I had the wonderful opportunity of completing my level 1 adults and seniors fieldwork at Kentfield Hospital in Kentfield, CA. This hospital is a critical care hospital, designed to provide quality care for adults and seniors with complex medical issues who require extended hospitalization. While they offer many services, the hospital is skilled in their utilization of tracheostomy tubes. I completed a total of 40 hours at this placement where I was able to observe the functions and inner workings of an acute hospital setting, inter-professional collaboration amongst therapies, as well as what the OT process looks like in this setting.
A theoretical framework that was frequently used in this setting by the occupational therapists was the rehabilitative frame of reference. As mentioned above, many of the patients in this hospital are experiencing complex medical issues which includes chronic illnesses and sometimes life-threatening conditions. Considering this is the case, much of the focus in this setting is on the patient's, "...remaining abilities, despite of any disabilities, to attain his/her highest level of functioning in the desired occupational performance" (Cho, 2014). Many of the conditions that the patients experience, can be debilitating and lead to many barriers in engagment of activities of daily living. Therefore,"The ultimate goal of this FOR is to maximize independence despite the presence of persistent impairments" (Cho, 2014).
I observed this frame of reference being applied to a middle-aged patient who had a level C6 spinal cord injury. Due to the level at which this patient's injury occurred and it's manifestation in terms of muscle function, the key muscles and joint actions that were reserved and functional were the rotator cuff muscles, elbow flexors, and wrist extensors. The patient's primary limitations were restricted range of motion in their finger flexors and limited forearm supination/pronation. In addition, the patient had been incorrectly splinted at a previous facility, where they were fitted with a standard resting hand splint instead of a modified splint with wrist flexion and digit extension. All of these factors contributed to the patient's limited and less than functional tenodesis grasp. The patient having already tried some adaptive equipment, such as a universal cuff, was still unable to reliably self-feed due to these physical limitations. Because these limitations could not be completely remediated, the occupational therapist worked to focus on the patient's remaining abilities by providing adaptive equipment that matched the patient's current level. To improve occupational performance and maximize the patient's ability independently self-feed, a vertical palm utensil and plate guard was provided to the patient. The occupational therapist educated the patient on the use of these pieces of equipment and facilitated their incorporation into the patient's meal times.
Some of the most memorable 'aha' moments I had during my fieldwork occurred while observing the occupational therapist work with a young adult with an incomplete C6 spinal cord injury. This fieldwork experience was really the first time I had ever worked closely with an individual with a spinal cord injury. Much of my prior knowledge regarding spinal cord injury was acquired through participation in the first part of our three part adults and seniors class series. In this course we did have an opportunity to speak with an individual who is living with a spinal cord injury, however this meeting was fairly brief and was over zoom. Spending time in person with this patient really resonated with me and facilitated my understanding of what living what a spinal cord injury looks like in a person's day to day life. This is something that the patient themselves was still coming to terms with while learning how to function with their recently acquired injury. Considering this individual was in the younger adult age group, I realized how the occupational therapist's approach and intervention may be different from an older or middle aged adult. While observing the OT sessions with this patient, I learned the importance of providing the "just right" challenge for your patient as a practitioner. This became apparent during one particular session where the OT facilitated trunk flexion exercises to increase ROM for lower body grooming/hygiene and dressing. The occupational therapist collaborated with the patient to determine the appropriate amount of repetitions, taking into consideration the patient's energy levels, pain, motivation, and more. Although the occupational therapist provided stand by assistance as needed, it was difficult for me at first to see the patient struggling as I found myself wanting to jump in to help them. However, I quickly realized how this struggle was positively contributing to the patient's ability to build strength and problem solve independently. Afterwards, the patient shared their feelings of satisfaction in participating in these exercises as they had not been able to be in this forward flexion position since the injury occurred. Reflecting on this experience, I now understand the importance of creating a "just right" challenge for patients through rapport building, collaboration, active listening, and grading an activity up or down to meet the client where they are at in order to facilitate participation in meaningful activities and occupations.
I had the opportunity to observe a session with a middle-aged adult who had experienced a traumatic brain injury resulting in hemiplegia, paralysis, and right side visual neglect. I noticed immediately that the occupational therapist had positioned themselves on the right side of the patient and identified this as a strategy to encourage the client to attend to their right side. While the occupational therapist was preparing oral care items for the patient to use, I was able to problem solve and came up with an idea on how to encourage engagement in the patient's right visual field while participating in oral care. The occupational therapist confirmed my strategy and demonstrated to execute it by holding the toothpaste and oral care tray to the patient's ride side. These visuospatial exercises worked to establish the patient's visuospatial skills and prevent right neglect through encouraging turning and reaching in order to acquire toothpaste and successfully brush their teeth. I connected this experience back to what we had discussed briefly in class recently about the different visuospatial strategies the practitioner can engage in to facilitate use of neglected visual field. Making this connection was really meaningful for me and helped me build confidence in putting these concepts discussed in class to practice.
This is a patient I observed session with during my entire 40 hour experience at Kentfield Hospital. This patient is middle-aged adult with an ABI, who was in a coma and at Rancho Los Amigos Level I. The patient's presentation consisted of an absence in response to visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli. They had abnormal muscle tone, which was primarily flaccid with some tone emerging with wrist extension and finger flexion. This experience was another first for me as I had not witnessed anyone in a coma before. The main goals were to continue monitoring for any changes in tone, splinting to maintain ROM, and facilitate proper positioning. Throughout the sessions with this patient, I learned how important positioning is for reducing swelling, for preventing pressure sores, and maintaining ROM. These experiences emphasized for me the importance of providing patients with every opportunity possible to have a better functional outcome no matter what the persons prognosis is. I was able to connect to the material that I am currently learning in the second part of our three part adults and seniors class series. Specifically, I identified that the focus of intervention should be on increasing response to sensory stimulation.
I really appreciated being exposed to and gaining experience in a brand new setting. Before coming into this fieldwork, I was not as drawn towards this particular type of setting compared to others. However, for this reason, I was even more excited to see how I would like it. I really enjoyed my time at Kentfield Hospital and felt grateful to have such supportive supervisors who created a safe, encouraging, and fun learning environment for me as a student.
With this experience, I was able to identify some pros and cons which will influence how I move towards my future practice. Some of the things I felt were really special about this setting and were things I will want to look out for when pursuing a job in the future would be having built-in documentation time, opportunities to collaborate with other professionals, and having a set start and end times to help maintain work/life balance. Some of the more challenging aspects for me was the fast-paced environment and limited time for documentation. However, I do recognize that these are things I would improve on with time. I could envision myself in this type of setting early on in my career for a shorter period of time, mainly due to the fast pace and emotional toll it could take on me personally seeing patients experience such serious, life threatening medical issues.
Cho, M. (2014). Rehabilitative frame of reference. Rehabilitative Frame of Reference | OT Theory.
ottheory.com/therapy-model/rehabilitative-frame-reference