It is hard for me to answer such questions because I do not work in a
skilled nursing facility, and I have not worked in one for over 7years.
I cannot really comment on changing practice patterns in nursing home
any longer because I do not work in that reality. I should only
comment on changing practice patterns in the acute rehab setting,
because this is where I have changed my practice patterns. I think
that the skilled nursing environment is one of the most diffiult
settings to work in for OTs based on productivity, payment level
structures, and the motivation level of most patients. To have a
patient get out of bed for the day is someimes a major victory in OT.
I would love to hear how OTs whom actually work in SNF have been able
to move from pegs to occuaption. Is is actually possible?
-----Original Message-----
From: [email protected]
To: [email protected]
Sent: Sat, 21 Feb 2009 11:52 am
Subject: Re: [OTlist] Puposeful activity
Hello Ilene,
Your post was satisfying to me, as I work in the same setting and am
faced with the same concerns re tx. Put my reaction down to "misery
loves company", although I am not miserable in my position. What I do
with patients may not be strictly OT as defined by most of those who
contribute to this site, but I have made peace with that because I know
that I am definitely helping my patients heal and return to20a higher
level of function in their daily lives. I, too, have been asking for
more concrete suggestions as to how this is done in the SNF/subacute
world which is so focussed on profit. Thanks for sharing a similar
concern. It is so easy to feel alone, and not good enough with regard
to the cones and pegs controversy!
Barb Howard COTA
----- Original Message -----
From: [email protected]
To: [email protected]
Sent: Wednesday, February 18, 2009 7:00:20 PM GMT -05:00 US/Canada
Eastern
Subject: Re: [OTlist] Puposeful activity
Hi Joan and thanks for your insight! May I ask what you would want an
OT to work on with you though before
you had sufficient range to fasten your bra behind your back, if
increasing the range of motion or adapting the task (i.e fastening int
he front) were not options you would want?
IMO, when therapists resort to cones, etc, it is not because they are
lazy, it is because they don't know what else to do, either because
they only have experience in work settings where cones and pegs were
used, or they are in a subactute setting where they are seeing multiple
people at once. Of course that is not ideal, but it is reality. I for
one would like to move into this more ideal realm and change the way I
practice, but there is precious little practical "how to's" for doing
this, especially in settings like mine, where there is no kitchen, ADL
suite, etc, and it is impossible to see everyone one on one for ADL's.
There is no course that I can find on taking OT back to the functional
in today's money-driven practice settings, in fact I have never seen a
shoulder course for OT that doesn't focus on increasing range and other
medically-based PT-type interventions. Even here, many people say "do
this" but very few say specifically HOW or offer any practical ideas
for the therapists stuck in peg/cone world who want to be more
functional but are up against a practice world that just wants numbers.
If you or anyone can offer any practical advice, point to a book or
course to help therapists work more functionally with patients (who
often, in a nursing home setting, can't even come up with goals of
their own or answer "nothing" or "watch TV" when asked what they would
like to be able to resume doing) I would be most appreciative.
Thanks,
Ilene Rosenthal, OTR/L
Message: 1
Date: Tue, 17 Feb 2009 11:30:40 -0700
From: "Joan Riches" <[email protected]>
Subject: Re: [OTlist] purposeful activity
To: <[email protected]>
Message-ID:
<!~!UENERkVCMDkAAQACAAAAAAAAAAAAAAAAABgAAAAAAAAAqpIeEyoaqEeUzXp6QaY++8KAA
[email protected]>
Content-Type: text/plain; charset="US-ASCII"
Greetings to all
I couldn't resist this one.
In my opinion (like Ron's) all activity has purpose for someone or
something (witness the reproduction of plants) .=2
0The OT question re the
activities we use as treatment interventions is: Does this activity
have
purpose and therefore meaning for this client in terms of their
explicit
and implicit occupational goals?
I absolutely agree with Ron's goal formulation where the only goal is
some form of OCCUPATIONAL performance.
(In the presence of cognitive deficits this becomes a much more
difficult question.)
Below is my personal physical and OT/PT case example.
I've been thinking about it a lot in my present situation and how it
plays out. I am still after 14 months working on the stability of the
hip that was pinned and the range and strength in the shoulder with a
nondisplaced fracture. Although I am determined not to walk or run with
the typical 'hip' gait or to limit my reach and ability with my arm I
find it very difficult to persist in activities that are not useful and
meaningful 'at the time'. Especially now that the physical limitations
are only apparent when I'm challenged - trying to walk a distance
across
a large parking lot quickly to keep an appointment for instance or
helping to unload plywood from the truck or screwing a light bulb into
a
ceiling fixture - it is easy to have 'life' push out the daily
excercises. I am not of the generation the 'works out for the sake of'.
I have a brilliant and understanding PT. He knows the 30 to 45 straight
minutes a day will just not get done. He knows that I want to recover
not adapt. So he knows what I need to do and collaborates with me to
find ways to incorporate the movements into my regular activities such
as mindfully using the stairs, varying pace, not using the railings to
pull myself up etc. The stairs themselves cue me as do the top shelves
in the kitchen where I store at least three things that I use for
breakfast each morning.
My morning routine now includes an exercise where I need a significant
break between sets. So I do a set and then clean my teeth etc. thus
being purposeful with the 'dead' time. There is an exercise for my
shoulder for which I need help. This has been tacked on to my husband's
regular morning care. I do his compression stockings and he does my
shoulder. Bob checks my style and is available if I have questions but
my next visit will be in eight weeks - down from six the last time -
down from 3X/week when we started.
I have no doubt at all that what Bob does for me is PT. His purpose is
directed to foundation abilities and what else affects my occupational
performance is not his concern. Over time he sees my delighted
reporting
of the things I can do as evidence that his treatment of the foundation
skill is effective. I have a good team with a PT and an OT(me).
My occupational goals include all the things that I need to walk or
run,
reach, carry or support including the effective use of my hands to be
able to do - however measureable goals are
demanded from us. So for the
shoulder I have picked one daily activity - doing up my bra that is a
measureable goal to monitor progress. (can now do effectively but with
some discomfort).
So PT goal - to increase shoulder range and strength to facilitate
dressing.
OT goal - to fasten bra with both hands behind the back without
discomfort. This is a good fit and focus for me - what would work for
someone else in a similar situation will depend on whether it is an
important thing to be able to do. Many women adapt by doing it up in
front and twisting it around.
Conclusion
Any deficit affects so much in present or future occupational
performance that I think some of us shy away from limiting the reason
for working on something to one goal. The progress in the physical
foundational skill is so easy to measure but it leaves out all the
other
the factors that also affect occupational performance.
Thanks for reading this far. It has been a joy to see all the new
members coming on. I haven't been at all active on the list lately
partly because to say everything I want to takes me so long to type. I
would very much appreciate your comments and feedback.
So many topics to wade into - the discussions are bearing great fruit,
I
think.
Soft theory - so important.
Blessings, Joan
Joan Riches B.Sc.O.T., OT(C)
Specialist in Cognitive Disability
Riches Consulting
High River, Alberta, Canada
403 652 7928
0A
-----Original Message-----
From: [email protected] [mailto:[email protected]] On
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