Abstract
BACKGROUND:
The effectiveness of occupation-based hand therapy and the barriers to the use of occupation-based interventions (OBIs) have been established, but the current experience of hand therapists using OBIs and the extent of the use of OBIs in practice is unknown.
OBJECTIVE:
This study aimed to identify the frequency that occupational therapists who are Certified Hand Therapists (CHTs) utilized OBIs, how occupational therapists who are CHTs described their application of OBIs, and identify the supports and barriers to the application of OBIs.
METHODS:
Twenty-nine participants completed a survey that included 27 questions. The questions consisted of close ended, Likert scale, and multiple-choice questions which were analyzed quantitatively, and open-ended questions which were analyzed qualitatively.
RESULTS:
The majority of the participants, 57.7%, reported implementing OBI at least 75% of the time. Barriers and supports to the use of OBIs reported include a lack of equipment and therapist creativity, and support for the use of OBIs included the therapist’s creativity, support from the facility, the availability of equipment, and the intrinsic motivation of therapists. Descriptions of OBI application included activity simulation, adaptive equipment use, and participation in meaningful activity.
CONCLUSION:
Although the use of OBIs in hand therapy may be expanding, occupational therapy practitioners and educators have a role to play in overcoming the remaining barriers to occupation-based hand therapy. Additional research is needed to gain further insight into use of occupation-based intervention by occupational therapists who are CHTs and explore the effect of education on promoting the use of OBIs.
Introduction
The difficulty in balancing the occupation-based approach recommended in the literature [1–5] and the biomechanical approach that characterizes hand therapy [3, 7] is well documented [4, 9]. While the effectiveness of an occupation-based approach has been reported [5, 8], barriers to the use of this approach which may influence the use of occupation-based interventions (OBIs) remain [9–11]. Previous studies have examined the use of OBIs in hand therapy [3], but the current extent of use, and possible influence of barriers, is not known, particularly among Certified Hand Therapists (CHTs).
Literature review
Occupation-based interventions are defined as treatment that allows each client’s individual interests and activities to guide the intervention process, leading to greater participation and better outcomes than therapist-directed interventions [12]. Providing evidence-based, client-centered care, including OBIs, is among the ideals laid out in the American Occupational Therapy Association’s “Vision 2025” that serves as a guide for the profession as it moves into the future [13]. Recent studies have highlighted the evidence for OBIs. Improvement has been reported in impairments such as range of motion, strength, pain, and edema [14–18]; increased functional abilities [15, 19]; increased client interest, motivation, and tolerance [17, 21]; faster recovery [19]; and improved occupational performance and satisfaction [14, 15].
While more recent studies have demonstrated the effectiveness of an occupation-based approach in hand therapy [5] past literature provided limited information on outcomes of occupation-based assessments and treatments [1]. This previous paucity of outcome studies may have created a credibility barrier for the integration of OBIs among hand therapists [3, 22].
Previous literature has reported other barriers that hand therapists experience while attempting to incorporate OBI into their practice. Along with the barrier of the questioned credibility of an occupation-based approach, barriers such as therapist creativity; a focus on the biomechanical including over reliance on protocols; space, time and equipment limitations; reimbursement; and client unrelated factors such as medical condition and their understanding and acceptance of OBI [3, 22]. These barriers demonstrate the effects of focusing on the medical model and biomechanical frame of reference in hand therapy [3].
Certified Hand Therapists are viewed as experts who work with individuals needing surgical and non-surgical treatments in varied practice settings including orthopedic outpatient clinics, senior centers, hospital settings, and community-based hand clinics [14, 23]. A shift away from the biomedical model to an occupation-based approach in hand therapy that is occupation-centered and client-focused has been purported to positively impact clients [4]. Some CHTs incorporate OBIs in clinical practice by implementing evidence-based treatments with clients and supporting the foundational principles of occupational therapy, however the frequency of use and experience of providing OBIs specifically by CHTs remains unclear [9]. It is also unclear exactly how OBIs are implemented in daily practice by CHTs and there is a need for specific examples of occupation-based interventions in the current literature [3]. Thus, the purpose of this study was to identify how occupational therapists who are CHTs use OBIs to guide therapeutic practice, the prevalence of OBI use, and the barriers to OBI use.
The following research questions guided the study: What is the frequency of occupational therapists who are CHTs utilizing occupation-based interventions (OBIs) in therapeutic practice as measured by an evidence-based definition of OBI; How do occupational therapists who are CHTs describe their application of occupation-based interventions in clinical practice?; and What supports and barriers affect occupational therapists who are CHTs integrating OBI into clinical practice?
Methods
This mixed-methods study used a convergent design [22] to explore the use of OBI among occupational therapists who are CHTs.
Participants
In order to explore the experiences of occupational therapists who work in the hand therapy setting with OBIs, inclusion criteria for this study were being an occupational therapist who is also a CHT. Participants were recruited using purposeful sampling to ensure that inclusion criteria were met. Participants were selected by consulting the American Society of Hand Therapists (ASHT) website directory and choosing the first seven therapists from each state with occupational therapy and CHT credentials as well as a working email address to reach a total of 250 valid email addresses. Sampling did not include Nevada, West Virginia, and South Dakota, due to a lack of sufficient occupational therapists who are CHTs with a valid email address listed in the directory.
Survey
The data was collected using a survey that included 27, of which 5 were open ended and 22 were close ended, including Likert scale and multiple choice questions. Question topics and style were influenced by previous literature [3, 25–31]. Questions about the participants’ background and experience, how they define and use OBI’s, as well as perceived supports and barriers to the use of OBIs in hand therapy practice were included.
The survey was reviewed by an occupational therapist who is a CHT and question language was altered for accuracy and ease of understanding. The survey was delivered using the QualtricsXM® survey software. The study was approved by the Shenandoah University Institutional Review Board. An invitation and link to the survey, including an electronic informed consent form, was emailed to participants. A reminder email was sent out after 2 weeks. The survey was kept open for 6 weeks.
Data analysis
This mixed methods study involved analysis of quantitative and qualitative data. Qualitative data was analyzed through a process that began with immersion in the data, then led to coding of similar concepts, and the development of overarching themes. To avoid investigator bias, the qualitative data was reviewed and analyzed prior to the quantitative data. This was done to prevent researchers from coding or creating themes based on results from the quantitative data. To further ensure trustworthiness of the results, researchers analyzed the data separately first, then together as a group through peer debriefing. Triangulation was achieved through analysis of data by multiple researchers and by asking questions that had the participants think about their responses in different ways. For example, in order to examine what may restrict the use of OBIs in hand therapy settings one open ended question asked participants to “Describe the barriers that affect your ability to incorporate OBI’s with your clients who have upper extremity conditions”. In order to approach restrictions on the use of OBIs from a different perspective, participants were also asked “Would you like to incorporate more occupation-based interventions into your practice with your clients who have upper extremity conditions? Why or why not?”. Quantitative data was entered into the Statistical Package for the Social Sciences, version 26 (SPSS IBM Corp., Armonk, NY, USA) for analysis. Descriptive statistics were run to aggregate the data and examine relationships between variables.
Results
Description of participants
Twenty-nine valid responses were received from the 250 surveys sent out making the response rate 11.6%. The average number of years worked as a CHT was 16 years, with a minimum of 3 years and a maximum of 30 years. The average number of years worked as an OT was 26 years with a minimum of 8 years and a maximum of 40 year [Table 1]. Please see Tables 2 and 3 for additional participant demographics [Table 2] [Table 3].
Participant years of experience as a CHT and as an occupational therapy
Participant years of experience as a CHT and as an occupational therapy
Practice settings
Average number of clients seen weekly, treatment sessions, and surgical versus non-surgical clients
The following definition of occupation based intervention was provided for participants: OBIs are treatment that allows each client’s individual interests and activities to guide the intervention process, leading to greater participation and better outcomes than therapist-directed interventions [12]. Based on this definition, 57.7% of participants stated they perform OBIs during treatment sessions frequently or always [Table 4].
Frequency of performing OBI with clients who have upper extremity conditions
Frequency of performing OBI with clients who have upper extremity conditions
Participants were asked which occupations from the Occupational Therapy Practice Framework (OTPF) they addressed using OBIs. Participants indicated that the most common occupations addressed during OBIs included meal preparation and cleanup (76%), dressing (69%), leisure participation (69%), social participation with family (66%), personal hygiene and grooming (66%), care of pets (66%), care of others (62%), and needs/interests exploration (62%) [Table 5].
Occupations addressed during treatment
Occupations addressed during treatment
Participants were presented with a list of barriers including time, productivity, equipment, environment, reimbursement, credibility, and protocol and asked to choose all that affected their ability to implement OBI in their practice. The most common barriers chosen by participants were time, equipment, and the environment [Table 6].
Barriers to performing OBIs
Barriers to performing OBIs
The relationships between frequency of OBI use and a number of factors were examined. Factors examined included years of experience as a CHT and how often OT CHTs perform OBI; overall years of experience as an OT and years of experience as a CHT; years of experience as an OT and how often OT CHTs perform OBIs. The only significant relationship present was between years of experience as an OT and the frequency of OBI use (r = –0.423, p = 0.040) indicating that the more years of experience a participant had as an OT, the more frequently they used OBI in practice.
Qualitative results
The qualitative analysis revealed the following themes: Client Factors in OBI, Therapist Agency in OBI, Indirect Use of Occupation in OBI, Direct Use of Occupation in OBI, and Influence of Context and Environment [Table 7].
Themes
Themes
This theme addressed the ways that clients influence the use of OBIs. One participant shared how patient preference influences the use of OBIs, stating, “Some patients don’t want to do them, they prefer traditional exercises.” (Participant 7). The client’s medical readiness was also reported as influencing the use of OBIs. For example, one participant stated that a “large majority of clients are post op and no [sic] yet ready for OBI’s, beginning of treatment is leading up to OBI”’ (Participant 13). Participants also noted that what is meaningful to the client also influences use of OBIs, with one participant stating “All clients are assessed for interests and activity/occupational goals at first visit and throughout and we tailor home programs to incorporate meaningful activities as much as possible” (Participant 9).
Therapist agency in OBI
This theme described factors related to the therapist which affect the implementation of OBIs. One participant shared that in order to provide OBI, their role in the OT process was to “analyze where the failure is, and remediate, compensate, or adapt to restore maximum performance, based on patient goals” (Participant 4). Participants discussed doing the best they can under limitations. For example, one participant reported, “I feel like I address this the best I can in the location I am at, just space limitations for including other interventions.” (Participant 6). Another participant discussed using their creativity to overcome barriers, stating, “[I] have [patients] bring things from home to use during therapy sessions (ie, knitting needles, sports equipment, utensils)” (Participant 11). Participants also reported that their own volition was needed to overcome barriers to the use of OBIs. For example, one participant explained that “you are your only barrier, meaning, it takes planning and creativity to incorporate OBI into practice as manual therapy, modalities, and exercises are typically effortless in hand therapy” (Participant 15).
Indirect use of occupation in OBI
This theme describes the approaches therapists use to indirectly incorporate occupations within treatment including patient education and home programs. For instance, one participant described an approach including “educating patient[s] on how wrist/hand strengthening will enable opening jars, [and] carry laundry basket[s].” (Participant 13) Another participant described assigning occupation as a home program, reporting, “I feel that in hand therapy we work on the components of an activity and the patient then has homework to do the activity at home” (Participant 24).
Direct use of occupation in OBI
This theme describes the therapists’ direct use of occupation in treatment. Participants reported that their end goal is “to meet the individual client’s physical needs to return to the optimum level of functional independence possible” (Participant 5) by using “interventions that take into account the patient’s occupations/activities that are important to them, and that help them work toward resuming those occupations” (Participant 10). A participant described these interventions that use occupations to include “meal prep, laundry or home management, simulated engine rebuilding, knitting or crocheting, golfing, pitching, fishing - casting” (Participant 16). Participants also used adaptations and simulations to directly address their client’s occupational needs. For example, one participant shared an example where they “worked with a client on specific adaptations for beginning to participate in golfing post rotator cuff surgery” (Participant 9). Other participants’ simulated components of occupations with their clients, including one participant who stated that they have their “patient lift trays to simulate work task of lifting, placing tray of donuts into oven.” (Participant 10).
Influence of context and environment
The final theme describes how the context and environment influence the therapist’ ability to implement OBI in treatment, whether as a barrier or as a support to the use of OBIs. Participants noted a lack of access to resources and space needed to provide OBIs. One participant shared that their clinic is limited to “basic functional activities that can be used in the clinic” (Participant 9), another discussed space limitations, reporting “no kitchen for cooking simulations, no work space for construction workers” (Participant 13). However, other participants reported having access to “Equipment such as washer and dryer cabinets various things to simulate home tasks” (Participant 7). Participants also pointed to limited time as a barrier to the use of OBIs. One participant explained, “I think [OBI] is fun, effective, and they enjoy it, but when I have 30–45 minutes to review the home program, teach new exercises, and assess how they are progressing, I don’t always have time” (Participant 25). Another participant stated, “sometimes wish I did less in terms of the extra documentation required to add items to activity lists etc and time spent creating the OBI” (Participant 22). In contrast, other participants reported not having similar time constraints, with one participant reporting, “I am in a setting where productivity is not an issue so I can let the treatment session be as short or as long as it needs to be (Participant 12).
Discussion
When examining the frequency of OBI use among OTs who are CHTs it was necessary to analyze agreement with the definition of OBI proposed in this study. In contrast with the lack of consensus about the definition of OBIs in previous literature [3, 22], 85% of the participants agreed with the definition of OBI used in this study.
This study found that 57.7% of participants used OBIs during treatment sessions at least 75% of the time, indicating their belief in the usefulness of OBIs, which is similar to other studies [2, 9]. However, this level of use indicates an increase compared to the 2010 report in Colaianni and Provident [3] where participants indicated using occupations in treatment with 41–50% of their clients. In addition, the more years of experience a participant in this study had, the more likely they were to implement OBIs in their practice, though they had less experience as occupational therapists than participants in Colaianni and Provident [3].
The majority of the participants reported using OBIs during interventions but gave varying descriptions of OBIs. Almost all occupations and categories of occupations as described by the OTPF were addressed in OBIs by the participants in the study. Participants described their application of OBIs through the use of simulation activities, participating in the meaningful activity, using adaptive devices, and incorporating splints. Other participants describe their application of OBI as doing the interventions at home or using education.
Similar to previous research [2–4, 10], participants reported the barriers to integrating OBI into clinical practice included limited time, space, equipment, and resources; non-patient care elements such as documentation, productivity standards, and reimbursement; a lack of credibility of OBIs; and the restrictions of medical protocols. In particular, the credibility of OBIs continues to be a barrier. Twenty six percent of participants in this study identified the credibility of OBIs as a barrier to use in practice, which has been noted as a barrier in previous studies as well [2, 9].
Conversely, supports for the use of OBIs in clinical practice included the therapist’s creativity, support from the facility, the availability of equipment, and the intrinsic motivation of therapists, which also agreed with previous findings [2–4, 10].
Limitations
The primary limitation of this study is the small sample size and low response rate which limits generalization of the quantitative findings to the population. Many surveys were also returned with succinct responses to qualitative questions which limited the thick, rich description desired in qualitative analysis.
Future research
Future studies would benefit from gathering a broader and larger sample including non-CHTs who work in a hand therapy, and the gathering of richer qualitative data through longer format interviews. Further research on the specific barriers that participants identified as preventing them from implementing OBIs is needed in order to allow the barriers to be addressed. Future research should also examine how occupational therapy students are being taught about OBIs and how their education influences their future use of OBIs in practice. In addition, examining how occupational therapists practicing in hand therapy communicate with their clients and other medical professionals about OBIs may illuminate why the credibility of OBIs continue to be a barrier. It would also be beneficial to examine clients’ perspectives after receiving OBI.
Implications
Occupational therapy practice
This study highlighted the importance of the use of OBI in clinical practice. The OTPF put forth “a vision that was occupation based, client centered, contextual, and evidence based” [32, p. S3] reminding practicing occupational therapists that occupation-based intervention is at the root and center of the profession. Occupational therapists are skilled at providing services, in collaboration with clients, to facilitate engagement in occupations that they need or want to do [32]. Thus, OBIs are an effective and skilled service that only occupational therapists can deliver.
In order to promote the supports for, and address the barriers for the use of OBIs, practitioners must address what they are able to control and learn to advocate for what is not in their direct control. Occupational therapists must use their creativity to overcome barriers to the use of OBIs and learn how to more effectively lobby for the institutional support needed to address these barriers. Part of that effort must include addressing credibility by honing our ability to understand and communicate the evidence for an occupation-based approach.
Occupational therapy education
Overcoming the continued barriers to the use of OBIs must start during occupational therapy education. The 2018 Accreditation Council for Occupational Therapy Education (ACOTE®) standards [33], as well as the previous iteration [34], ensure occupational therapy students are equipped with the knowledge and skills they need to overcome barriers to the use of OBIs. However, students may not be equipped to employ their knowledge and skills when they are met with resistance or less than ideal situations in the clinic. Presenting more cases to students where they have access to limited funds, equipment, supplies, and space in which to plan and carry out OBIs could promote creativity once they enter the clinic. In addition, occupational therapy educational programs need to focus on enculturating students to the profession’s values to promote their intrinsic motivation to apply OBIs in practice.
Conclusion
This mixed methods study explored the frequency of use, supports and barriers to the use of OBIs, and application of OBIs in clinical practice among occupational therapists who are CHTs. Although a majority of participants stated they implemented OBI frequently, there are still many barriers present that can influence the therapist’s ability to use OBIs. Occupational therapy practitioners and educators have a role to play in overcoming barriers to OBIs. The themes that emerged from the study describe the direct and indirect use of OBIs that the participants administered as a result of their clinical judgement and working environment. Additional research is needed to gain further insight into use of occupation-based intervention by occupational therapists who are CHTs and explore the effect of education on promoting the use of OBIs.
Conflict of interest
The authors declare no conflicts of interest.