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The joy of running flat out along the beach - is there anything more freeing?!

Teams, roles, and contributions


ResearchBlogging.org
I’m quite keen to generate some more discussion about how individual professions can contribute within Interdisciplinary/Interprofessional Team without being defensive of their contribution, nor allowing other disciplines to encroach on their specialist skills.
I really struggle with the whole concept of “role definition” because so often I see “the OT role is…” without considering that there are a number of core areas many health professionals in pain management use such as goal setting, relaxation, pain “education”, activity pacing/management, relaxation, biofeedback, cognitive behavioural therapy.

Some examples: Once I heard an occupational therapist say that only occupational therapists should “set functional goals”. Yet if goal-setting is client-centred, I can see how physiotherapists, nurses, social workers, psychologists and doctors can ALL work with a person to “set functional goals”.

I also heard an occupational therapist suggest that “only” occupational therapists should go into the home, or workplace. Yet I’ve had some fabulous physiotherapists and psychologists go into both these places and do fantastic work.

The current debate is whether occupational therapists or physiotherapists should do mirror therapy or laterality training.

Sadly I also heard of a doctor who told the interdisciplinary team that he thought it was fine to advise a person to begin a walking programme – without consulting a physiotherapist! Oh no! How dare he! Actually, isn’t this what many nonmedical clinicians have been wanting our doctors to do? And if a physiotherapist begins talking about function in the real world, isn’t this what occupational therapists have been saying physiotherapy doesn’t do but should? Seems to me we don’t recognise our own cognitive dissonance even when it’s sitting right in front of us.

To be quite honest – I don’t care WHO does what! As long as a clinician is competent, the client has had a hand in establishing priorities, and there aren’t two clinicians doing exactly the same work, to me it does not matter.
BUT I’d love to find out some other points of view, and poke holes in my assumptions – so, go to it ladies and gentlemen!

Someone asked me “so what are the skills people should have to work in chronic pain management?”

  1. I’m thinking about this right now – firstly, people who “get” pain. So well-educated, knowledgeable people who have a really good grasp on neurobiology and psychology of pain. I don’t really care about the professional background, but I’d like someone who can reassure patients/clients that their pain (a) has a name (b) doesn’t mean its harmful (c) can be managed. I would help if one person in the team can prescribe rationally.
  2. Someone should address movement and pain - don’t care if it’s an occupational therapist, physiotherapist, exercise physiologist or whatever. Best if this person can grade movement from simple/low intensity to higher and definitely functional intensity. And critically, that person needs to know the relevance of any exercise on what the client/patient does in daily life.
  3. Someone else needs to talk about the meaning of pain on the sense of self, and help the person understand that doing things differently doesn’t mean losing your self concept.
  4. It would be good to have someone who understands behaviour, and interactions between behaviour, emotions and cognitions.
  5. Absolutely, someone in the team needs to help the person identify what they WANT to, or NEED to do to feel complete, then help the person work out ways to do that.
  6. And I think it’s vital someone can interpret psychometrics, and knows enough about outcome measurement to produce regular reports on how participants in pain management are doing once they leave the service.

And all the other things like using biofeedback, diet, relaxation, communication, health literacy, would need to be incorporated by those will skills in these areas.

I think teams need someone who will bat for them in management, someone who really cares about the team and how it functions, and will wave the flag in terms of retaining an interdisciplinary self management focus, ensuring the team remains client-focused and team-focused, rather than discipline-focused.

Teams need to negotiate their contributions (note I say contributions not “roles” – contributions are offered, roles are defined and possessive). Team members need to renegotiate what they can offer when new team members join the team, or when a team member develops a new skill. Defining one “role” means, implicitly, that other roles are also “defined”. Sometimes this happens without negotiation. And if role definitions are not regularly reviewed, innovation and responsiveness drops, positions get reified – and we end up with a cookbook approach to pain management that means the personal relationship between the person who has pain and his or her clinicians is valued less highly than the professional title of the clinician. I don’t see this as client-centredness.

One argument for defining roles is to avoid duplicating skills. It’s intended to ensure “the right clinician with the right skills sees the right patient at the right time”. I think this ignores the common skills all clinicians working in chronic pain management need. It ignores individual team member development. It means clinicians who are not “meant” to do the tasks nominated within another role’s definition can’t develop their skills to support one another within the team. It creates barriers and obstacles to developing a common language, using a common model (cognitive behavioural approach, in the case of chronic pain management), developing common goals. It can lead to multidisciplinary practice instead of interdisciplinary/interprofessional teamwork.

It can, unintentionally, create over-servicing because instead of selecting clinicians to work together on the basis of what the client/patient needs, professional demarcation lines are drawn and THREE clinicians need to work with the client/patient instead of two. Maybe even more because if the person needs to develop communication skills at work – maybe the occupational therapist “should” work on this; if the person needs to develop effective communication at home – maybe the social worker “should” be involved; maybe it “should” be the psychologist because it’s about the person’s core schema. See how complex this can become? It’s even more difficult if we look at activity management. Should the occupational therapist be involved because it’s about occupation? Or the psychologist because it’s about contingencies and core schema? Or the physiotherapist because it’s about building exercise tolerance? Or the social worker because it’s about negotiating boundaries with other people?

Teamwork – more than a group of clinicians who happen to work with the same patient.

 
Sandra G Leggat (2007). Effective healthcare teams require effective team members:
defining teamwork competencies BMC Health Services Research, 7 (17), 1-10 : 10.1186/1472-6963-7-17

More discussion on Functional Capacity Evaluations


Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work “fitness”. 

I’ve received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable.  I haven’t found anything recently, and I’m still concerned that FCE are used inappropriately for people with chronic pain.  There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves – and have a flare-up for some days afterwards but get a “good” report suggesting they have put in “full effort” and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies – and avoid a flare-up but receive a “bad” report, suggesting they haven’t put in “full effort” and despite this, they can manage a full time job of a certain MET demand.

I can’t understand why FCE providers don’t work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. 

For the record, I’m not against establishing functional abilities.  And I think having a systematic approach to doing this.  I am against FCE’s being touted as a way to reliably determine work capacity, or to being able to determine “effort” through “consistency”. There simply isn’t published evidence to support these claims.  If someone can provide me with evidence, I’ll gladly change my mind because if there is one thing scientific training teaches, it’s that it’s OK to change your mind – if there’s evidence to do so.

This doesn’t mean that FCE’s would then be fine and dandy – because, as I’ve seen far too many times – HOW they’re used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same.

Here’s my original post, and some very good references are at the end of it.

Journal impact factors


If you’ve ever wondered about how well-connected and respected a journal is, journal impact factors claim to give you the answer. Theoretically, a “good” journal will be cited widely by others, and have authors clamouring to contribute to it. Of course, unpopular topics like chronic pain are trounced by their flashier cousins exploring things like global warming and new theories of evolution, and there is the effect of advertising and prominent endorsements on circulation numbers, but there you have it.

This is from a respected university, so read and enjoy.citation_analysis

Patients Are Often More Engaged In Their Health Than Providers Think


adiemusfree:

This post rang particularly true for me – both as a patient myself (who isn’t from time to time?!) as a clinician involved in helping people develop self management (which includes health literacy), and finally, as a researcher looking at the ways people who are resilient despite their chronic pain cope with their health condition. Whew! Sorry for the long sentence!
I don’t know that I completely agree that patient engagement isn’t for health care providers, because plenty of people are ambivalent about enacting their good intentions. This is where what we do counts most. Listening, helping establish what is important to the person, then supporting them to “take the next best step” for their health. This might mean giving them a call a couple of days later to see how they’re getting on, helping them set specific actions to take (time, date, what, when, where), and then reviewing how this is working some time in the future. Being proactive.
Thoughts?

Originally posted on Mind The Gap:

Patients often don’t get the respect they deserve. Take the subject of patient engagement.  Just about everywhere you turn in the health care literature these days we are told how physicians and other providers need to do a better job getting patients involved in their own health.

But is that really their role?

Patient Engagement Is Not The Job Of Health Care Providers

Why?  Because by the time a person (aka patient) presents for care in the primary care physician’s office…they are already engaged in their own care to some degree…albeit now necessarily in the way providers expect.   Here’s what I mean.

People consult with their doctor when they have a need or concern which they believe needs to be addressed.  Often times before they make an appointment to see the doctor, people will do their own home work to see if a doctor’s appoint is really necessary.   Many of us…

View original 395 more words

Online Technology and Occupational Therapy Survey


If you’re an occupational therapy practitioner and haven’t heard of Anita Hamilton’s survey on the use of online technology – here’s the link – what do you mean, what’s it about?  Online technology and occupational therapist’s use of it.  Oh, Anita’s use? She, like me, is doing her PhD.  Please help her – PhD’s are just as much about tenacity as they are about academics!

Quick update from earthquake city


The aftershocks seem to have slowed a little, and they are not as powerful so hopefully things will settle down a bit. We still don’t have water, so we’re having to use our emergency stash (60 litres!) and boil it to wash, do dishes etc. Even when the water comes back on, we’ve been advised to boil the water again because there’s damage to the sewers.
I feel OK in myself, in that I’m not fearful of the quakes (a bit fatalistic really, but there is so little time to react when a quake hits, there seems little point in being afraid – you can’t do anything!), but I am very tired and not sleeping all that well.
I think the difference for people in Christchurch now, compared with the previous two big earthquakes is that the adrenaline rush that was there last time hasn’t been available this time. There’s less energy reserve to draw upon and the daily hassles of dodging potholes and cleaning up liquefaction and working out which shops are still open and where they’ve relocated to – all of that practical ‘stuff’ that is usually there in the background – these things take cognitive effort. Routines and habits make life easier, mean the brain can be freed for more important things. For me anyway, the routines and habits are disrupted and require thinking and planning and time.
I ask myself how are these changes I’m working through any different from the sort of changes in “how to do” that a person with disability needs to make? How often do clinicians forget that doing things “differently” takes mental effort – and in pain management, we’re often asking people to do almost everything in life “differently”. No wonder there are times when people who have limited resource to draw on (maybe fewer social supports, fewer original habits and routines, mental health problems, less flexibility in the ways they are able to view their world) struggle to cope with the demands of both a pain problem (which already makes demands on them) AND our suggestions for change!

I’m off to work shortly, to work with a group of people who have chronic pain and who have been incredibly courageous in wanting to keep going with the last week of their programme despite the earthquake. They were given the choice to stop, to defer the programme and return again, but they chose to stay. That is strength and resilience folks. I am so lucky to work in this field, with the team and patients I work with.

Wobbles in the Quakey Isles


By now, if you’re a regular reader of my blog, you’ll know that I’m from Christchurch, NZ, and yes, we’ve had a few earthquakes recently! I’m happy to report that while we’ve had some more damage to the surrounds of our house, and there are a few more cracks in the ceiling and bricks, we’re pretty well off. No serious damage done except a rather disrupted night!
My nerves are a bit frayed and I keep monitoring any deep rumbling sound or rattle of the windows just in case it’s the beginning of another one – and yes, it’s a bit wearing. I’ll keep blogging but will keep the number of posts down, as I have been, just to reduce some of the (internal) pressure I put on myself to post often!
It’s tempting to say something a bit trite like “we’re all tough here” or something but really, it seems to me there is little I can do to change our situation, much to be grateful for, and more reasons to be positive than not. So if being tough is equal to being occasionally grumpy, tearful for a moment or two, laughing often, taking time out, and finding good things to appreciate, then I suppose I’m being tough! This is life, and life can randomly throw challenges as well as delights. That sounds awfully philosophical, but seriously folks – that’s my way of getting through and being OK.