RCOT publish: Retaining the essence of occupation remotely.
The following article was written by Krysalis Clinical Director, Jo Throp in response to an urgent call from the Royal College of Occupational Therapists to pool expertise as Covid-19 coursed across the UK, forcing sudden changes to rehabilitation service provision.
Jo’s article is published in the June edition of the RCOT’s magazine, OT News.
Retaining the essence of occupation remotely
The COVID-19 outbreak is presenting a very real threat to service provision for individuals with complex cognitive and executive needs. Here, the team from Krysalis Consultancy, specialist independent providers of neurological occupational therapy services, reflect on the journey they took to deliver remote services “overnight” while remaining true to the OT values of occupation.
The underpinning principles of occupational therapy have intensified in all our minds due to the dramatic changes to our daily routines caused by the COVID-19 outbreak and the consequences of social isolation. Now, more than ever, we are recognising the value of occupation and social connection.
As professionals, occupational therapists are unique in placing activity participation at the heart of our therapeutic intervention. Our holistic assessment process enables us to consider and analyse the consequences of the pandemic in relation to the sociocultural and geopolitical elements that may further impact on the people we support.
These consequences can have a very real impact on an individual living with brain injury.
The security and consistency offered by familiar routines promotes feelings of confidence and wellbeing. Previously valued activities, both within extended family networks and community environments, offer opportunity for social connection, skill acquisition, and leisure and work opportunities.
These interactions are the central component of community-based neurological rehabilitation but, when the UK went into COVID-19 lockdown, maintaining them posed a very real challenge for Krysalis as an organisation and the clients we support across the country.
Adapting to crisis
The reality for most individuals living with brain injury is that social isolation also means physically distancing themselves from their professional support team. Routine rehabilitation needs may not an immediate priority in the face of a global pandemic; however, the risks associated with a sudden reduction in rehabilitation are very real.
A sudden change to the physical and social environment can potentially, for some, cause a deterioration in function and / or psychological wellbeing and behaviour. There may be associated complications, including carer distress and family breakdown, or the worry of accessing acute and emergency services while COVID-19 infection risks prevail.
Our role as specialist occupational therapists is to support individuals during times of crisis and periods of transition. But how could we, as individuals, continue to offer an effective service if we too were experiencing trauma and struggling with the transition, both from a personal and professional perspective?
In a world where remote conferencing tools had suddenly become the new norm, could our occupational therapists adapt?
Our only option for meeting the ongoing needs of our clients during COVID-19 was to move all intervention, almost overnight, to remote delivery. But how could we ensure that remote intervention was safe and retained a focus on occupation? Could we connect therapeutically in the virtual world with our clients and deliver an effective service?
The solution for the team was to approach the actual and perceived challenges, for ourselves as professionals and our clients, in a practical way. We had to put in place, for all concerned, a plinth of stability amongst the shifting sands of coronavirus.
We started by devising a client-centred remote working framework that would act as our guide. It would provide much-needed structure to meet the challenges of delivering intervention to clients with such varied and complex needs.
In this new and evolving area of practice, it was essential that we remained focused on the core of our profession - occupation.
As such, advice was offered to the occupational therapy team to guide the structure of their remote sessions, focussing on:
- Keyframes of reference, such as transition theory which is useful in times of crisis.
- Key models of practice were used to help to inform our clinical reasoning and intervention.
- Therapeutic resources to enhance online intervention, such as coaching techniques.
The first step for our occupational therapists was to undertake an analysis of each of their client’s ability to access technology and remote meeting tools – and it quickly became clear that this was a significant barrier.
Indeed, if any good is to come out of this crisis, it will be in defining the role of the occupational therapist in enabling individuals to access virtual worlds and ensure they are not left behind.
The team were also encouraged to:
- Facilitate their client’s performance and participation with a communication device of choice.
- Reflect on the impact of belief systems in engaging with technology and recognise that, for some, just the thought of a computer presents a significant internal barrier.
- Review environmental challenges and consider solutions.
- Utilise all possible social support, including family members and support workers, to assist with online access.
- Remain mindful of the experience of the client themselves.
Whilst the world was ‘going remote’, it was also vital that the focus of occupational therapy involvement remained, first and foremost, on maintaining a therapeutic relationship.
Using technology to deliver therapeutic intervention was new to many of us. However, further investigation highlighted that telemedicine as an approach is utilised successfully in other countries.
Practical considerations needed to be addressed, including, fundamentally, did team members feel confident in using the technology themselves? If not, individual clinicians were encouraged to seek help from an IT expert.
Remote session pre-checks ensured successful delivery and maximum client engagement, including device set-up to minimise technical glitches, connectivity and sound quality issues.
Environments were modified to ensure they were conducive to a successful session and, to help meet communication needs, sessions were structured to incorporate:
- A beginning, including a summary of the previous session and plan.
- A middle, to deliver the therapeutic intervention.
- An end, for review purposes.
Staples and stability
One element of our intervention for clients with brain injury is to look at the value of meaningful activity specifically around leisure.
Interest checklists are useful here in stimulating ideas and highlighting potential interest areas or to adapt existing goals to enable access to meaningful leisure activities during a lockdown.
In a world of shiny new technology, it is important not to forget simpler things, such as board and card games which can be tailored to specific needs, including Uno, Dobble, Othello, Chess and Risk, or jigsaw puzzles and construction kits.
(The Krysalis team has compiled a list of over 200 activities for brain injury survivors and their families during COVID-19 here: 200 Stay home activities for brain injury survivors and their families)
Our ‘virtual’ occupational therapists have been conducting functional assessments while taking part in games and activities with clients located many miles away!
One client, notably, could not see how board games would be appropriate for him. However, by tapping into his long-held values relating to the importance of helping others, he was encouraged instead to evaluate the games for use by others with brain injury. This promoted engagement, offered a sense of purpose and served as a therapeutic process for him personally.
Other clients have explored the value of gardening as a meaningful activity. For one client, a portable greenhouse was sourced and delivered with the help of his support worker after he identified the equipment that he needed during remote occupational therapy sessions. He now has the daily responsibility of tending the seeds growing within it.
Adapt and pivot!
For many of our clients, the lockdown has meant a shift of neurological occupational therapy provision to virtual delivery. Our team have physically engaged their clients in therapeutic sessions, helping them to adjust to the crisis, develop personal resilience and continue with activities and rehabilitation goals that are important to them.
As a team, in the face of personal and national crisis, we have shown that we can overcome our fears of the unknown by:
- Integrating our core skills into a careful, measured and informed process.
- Mastering the use of digital aids such as whiteboard drawing, remote coaching, screen sharing and questionnaires.
- Drawing stability from our models of practice and applying them to a useful framework.
- Engaging our clients in traditional activities more suited to a slower pace of life.
In times of crisis, it is the familiar that offers stability and certainty, and it is our specialist knowledge base that guides our way forward. We must be open to opportunities for growth and innovation, demonstrating what we, and all occupational therapists, are capable of.
Above all, however, we must ensure we continue to deliver occupation focused, goal-led, remote therapy services to the most vulnerable in our society throughout the COVID-19 pandemic.
Jo Throp - Meet Jo
Krysalis Consultancy Ltd
Nichola Shellum - Meet Nichola
Krysalis Consultancy Ltd
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More resources to help brain injury survivors and their families during Covid-19 here: Krysalis public resources