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Rock Steady Boxing (on Zoom)
Rock Steady Boxing (on Zoom)
Communication with Clients in a Telehealth Service Delivery Model
I found the virtual format of this fieldwork to be both challenging and rewarding in unique ways. In general, I experienced the virtual context as less personal than I imagine in-person classes would be. Especially when I was instructing my occupation-based exercises, it was difficult to see and cater instruction to individual clients due to the nature of Zoom. It was difficult to observe and instruct clients due to the varying camera angles, microphones being muted/unmuted, and especially my limited screen layout options-- using “gallery view” on my rather small screen to attempt to observe as many of the clients as possible while still needing to view myself to make sure I was in frame while teaching.
I had the pleasure of working with three different coaches, getting to observe, experience, and compare their coaching styles.
Yoga-informed coaches:
Emphasis on breathing
Emphasis on general exercise and movement, boxing secondary
Informed by importance of a mind-body connection
Utilizes progression and regression to build up exercises physically and cognitively
Participant microphones mostly muted due to large class size
Coach informed by a healthcare and boxing background:
Science-based, considers exercise a “prescription”
Predominantly boxing exercises
Emphasis on movement
Utilizes a timer, music, high level of verbal instruction and feedback
Interpersonal connection is key
Adjusts instruction as needed to find “just-right challenge” for group and individuals
My ability to use a therapeutic use of self was highly restricted due to the low level of opportunity for interaction with the clients in the virtual format. Joining the meetings early and staying late provided a few minutes of social interaction for the clients that we as students got to observe. The participants all seemed genuinely excited to see each other each week, and though the discussions usually consisted of brief smalltalk or talking about the class, many of them seemed excited just to see and hear from each other. It was my understanding that the social interaction these classes provided in-person were very beneficial to the clients emotionally and cognitively, and I feel that this was the most affected by the shift to virtual classes.
Personally, I felt that the most rapport building I was able to achieve with the clients was via active participation alongside them in the smallest size and most interactive weekly class. In this class, the coach shared his computer sound with music and timers correlating to the exercises, and utilized a highly verbal teaching method. Most of the clients kept their video on and microphones unmuted, and as a result were able to hear each other vocalizing the exercises with the coach, and found the opportunities to talk to and make jokes with one another. Though I predominantly kept my microphone muted, I engaged in expressive nonverbal communication, and got to observe and moderately participate in this environment where the clients were the most socially engaged and cognitively active.
My “Ah-Ha” Experiences
Two of my “ah-ha” moments were realizations that I had about a client who, in my first few sessions observing them in class, I believed was barely participating. From my initial perspective being largely uninformed about Parkinson’s disease, it seemed to me that this client was low-engagement and low-energy, often starting or ending an exercise halfway through and not using their full range of motion. Through the development of my knowledge regarding the characteristics and symptoms of Parkinson’s disease, I was able to realize that this client was participating, just not in the ways I expected. Based on my previous experiences with pediatric and psychosocial populations, I would have guessed that this client may have been experiencing emotional or cognitive barriers to participation, such as sleep deprivation, depression, or cognitive delays. In learning about Parkinson’s, I developed an understanding that these were all likely possibilities for this client as well as other difficulties due to their condition. My educated guess is that this client is likely a level 4 on the Hoehn and Yahr Scale. Beyond the possible psychosocial barriers, I realized that what I was interpreting as disengagement by starting exercises late and using a limited ROM was actually likely due to bradykinesia, slowed cognitive processing speed, and impaired postural reflexes. It was not that they didn’t desire to participate in the full duration of the exercises, they simply took longer to process the instructions and begin to move their body accordingly. And it was not true, either, that they were not able to move in a wider ROM, simply that they needed to be cued for “Big Movement” in order to realize that they were not already moving to their end-range of motion.
Another “ah-ha” realization I had was regarding a client who appeared to me to be disinterested in the classes. In my psychosocial courses and fieldwork experiences, I have encountered many instances of clients not being intrinsically motivated to participate in the services offered, such as a group activity that was incentivized or required. My instinctual guess was that maybe this client had a healthcare provider or family member who told them to attend these classes, and that they might not feel excited or motivated to participate for their own sake. Though they were in a class that kept microphones muted most of the time, I never saw any nonverbal communication from them, nor did they appear to be vocalizing exercises to themself as instructed. The client maintained a neutral, almost flat-affect facial expression even while exercising, which I initially interpreted as lack of energy, attention, and/or interest in the class. After learning more about Parkinson’s disease and its symptoms, it occurred to me that this client’s “flat affect” was likely to be facial masking, a result of stiffness and slowness of the facial muscles as well as the vocal cords. Contrary to my initial assumptions, this client may very well have been interested in the classes, as their consistency and participation demonstrated. They likely were not bored or unenthusiastic, but rather unable to be expressive with their facial muscles or loud enough with their voice for me to pick up on their nonverbal or verbal communication.
Another “ah-ha” moment I had in this fieldwork experience pertained to a client who attended multiple classes each week, yet seemed like a totally different version of themself depending on the class. Their demeanor changed drastically depending on coaching/class style. Based on my previous pediatric knowledge and experiences, I equated this to how a child’s energy can fluctuate greatly based on their sensory environment. After a few weeks of observing the client in both classes, I realized that their level of engagement and energy was indeed not fluctuating randomly, but was tied to the class environment and the teaching style of the two different coaches. The client appeared to me to be their most bright, engaged, talkative, and humorous self in the smaller of the two classes. In this smaller class, the participants seemed to know one another from previous in-person classes. In combination with this social familiarity, the coach kept all of their microphones unmuted, played music during the session, and utilized 1-on-1 interaction himself to cue or praise individual clients throughout the session. I believe that this set the stage for the clients themselves, especially this particular individual, to socially interact with the coach and other classmates. It is my assumption that this increased social interaction combination with the more personalized environment of the class was more cognitively and emotionally stimulating to them, which supported them in being more expressive and higher energy in this particular class.
Implications for Future Clinical Practice
I believe that this fieldwork experience will have a lasting impact on my future clinical practice as an OT in multiple ways. First and foremost, it has increased my understanding of a population of clientele that I had no experience with prior. I have had little experience personally or clinically with older adults, and no experience with older adults with Parkinson’s disease. Through this fieldwork, I was able to engage with groups of older adults as an observer, classmate, and instructor. These varying roles gave me insight into common supports and barriers to the occupations of exercise and social interaction that they experience, in addition to the unique occupational impacts of Parkinson’s disease. Another element of this fieldwork experience that will have a lasting effect on my future practice as an OT is my increased expectations of what Telehealth service delivery can provide. My observations, participation, and instruction within a virtual service delivery format challenged my existing understanding of what can and can not be done virtually. This experience deconstructed my preconceived belief that seniors with Parkinson’s would have trouble accessing, let alone meaningfully engaging in Telehealth service delivery. The clients and coaches I met through RSB were dedicated and resilient, and through trial-and-error and persistence, they each found unique ways to adapt a program rooted in in-person group participation with specialized equipment to be something they can access and find just as meaningful from their own homes. Further, this experience enlightened me in some of the different ways in which Telehealth settings can be more accessible. Clients were able to participate from other states and time zones, avoid the barriers required to commute from home to the gym and back, and adapt the equipment to be more economically and practically available in addition to suiting their individualized needs (e.g. using canned goods of different weights instead of handheld free weights, or a t-shirt instead of a resistance band). Overall, this experience broadened my understanding not only of older adult populations and Parkinson’s disease, but of the limitless potential of the Telehealth service delivery model, and the normalization of accessibility it can accommodate.
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