Shifting our focus in acute settings: function to occupation

Both as an undergraduate student and as a qualified Occupational Therapist working within my current role, I have maintained a passion to work with people living with dementia and their care givers. Throughout my career I have continued to seek out opportunities to contribute to my own continuous professional development in relation to dementia care.  I was therefore thrilled when my application to the Alzheimer Scotland and Queen Margaret University, Edinburgh MSc Module, “Developing rights-based practice for Allied Health Professionals (AHP) working with people living with dementia, their families and carers’ was accepted. Although a bit apprehensive about being a student (again!) I was looking forward to learning more about developing an AHP rights-based approach to dementia care.

What is “rights – based practice?”

Human rights are defined as the basic rights and freedoms that belong to every person (Equality and Human Rights Commission, 2020). Underpinned in Occupational Therapy practice by both the Royal College of Occupational Therapists (2017) and the Health and Care Professions Council (2013), we as Occupational Therapists, including AHPs generally, are legally obligated to ensure these rights are adhered to in daily practice. Unfortunately, stigma still surrounds the treatment of those with dementia which in turn can restrict their human rights (Scottish Government, 2011).

Pertinent policies which underpin human rights and informed the MSc module content included, ‘Connecting People, Connecting Support, (Alzheimer Scotland, 2017) which helps to bring the importance of human rights to the forefront of my practice. Within this policy is the AHP Approach, of which one element is ‘Enhancing Daily Living’ (diagram 1), which led me to the topic on which I based my assessed presentation for the MSc module.

Diagram 1: The AHP approach
(Alzheimer Scotland, 2017, 2020)

Right to meaningful activity in an acute setting for people with dementia

Meaningful activity is defined as “physical, social and leisure activities that are tailored to the person’s needs and preferences” (Kitwood, 1997 pg. 7).

While listening to the first-hand experiences of people living with dementia during our module, it made me consider how, and in what way, meaningful activity could be encouraged when admitted to an acute hospital setting. One carer put it perfectly recognising their loved one was only occupied when directly engaged with rehabilitation, but what about when therapy input stopped for the day?

It prompted me to reflect on my own and our team’s practice in relation to meaningful activity and question if the standardised occupational therapy process adopted in acute settings may impact on a person’s right to access meaningful activity by focusing too much on the physical function and risk/safety for discharge. Although our assessments encompass important functional activities to support health and wellbeing including independent function, I felt with the pressures of a busy setting, the importance of other areas of daily living e.g. money management, routine, hobbies suggested by Perrin (2008) as important, tended to be overlooked.

In completing a literature search related to the use of meaningful activity in acute settings, there was a paucity of high-quality research found. However, there was some research that critiqued the lack of meaningful activity in acute settings which could adversely impact the goals of rehabilitation, including wellbeing and personhood (Clisset et al 2013; Clarke et al 2018). Research also highlighted the importance of continued engagement in meaningful activities and the positive effects for the person, carers and staff both during an inpatient stay and on discharge home.

Reflecting on my practice there is scope to shift the focus from function to occupation to embed a rights-based approach by adapting our current assessments to incorporate activities that are identified as being meaningful by the person living with dementia. For example:

  1. Ensure “Getting to Know Me” forms are fully completed on admission and translated into assessment and ward-based routine(s) so meaningful activities can be identified. Bring items from home e.g. knitting.
  2. Initiating Occupational Therapy input sooner rather than when mobility allows.
  3. Use meaningful activities as part of therapy e.g. discussing important activities with the person prior to or during treatment e.g. football/ having favourite music on to encourage engagement and provide reassurance to support overall assessment.

Since completing this module I have fed back to the occupational therapy team and also the wider AHP and multidisciplinary team about simple alterations to practice we could make, informed by theory, that won’t reinvent the wheel, but can change the way we approach assessment and rehabilitation.

A lovely example given by my physiotherapy colleague on completion of this module was accompanying a person to the hospital shop to get her a can of Irn Bru or her “can of ginger”. This was identified by the person as something they would like to do.  This allowed my colleague to review functional mobility, use of stairs and allowed assessment of handling money, decision making, way finding. Overall, however, it provided the person living with dementia a level of independence and she voiced how much she enjoyed this.

Looking to the future I am hoping to develop activity boxes that can be accessed on each ward to encourage engagement in activity both within and out with rehabilitation sessions.

Summary

Completing the MSc AHP rights-based dementia module has given me a deeper understanding of a rights-based approach and how simple changes to practice can further embed the rights of people living with dementia during rehabilitation. I would encourage all AHPs to engage in this module as dementia is everybody’s business. Although a bit daunting to go back to your student days, the knowledge and experiences you will gain for your personal learning and service development are invaluable.

Contributor

My name is Emma Loftus and I am a Band 6 Occupational Therapist in Older Peoples Services within the Royal Alexandra Hospital in Paisley. My role involves assessing and implementing patient centred goals and treatment plans to maximise occupational performance and support timely discharge from hospital. @letsallbuybees

References

ALZHEIMER SCOTLAND., 2017 Connecting People, Connecting Support Transforming the allied health professionals contribution to supporting people living with dementia in Scotland 2017-2020. Edinburgh: Alzheimer Scotland.

CLARKE, C., STACK, C., and MARTIN, M., 2018. Lack of meaningful activity in acute physical hospital wards: Older people’s experiences. British Journal of Occupational Therapy [online]. 81(1), pg 15-23 [viewed 20 October 2020]. Available from: https://journals.sagepub.com/doi/full/10.1177/0308022617735047

CLISSETT, P., POROCK, D., HARWOOD, R. and GLADMAN, J., 2013. The challenges of achieving person centred care in acute hospitals: A qualitative study of people with dementia and their families. International Journal of Nursing Studies [online]. 50, pg. 1495-1503. [viewed 01 November 2020]. Available from: https://www.sciencedirect.com/science/article/pii/S0020748913000692?via%3Dihub

EQUALITY AND HUMAN RIGHTS COMMISSION., 2020. What are human rights? [Online] [Accessed 30 November 2020] Available from: https://www.equalityhumanrights.com/en/human-rights/what-are-human-rights

HEALTH CARE AND PROFESSIONS COUNCIL., 2013. The standards of proficiency for Occupational Therapists. London: HCPC.

KITWOOD, T., 1997 Dementia Reconsidered: the person comes first. Open University Press, Milton Keynes

PERRIN, T., MAY, H. and ANDERSON, E., 2008. Wellbeing in Dementia – An Occupational Approach for Therapists and Carers, 2nd ed. Philadeplphia: Elsevier Ltd

ROYAL COLLEGE OF OCCUPATIONAL THERAPISTS., 2015. Code of Ethics and Professional Conduct. London: RCOT.

SCOTTISH GOVERNMENT., 2011. Standards of Care for Dementia in Scotland: Action to support the change programme, Scotland’s National Dementia Strategy [online]. Edinburgh: Scottish Government [viewed 27 November 2019]. Available at:https://www.gov.scot/publications/standards-care-dementia-scotland-action-support-change-programme-scotlands-national-dementia-strategy

Engaging in meaningful activity in hospital

How do you engage people living with dementia in meaningful activity? How do you then adapt and adjust that activity for a hospital ward? Add in a pandemic that brings with it many restrictions and it can be challenging! James and I are third year occupational therapy students who have been asking ourselves these questions whilst here on placement at Dumfries and Galloway Royal Infirmary (DGRI).  

As occupational therapists in training, our focus is how to engage people living with dementia in meaningful activity whilst they are on the ward. Occupational therapists look at the people they work with as holistic beings; taking in every aspect of a person, their occupations, and their environment. This ensures when we work with people that we are supporting them in every way we can. It also aids us in facilitating people to engage in activity that is actually meaningful and enjoyable to them.

Everyone should be able to take part in the pursuits that they enjoy, and this is no less true in an inpatient setting. Providing meaningful and stimulating activities for people on a hospital ward can lead to a decrease in boredom and loneliness, and improvements in overall health and wellbeing. Activities can minimise stress and distress in those living with dementia and can lead to better sleep and improved quality of life.

When considering possible activities, we need to consider resources – how do we access physical resources for the ward, and can these resources be appropriately disinfected in line with infection control? We also need to grade the activity to the individual – what are their levels of cognition and functioning? There is a lot to learn!  Something we do know are the benefits nature and the outdoors have on people. Fresh air and even sunlight (whilst infrequent!) are free resources. The Dumfries landscape is beautiful, and the location of the hospital lends a great opportunity for patients to engage with their surroundings. This led us to one of our ideas whilst here on placement – the bird table.

We know from previous conversations with those on the ward that a number of people are missing their gardens and the birds they often see there. The idea of having a bird table and some bird feeders outside the ward was to encourage some new life into the green spaces outside people’s windows. It also had the added benefit of being accessible to all; if patients are not able to get outside or leave their rooms, they can still have the view of these new visiting birds to engage with and enjoy.

We are extremely lucky to have a great group of volunteers at DGRI, who are not only fantastic with everyone on the ward, but who also seem to have hidden talents! Volunteer Jason Levy happened to hear about our idea and offered to build us a bird table, which he has since donated to the ward. As you can see, it is truly fantastic. Having volunteers who are involved in not only providing great comfort to those on the wards, but who also bring their other talents has been very exciting to witness and we are extremely grateful for this donation.

With a bird table and a few bird feeders in place, we now have the opportunity to explore a number of new activities with patients and volunteers. This could be anything from bird watching, to volunteers making fat balls with people on the ward for the birds to enjoy!

Left to right:  James Carolan (OT student), Maureen Huggins (volunteer), Louise Clark (nurse), Dr Laura Ene, Tabitha  McClelland (OT Student), Jason Levy (volunteer and Bird Table maker)

Providing meaningful activity can be a challenge, especially during these uncertain times. Hospital staff, volunteers, and our practice educator Wendy have all been amazing at supporting us throughout this placement. Implementing new activities on the ward and having things like the bird table would not be possible without everyone’s input and support, and we are excited to see what changes will happen next.

Contributor

Tabitha McClelland, Occupational Therapy student, Queen Margaret University, Edinburgh @tabsOTstudent

Virtual AHP Student Placements at Alzheimer Scotland

Breaking with tradition

We are all having to do things differently during the Covid-19 pandemic and it feels like we are constantly adapting and learning.  An area in which this is most definitely the case is in relation to Practice Education placements.  I know that many of the ever adaptable AHP workforce have already facilitated virtual or blended placements (or may be about to do so) and I have found it valuable hearing about this.  To join in, I wanted to share my experiences of occupational therapy virtual placements in Alzheimer Scotland.

Ambition 3 in Connecting People, Connecting Support (Alzheimer Scotland 2017, 2020) is for an AHP workforce skilled in dementia care.  AHP students are our workforce of the future and within Alzheimer Scotland there has always been a strong commitment to supporting AHP student placements in occupational therapy, physiotherapy, art therapy and music therapy.   Many AHP students have benefitted from the experience of working within the Alzheimer Scotland Dementia Resource Centres, which is often classed as a “non-traditional” practice placement. Due to the covid-19 pandemic, unfortunately the building-based support offered by Alzheimer Scotland was forced to close.  However, it was vital that students still benefitted from the experience of working with, and learning from people living with dementia and those who support them.  So it was time to “try something new”

Non-traditional placement in a non-traditional style

We already know the benefits of non-traditional placements but include an additional layer of being entirely virtual and I’ll admit to feeling nervous.  At the same time, being aware of how it must feel for the students.   Our occupational therapy student pioneers were Abi and Gemma from Queen Margaret University who started their placement at the beginning of September 2020.  They worked across the whole organisation in Alzheimer Scotland depending on identified need.  Laura and Michaela from Glasgow Caledonian University then joined us at the start of November 2020 for role emerging placements hosted in the Renfrewshire locality.   I want to thank them all for embracing new ways of working and helping us to learn about virtual placements. 

Here are some of my thoughts and learning:

Be open and acknowledge what might be difficult                                                                                                           Even although it was a long time ago, I still remember the butterflies of preparing to go to placement on the first day, hoping for no transport or navigation issues and wanting to make a good impression.  Now before virtual placement, we are all sitting in our houses with other issues to worry about – will MS Teams work? will the Wifi be okay? When are the dogs going to bark? to name just a few.  Acknowledge this from the beginning and recognise that we are all adapting and learning together.  Share ideas with each other about how to avoid interruptions, how to maximise online communication, how to look after ourselves.  A positive is that in person pre-placement visits were not always an option however it is much easier to facilitate this virtually, which can help.

Communication is key                                                                                  

It might be said that I like to blether, or another way to look at it is I recognise the value of the chat while the kettle is boiling (for building relationships, sparking new ideas and self-care).  This is also when a student might feel comfortable in sharing thoughts and ideas outwith ‘formal’ meeting time.  Pay attention to this in the virtual environment, even if it’s a blether after a meeting, a check-in or a “how’s your dogs/cats/family?”.  In person, as part of an informal chat, students may happen to mention something they are working on or the seeds of an idea, ensure there are opportunities to translate this into the virtual environment too.

Promote student partnership opportunities                                        

Both occupational therapy placements have coincided with other AHP placements within Alzheimer Scotland: Physiotherapy, Edinburgh Napier University and Art Therapy &  Music Therapy, Queen Margaret University.  This has enabled inter-disciplinary learning and support in action.  The creation of an ‘AHP Students’ Microsoft team enabled collaboration around joint projects and a space for the students to share ideas and their projects.  An added bonus is that this is available for future students to build on.  There is great potential for future student partnership working across settings.

Embrace digital solutions                                                                                                                                            

I am aware that there can be concerns about missing certain experiences due to the virtual setting.  But when else would you be able to attend a virtual Team Meeting in the Western Isles in the morning to hear about dementia innovations and to share your role and quality improvement project?  Then over to the Central Belt in the afternoon to be part of a virtual Carer’s Group (one of numerous virtual groups hosted within Alzheimer Scotland).  To finish off the day, take part in a webinar learning about AHP innovative practice in dementia.  This is just a small flavour of some of the digital opportunities available. 

I want to close my blog today,  by again thanking all of our AHP students and the many people who have been involved in supporting the virtual placements within Alzheimer Scotland.  We look forward to building on the learning and continuing to try new ways of working.  Our next Occupational Therapy students are virtually arriving in May so keep an eye out for them!

To hear more from our Occupational Therapy students, here is a blog by Abi that you can read here & a joint blog by Abi, Gemma, Toni and Steff where they share their 10 Top Tips for an AHP e-placement in @alzscot and you can find that here

Contributor

Alison McKean, AHP post diagnostic lead, Alzheimer Scotland 

@AliAHPDem

Dementia: Post-Diagnostic Support App

Dementia affects everyone differently and reactions to a diagnosis of dementia can vary. For some people it may come as a shock and for others there may be an initial sense of relief at finally being able to understand symptoms they have been experiencing.

It often takes time for people to come to terms with their diagnosis and individual support needs vary. High quality post diagnostic support is essential to equipping people with dementia and their families with the tools, connections, resources and plans they need to live as well as possible with dementia.

Post diagnostic support services have been long established within NHS Ayrshire and Arran and in health boards across Scotland. However, the Coronavirus pandemic has led to nationwide difficulties in people with dementia and their families accessing face to face post diagnostic support. There is nevertheless evidence that “Virtual post diagnostic supports” have worked well during the pandemic.

For the foreseeable future it is likely that a more blended post diagnostic support service model may be required. In recognition of this, NHS Ayrshire and Arran launched their new post diagnostic support App on 5th February 2021. The App was co-designed in partnership with local health and social care practitioners and local family carers of people with dementia. It complements the national Alzheimer Scotland App and existing post diagnostic support services within NHS Ayrshire and Arran, by extending access to local information, resources and dementia support services.

The launch of the App has received national and international interest. However, perhaps the greatest endorsement of its potential is the initial positive response it has received from local people with dementia and their family carers and those who support them:

“Looks good and well presented”

“Great App, very informative and easy to navigate”

“So helpful that it’s local info”

“What a much needed and amazing thing this is”

Over 100 people have signed up to the App during the first 4 weeks of its release. If you would also like to sign up to the free App please follow the instructions below

Contributor

Susan Holland

Alzheimer Scotland Nurse Consultant, NHS Ayrshire and Arran

@Susan_hol1

Footcare at home

Helpful tips for looking after your feet at home.

Allied Health Professionals have created a suite of information resources for people with dementia and those who support them. This includes information on activities at home, physical activity, footcare and diet and hydration. This information is relevant for people living at home, being supported at home or in a care home setting. This will be updated on a regular basis so please check back to see the most up-to-date information. You can find all the resources here

Footcare at home

Over the coming weeks and months we are all being asked to change the way we live our lives so that those who are at most risk of coronavirus are kept as safe as possible. For people with dementia and their families and carers this period of change will be unsettling. Not being able to go about your daily routine or undertake the activities you normally do, could be quite stressful. In collaboration with allied health professionals, we are preparing a range of information to help you through this time and this guide is one example. This sheet has been written in partnership with podiatrists, who can help you by diagnosing, treating, rehabilitating and preventing foot, ankle and lower limb problems. This can assist you with sustaining an active and healthy lifestyle by helping you to maintain your mobility. If you need more information please call our 24 hour Freephone Dementia Helpline on 0808 808 3000 and we will do our very best to help you.

Personal footcare is important for everyone. Good foot health can reduce discomfort and pain, prevent health complications, maintain mobility and improve both independence and quality of life. Having healthy feet can help you to remain physically active and allow you to participate in the activities you enjoy. However, neglecting personal footcare can contribute to poor health and reduced wellbeing, which can be avoided. During this time when your normal activities may be restricted and you may not be able to have the same access to a podiatrist, there are things you can do to look after your feet.

Helpful tips for looking after our feet at home:

Wear appropriate footwear. Avoid walking barefoot or in old slippers at home as these can cause foot strain or falls. Instead try trainers or your normal shoes to protect and support your feet. Make sure to change your socks or tights daily too. If you are going out, make sure your shoes fit properly. Check the bottom of your shoes to ensure nothing sharp has pierced the soles and run your hand inside them to check for objects such as small stones. At this time it can also be harder to buy new shoes. If someone is buying them for you then try giving them a template of your feet by standing on paper and drawing around your feet. This can be slid inside a shoe. If it curls up at the sides or front then the shoe is too small.

Check your feet every day. You should check your feet every day for any discolouration, blisters, breaks in the skin, pain or any signs of infection (i.e. redness, heat, swelling, pain, loss of function). A hand mirror can help with this. If you have any concerns seek help from your NHS Podiatry service or local HCPC registered private podiatrist for advice.

Wash your feet daily. Try to shower and wash your feet every day in warm water and with mild soap. Rinse them thoroughly and then dry them carefully, especially in between the toes before putting on your socks and shoes. If you are unable to get into the shower or bath regularly, it may be easier to wash your feet using a basin. Don’t soak your feet as this can reduce the natural oils of the foot, causing dry skin.

Put lotion on your feet daily. Use moisturising lotion on your feet daily, especially if your skin is dry. Don’t put any between your toes as it can lead to infections. Reduce hard skin by gently rubbing with a pumice stone or foot file. Just after you have washed your feet is best. You may have areas of yellowish thick skin on your toes or feet. These are calluses and corns which can be painful. DO NOT use any sharp implement to cut these as it it’s very dangerous. Do not use any creams or plasters which contain acids to remove them. If you are in pain, contact a podiatrist for advice.

Try to keep your toenails comfortable. You can file (1 to 2 times per week) or cut your toenails to help keep them comfortable. If you choose to cut your toenails then it is best to use proper nail nippers. Do not cut them too short. It is safest to cut straight across, cutting down the sides can cause a wound or an ingrown toenail. Once cut, file with an emery board to ensure there are no sharp edges. If you have problems with the sensation in your feet, or your vision, ask a family member or carer for help. If you have been advised not to cut your own nails, or have any difficulty, please contact your NHS Podiatry service or local HCPC registered private podiatrist for advice.

If you’re unsure about something, it’s always better to call your podiatrist or GP than to take things into your own hands or ignore any issue. Podiatrists are still seeing patients based on current Government guidelines which are frequently updated. If you are worried about low mood or pain you can still seek medical assistance, the NHS is still there for you during this time. Speak to your GP or you can call NHS24 on 111.

A podcast of Elaine and Karen in conversation about footcare at home can also be found here