Vol. 23 Issue 20
Person to Person
A Case Study Using the Practice Framework
Recently, as part of an assignment for one of my graduate courses as San Jose State University, I was asked to read the Occupational Therapy Practice Framework and apply it in practice. Prior to this assignment, in my 20 years of practice, I had read neither the Uniform Terminology-III nor the Framework.
N.A., a 78-year-old male, was admitted to the acute hospital on May 22 for abdominal aortic aneurysm and bilateral iliac artery repairs. His medical complications during hospitalization included renal failure and need for dialysis three times a week, tracheotomy, prolonged ventilator dependence and NG-tube placement secondary to trach-related dysphagia. He also had anemia, major depression/PTSD/anxiety, shortness of breath, general deconditioning, and unexpected bilateral femoral artery repairs.
Prior to his acute admission, he was independent in self care and ambulation without an assistive device, and independent in all home, leisure and community skills. Mr. A., a retired buyer for Litton, lives in a two-story house with his second wife of 26 years. He wants to be independent in self care, ambulation and able to walk upstairs to his computer room to use the computer. His wife, a retired RN, is willing to help him as needed, but wants him to be able to do as much for himself as possible.
Mr. A. required moderate assist with upper-body ADL, maximum assist with lower-body ADL, and maximum assist with transfers, toileting and high-level ADL. His upper-extremity strength was fair minus on both upper extremities, and he had severe range of motion limitations on the left due to a Korean War gunshot wound. His activity tolerance was poor.
Prior to reading the Framework, I would ask clients what kind of work they used to do, about their social living situations and extended families, how they spend their time and whether they cook. I would ask them what they want to accomplish, and I would use the discussion as an initial informal cognitive assessment. I would assess clients' motor and ADL skills, and activity tolerance. I would make every attempt to use clients' interests and the information gleaned in the evaluation process to maintain client-centered treatment.
After reading the Framework, I realized that I already use parts of the domain and process, but didn't know what the terminology or process was officially called. My initial questions would be considered an occupational profile. For example, I learned that N.A. is a Korean War veteran, and was knowledgeable about the rehabilitation process because he spent approximately a year in rehab following a service-related gunshot wound. In applying the domain and process, I was able to use this information dynamically in the relationship between therapist and client. Through therapeutic use of self, I was able to integrate my knowledge of both the military (as a military brat) and rehabilitation (as a recovered physical rehabilitation client).
In looking at what affected his ability to engage in occupation, one component, context, included the subsets of the social context of a knowledgeable, supportive wife; the personal context of valuing physical and emotional independence and equality; the temporal context of his age; and the environmental contexts of his two-story house and the skilled nursing facility. Client factors included decreased activity tolerance related to respiratory deficits and the after-effects of dialysis, as well as decreased muscle power, muscle tone, muscle endurance and exercise tolerance. These factors impeded his functional mobility and the occupational performance of ADL, IADL, social participation and leisure.
Using the Framework language, the focus and method of occupational therapy intervention for N.A. included:
improving his motor skills and activity tolerance through therapeutic activity and actual activities of daily living (occupation) in order to build competence in areas of occupation related to his being an independent self caregiver, husband and retiree;
therapist provision of hope, encouragement and education to facilitate his knowledge of disease processes and build self confidence and self esteem important in the recovery process; and
facilitating both his and his wife's processing of the emotional or psychosocial aspects of grief related to illness and recovery.
The desired outcome was to improve his occupational performance in self-care activities and functional mobility to allow him to return home, to facilitate his wife's transition from registered nurse to caregiver, to facilitate client satisfaction with his and my performance, and to improve his quality of life through role competence related to husband, father, self caregiver, retiree.
Initially, I found the Framework to be confusingspecifically, the dual role of the word occupation as both a small set of activities "having unique meaning and purpose in a person's life" and as "everything people do to occupy themselves." (Framework, p. 610) I had to read it over and over; however, after grasping the concepts, the Framework document seemed to be common sense. The descriptions in the Framework were thorough to the point of being longwinded. It seems as if these concepts can be naturally internalized by a seasoned occupational therapist without knowing the terminology and description involved.
This process of natural internalization appears to be instinctive, but really stems from trial and error of practicing occupational therapy and learning about the process clients go through in returning to health and independence. Some of this I learned myself as a three-time rehabilitation client. The Framework adds a standard format and application and adds substance to my quest for advanced practice.
Jacqueline Thrash, OTR, has nearly 20 years of clinical experience in California and Arizona, in acute care and outpatient rehab, SNF, adult day treatment, and home health. Reach her online at www.livingskillstherapy.com or by email at firstname.lastname@example.org.