Occupational justice within residential aged care settings – Time to focus on a collective approach

The role of the occupational therapist in aged residential care

The traditional practice of occupational therapy focuses on the individual, and discipline-specific literature predominantly reports on individual, rather than collective, outcomes (see, for example, Adams and Casteleijn, 2014). Most assessment tools, outcome measures and profession-specific models of practice available to guide occupational therapists are focused on the person, creating a confined scope of individualised practice that emphasises functional outcomes.

In residential care contexts, our profession lacks an approach that distinguishes us from less expensive and, in many cases, equally effective colleagues. Occupational therapy for individuals in residential care is perceived as an expensive intervention in comparison to that of an activity therapist or nursing aide. Additionally, funding structures often dictate the occupational therapy role within aged residential care to focus on pain management or issuing assistive devices. When considering the associated cost of having a group-based leisure programme run by volunteers, it is hardly surprising that group interventions are not viewed as an occupational therapy domain in this care context.

Besides the ability to enable meaningful engagement for residents despite their level of ability, the occupational therapy profession could address other occupation-specific issues affecting staff that cause them to experience disenfranchisement and disempowerment (Thomas et al., 2014). To date we have limited data to document how occupational therapy could add significant value to existing residential care services.

Changing our game

While there will always be the need for skilled occupational therapy services for individuals, we recommend that our profession adopt a more strategic and comprehensive approach to residential populations. Pereira and Whiteford (2013) recommend changing our focus to the collective to promote social and environmental change that will influence social policy. In this opinion piece, we reinforce these ideas. We recommend that residential facilities are viewed as micro-communities (Du Toit et al., 2018) and strive towards a shared vision and intentionality to collectively achieve outcomes that are mutually beneficial (Adams and Casteleijn, 2014). A shared vision by staff, families and residents will lead to the increased belonging and meaningful engagement of all parties. However, this process of participating collectively does not come automatically and requires expert facilitation.

We propose that an occupational therapy focus on collective participation within aged care settings would greatly contribute towards health and wellbeing. The right to active and engaged ageing for older adults is supported by our profession. Policies acknowledging older people’s right to self-fulfilment through meaningful engagement are complemented by a large body of multi-disciplinary research evidence documenting the adverse impacts that inactivity, lack of connection/loneliness and boredom have on institutionalised people (see, for example, Brownie et al., 2014). Moreover, by addressing meaningful engagement for both residents and staff, staff burnout could be prevented when purpose and meaning are incorporated into caregiving. Meaningful engagement can also support occupational identity (Thomas et al., 2014).

At the beginning of the new millennium, Ilott et al. (2006: 40) urged for ‘an openness to new ways of thinking and doing; and a commitment to offer services of proven effectiveness’ to promote the agenda for evidence-based practice in occupational therapy. Our next step should be to incorporate collectives into this agenda through the combined effort of national associations, occupational therapy services and individual practitioners. Research initiatives to build empirical evidence are needed to address our deficiency in authoritative research on collective settings, without which the profession’s comments remain devoid of expert status.

Residential care as a collective context

Aged residential care settings contain neighbourhoods within a finite geographical setting, creating a contrived micro-community (Du Toit et al., 2018). Paradoxically, current residential care settings typically foster a lack of belonging and exclusion from collective intentions, which leads to feelings of isolation, anxiety and dissatisfaction among staff, residents and families (Thomas et al., 2014). These micro-communities are the ideal settings to investigate and research the social impact of creating collective occupations such as group participation and the involvement of external communities. The need for belonging within a micro-community could address social cohesion while simultaneously advancing a common good (Ramugondo and Kronenberg, 2015). Furthermore, the unique occupational science perspective on how settings affect function, integration and engagement in everyday occupations (see, for example, Morgan-Brown and Chard, 2014) can be utilised to explore and explain how the routines and habits of daily life within micro-community settings positively promote collective occupations.

Townsend and Polatajko (2007) identify four features that provide a way to conceptualise the whole setting, namely (a) accessibility and access to everyday objects (physical environment); (b) access to relationships and social engagement, and the use of language (social environment); (c) ethnicity and spiritual preferences (cultural environment) and (d) an organisation’s care culture (institutional environment). These features could support identifying potential barriers or enablers to collective engagement within a residential care facility micro-community.

Substantiating a whole-setting perspective

Addressing the collective needs of a residential care facility as a micro-community and identifying sources of occupational injustices requires a whole-setting perspective. At present, there is very little occupational science-specific research and our values and outcomes for enhancing meaningful engagement rely mostly on measures developed by other professions, such as such as dementia care mapping (Brooker and Surr, 2005). Other important multi-disciplinary research focuses on the impact of settings on occupational and social engagement (see, for example, de Boer et al., 2017) and on the factors that make it most likely that individuals will engage in occupations (see, for example, Cohen-Mansfield et al., 2017). To add to the body of evidence, interventions and contributions should be assessed with valid and reliable measures, such as the Assessment Tool for Occupational and Social Engagement (Morgan-Brown and Chard, 2014) and the Residential Environmental Impact Scale (Fisher et al., 2014), which evaluate and compare collective occupational engagement within a whole setting from an occupational perspective.

Collaborative engagement in everyday occupations in a residential care setting would enable an older adult to build a sense of belonging, personal identity and interdependence with others (Ramugondo and Kronenberg, 2015), promoting occupational justice. Thriving micro-communities, which foster citizenship for older adults living in residential care, depend on the meaningful engagement of both residents (Du Toit et al., 2018) and staff (Thomas et al., 2014). An essential component of meaningful and mutual engagement is an objective analysis of institutional contexts that impact on staff occupations and consequent engagement with residents. Research is required to understand how to translate real life contexts into settings that support a shared collective vision, with collective actions amongst staff that promote engagement with one another and with residents.

Understanding meaningful engagement within a collective requires all factors within the whole setting to be considered. Only then would the collective increases in social and occupational encounters reflect the belonging and meaningful engagement of everyone in that setting (Du Toit et al., 2014). Morgan-Brown and Du Toit (2018) propose six assumptions about residential settings that impact on levels of interactive occupation and social engagement (see Table 1). They recommend that these assumptions need to be investigated in order to build a solid data base that will underpin the occupational therapy profession as it seeks to better the lives of those living in residential care. Table 1 proposes how assumptions about residential contexts could be explored to develop collective-specific theories, recommendations and interventions.

OPEN IN VIEWER

Table 1.

The impact of residential settings on interactive occupation and social engagement.

Assumptions of the impact of residential care contexts on interactive occupation and social engagement	Proposed research questions
1. The culture of the context impacts on occupational and social engagement	What are the factors most likely to create engagement and occupational justice for both staff and residents?
2. Resident, family and staff behaviours adapt to the physical, social, institutional and cultural context.	How can the concepts of interdependence and shared doing (co-creating) be engendered to increase meaningful engagement for staff and residents?
3. Residential care environments will be organised in different ways depending on the social, cultural, institutional and physical environments.	What current evidence is available to provide an international overview of how models of residential home care impact on occupational and social engagement?Can the effectiveness of residential settings be evaluated by using collective and social engagement as outcome measures?
4. Redefining communal rooms as occupational spaces emphasises participation and engagement, and gives meaning and purpose to communal living.	How can staff and residents be supported to transform communal areas into spaces for collective engagement, equity and shared doing?
5. Staff are an essential component of the life within collective spaces.	How can staff be engaged to promote interdependence, connectivity and shared doing?
6. Whole-setting interventions are more effective than individual therapy for residents who are frail and vulnerable.	How can an evidence base be built where whole-setting interventions promote collective engagement and interaction?What enables a collective vision of interdependence and collective participations between staff, residents and families?

Summary

This article challenges occupational therapists to consider how they could influence meaningful engagement for an aged residential care setting and to widen our focus from an individual to a collective approach. This redirection needs the support of national and international associations to develop strategies for prioritising research and accessing funding in order to create a substantial evidence base for evaluating and strengthening environmental interventions (physical, social, organisational and cultural) and to support evidence-based occupational therapy roles that will achieve greater occupational engagement in collective settings.

Key message

The occupational therapy profession needs a holistic, evidence-based approach to promote occupational justice in the collective context of residential care.