Running head: FIELDWORK PARADIGM CRITIQUE1FIELDWORK PARADIGM CRITIQUE15

Fieldwork Paradigm CritiqueGretchen KempfThe University of Scranton

Introduction

This paper discusses the constructs of the Contemporary Occupational Therapy Paradigm (Contemporary Paradigm), the Paradigm of Occupation, and the Mechanistic Paradigm in relation to my level II physical rehabilitation fieldwork experience at Pine Run Rehabilitation Health Center in Doylestown, Pennsylvania (Pine Run) during the summer of 2013. In addition to an overview of the general concept of a paradigm, the paper sets forth the focal viewpoints and core constructs of each of the three aforementioned paradigms. Following a critical examination of my fieldwork experience at Pine Run, evidence will be presented to support the conclusion that the occupational therapists at Pine Run rarely operationalized the constructs, focal viewpoint and values of the professions Contemporary Paradigm in client treatment and more often practiced under the constructs of the Mechanistic Paradigm. This paper also proposes a design for a workshop that would allow an interdisciplinary team to be educated on the purpose of occupational therapy (OT) through the lens of the Contemporary Paradigm. The proposed design encompasses workshop objectives, delivery method, and methods of assessment to ensure objectives are being met. Solutions for overcoming potential barriers to operationalizing the professional paradigms constructs also will be presented. The paper concludes with an examination of the connection between the Contemporary Paradigm and the Occupational Therapy Practice Framework.General Overview of a ParadigmA paradigm serves as a common vision in a field of practice. It is made up of broad assumptions and perspectives, which, in turn, unify the field and define the nature and purpose of the particular field of practice as well as its primary concerns, methods, and values (Kielhofner, 2009). A paradigm also functions to create a professional culture with common beliefs and values that make sense of and guide professional action (Kielhofner). This allows practitioners to gain a broad understanding of what they are doing when they practice (Boniface & Seymour, 2012). More specifically, OT paradigms allow occupational therapists to justify and define the services they provide to clients. A paradigm is made up of core constructs, a focal viewpoint, and values (Kielhofner). The core constructs identify the nature of the fields services and provide an understanding of why the service is needed. The focal viewpoint directs practitioners attention to certain aspects of therapy and offers a way of seeing those aspects. Values are required to identify why practice matters and to determine what should be carried out in practice. This is especially important for the profession of OT because practitioners are constantly engaged in practical action, which requires them to keep in mind the good of that action when selecting the proper techniques and methods to implement client service (Kielhofner). During its history and development in the United States, the profession of OT has had three major paradigm shifts. The first paradigm, the Paradigm of Occupation, was prominent from the early 1900s to the 1940s. This paradigm was founded on the principles of using occupation to influence recovery from illness and adjustment to disability (Kielhofner, 2009). It grew out of the arts and crafts movement as well as habit training. It was thought that humans were occupational beings whose minds and bodies were shaped through the occupations in which they were engaged. There was a great emphasis on the interrelationships of the mind, body, and environment (Kielhofner). Despite this unifying paradigm, a crisis emerged in the field due to many social/environmental factors (such as World War I & II, the Great Depression, and scientific/technological advances) and the professions adoption of reductionism (Kielhofner). This major crisis culminated in the formation of the Mechanistic Paradigm, which emerged during 1942 and governed the profession until 1960. The Mechanistic Paradigm moved away from the use of arts and crafts and focused on treatments for specific diseases. Occupational therapists believed that this practice shift would bring OT recognition as a valuable, effective medical service and increase the professions respectability within the scientific community (Kielhofner, 2009). This paradigm drastically changed both the manner in which occupational therapists viewed their practice and the types of services they provided to clients. Occupational therapists were no longer focused on the benefits of occupation and the interrelationship of the mind, body, and environment; rather, they focused on understanding and addressing impairments related to what was known as the muscltrapsychic systems. OT interventions identified disrupted mechanisms within these systems and attempted to fix what was broken (Kielhofner). This sudden change in the focus of OT interventions from engagement in occupations to a more medical viewpoint created identity confusion among occupational therapists and other healthcare professionals. This identity crisis served to spur the development of another major paradigm shift within the profession which resulted in the creation of the Contemporary Paradigm.The Contemporary Paradigm came into being in the 1980s and is the paradigm governing the profession of OT at the present time. This paradigm integrated useful concepts from both the Mechanistic Paradigm and the Paradigm of Occupation and focused the profession on being occupation-based, theory-based, evidence-based, and client-centered , while emphasizing the importance of working collaboratively with clients, family members, and other professionals (Kielhofner, 2009). The focal viewpoint of the Contemporary Paradigm reflects a return to occupation as embodied in the original Paradigm of Occupation, but it seeks to steer a therapists intervention away from an emphasis on a clients impairments. The values integrated in the Contemporary Paradigm relate to client centeredness, caring, and empathy, all of which serve to create and strengthen the therapeutic relationship (Kielhofner). Level II ExperienceWhen reflecting on my twelve-week level II physical rehabilitation fieldwork experience at Pine Run, I feel an overwhelming sense of regret in that I did not get to observe or participate in the provision of OT services that were based upon the constructs of the Contemporary Paradigm. Interventions at Pine Run more often than not lacked occupation-based components and, in some instances, the goals of therapy did not appear to be client-centered. Consequently, I was not often able to observe the dynamic, contemporary practice of OT. As will be discussed below, in some ways, my fieldwork experience at Pine Run served as a time-capsule experience of how the profession practiced during the heyday of the Mechanistic Paradigm.Overview of SettingPine Run serves as both a sub-acute/outpatient facility and as a provider of skilled nursing services for inpatients. The facility provides OT, physical therapy (PT), and speech therapy (SLP) services for a wide range of diagnoses. The main diagnoses in my assigned caseload were knee, shoulder, and hip replacements, stroke, ORIF, and dementia. The majority of the patients I saw were 60 years old or older. This facility was very Medicare Resource Utilization Group (RUG) level oriented, so it was essential that therapists from all three professions (OT, PT and SLP) met with each patient for a set number of minutes. Most patients received all three services once a day and professionals worked in collaboration to reach patient goals. The average caseload varied between eight and thirteen clients and all Medicare Part A and Part B clients were seen for roughly one hour and Health Maintenance Organization (HMO) clients were seen for only 30 minutes (and usually at the same time as another HMO client). The facility provided therapists with a gymnasium that contained a wide variety of exercise equipment and had storage for adaptive equipment. Direct access to two small bathrooms was provided from the gym. Paradigms Operationalized in TreatmentAs mentioned previously, most therapeutic interventions at Pine Run appeared to be within the realm of the Mechanistic Paradigm. Curiously, regardless of what the diagnosis was, upper body strengthening and endurance always became a large focus of treatment. At times, I had the sense that clients were not viewed as individuals and the intervention was focused primarily on filling up the allotted time in order to meet RUG levels rather than being directed toward a clients individualized functional needs. A typical OT session consisted of the use of an arm bike and free weights, exercises utilizing Thera-Bands, and cone-reaching activities. This type of treatment illustrates reductionism instead of a holistic approach to therapy. On my first day, a patient asked my supervisor what OT was. My supervisor responded without hesitation and said, [i]ts just like physical therapy only occupational therapists take care of the upper body whereas physical therapists work more with the lower body. This statement unnecessarily blurred the roles of therapists in the eyes of the client since it sought to define OT by using another profession in the definition. This type of role blurring is congruent with the practice of OT under the constructs of the Mechanistic Paradigm in which treatment was focused on specific muscles that limited functional performance in the upper body. In contrast, the practice of OT under the core constructs of the Contemporary Paradigm would address the importance of occupation in health and well-being, would recognize the occupational problems/challenges, and would be an occupation-based practice (Kielhofner, 2009). A key advocate in the shift from the Mechanistic Paradigm to the Contemporary paradigm was Mary Reilly. Ms. Reilly called for a refocus on the theme of occupation and provided the field with a broad and scholarly understanding of the complex parts of an occupational therapists work (Kielhofner, 2009). This pioneering therapist envisioned occupational behavior as the therapeutic framework for practice and I suspect she would strongly oppose the intervention activities utilized by occupational therapists at Pine Run since these interventions were not occupation-based and provided clients with very little meaningful activity. Clients at Pine Run were referred to as patients in spite of the mandates of the Occupational Therapy Practice Framework, 2nd Edition, which provides that OT is provided to clients (AOTA, 2008). I have no doubt that the late Gail Fidler, a noted advocate for the recognition of OT as a distinct profession, would disapprove of the treatment interventions at Pine Run and the manner in which occupational therapists misrepresented their profession to clients (Fisher, 1998). The professional identity blurring promoted by occupational therapists at Pine Run between occupational therapists and physical therapists mistakenly suggests that the OT services being provided were not unique and that they could have been provided just as easily by a PT. Although Pine Run provided many examples of treatment practices that I do not wish to follow in my future career as an occupational therapist, my experience there was not completely negative. Although it was rare, Pine Run therapists did touch upon some of the core constructs of the Contemporary Paradigm in their practice. Clients often were given a functional diagnosis of generalized muscle weakness and muscle strengthening, therefore, was addressed. This strengthening was accomplished through the use of free weights and Thera-Band exercises, but it was also addressed through transfers. This would include either a shower/tub transfer or a toilet transfer. Although he was not always successful, my fieldwork supervisor did strive to incorporate something functional in every treatment session and that indicates his recognition of occupational challenges and the importance of an occupation-based practice. Activities of daily living (ADL) also were addressed when it became apparent in an evaluation that a client was unable to dress themselves without the use of adaptive equipment. The sessions that I spent educating clients on the use of adaptive equipment or practicing the use of such equipment with them always felt very productive and seem to give the clients a sense of regained independence. Many of them subsequently were able to decline the assistance of an aide when dressing themselves. These interventions were congruent with the Contemporary Paradigm since they were occupation-based and recognized individual occupational challenges and difficulties. Another intervention utilized at Pine Run that seems to be congruent with the Contemporary Paradigm was having the client make a cup of tea. Although the activity required every client to make tea without regard to whether the client even liked that beverage, it nevertheless was an occupation-based activity that also served to address safety concerns in the kitchen. The core values at the heart of the Contemporary Paradigm did not appear to be uppermost in the minds of many of the occupational therapists I observed in practice at Pine Run. Their interventions did not seem to be designed to stress the importance of supporting clients desires to integrate themselves into the mainstream of life through participation in occupation or the importance of the therapeutic relationship. In addition, a lack of a client-centered practice, as well as a generalized lack of a caring and empathetic attitude, was evident among occupational therapists throughout the facility. During the era when the Mechanistic Paradigm was prominent, therapists came to realize that two primary shortcomings of the paradigm were that it did not permit a client to be seen as a whole person and that it promoted therapy that was impersonal and not meaningful to individual clients. These two flaws were addressed during the professions shift to the Contemporary Paradigm, but therapeutic practice at Pine Run continues to lag behind in this regard. For example, I observed my supervisor treat two HMO patients at the same time with identical strengthening exercises in spite of the fact that the two patients had completely different diagnoses. The occupational therapists at Pine Run seemed to function on autopilot throughout their work day, appearing to put little thought into treatment interventions and merely recycling the same mundane interventions each day. Treatment also appeared not to be evidence-based since I never observed the administration of any assessments to track clients progress. Once again, this serves as evidence that the practice of OT at Pine Run is not in line with the constructs of the Contemporary Paradigm.Contemporary Paradigm WorkshopTo address the aforementioned issues and to encourage a more contemporary practice of OT at Pine Run, an interdisciplinary workshop may be helpful. The purpose of such a workshop would be to educate an interdisciplinary team on the purpose and practice of OT congruent with the Contemporary Paradigm. The workshop would be presented to occupational therapists, physical therapists, and speech therapists so that all team members can understand the true definition of OT and can learn how their particular profession can work toward client goals in a collaborative manner with other therapists. My experience at Pine Run illustrated that there are still misconceptions about OT as a profession among healthcare practitioners, including occupational therapists themselves (as demonstrated by my supervisors horrific definition of OT). The objectives of this workshop would include: (1) the ability to define occupational therapy and the services occupational therapists provide; (2) the ability to define paradigm, core constructs, focal viewpoint, and values; (3) the ability to identify Contemporary Paradigm core constructs, focal viewpoint, and values and to describe differences between the current Contemporary Paradigm and past paradigms; and (4) the ability to apply the Contemporary Paradigm to various healthcare professions. The workshop would be presented utilizing PowerPoint so that it can present important terms and visual aids (such as diagrams) to illustrate the concentric layers of knowledge within the conceptual foundations of the Contemporary Paradigm. The presentation would touch upon previous paradigms and identify each paradigms key characteristics, as well as relevant historical events that directly influenced paradigm shifts. After this historical review, the Contemporary Paradigm would be introduced and its core constructs, focal viewpoint, and values would be discussed in depth. This discussion would allow the workshop participants to understand the development of the Contemporary Paradigm and have an understanding of the flaws of previous paradigms that the Contemporary Paradigm aimed to overcome. After the PowerPoint presentation, interdisciplinary workshop participants would be divided into groups and provided with a case study. Working together, they would be asked to develop intervention plans that are true to their professional domains and that contribute to a common goal among the all the healthcare professionals on the team. This exercise would allow them to understand the importance of collaboration in the workplace. In order to evaluate and assess that workshop objectives were met, audience members would be asked to take a pre- and post-workshop quiz. After the post-quiz has been administered, questions would be posed to the audience as a whole in order to facilitate a group discussion. Three possible questions would be: (1) How can using the Contemporary Paradigm benefit your profession? (2) What are some barriers to operationalizing the Contemporary Paradigm and what are some solutions to overcoming these barriers? (3) How well is this facility operationalizing the Contemporary Paradigm and what areas or aspects of practice need to be improved? At the end of this group discussion, journal clubs among team members would be recommended to assist them in keeping abreast of the current literature and the relevant research in the sphere of each profession. This activity is designed to increase evidence-based practice within the facility and to increase practitioners awareness of the latest intervention techniques.Barriers and Solutions to OperationalizationWhen it comes to the lack of operationalizing the professional paradigms constructs at Pine Run, one primary contributing factor appears to be the lack of awareness of current literature and research within OT. The profession of OT requires a constant striving for the best possible practice and awareness that research is ongoing. A successful and effective occupational therapist must commit to being a lifelong learner. Although it is time-consuming, it is crucial to stay up to date on current literature to better enable the justification of services and to benefit the clients recovery by encouraging the development of interventions that are evidence-based, occupation-based, and the best possible practice. Working occupational therapists have learned that journal clubs can greatly assist them with this mandatory obligation of their profession. The club members, usually co-workers at the same health care facility, typically designate one day a week as a journal club day. The meeting often takes place over the designated lunch time. Each week, a different club member is assigned to bring in a current article from a professional research journal such as American Journal of Occupational Therapy or OT Practice and present it informally to the group. After the short presentation of the articles facts and main points, a group discussion of the relevant information and the ways in which it can be implemented in practice is encouraged. This is an easy way for practitioners to keep knowledgeable about the current literature being published in their profession. Another barrier at Pine Run that seemed to contribute to the negligence of the Contemporary Paradigms constructs was the overemphasis on meeting RUG levels. Meeting the time requirements in a treatment session took precedence over the well-being of the client. The OT interventions at Pine Run were rarely occupation-based since setting up such an intervention was time consuming. Another related barrier to the implementation of a contemporary OT practice at Pine Run was the limited availability of supplies. The gym was filled with different exercise equipment and, thus, it was quicker to set someone up on an arm bike than it was to set up a craft or gardening activity for them. In summary, the easy accessibility of exercise equipment (such as free weights and Thera-Bands) and a misplaced focus on the number of minutes that treatment lasted both served to discourage therapists at Pine Run from using occupation-based activities. A possible solution would be to create pre-made occupation bins for the facility which would be readily accessible in the gym. Each bin would contain materials for a different occupation-based activity such as gardening, dressing, sewing, medication management, money management, nail care, grooming kits, and cosmetic application. This would eliminate the set-up time from the treatment session and enable the therapist to meet time requirements. Placing the bins in the line of sight of the therapists would have them serve as a visual reminder that treatments should revolve around the engagement of meaningful occupations.Relationship of Contemporary Paradigm and OT Practice FrameworkThe Contemporary Paradigm and the Occupational Therapy Practice Framework 2nd Edition (OTPF-II) are closely related. The OTPF-II was published to guide occupational therapists in practice by articulating OTs contribution to promoting the health and participation of people, organizations, and populations through engagement in occupation (AOTA, 2008). Both the Contemporary Paradigm and the OTPF-II emphasize the centrality of occupation to health and well-being and recognize that engagement in occupations structures everyday life and contributes to health and well-being (AOTA; Kielhofner, 2009). Another congruency between the OTPF-II and the Contemporary Paradigm is that they both value the interrelationship between the person, environment, and occupational factors. The OTPF-II clearly states that occupational therapists must deliver service with a holistic perspective and address all aspects of performance when providing interventions (AOTA). The Contemporary Paradigm core constructs, focal viewpoint, and values are expressed through the OTPF-II overarching statement supporting health and participation in life through engagement in occupation (AOTA, p.626). Both the Contemporary Paradigm and the OTPF-II serve to unify the professions identity and clearly articulate the nature, purpose and domain of practice. The content of the OTPF-II and the Contemporary Paradigm both allow therapists to justify services and provide focus for service delivery to support a clients health and participation. The structured outline provided by the OTPF-II allows practitioners an easy way to implement the Contemporary Paradigm into practice. It provides for an evaluation through use of an occupational profile and the analysis of occupational performance, an intervention process consisting of a plan, implementation, and review and an assessment of treatment outcomes (AOTA). ConclusionAs the future generation of occupational therapists, it is fundamental that we continue to embark on a journey of continued learning in order to implement the most current research and literature into our own OT practice. This paper has given a general overview of the three paradigms and the factors precipitating paradigm shifts. The Contemporary Paradigm has been discussed in depth and the core constructs, focal viewpoint, and values of the paradigm have been identified and examined in relationship to the OTPF-II. A design for a workshop to educate an interdisciplinary team on the purpose of OT through the lens of the Contemporary Paradigm has been proposed and the design includes objectives, delivery method, and methods of assessment. Lastly, barriers and potential solutions for operationalizing the Contemporary Paradigms constructs at Pine Run have been identified. The Contemporary Paradigm has become the paradigm of current times because it aims to address the shortcomings of the previous paradigms. It is essential that therapists strive to implement the core constructs, focal viewpoints, and values of the Contemporary Paradigm to ensure that clients are receiving the best possible treatment, which entails clinical reasoning, research, and evidence-based interventions. Analyzing my fieldwork experience at Pine Run through the lens of this paper has enabled me to better identify the qualities of an effective occupational therapist, has provided me with a stronger foundation upon which to base my future practice and has renewed my commitment to operationalize the Contemporary Paradigm in whatever therapy setting my career may lead me.

ReferencesAmerican Occupational Therapy Association. (2008). Occupational therapy practice framework:

Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683.

Boniface, G., Seymour, A., & Taylor, M.C. (2012). Using occupational therapy theory inpractice. Chichester, West Succesx, UK: Wiley-Blackwell.

Fisher, A. G. (1998). Uniting practice and theory in an occupational framework- Eleanor Clarke Slagle Lecture. America Journal of Occupational Therapy, 52, 509-521Kielhofner, G. (2009). Conceptual foundation of occupational therapy practice. (4 ed., pp. 108-126). Philadelphia: F.A. Davis.