Clients’ Comprehension of Occupational Therapy

Research by Charity Bass, Lydia Hensel, Mark McMullan and Chia-Wei Fan
 AdventHealth University Master’s Program of Occupational Therapy

An education in occupational therapy (OT) teaches the foundations, purpose and theories of the profession, however an open-mind is beneficial. Practitioners - as well as the field of OT - will always have room for improvement. One of those areas of continual growth is persistently striving to ensure the client is receiving optimal care in their occupational therapy. Boutin-Lester and Gibson (2002) argued that the only way to truly know the effect of treatment is to hear directly from clients. Clients should remain the central focus in therapy; occupational therapists must desire to appreciate what clients experience and how well they understand the purpose of their rehabilitation. We have aimed to discover, through our research, if therapists educate their clients throughout the treatment, evaluation and discharge, in accordance with American Occupational Therapy Association (AOTA)'s standards of conduct. AOTA states that clinicians must “provide occupational therapy services, including education and training, that are within each practitioner’s level of competence and scope of practice” (AOTA, 2020, p 2).

By exploring the clients’ understanding of their therapy, occupational therapy can remain true to its ethical compass of being client-centered.

The inclusion criteria for our subjects included: clients age 18 and older, cognitively intact, and had an initial evaluation and one treatment session with occupational therapy, as a minimum. Clients who do not speak English, or had not yet received an evaluation and at least one treatment session of occupational therapy, were excluded. Clients under the age of 18 were not interviewed. Clients who could not answer orientation questions (name, date, location) on the survey were excluded from participating in the study, demonstrating cognition was not intact.

The research team utilized purposive sampling in our qualitative study. First, we posted flyers at each research site where occupational therapy services were conducted, including: The Neuro Hub at CORE, Advent Health Hendersonville, St. Francis Rehab Hospital, the HOPE clinic and the Hale Hand Clinic. The clinic locations varied among three states, including Florida, North Carolina and Tennessee. Individual copies of the flyer were given to occupational therapists at some of the aforementioned clinics, who agreed to hand them out directly to their clients, specifying no obligation or recommendation to participate, but informing clients of the opportunity objectively. Once clients noticed the study flyer advertising the research interview opportunity and reward clearly explained, interested clients took initiative to contact the researchers via phone to participate. After the clients were contacted, the researchers coordinated a time to meet in person, or call them on the phone.

A basic screening was completed to ensure the clients met the inclusion criteria; then they were invited to interview with an interviewer, at the mutually agreed upon time and location, or via phone call. Later, the appointment was scheduled and the interview was conducted at the clinic, or virtually. Once the clients signed the informed consent or gave verbal consent over the phone, they were formally enrolled in the research study. The researchers proceeded to ask the semi-structured interview questions. The interviews lasted an average of 15-30 minutes. Interviews were recorded with the Otter Voice Notes app, that converts audio to text, to ensure no data was lost. The clients were informed of the software’s privacy policy and the inherent risks associated with it. Clients were provided with a $20 Amazon gift card after the completion of the interview, either handed to them directly in person, or sent via mail to their verbally-provided address if it was a phone interview.

The initial interview questionnaire was developed by the research team based on the research objectives the team wanted to explore. The semi-structured interview allowed for flexibility of the interviewer to dive deeper when needed, but also served as a solid baseline to obtain the interview objectives. To inquire about a client's comprehension of occupational therapy, clients were asked questions such as:

The same interview questionnaire was utilized with all clients participating in this study, with the exception of the first interview, which used the pilot questionnaire. Subsequent interview questions were altered based on the pilot results, to provide more targeted, comprehensive guidance for each question.

After the interviews were fully conducted and recorded using the Otter app, the researchers transcribed the contents and then analyzed the text for common key words and overarching themes. Individually, the interview transcriptions were read and scanned multiple times for repeated words, phrases and themes, with distinctive highlighted colors representing each common idea. The compared data was then synthesized for data analysis and final conclusion of the research study.

The three student researchers interviewed 10 clients in total. Of the participants, seven of the ten total were male. The participant’s ages ranged from 22-83 years old, with a mean age of 54. Four of the ten participants had a primary diagnosis of cerebral vascular accident (stroke), while two clients had a spinal cord injury; the other four had other diagnoses. Seven of the ten participants had college degrees or higher, while the remaining three participants did not disclose their education level.

From the data gathered, there was a diverse range of responses. One quality that makes occupational therapy unique among the health field is its adaptable approach, catered to each individual. There are also considerations to be given to the varying levels of comprehension for each client, based on their education. Regardless of these factors, there were some commonalities from these interviews.

One of the recurring themes throughout the interviews was the difference between life before and after their diagnosis. Each client discussed the life-altering differences in their functional capacity after their injury and subsequently expressed a desire to return to their prior level of functioning. For the most part, clients understood that participating in occupational therapy would benefit them personally, in order to help regain some level of function that they did not currently have. Gordon stated:

"When you first go [to occupational therapy], what they want to try and do is get you so you can function, get back in the world." (Interview #2, December 4, 2019)

Each client displayed a varied level of understanding of what abilities they anticipated regaining and how the activities they performed related to their goal of returning to their prior level of function. “We are working with my left hand and trying to get my left back to functioning with my brain, which is, you know, it's slow going but it's coming around. It's doing all right” (Michael, Interview #10, January 9, 2021). When asked about what his occupational therapy goals were, Christian included “Driving”, “And just getting it to where I can be more independent” (Interview #1, October 28, 2019).

Furthermore, a large part of the clients’ reports were focused on activities of daily living (ADLs). The interviewees may not have referred to ADLs with proper medical terminology, but they were aware of the role of occupational therapists in equipping them to regain independence in their everyday activities, including - but not limited to - bathing, dressing, and eating. For example, Joe shared, “I can’t dress with my left hand. Now I tried to use my left hand to hold something, like my pants in place ‘til I get all one side up, but my left side don't want to play” (Interview #8, December 7, 2020). The majority of clients were recruited from outpatient clinics, so naturally daily living activities would be the primary focus of OT treatment because of the physical environment in which clients spend most of their time. Some of the activities were different between clients, such as sweeping or putting away dishes, but most interviewees expressed knowledge that occupational therapy could improve their participation in occupations performed at home.

A final theme across the ten interviews was improving a client’s mobility, whether it be stretching, strengthening or range of motion. The interviewees were typically able to articulate why they did stretching exercises: “I’m really tight. Like right now you can see -- sometimes they’re a little more loose. They’ve been really tight lately. They’ll get a paddle and they’ll wrap my hand to a paddle for a stretch” (Casey, Interview #4, January 22, 2020). When asked about stretching, Joe replied, “Well, it keeps you loose enough where you can keep doing things. If you don't do those kind of activities, you will just tighten up and not be able to do it later” (Joe, Interview #8, December 7, 2020). Additionally, they were able to understand the progressive nature of strengthening exercises performed throughout the treatment sessions over time. “You have to twist it up left or right just to see your level of strength in your hands... I know that I’m stronger on my left side than on my right side” (Lesia, Interview #7, November 6, 2020). In summary, it is clear that the clients understood their needs to move their body to improve their flexibility and strength, in order to further their recovery from injury or insult.

One overarching theme gathered from this qualitative study was that...

Clients have an intrinsic desire to improve their conditions - and they see occupational therapy as a way to do that.

It was clear that the clients understood that what they did in therapy would benefit them overall. As practitioners, this is important to address with all occupational therapy clients. Practitioners need to verbalize the importance and purpose of each activity to communicate to the client why they are doing what they are doing. Clear expression of each treatment in relation to the overall plan of care will increase the client’s confidence in their therapist and better reiterate that the OT is furthering progress toward their goals.

Despite not understanding the exact purpose of some specific treatment activities, a majority of the participants had a clear idea of occupational therapy’s role in relation to their recovery process. Most definitions given by clients consisted of regaining daily function in some shape or form. This idea has been evidenced in other research studies, one being performed with inhabitants of Poland (Żmudzińska and Bac, 2017). Additionally, clients had a proper understanding of what occupational therapy’s role in their own life was.

"[Occupational therapy] helps an individual like me or somebody else that, um, doesn’t have the function to, um, do things, adapt to life after their injury (Casey, Interview #4, January 22, 2020).

Occupational therapists have a responsibility to articulate the many facets of their occupational therapy input, in order to explain the scope of OT and advocate for the profession as a whole. A broader explanation of OT’s role among specific settings could help clients as they transition between acute care and home health, for example. Likewise, education on the specific implications and specializations available within OT and relevant to individual clients would increase awareness of the field overall and among health care.

In a similar study, where clients participated in client-centered activities of daily living, the clients reported transparency as the most important factor in their treatment (Ranner et al., 2018). They wanted to be involved in the treatment throughout and they wanted to be able to trust their therapist. However, a five year longitudinal study indicated that there is not a significant difference between client-centered activities of daily living and typical activities of daily living in the long term recovery process (Hedman et al., 2018). Activities of daily living were the main mechanism for recovery in this study specific to clients’ post-cerebrovascular accidents. Many of the clients we interviewed had strokes and identified activities of daily living as purposeful to them. “I have to get back to swinging a golf club then this left arm and shoulder will be no problem because I'll work it back into shape” (Michael, Interview #10, January 9, 2021).

Admittedly, the scope of this particular research study is limited within certain bounds. Further studies in other therapy settings and geographical locations around the world could prove useful in judging the significance, accuracy and transferability of these results.

If this qualitative study was conducted in a variety of settings, apart from inpatient rehab and outpatients - such as acute care or pediatric clinics - the data may prove stronger, with more significant results.

Secondly, this study was conducted in close association with Advent Health University and sites that agreed to their students interviewing their clients. The narrowed site inclusion could skew results, because the therapists and patients that participated were in close contact with the authors of the study. Despite these limiting factors, there are important findings as a result of this research project, that contribute to the occupational therapy profession as a whole.

The purpose of this study was to explore clients' understanding regarding their occupational therapy treatment. Participants demonstrated a good understanding of their therapeutic activities overall, with room for increased clarity of occupational therapy’s focus on client-centered care. One theme that recurred in the interviews was that change occurred post-diagnosis and that occupational therapy fervently strives toward the prior level of function. Another theme was the importance of activities of daily living. Clients understand occupational therapy as a way to improve their independence in everyday tasks or routines. Third, clients understood that therapeutic intervention improves generalized mobility of the affected body part(s). Evidently, some clients demonstrate a superficial understanding of OT’s broader purpose;

Clients are not necessarily connecting the dots that, in order to return to their prior level of functioning and/or increase independence in (individualized) activities of daily living, they must improve their mobility.

Overall, each client involved in this study expressed an elemental grasp of the occupational therapy process, in relation to their individual experience. Naturally, further and broader data would further validate the conclusion of this study.