Model of Human Occupation

Transcription

1 Model of Human Occupation Archived List Serv Discussion Occupational therapy on a Psychiatric ICU- under MOHOST framework June 28, 2011 Hello, As I am new to this process and LISTSERV, I hope that this message reaches the right people! I wanted to post a question regarding implementation of the MOHOST within my workplace. I am the Band 5 OT currently based on an 8 bedded Psychiatric Intensive Care Unit (PICU). As there has not previously been an OT service existing on this ward, I am providing a brand new OT service through inter-disciplinary working with the nursing staff. The PICU ward environment is designed to provide support for service users to manage distressing and challenging mental health problems in the safety of a secure environment. MOHO is used within the wider OT service for this hospital and identified as the most appropriate model for the OT service, in order to provide a fully occupational perspective. On the acute wards of the hospital, Model of Human Occupation Screening Tool (MOHOST) has generally been found to be the most appropriate assessment for service users, and generally this can also be applied to OT practice on the PICU. However, this PICU physical environment, although assessed as appropriate to meet the service users needs at that time, will affect the scores for the 'environment' concept on a MOHOST assessment. When completing a MOHOST, I have addressed this issue by discussing the physical environment in the 'comments' section. I.e 'Environment: Due to D's high risk, unpredictable actions and attempts to self harm, the current PICU ward environment is as safe as is reasonably practicable to meet his needs. This however, has an impact on the

2 range of opportunities, equipment, occupations, activity demands, privacy and opportunities for social groups avaiable to D.' However, on completing MOHOST assessments including the 'environment' section, I am greatly aware that this will impact negatively on the rating score. Please could you advise me if you feel there is a more appropriate assessment tool/ outcome measure for this specialist ward environment? Or if there is a more effective way of completing the assessment? Also, I would be interested in discussing with other OT's who have an experience of practising within Mental Health in a PICU, to share experiences and successful interventions. With many thanks, Lorna July 1, 2011 Dear Lorna - Please find below a response from a colleague working in our Trust following your earlier , which I am posting on her behalf. Best wishes, Hilary Hi Lorna I am a band 6 OT recently started working on a 12 bedded male PICU, and am in a similar situation to you as there has not previously been an OT service on the ward. Quite a challenging situation but very rewarding also! In response to your question about the environment scores on the MOHOST, I would probably be thinking about the scoring slightly differently. As you mentioned, the level of risk to self or others would mean that the environment is seen as the safest and most containing and appropriate place for the person at that time, meaning that I would usually see the environment as supportive of their occupational performance at the point where a PICU has been assessed to be appropriate to meet their needs. In my opinion, it is the other areas such as volition, habituation and performance skills which are where the difficulties potentially lie, and improvement in these areas may naturally improve ratings on the environment side (where considering the PICU as the

3 environment) for instance decreased risk to others may result in improved privacy as nursing observations are decreased; or an improvement in overactivity and ability to focus may result in improved stimulation where clients may feel more able to participate fully in a greater range of activities on the ward. With regard to social groups, a person may still feel a sense of belonging with their social groups even if the ward environment means that they are not attending their usual activities associated with these. They may keep up with their social groups in different ways, such as telephone, or visits from family and friends. In terms of religious groups, they may still be able to exercise religious expression, for instance praying at certain times of the day, or following certain diets. I would still see these things as active participation within their social groups, as they are opportunities that do exist for interaction and involvement. If they were scoring low in this area, I would therefore not feel that the ward environment was responsible, and would probably need to think with the client about what their barriers to participation were. Perhaps also to consider is that environment can be broken down to the different physical environments within the ward (such as rooms, garden, gym, groups), different social environments (e.g. 1:1 interactions, group interactions, informal vs formal), and times (daytime vs evening, weekday vs weekend). Clients are usually more motivated in certain environments that in others, meaning different presentations. The MOHOST multiple observations can be really useful in thinking about which contexts have a positive or negative impact on occupational performance meaning more opportunity to understand the person, what they feel most comfortable by, interested in, competent at, where they feel safe enough to take positive risks etc. Lastly with regard to the MOHOST, I would also say that it is a dynamic tool that should be changing constantly, one low rating is not a reflection on how things are always going to be, just a snapshot of that moment in time, and an opportunity for us as OT s with our clients to think about the opportunities and barriers within that to work on / with. In terms of other tools, as I mentioned I find the multiple observation sheets for the MOHOST really useful. I have also found the Volitional Questionnaire to be a useful tool in terms of identifying what motivates people, what things are supportive of or barriers to participation, and to be able to identify how to structure interventions and the environment to be most supportive of the person moving forward. The Remotivation Process then is a great tool to be able to use this information to plan, implement and evaluate interventions. The VQ, like the MOHOST, can also be used for multiple

4 observations, really useful in a context like a PICU where you will probably be seeing a lot of the clients, in many different groups and individual interactions. Where appropriate, the OCAIRS is also a great information gathering tool, and one that focuses purely on the clients perspective, so an opportunity to really get to know someone. Lastly, if you would like to contact me my address is below, would be good to share ideas! Best wishes Sarah Young Occupational Therapist July 6, 2011 Hi Lorna I m a Band 7 Clinical Specialist OT and I ve been working in a PICU environment for several years now in Newcastle upon Tyne. I agree with the helpful comments from Sarah and would add that as long as you keep the qualitative information in the comments so it is clear why you are scoring the environment in the way that you have then there is no problem. I haven t found a better tool than MOHOST to use in this environment as its flexibility in data gathering methods is the most realistic way of capturing as much information as possible when people are acutely unwell. I do use the interest checklist too with some people and occasionally the OSA when someone is able to engage with that process. Usually though, the biggest challenge is getting people engaged at all in this type of environment. The other thing to think about is the timing of the assessment are you using it as an outcome measure at points of transfer in and out of the PICU or are you contributing to the ongoing assessment of needs, most of which will be picked up when the person returns to the acute ward once the crisis period has settled. This will influence whether you decide to assess the ward environment or gather data around the person s usual environment. As Sarah identified, when the person is getting essential needs met by the environment in terms of keeping themselves and others safe and having access to interventions that are required at the time then the environment score could be quite positive. However you can also use this to highlight when you feel that someone is misplaced on PICU or perhaps is ready to move on as the environment would then be less suited to meet their immediate needs. Presentations change rapidly on PICU, so the assessment of needs will change rapidly too.

5 Although as OTs we are very concerned with people s global functioning, I have found that when people are in acute crisis and transferred to PICU their immediate needs are most pressing and much of my focus is how they can best get through that day/week and helping them identify what is beneficial to their recovery. I frequently gather lots of other useful information too that I pass on to colleagues on the acute wards and community teams for them to follow up once the person has left PICU. And of course, the future planning for what someone would like to do or how they would like to improve their functioning can begin in small ways on PICU and give a sense of hope and recovery rather than just a focus on current problems. I have found that one of the biggest roles I have had on PICU is influencing the environment in terms of trying to create a culture of activity amongst staff and service users. This can be challenging at times in an environment where there is a lot of focus on risk management. However, over my time in PICU I have seen much progress in this area and would encourage you to keep your OT focus and keep voicing your different perspective on the ward. If you want to talk more generally about your role on PICU I am happy for you to contact me my details are below. I work Wednesday, Thursday and Fridays. Good luck! Rebecca Trevarrow Clinical Specialist Occupational Therapist July 7, 2011 Once again, I am so glad that I resisted the urge to try and answer this question. Thank you so much Lorna for starting this conversation. Both Sarah and Rebecca have made some thoughtful and well-reasoned points. Sarah's recommendation to use the single observation/multiple observation sheets to record the impact of specific environments is really helpful, and Rebecca is absolutely right to note that the environment section is useful when it comes to advocating a change in the environment; whether this involves making a case for a person to be transferred to a more suitable environment, arguing for greater resources, adapting the social environment or grading available activities. - Two fabulous responses. When working in a PICU there is a huge emphasis on risk assessment and the person's risk history. The MOHOST can help the whole team to think about the risk that the person is currently presenting. Each item can be thought of as a factor that influences

6 risk. E.g., If a person doesn't adequately appraise their own abilities, they may choose activites that pose a risk to themselves and/or others, or their mood could be affected because they think they can't manage, leading to risk of self-harm. When I worked in PICU, I remember being particulalry concerned about increased risks when a person showed reduced responsibility & problem-solving coupled with high energy levels. Do other people recognise particular combinations of factors that are associated with particular issues? I am struck by the occupational profiles that were published in the latest issue of the British Journal of Occupational Therapy. They show very clearly that someone with psychotic depression will have lower levels of volition than other clusters of clients, and that someone with over-valued ideas will have much reduced habituation. The study was undertaken in preparation for a Payment by Results system in mental health services (England). Forensic services are not included as yet, and it will be fascinating to find out if particular clusters of clients have equally clear profiles in secure settings. Sue Parkinson