Level 1 - Adults and Seniors

Acute Rehab Unit

Below is an analysis and reflection of my experience in my adults and seniors fieldwork placement. I discuss my key takeaways and observations of a specific frame of reference used by occupational therapists (OTs) in the acute rehabilitation setting.

Overall Reflection

My experience in the acute rehabilitation unit allowed me to translate material learned in the classroom to real-world application. In reflecting, there are significant takeaways that will be influential in my future practice. I observed the OTs and noticed the role they played in emotionally supporting their patients through treatment sessions. The OTs in the acute rehabilitation setting encourage their patients' independence in self-care tasks through the regaining of strength, compensatory strategies, or adaptive equipment. I noticed that embedded in each session is an inevitable psychosocial aspect that comes with loss of prior abilities or injury. The patients in this setting are in a vulnerable state, often recently experiencing a life changing accident or surgery. The OTs continually demonstrated active listening, empathetic communication, and motivational interviewing. Aside from ADL training, the OTs are there to motivate and re-instill confidence in their patients as they navigate their physical limitation. In encouraging patients' independence, it was clear that the OTs provided their patients with a safe and brave space (physically and emotionally) to struggle and make mistakes. The OT explained that while it is challenging and frustrating to struggle, the struggle and practice leads to increased independence.

Additionally, I reflect on the importance of communication and collaboration within the healthcare team. I was drawn to the collaboration aspect of the acute rehabilitation unit. The team was comprised of OTs, physical therapists (PTs) speech therapists (SLPs), doctors, and nurses, who were in continual communication regarding the status of all patients on the unit. There were set meetings and rounds for the team to discuss the status of each patient overall, however after each treatment session I watched as the OTs collaborated with the PTs and SLPs. Further, when questions regarding medication or symptoms arose, the OTs would engage in open communication with nurses and doctors. The collaborative environment provided all healthcare professionals a safe space to exchange ideas, questions, or concerns. Such collaboration across disciplines allowed the team to provide the overall best form of care to the patients. In my future practice, I will take with me all that I learned in this fieldwork experience, but I will especially take with me the active listening, empathic communication, and collaboration skills that I acquired and observed from my fieldwork mentor and acute rehabilitation unit team.

Specific 'Ah-Ha' Moments

SPINAL SURGERY

Key Takeaway: Importance of Creativity - In observing a treatment session with a patient who had undergone spinal surgery, I learned several lessons regarding the use of compensatory strategies to support a patient's independence. The patient was required by the doctor to wear a TLSO brace when out of bed. Despite practicing donning and doffing the spinal brace throughout several sessions, the patient continued to struggle to remember the sequence of steps. To increase the patient's independence, the OT made a visual support aide with steps to allow the patient to reference. The OT demonstrated creativity in designing a visual support that used the exact wording the patient used to describe each step. The OT hung the aid from the patient's front wheeled walker to ensure the aid would be in a line of sight that was supportive of the patient's decreased visual acuity. The visual support was helpful in supporting the patient to be independent in donning and doffing their TLSO, while maintaining the required spinal precautions.

R CVA LEFT NEGLECT

Key Takeaway: Importance of Determination - Upon observing a patient with a right CVA, the power of determination was evident. Due to a right CVA, the patient experienced significant left sided weakness and left neglect, but expressed desire to dress independently. The OT educated the patient to transfer from sitting to standing at the counter and then use his left arm for stability. Once standing and leaning on his left arm for balance, the patient could don his shirt and shorts with his right arm. The transfer proved to be challenging as the patient was nervous to place weight on his weak left arm. After 40 minutes without success, I noticed both the patient and the OT becoming fatigued. Eventually, the patient completed the transfer and found the confidence to use his left arm for support. The patient then donned his shirt and shorts with their right arm and a smile on their face. Through moments of doubt the OT remained determined while continually motivating their patient to demonstrate belief in themself despite challenging physical limitations.

TOTAL HIP REPLACEMENT

Key Takeaway: Importance of being Client-Centered - An "ah-ha" moment with a patient who had recently undergone a total hip replacement reminded me of the importance of being client-centered. Prior to the treatment session, the OT developed a plan to practice ADLs while maintaining hip precautions. However, upon entering the patient's room, the patient expressed that their goal for the session was to increase their standing and walking endurance. They had written in their journal that their goal for the day was to walk 6 laps around the unit. Remaining client-centered, the OT completely deviated from their original plan to honor the patient's goal and wish for the session. Although the OT had developed a treatment plan they valued, the OT understood that the patient's walking goal was meaningful to them. In this moment, the OT demonstrated the importance of being client-centered, and the importance of deviating from a plan to support the patient's desires and goals.

Frame of Reference - Rehabilitation

Rehabilitation

The rehabilitation frame of reference (FOR) was the most apparent model used by the OTs throughout the acute rehabilitation unit. The rehabilitation FOR utilizes compensatory strategies and adaptive technology / equipment to optimize occupational performance. The rehabilitation FOR allows patients with permanent physical limitations to restore and improve functional skills, strength, endurance, ROM, and independence. The goal of the rehabilitation FOR is to maximize occupational engagement rather than attempting to "fix" the individual, or rid of their impairment. In the acute rehabilitation unit, the OT utilized compensatory strategies and adaptive equipment to encourage their patients to adhere to precautions according to their surgeries. The OTs continually educated patients on the important of their precautions, and the importance of utilizing such strategies and equipment to increase independence. To get out of bed independently while maintaining hip or spinal precautions, compensatory techniques such as log rolling were used. Adaptive equipment such as a reacher, dressing stick, sock aid, long handled sponge, front wheeled walker, and wheelchair were used in every treatment session. Such adaptive equipment allowed patients to increase their independence when engaging in ADLs. When needed, the OTs adapted a task to increase the patient's occupational performance. For example, a patient with a right CVA found that it was easier and allowed for increased independence when they dressed themselves in their wheelchair, rather than dressing while laying in bed. Further, due to the patient's left side neglect secondary to their right CVA, the patient was unable to dress their left side, as they could not see their left arm. To compensate, the OT provided the patient with a mirror. The mirror allowed the patient to see their left side, and then thread their left arm through the shirt arm hole. Such adaptation allowed for optimal independence and success. For patients with cognitive dysfunction, the OTs utilized visual support aids with step by step instructions that not only increased independence in ADLs, but also provided reminders for patients to follow their surgery precautions.

Pendleton, H. & Schultz-Krohn W. (2018) Pedretti’s Occupational Therapy: Practice skills for physical dysfunction. 8th Edition. Mosby Elsevier.

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