, visit http://www.aota.org/Practice/ Rehabilitation-Disability/Evidence-Based. aspx#TBI.

ments to improve occupational performance for individuals following traumatic brain injury.

Summary of Key Findings

What is the evidence that goal attainment and goal directed therapeutic interventions to address psychosocial, behavioral, and/or emotional impairments and skills improve occupational performance for individuals with traumatic brain injury?

Summary of Levels I, II, and III Two Level I randomized controlled trials (RCT) were included that evaluated the effect of goal directed therapy interventions in adults with traumatic brain injury. Interventions in the outpatient setting included but were not limited to: group-based support, individual occupation-based support, combined group of group-based and individual occupation-based support, day hospital settings, and home based settings.

Clinical Scenario

ӹӹ There is strong evidence from two

Focused Question

Traumatic brain injury (TBI) affects approximately 2.5 million individuals in the United States each year. Individuals who survive TBI are living with lifelong disabilities affecting their cognitive, motor, sensory and emotional functioning which limits their ability to live independently, work, and enjoy leisure activities (The Centers for Disease Control and Prevention, 2014). Approximately 20-30% of traumatic brain injury survivors will have major depression 12 months post injury and 18-23% will have thoughts of suicidal ideation. Additional psychosocial issues following traumatic brain injury that may impact occupational performance are increasing the risk of problems with the experience, expression, and control of anger (Bailie et al., 2014) and developing maladaptive coping strategies associated with increased depression and lower productivity status (Dawson, Cantanzaro, Firestone, Schwartz, & Stuss, 2006). Occupational therapy practitioners can help individuals with traumatic brain injury improve their participation by remediating skills, modifying activities and environments, educating on prevention, and promoting health and well-being. The purpose of this systematic review is to provide occupational therapy practitioners with the evidence supporting the use of goal attainment and goal directed therapeutic interventions addressing psychosocial, behavioral, or emotional impair-

Level I RCT to support the use of goal directed interventions in outpatient settings to improve self-ratings with performance and satisfaction (Doig, Fleming, Kuipers, Cornwell, & Khan, 2011; Ownsworth, Fleming, Shum, Kuipers, & Strong, 2008).

ӹӹ There is moderate evidence from one

Level I RCT to support the use of individual occupation-based supports and combined group (individual occupation-based and group-based) supports to improve performance self-ratings on the Canadian Occupational Performance Measure (COPM) (Ownsworth, et al., 2008).

ӹӹ There is moderate evidence from

one Level I RCT to support the use of group-based supports and combined group (individual occupation-based and group based) supports to improve self-rated satisfaction on the COPM (Ownsworth et al., 2008).

ӹӹ There is moderate evidence from

one Level I RCT to support the use of goal directed outpatient rehabilitation following traumatic brain injury to improve goal attainment, occupational performance, psychosocial reintegration and ability and adjustment levels (Doig et al., 2011).

ӹӹ There is moderate evidence from one

Rehabilitation, Disability, & Participation ••• 25

Level I RCT to support the use of goal directed therapy in the home to improve patient satisfaction (Doig et al., 2011). ӹӹ There is insufficient evidence from one

Level I RCT to support the use of only group-based supports to improve performance self-ratings on the COPM (Ownsworth et al., 2008).

ӹӹ There is insufficient evidence from one

Level I RCT to support the use of only individual occupation-based supports to improve self-rated satisfaction on the COPM (Ownsworth et al., 2008).

ӹӹ There is insufficient evidence from one

Level I RCT to support the use of goal directed therapy to be carried out at a day hospital or home setting over the other (Doig et al., 2011).

Bottom Line for Occupational Therapy Practice Overall, the evidence indicates that the use of goal directed therapy improves perception of satisfaction and performance regardless of treatment context following traumatic brain injury. There is a moderate strength of evidence that supports the effectiveness of client centered goal directed interventions on psychological well-being and adaptability. Occupational therapy practitioners should continue to practice client centered goal directed care with their clients with brain injury. The strongest evidence to support the use of goal directed interventions in outpatient settings to improve psychosocial function is from the systematic reviews that found that goal directed interventions are associated with higher levels of self-rated satisfaction and performance (Doig et al., 2011 & Ownsworth et al., 2008). While there were two Level I studies that evaluated goal directed interventions, there were limitations: (1) small sample sizes; (2) heterogeneity of participants; and (3) brief intervention formats. This work is based on the evidence-based literature review completed by Steven Wheeler, PhD, OTR/L, CBIS; Amanda Acord-Vira, MOT, OTR/L, CBIS; and Diana Davis, MA, OTR/L. References can be found at http://bit.ly/1Xg4C0L

Work & Industry Sponsored in part by

Returning to Work After Traumatic Brain Injury WI

post injury (Johnstone, Mount, & Schopp, 2003) and only 28.4% were employed in comparable jobs 2 years post injury (Ponsford et al., 2014). Long-term participation in vocation or paid work appeared to be worse for individuals with more severe injuries (Ponsford et al., 2014). Occupational therapy addressing vocational participation can be offered in a variety of settings anywhere along the continuum of rehabilitation. However, because return to work is usually achieved in the later stages of recovery, most return-to-work skills are likely to be addressed in post-acute rehabilitation settings. Unlike other professions, occupational therapy addresses the needs of clients along the entire continuum of work, including rehabilitation, skill identification and development, identifying appropriate jobs, transitioning to work, and maintaining employment.

Amanda Acord-Vira, MOT, OTR/L, CBIS; Steven Wheeler, PhD, OTR/L, CBIS; and Diana Davis, PhD, OTR/L

A common goal for many individuals recovering from traumatic brain injury (TBI) is vocational participation. Work can provide economic independence as well as other positive influences by providing a structure for daily activities, and improving psychological and social health (Saltychev, Eskola, Tenovuo, & Laimi, 2013). Individuals who sustain a brain injury often experience impairments in client factors and performance skills. Behavioral and/ or social skills and executive functioning disorders often interfere with vocational performance, and difficulties in these domains are associated with termination of employment (Chappell, Higham, & McLean, 2003). Return to work is notably related to greater perceived success of transition from hospital to home 6 months post injury (Nalder et al., 2012). Return to vocation was found to be related to higher satisfaction with life as a whole post injury (Jacobsson & Lexell, 2013). Yet researchers have documented that of the individuals who were employed at the time of injury, only 50% were still employed 1 year

Case Example: Evaluation and Goals Kevin was a 23-year-old single man with a severe TBI who was admitted to a community-based day treatment program that included occupational therapy. The injury had occurred approximately 12 months earlier when Kevin was hit by a car while walking near the university where he was a part-time junior. At the time of the injury, Kevin was also employed full time. Since the injury Kevin had been living at home, and his family reported to his case manager that they were experiencing increasing stress and tension as they tried to

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26

manage Kevin’s emerging anger and frequent oppositional behavior. Kevin’s family was eligible for a state Medicaid Waiver program, which qualified him for rehabilitation services that included 10 hours per week of occupational therapy.

Treatment Planning and Resource Facilitation The occupational therapist evaluated Kevin using such assessments as the Canadian Occupational Performance Measure (COPM; Law et al., 2014) and the Functional Assessment Measure (FAM; Hall, 1997); a functional capacity evaluation; and through observing both simulated and actual instrumental activities of daily living pertaining to home management, work, and school activities. The assessments showed that Kevin needed assistance for basic community and vocational participation, attention, judgment, and safety awareness. Kevin indicated that the most important activities to him were returning to work, finishing his college degree, socializing with friends, going fishing, and cooking. A crucial part of the early stages of Kevin’s work reintegration program was organizing resources to support his rehabilitation while providing a positive experience. Resource facilitation is a means of providing support that considers potential environmental barriers to the return-to-work transition. Engaging employers in return-to-work plans and providing TBI-related employer education are key areas of focus (Trexler, Trexler, Malec, Klyce, & Parrott, 2010). Other aspects of resource facilitation for Kevin included helping him use public transit, facilitating access to job supports (e.g., job coach, life skills trainer, trained co-worker) and mental health services, providing family education, and assisting with access to various state agencies (Trexler et al., 2010). The rehabilitation team (e.g., occupational therapy, speech therapy, psychology) collaborated with Kevin and his family and decided that he would begin the vocational component of his community re-entry program by helping in the lunch program at a local community shelter. In addition to an understanding staff, the shelter had a variety of volunteer tasks that could accommodate Kevin’s current work capacity and allow a progression in job demands to accompany clinical progress.

Placement and Job Coaching An intensive individualized plan to address work-related skills was established for Kevin that included a job coach as well as a structured environment to meet his specific needs. The occupational therapist

About the Work & Industry SIS The Work & Industry Special Interest Section (WISIS) focuses on the distinct role of occupational therapy in assisting people and groups across populations to engage and reengage in the meaningful occupation of work throughout the lifespan. The WISIS is dedicated to understanding the relationship of work to human development, motivation, and performance and supporting occupational therapy practice in a wide variety of settings. The WISIS provides a forum for networking with peers and other professionals, a means to access clinical resources, and a way to share emerging service delivery systems. ӹӹ Meet the WISIS committee members at www.aota.org/WISIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/21.aspx.

determined that Kevin could tolerate approximately 30 minutes of continuous physical activity per day before showing signs of fatigue and agitation. As a result, Kevin’s first volunteer job involved a 30-minute shift, 5 days per week, requiring him to separate and collect plastic cutlery from a basket and hand it out during lunch. Job analysis identified the tasks involved as continuous standing; sedentary lifting; and continuous social interactions, such as greeting attendees and having occasional conversations. This work was initially supplemented with clinic-based occupational therapy focusing on work conditioning to develop physical capacity, and to address cognitive tasks requiring sustained attention, safety awareness, impulse control, and home management activities. As Kevin’s conditioning improved, the therapy focused more on work hardening; as Kevin’s tolerance improved, his volunteer work shift would be extended, job demands would be increased, and clinic time would be reduced. Compensations for Kevin’s decreased visual acuity were implemented (e.g., using a dark tablecloth with the white utensils) and assistive technology was explored to enhance day planning by communicating through e-mail and social media, and using the Internet to learn new information and create a career plan. After Kevin’s volunteer work was initiated, the occupational therapist worked in collaboration with the occupational therapy assistant on the multidisciplinary team to provide job coaching services (e.g., 1:1 training, advocacy, compensation, adapting work-related tasks, social support, safety awareness, problem solving, supervision, planning). The occupational therapist working on site with Kevin was initially assisting with approximately 50% of the required tasks, but Kevin’s skills quickly improved and he began assuming greater independence in all aspects of his shifts. Kevin was able to progress to 60-minute shifts by the end of week 2. By week 4, he complained about being bored and requested a “better job.” Kevin was able to progress to kitchen duties, where he participated in organizing and storing food, washing dishes, and general cleanup. As expected by the rehabilitation team, the change in demands introduced new struggles, making Kevin more aware of his deficits and causing frustration and agitation. On occasion, Kevin made derogatory comments to the occupational therapist working with him. Understanding these emotional adjustments helped the occupational therapist to remain supportive of Kevin, further strengthening their rapport and facilitating a successful transition to changing job demands. Kelley and colleagues (2014) examined neurobehavioral outcomes 5 years or more after moderate to severe TBI and concluded that people were more likely to gain employment when aware of their cognitive deficits and abilities. Life experiences relevant to an individual with TBI’s goals may increase their understanding of the implications of the injury, leading to more realistic expectations about future outcomes. Sloan, Winkler, and Callaway (2004) emphasized the following factors for success with TBI: Address skills related to the individual’s goals; simplify and structure the task in which the skills are to be learned; build on strengths; and develop routines to make the skills required for daily routines automatic. The rehabilitation team incorporated these findings as Kevin’s program progressed over a 6-month period. Goal setting and goal attainment scaling served as a motivating force, allowing Kevin to recognize his progress and to make necessary connections between his current activity and long-term goals. His structured day treatment program included a goal-setting group that provided an important forum for Kevin to report on his activities and receive additional feedback, encouragement, and support.

Work & Industry ••• 27

After Kevin had progressed to 2 hours of kitchen work per day at the community shelter, he was accepted to volunteer at a local restaurant performing similar tasks but with less structure, a faster pace, more distractions, and greater expectations. After struggling to adjust through the first 4 weeks, Kevin gradually adapted and currently works 3-hour volunteer shifts with a 15-minute break. He enjoys the age-appropriate social interactions and the manner by which he is “treated just like everyone else.” Kevin’s improved level of productivity with minimal errors has resulted in discussions to phase out occupational therapy involvement at the work site for coaching and transitioning him to regular part-time paid employee status. Through this volunteering opportunity and additional community outings, Kevin continues to make progress toward meeting his goals of socializing with friends, cooking, and fishing. Kevin and his occupational therapist also explored opportunities for him to pursue his educational goals, such as applying for accommodations at college. References Chappell, I., Higham, J., & McLean, A. M. (2003). An occupational therapy work skills assessment for individuals with head injury. Canadian Journal of Occupational Therapy, 70, 163–169. Hall, K. (1997). The Functional Assessment Measure. Journal of Rehabilitation Outcomes, 1(3), 63–65. Jacobsson, L., & Lexell, J. (2013). Life satisfaction 6–15 years after a traumatic brain injury. Journal of Rehabilitation Medicine, 45, 1010–1015. http://dx.doi. org/10.2340/16501977-1204 Johnstone, B., Mount, D., & Schopp, L. H. (2003). Financial and vocational outcomes 1 year after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 84, 238–241. http://dx.doi.org/10.1053/apmr.2003.50097 Kelley, E., Sullivan, C., Loughlin, J., Hutson, L., Dahdah, M., Long, M., … Poole, J. (2014). Self-awareness and neurobehavioral outcomes, 5 years or more after moderate to severe brain injury. Journal of Head Trauma Rehabilitation, 29, 147–152. http://dx.doi.org/10.1097/HTR.0b013e31826db6b9 Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N.

(2014). The Canadian Occupational Performance Measure (5th ed.). Ottawa: CAOT Publications. Nalder, E., Fleming, J., Foster, M., Cornwell, P., Shields, C., & Khan, A. (2012). Identifying factors associated with perceived success in the transition from hospital to home after brain injury. Journal of Head Trauma Rehabilitation, 27, 143–153. http://dx.doi.org/10.1097/HTR.0b013e3182168fb1 Ponsford, J. L., Downing, M. G., Oliver, J., Ponsford, M., Archer, R., Carty, M., & Spitz, G. (2014). Longitudinal follow-up of patients with traumatic brain injury: Outcome at two, five, and ten years post-injury. Journal of Neurotrauma, 31, 64–77. http://dx.doi.org/10.1089/neu.2013.2997 Saltychev, M., Eskola, M., Tenovuo, O., & Laimi, K. (2013). Return to work after traumatic brain injury: Systematic review. Brain Injury, 27, 1516–1527. http://dx.doi.org/103109/02699052.2013.831131 Sloan, S., Winkler, D., & Callaway, L. (2004). Community integration following severe traumatic brain injury: Outcomes and best practice. Brain Impairment, 5, 12–29. http://dx.doi.org/10.1375/brim.5.1.12.35399 Trexler, L. E., Trexler, L. C., Malec, J., Klyce, D., & Parrott, D. (2010). Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. Journal of Head Trauma Rehabilitation, 25, 440–446. http://dx.doi.org/10.1097/ HTR.0b013e3181d41139 Amanda Acord-Vira, MOT, OTR/L, CBIS, is a certified brain injury specialist

and an assistant professor of occupational therapy at the West Virginia University School of Medicine in Morgantown, WV. She can be reached at [email protected].

Steven Wheeler, PhD, OTR/L, CBIS, is an associate professor of occupational

therapy at the West Virginia University School of Medicine. He serves as a consultant with NeuroRestorative’s community-based, brain injury rehabilitation program in Ashland, KY. He is also a Governors Appointee on the West Virginia TBI/SCI Rehabilitation Fund Board.

Diana Davis, PhD, OTR/L, is an assistant professor of occupational therapy at

the West Virginia University School of Medicine. She has more than 25 years of experience working with individuals with acquired and traumatic brain injuries in a variety of settings.

Critically Appraised Paper Supports Ergonomic Program Learn how a structured intervention program can reduce pain and improve body posture in health care professionals in the Critically Appraised Paper (CAP) at http://goo.gl/iOxo25. Based on a peerreviewed article, the CAP provides an at-a-glance summary of the effectiveness of an ergonomic program that offers education and skill training to address work-related body posture and lowerback pain. The program can be used as in-service or continuing education opportunity to prevent or restore function for health care professionals. For other CAPs and information on opportunities to submit or serve as a reviewer for a CAP, visit www.aota.org/Evidence-Exchange. Work & Industry ••• 28

Addressing Sensory Integration for Work Participation SI

Beth Pfeiffer, PhD, OTR/L, BCP

Transitioning into work settings can be challenging for any young adult, but those with sensory processing disorders (SPD) may experience additional barriers to participation due to the demands of the sensory environment. Research has identified the concerns of adults with SPD (Brown, Tollefson, Dunn, Cromwell, & Filion, 2001; Kinnealey, Oliver, & Wilbarger, 1995; May-Benson, 2011; May-Benson & Kinnealey, 2012) in areas such as quality of life, mental health, and overall participation. Many adults living with SPD do not receive the basic supports and interventions necessary for participating in the most essential of life’s activities, such as work. Although the prevalence of SPDs is unknown in adults, it was estimated in one study with college students that as many as 15% have sensory hypersensitivity (Johnson & Irving, 2008). One concern that is not commonly addressed in the sensory integration literature is the demands of the work environment on adults with SPD, and how occupational therapy can address those demands. Work environments are often stimulating and require multisensory integration for complex motor tasks that are challenging for adults with SPD. Everyday workplace routines such as commuting on public transportation and eating lunch in a cafeteria occur in stimulating environments that can affect participation for someone with SPD. Common sensory issues, including sensory modulation disorders and dyspraxia, can have a profound effect on overall work performance and satisfaction. Although there is limited research addressing these specific issues, some preliminary literature identifies aspects of work as important outcomes of intervention when working with adults with SPD (Hough & Koenig, 2014; May-Benson & Kinnealey, 2012). The fit between the unique way a person responds to sensory stimuli and the praxis abilities of the individual, along with understanding the demands of the work environment, is an important consideration in supporting the adult with SPD. This person-environment fit is frequently discussed in the work literature (Hardin & Donaldson, 2014). However, there has been little discussion of either an individual’s sensory processing response to sensory stimuli or the sensory environment and the potential effect this has on a person. A mismatch between these two can result in a reduction in both work satisfaction and performance, and in extreme cases the inability to maintain or sustain employment in addition to associated issues regarding mental health, social identify, quality of life, and independence. Occupational therapists with training in sensory integration are well suited to evaluate and provide interventions to improve the match between the person and environment. Guided by models such as Person-Environment-Occupation Model (Law et al., 1996) and the Ecology of Human Performance (Dunn, Brown, & Youngstrom, 2003), occupational therapists have the unique background to evaluate and modify sensory environments across a continuum of employee needs, improving access and participation in work environments through broad universal design and individualized modifications. Occupational therapists, along with Human Resources specialists, managers, and other providers of employment services, are a pivotal part of a team to enhance work participation for individuals with SPD. Tools to guide intervention include general environmental and person-centered assessments such as the Adult Sensory Profile (Brown & Dunn, 2002), Adult Defensiveness, Understanding, Learn-

ing, Teaching: Sensory Interview (Kinnealey & Oliver, 1999), and the Canadian Occupational Performance Measure (Law et al., 2014). Interventions tailored toward supporting optimal processing and that use sensation, as well as the individual’s understanding of his or her unique needs, are an important component of the intervention process. Additionally, an environmental assessment and interventions targeting adaptations to the sensory environment can have an immediate effect on the person-environment fit. In a recent qualitative study (Pfeiffer, 2015), high functioning adults with autism identified environmental factors that affected work satisfaction and performance. When not previously adapted or modified, the sensory environment was frequently identified as a negative factor affecting work outcomes. One participant identified the profound positive effect on both her satisfaction and performance when her work environment was changed to support her unique sensory processing needs. Megan (a pseudonym) worked in a busy call center, where there were many other people talking on the phone at the same time. The environment had tile floors and only small moveable barriers between each of the employees. This resulted in a noisy environment that negatively affected Megan’s work performance. Additionally, Megan demonstrated notable tactile hypersensitivity, which affected the clothing she would wear for work. She reported that she needed to wear comfortable clothing, which others perceived as unprofessional or socially unacceptable. She needed to drive to work each day, as she found public transportation too noisy and overwhelming. Although her work did not require a high level of complex motor planning, Megan reported that she would often bump into others when she moved around the work environment and was perceived as clumsy by her coworkers. This further affected her social acceptability and the perceptions of her supervisors regarding her work performance. After talking with a friend who had a child with SPD, Megan pursued an occupational therapy evaluation because of her struggles with feeling disconnected and her difficulties performing basic work duties such as concentrating and responding to customers on the phone. She reported that the occupational therapist helped her to advocate for a work environment that was a better fit for her unique sensory needs. Megan advocated for reduced noise and physical interactions with others. Her employer was supportive, although it was not possible to adapt the work environment because of the design of the space and the amount of people. Instead, he agreed to allow her to work at home. By working at home Megan is able to dress comfortably and eliminate distracting noise. She participates in meetings and other

About the Sensory Integration SIS The Sensory Integration Special Interest Section (SISIS) focuses on the research and development of sensory integration theory, assessment, and intervention as applied in occupational therapy practice. Sensory integration is used to enrich the occupational performance and participation of individuals with a variety of disabilities across the lifespan by focusing on the neurobiological, sensory, and praxis foundations of occupation. ӹӹ Meet the SISIS committee members at www.aota.org/SISIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/19.aspx.

Work & Industry ••• 29

Explore evidence on Sensory Integration and Processing in the Topics section of the American Journal of Occupational Therapy http://ajot.aota.org/topics.aspx work activities through the use of technology, and reported that her social interactions with her colleagues have notably improved, as she is not distracted by sensory stimuli or concerned about potentially uncomfortable physical interactions. Megan reported that she meets friends from work out in the community in environments that she reports as less stimulating and taxing than the workplace. Her employer now considers her a high performer and she reported feeling valued by her supervisor. This is only one case example of the potential role occupational therapists can fill in meeting the unique needs of adults with SPD in their work environments. A considerable need exists for more empirical research to understand the efficacy of interventions for SPD addressing both the person and the environment on work satisfaction and performance. Occupational therapy’s role in increasing participation in the purposeful and meaningful occupation of work has the potential to affect larger societal outcomes through the reduction of employment disparities for individuals with SPDs and related disabilities. References Brown, C., & Dunn, W. (2002). Adolescent/Adult Sensory Profile user’s manual. San Antonio,, TX: The Psychological Corporation. Brown, C., Tollefson, N., Dunn, W., Cromwell, R., & Filion, D. (2001). The Adult Sensory Profile: Measuring patterns of sensory processing. American Journal of Occupational Therapy, 55, 75–82. http://dx.doi.org/10.5014/ajot.55.1.75

Dunn, W., Brown, C., & Youngstrom, M. J. (2003). Ecological model of occupation. In P. Kramer, J. Hinojosa, & C. Royeen (Eds.), Perspectives in Human Occupation: Participation in Life (pp. 222–262). Philadelphia: Lippincott Williams & Wilkins. Hardin, E. E., & Donaldson, J. R. (2014). Predicting job satisfaction: A new perspective on person-environment fit. Journal of Counseling Psychology, 61, 634–640. Hough, L., & Koenig, K. (2014, February 10). Autism in the workplace. OT Practice, 19(2), 14–16. Johnson, M. E., & Irving, R. (2008, September). Implications of sensory defensiveness in a college population. Sensory Integration Special Interest Section Quarterly, 31(2), 1–3. Kinnealey, M., & Oliver, B. (1999). Adult Defensiveness, Understanding, Learning, Teaching: Sensory Interview (ADULT-SI). Unpublished manuscript. Kinnealey M., Oliver, B., & Wilbarger, P. (1995). A phenomenological study of sensory defensiveness in adults. American Journal of Occupational Therapy, 49, 444–451. http://dx.doi.org/10.5014/ajot.49.5.444 Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-Occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9–23. Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollack, N. (2014). The Canadian Occupational Performance Measure (5th ed.). Ottawa, Ontario: CAOT Publications. May-Benson, T. A. (2011, June 6). Understanding the occupational therapy needs of adults with sensory processing disorder. OT Practice, 16(10), 13–17. May-Benson, T., & Kinnealey, M. (2012). An approach to assessment of and intervention for adults with sensory processing disorder. OT Practice, 17(17), CE-1–CE-8. Pfeiffer, B. (2015, May). Environmental factors impacting work satisfaction and performance in adults with autism spectrum disorders. Paper presented at the annual Occupational Therapy Summit of Scholars, Los Angeles. Beth Pfeiffer, PhD, OTR/L, BCP, is an associate professor at Temple University

in Philadelphia. She is also the Quarterly editor for the Sensory Integration Special Interest Section. She can be reached at [email protected].

Work & Industry ••• 30

Education Sponsored in part by

Transitioning From Clinician to Fieldwork Educator E

method with all students, regardless of the students’ knowledge or skill levels, and without regard for each student’s learning style, which can result in passive student involvement, dependence on the fieldwork educator, and diminished critical thinking and problem-solving skills (Dowling, 2001; McCrea & Brasseur, 2003). Training specific to fieldwork education can expose the fieldwork educator to strategies and behaviors that promote student learning and development. Practitioners may not have been taught methods specific to helping students apply concepts learned in the classroom to practice (American Occupational Therapy Association, 2009; Christie, Joyce, & Moeller, 1985; Costa, 2004; Herkt, 2005; Ilott, 1995; Johnson, Haynes, & Oppermann, 2007; Kautzmann, 1990; Quilligan, 2007). They may possess supervisory skills but lack expertise in instructional design. One reason for this lack of training may be that limited empirical evidence exists in the area of fieldwork education, especially as it relates to fieldwork outcomes. Knowledge about fieldwork education has primarily come from descriptive studies that have led to the identification of methods for selecting various teaching styles and facilitating critical thinking in students (Dowling, 2001; McCrea & Brasseur, 2003). Fieldwork educators can benefit from research that has been conducted in the area of fieldwork education specific to developing relationships with students, analyzing and applying evidence-based research regarding educator and student

Lynne Margaret Chapman, MS, OTR/L, LICDC, Instructor, AOTA Fieldwork Education Certificate Program

Throughout the fieldwork education process, the amount and type of involvement of both the educator and the student change. As the amount of direction by the educator decreases, the amount of participation by the student increases. Students may be performing at any stage in the continuum of learning to apply knowledge and skills in the fieldwork setting, depending upon the variables specific to the setting and the knowledge base and skill set of the student. It is important that the fieldwork educator modify the approach to education in response to the unique challenges of the learning environment and knowledge base and skill set of the student at each stage of fieldwork development. Many practitioners enter into the role of fieldwork educator without adequate preparation (Dowling, 2001; McCrea & Brasseur, 2003; Spence, Wilson, Kavanagh, Strong, & Worrall, 2001). Without preparation, fieldwork educators may default to their own student experiences as a source for methodologies and have misperceptions related to students’ fieldwork preparation. They tend to use the same

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Explore information about fieldwork education and workshops http://aota.org/Education-Careers/ Fieldwork.aspx behaviors, and understanding and applying principles related to conflict resolution. Based on a review of the literature, one of the most influential factors relevant to the effectiveness of the fieldwork educator is the ability to communicate effectively (Quilligan, 2007). Adopting an effective style of communication with students has been shown to improve student performance. Research has supported a correlation between superior student performance and a student’s perception of being able to share their thoughts and feelings with the fieldwork educator without fear of judgment, verbalize their learning needs, and ask questions. Students’ performance has been positively affected by positive reinforcement and constructive feedback that is provided with perceived genuineness and empathy (McCrea & Brasseur, 2003).

Methods to Enhance Fieldwork In addition to enhancing their communication skills, fieldwork educators need to help the student systematically develop goals and design and implement interventions based on the results of a client evaluation. Given the current shift from fieldwork supervision to fieldwork education, practitioners may not be prepared to apply instructional design principles to create the most effective learning experiences if they have not been educated in how to design learning in a systematic way. Instructional design is the practice of creating educational experiences with the goal of maximizing the efficiency and effectiveness of knowledge and skill acquisition (StutzTanenbaum & Hooper, 2009). The fieldwork educator assesses the student’s knowledge and skills, establishes goals of instruction, and designs interventions to assist in the process of learning. Instructional design includes the analysis, design, development, implementation, and evaluation of instructional experiences. The fieldwork educator demonstrates knowledge about the subject matter being taught; interacts effectively with the student; demonstrates leadership and administration skills; and possesses the skills required for designing learning experiences (Fink, 2003). The effectiveness of the fieldwork experience is influenced by the competency of the educator in implementing effective and efficient instructional design principles. During a positive fieldwork experience, the student experiences a role shift from student to practitioner and professional and becomes increasingly aware of his or her own values, perceptions, biases, and ethics. The student’s relationships shift from those with classmates and professors to those with co-workers and clients and/or caregivers. The student develops a sense of identity as a professional as he or she begins to articulate and demonstrate the values and perceptions of role models and to blend personal style with practice. Students grow and develop through reflective practice. The student’s role also shifts from recipient of knowledge to provider-teacher of knowledge, routinely incorporating teaching into practice (Johnson et al., 2007). As practitioners, students become accountable to clients, caregivers, employers, and inter-professional team members. Methods of teaching to facilitate a positive experience can include using graded learning with the intent to increase the student’s responsibility for learning (Provident, Leibold, Dolhi, & Jef-

fcoat, 2009). The student can provide input into the development of goals, which can enhance his or her sense of empowerment and accountability. Graded learning can be effective in situations where a specific learning need is identified. The educator can provide the student with opportunities for observation by serving as a role model. The student can be challenged by using strategies that include cues, probing questions, and selective trial and error. Satisfaction with learning is linked to quality and timeliness of feedback (De Beer & Mårtensson, 2015). Students who receive feedback perform better when strengths and areas for growth related to performance and behaviors that need to be changed are identified (Quilligan, 2007). Through feedback, barriers to learning and subsequent ways to achieve the goals are identified, and the student is encouraged to explore alternative methods. Self-reflection strategies designed to increase student self-awareness can include written, verbal, audio, or video mediums. Styles may include feedback that is direct, indirect, sandwiched, constructive rather than destructive, nonverbal, ongoing versus intermittent, specific versus generic, active versus passive, and formal versus informal. Effective feedback can be provided through partnership, empathy, acknowledgement of barriers to learning, respect, legitimizing feelings, and supporting efforts towards improvement. Strategies for providing effective feedback include identifying the source(s) of the feedback that are credible and well-intentioned; modifying feedback based on the student’s level of experience or education; and briefly summarizing. When providing effective feedback, it is important to be mindful of student self-esteem, maintain a focus on the behavior versus on the student, allow the student time to respond, relate feedback to the learning goal, preface feedback with “I” statements, be non-judgmental, and avoid making assumptions. Effective feedback should be provided routinely, sought by the student, accurate, factual, clear, relevant, descriptive, timely, and private. A feedback checklist can help the educator provide feedback that is well-timed, expected, based on firsthand or observed data, appropriate in amount, focused on changeable behaviors, phrased in descriptive and nonjudgmental language, specific to performance versus generalities, identifies subjective data, and avoids assumptions. A feedback grid can encourage the student to continue to demonstrate performance skills and behaviors that have been effective by citing specific examples that include a description of his or her impact and identify performance skills and behaviors that the educator would like the student to develop or demonstrate more often. The educator can

About the Education SIS The Education Special Interest Section (EDSIS) members share a common interest in the field of occupational therapy education and include program directors, fieldwork educators, academic fieldwork coordinators, and faculty. The EDSIS has a Fieldwork Subsection for fieldwork educators and academic fieldwork coordinators, and a Faculty Subsection. The EDSIS strives to share current evidence-based teaching and learning tools and strategies in order to facilitate best practices in occupational therapy and occupational therapy assistant education. ӹӹ Meet the EDSIS committee members at www.aota.org/EDSIS. ӹӹ Join the OT Connections discussion at

http://otconnections.aota.org/sis_forums/f/12.aspx.

Education ••• 32

identify an area of potential growth for the student that could include decreasing or terminating specific performance skills or behaviors that are not helpful or even potentially harmful by predicting their potential impact (Quilligan, 2007). Clinical reasoning is developed through students planning, directing, performing, and reflecting on client care (Cohn, 1989), and assists them with integrating therapeutic concepts and skills. Clinical reasoning can be developed through having discussions; processing personal feelings and/or values; establishing accurate and appropriate intervention plans based on evaluation results by integrating client priorities, context(s), theories, and evidencebased practice; and articulating a clear and logical rationale for the intervention process. Clinical reasoning skills can be evaluated by questioning what the student knows and evaluating his or her level of performance. Effective questions include informational, which refers to asking the student for specific information; application, which asks the student to apply knowledge to a specific situation; and problem-solving, which asks for principles and creative answers to new ideas (Crist & Scaffa, 2004). Reflection promotes the application of newly learned skills to improve student outcomes. Reflection involves thinking in both retrospective and prospective ways (Cohn, Schell, & Blesedell Crepaeu, 2010). Retrospective reflection involves processing the results of what happened and considering one’s response to it. Prospective reflection identifies goals, and strategies for achieving those goals. Effective strategies to encourage student reflection include planning key questions in advance; phrasing questions clearly and specifically; adapting questions to accommodate the student’s needs and level of understanding; avoiding answering the question; and allowing the student to question the educator. As the student responds, the educator can provide positive reinforcement, pose additional probing questions, ask for justification, clarify questions, elaborate, or re-direct the question to another student for additional perspectives.

Conclusion Fieldwork educators are the primary resource in supporting practice through developing innovative and evidence-based approaches to intervention, implementing health care changes, and expanding client-centered approaches. We need to be leaders who demonstrate the ability to integrate the roles of practitioner and educator as we engage students in learning opportunities. References American Occupational Therapy Association. (2009). Self-assessment tool for fieldwork educator competency. Retrieved from http://www.aota.org/-/media/

Corporate/Files/EducationCareers/Educators/Fieldwork/Supervisor/Forms/ Self-Assessment%20Tool%20FW%20Ed%20Competency%20(2009).pdf Christie, B., Joyce, P. C., & Moeller, P. (1985). Fieldwork experience, part II: The supervisor’s dilemma. American Journal of Occupational Therapy, 39, 675–681. http://dx.doi.org/10.5014/ajot.39.10.675 Cohn, E. (1989). Fieldwork education: Shaping a foundation for clinical reasoning. American Journal of Occupational Therapy, 43, 240–244. http://dx.doi. org/10.5014/ajot.43.4.240 Cohn, E., Schell, B., & Blesedell Crepaeu, E. (2010). Occupational therapy as a reflective practice. In N. Lyons (Ed.), Handbook of Reflection and Reflective Inquiry (pp. 131–157). Costa, D. M. (2004). The essential guide to occupational therapy fieldwork education: Resources for today’s educators and practitioners. Bethesda, MD: AOTA Press. Crist, P., & Scaffa, M. (2004). Best practices in occupational therapy education. Occupational Therapy in Health Care, 18(1/2), 31–39. De Beer, M., & Mårtensson, L. (2015). Feedback on students’ clinical reasoning skills during fieldwork education. Australian OT Journal, 62, 255–264. Dowling, S. (2001). Supervision: Strategies for successful outcomes and productivity. Needham Heights, MA: Allyn and Bacon. Fink, L. D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco: Jossey-Bass. Herkt, A. (2005). Exploring the supervision of occupational therapists in New Zealand. Unpublished master’s thesis, Auckland University of Technology, New Zealand. Ilott, I. (1995). To fail or not to fail? A course for fieldwork educators. American Journal of Occupational Therapy, 49, 250–255. http://dx.doi.org/10.5014/ ajot.49.3.250 Johnson, C., Haynes, C., & Oppermann, J. (2007). Supervision competencies for fieldwork educators. OT Practice, 12(22), CE-1–8. Kautzmann, L. N. (1990). Clinical teaching: Fieldwork supervisors’ attitudes and values. American Journal of Occupational Therapy, 44, 835–838. http://dx.doi. org/10.5014/ajot.44.9.835 McCrea, E. S., & Brasseur, J. A. (2003). The supervisory process in speech-language pathology and audiology. Boston: Allyn and Bacon. Provident, I., Leibold, M. L., Dolhi, C., & Jeffcoat, J. (2009). Becoming a fieldwork “educator”: Enhancing your teaching skills. OT Practice, 14(19), CE-1–CE-8. Quilligan, S. (2007). Communication skills teaching: The challenge of giving effective feedback. Clinical Teacher, 4, 100–105. Spence, S. H., Wilson, J., Kavanagh, D., Strong, J., & Worrall, L. (2001). Clinical supervision in four mental health professions: A review of the evidence. Behaviour Change, 18, 135–155. Stutz-Tanenbaum, P., & Hooper, B. (2009, June). Creating congruence between identities as a fieldwork educator and a practitioner. Education Special Interest Section Quarterly, 19(2), 1–4. Lynne Margaret Chapman, MS, OTR/L, LICDC, Instructor, AOTA Fieldwork

Education Certificate Program, is a clinical associate professor in the Occupational Therapy Doctoral Program in the Department of Rehabilitation Sciences at The University of Toledo and Senior Clinician in the Department of Rehabilitation Services at The University of Toledo Medical Center in Ohio. She can be reached at [email protected].

Help the Profession be More Science-Driven and Evidence-Based What can you do as an educator to help the profession be more science-driven and evidence-based? Through AOTA’s Evidence Exchange, students and faculty are able to contribute to the critical appraisal of evidence by submitting Critically Appraised Papers (CAPs), at-a-glance summaries of the findings and methods of individual articles. Educators are also well positioned to serve as Evidence Exchange CAP Reviewers. To learn more about the program and review the CAP toolkit, guidelines, and research statistics resources, visit http://www.aota.org/Evidence-Exchange. Education ••• 33

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