Wednesday, February 25, 2009

Communication with the team

I certainly think that my communication has come along way in the last 2 weeks at work (as i get to know them all) however i think there are a few things that i need to go over in my brain as to when i should talk to other team members....

- If i am unsure if they are involved or had a referral - just check out - as there is nothing worse than receiving a late referral

- To pass on vital info - as there is only an MDT once a week - for this very reason i think it would be good to sit down as an interdisciplinary team and discuss patients once a week also
This would give us an opportunity to ensure that others were involved and help know if we are going to have to be involved and help us prioritise the case load.

- In a mtg like this we could all get a good understanding of social situ, presenting problems and the patients progress and any recommendations for discharge.

Just a thought

I just had a thought!

All this time i have been focusing on patients limitations and using them to aid discharge planning..i feel awful i want to focus on both the clients strengths and weaknesses.

I think that when i document in patients notes (after assessments) i always put the problems and things that they did independently however from now on i wish to document their strengths, and not get tied up in their problems.

Im sure that this would also help the therapeutic relationship as well - everyone must want to know what others think they are doing well at!

I think of an example from practice where i could have done a better job!

I was discussing the results of a cognistat assessment with a patient and his wife. Im sad to report that i kind of brushed over what he did well and then talked more about the limitations of his cognition.

From now on im going to make sure that i place emphasis on patients strengths and then introduce the limitations.

Tuesday, February 24, 2009

Case review

Name/age/primary diagnosis

Reason for referral
Anxiety/?cognitive impairment

Medical Hx:RA

Social situ: Lives alone/Near Friends and Mother (walking distance)
Has a pet cat

Prior OT input:
Home environment set up/adaptive cutlery

Supports before admission: HH/PC 2/24.

How managing before admission: up and down days, assistance with most daily tasks e.g. showering, meal prep, cleaning. Independent mobility but has a wheel chair at home

Assistance on ward (mobility/self cares) - Independent mobility, d/c from PT; Full assistance of 1 on ward

OT input this admission/ Assessment(s): initial interview/functional tx assessment
Shower assessment.

Problems identified:

1) SH is struggling with alot of pain and is quite anxious about this.
2) SH is sick of being positive
4) SH has difficulty griping, doing bilateral hand skills, and manipulating small objects
5) SH overdoes things on "good days"

NIL evidence of any significant cognitive problem other that mild short term memory impairment

Beliefs: SH likes to keep her house tidy; do as much as she can; not be a burden on anyone.


1) Education about pain - "it is real"
2) Education about energy conservation - pacing/planning/prioritsing
3) Discussion about relaxation


SH really appreciated the discussions and education and knows that pacing and not over doing things will decrease the chance of being in extreme pain. She has to decide for herself if she will take on the information and put to practice some of the energy conservation techniques.

SH has adequate supports in situ and her home environment is set up for her from prior OT input


D/C from OT

Monday, February 23, 2009

Developing rapport with a patient who is "known as" grumpy

I was referred to a patient that other team members had trouble connecting with.

So i went and me the patient and introduced myself and my role etc.
My initial thoughts were oh my golly shes going to be very hard to connect with and work alongside. I thought this because she basically insulted me and said i was probably un educated like all other NZ children.

When i first met her she mentioned that she was English - and i notice she spoke very fast and prober. So i though prehaps if i asked her more about where she came from and her background this may help me develop a working relationship. We got talking and soon enough she was asking me questions in reciprocal. I spent time getting to know her and we got on to her interests and what she enjoyed doing. As we talked i gradually changed the topic from what she enjoyed doing to when she did it and then we began talking about her home and how she spent her day. I felt like we had a good conversation going and i was able to take her lead and talk about her home environment along the way.

Thinking about this later on..i think if i went in to see her and just asked questions about her home environment in a rather structured way i wouldnt have got the depth of information that i got and i wouldnt have found out about her as a person and her interests and needs.

It was very clear to me that this patient was very fussy and particular. But i feel after we had had that initial contact that gave us something to continue talking about next time i saw her. We began talking about the ships that came from England (as she was very interested in English literature and history) and my great grand father cam over on one of those boats - so we had a connecting point.

Anyway i learnt that it may take more time but you will get a better result if you do take the time to find out about them and let them guide the converstation.

This patient from my percpetion wasnt grumpy at all she was just particular and i think that may just have been part of her culture.

Thursday, February 19, 2009

Highlights of this week

Well i have to say that the busy nature of the acute ward has not yet hit - but its been a great week being not so busy.

I think my notes and observation have been good this week, and my time management has been pretty good also.

Still settling into the routine of the ward rounds but i am please to have figured out all the hiding spots of the notes and some key contacts that can help me if i need a question answered.

Getting to know the allied health staff on the ward well and feel confident discussing patient with them and doing joint sessions etc.

Wednesday, February 18, 2009


Analysis to me is the hardest part of the OT process - meaning ok this is what is wrong, this is what i have seen - know what does this mean? - how will this affect the patient?

It takes me time and a little prompting but i get there in the end. I want to start prompting myself so that i am taking responsibility for this and are able to run through cases with my supervisor and not have to sit there going ummmmmm...... maybe.... and then get prompted for the answer. Thats the plan from now on - filling in the gaps of the OT process and being able to take responsibility for my own work and thinking more.

Reflection from first week on medical ward

This week has gone so fast!

I have seen quite a few patients and im starting to get to know the processes better. But i guess il learn them as time goes by and with experience using them.

Learning is a major part of my transition into this week - and i have to make sure that i bear this in mind when working with patients. In particular it is important that i identify things that i am unsure of and aim to find them out.

There are a few diagnosis that i am unsure of...yes it is important to know about conditions however i feel its more important to not focus on the condition, go into see a patient with an open mind and listen to their experience, learn from them and observe their function. I guess not going in with any preconception about how they should present with a certain condition will help me focus on the occupational performance. I would be interested in my supervisors view of this analysis of mine.

I think its become incredibly hard to be holistic on the medical ward...even though im still coming to terms with what holistic means in acute occupational therapy practice. Over the last week i have found myself talking with patients a lot more about their occupation, what things interest them, how they spend there day- and i find this helps me a) get an idea of their functional level before admission and b) connect and develop a rapport with them. I think thats why occupational therapists get along side patients much more because we are interested in their lives and not purely their pain/symptoms and medical readiness for d/c.

I am finding that my colleges are so useful to run ideas past, get advice and just flll me in or remind me of the hospital processes. Unlike my last job - its easier when your full time you can get some constancy going and learn at a quicker rate.

Im finding checking in with my supervisor very helpful and supportive. And its funny the day after i posted the articulation of reasoning post she recommended that i get some more structure so she can easily follow my clinical reasoning. I have made myself some wee prompts when i am reviewing cases and i think it will take some practice until i get some sort of flow. Im also not great at expressing what i think and this needs some practice and development as well. This is where this blog will come in helpful. I plan to review a case on this blog with no identifying information once a week on a thursday and take it to supervision to do a peer review and critical reflection.

Monday, February 16, 2009

Difficulty connecting with a patient

Usually when i go and see a patient i find it really easy to connect with them and motivate them, however one patient i saw today was particularly hard to do this with. I didnt really know what to do - she presented with a short attention span, and didnt seem to be able to understand what i was asking her. However this ability seemed to fluctuate. She could give me an answer (during the initial interview) every know and then but other times she was very vague, looked out the window and just sat there as if i wasnt even there.

I tried some strategies to engage her like changing the positioning of my chair, using her name when i asked questions, and trying to take her lead when choosing questions. But unfortunitly i just didnt have any luck. I think maybe i was asking to longer questions and trying closed questions may have been more sucessful however on the spot i didnt think of this. This confused me alot as i wasnt aware that there was any cognitive impairment..

After discussing this case with my suprvisor she recommended that i contacted other OT's who had worked with her (to see if they had any of these problems) and to talk to her daugther to see if she has noticed any changes in her attention/memory and concentration. Unfortunitly i could not get hold of her daughter after several attempts but the OT could not remember the patient vividly enough to give me any detail.

So i decided to talk to other members of the team - i found the physio who had been working with her and she agreed that she was vague sometimes but she thought the problem was motivation...when i think about it i guess that could also be the case.

All this problem solving reminds me of in my training when we learn about cues/hypothesis etc

So heres it all broken down from the reference

(1) Cue acquisition: gathering cues through observation, history, or physical examination;

(2) Hypothesis generation: generating initial hypotheses based on initial cues;

(3) Cue interpretation: formulating patterns of cues through weighing positive and negative evidence; and

(4) Hypothesis evaluation: applying the cues to the hypotheses and evaluating whether the hypotheses hold.

To problem solve this one i will break it down

(1) Cue acquisition: vague appearance when asked a question/not able to follow directions/

2) Hypothesis generation: un interested/un motivated/didnt understand the question/didnt hear me/short attention span

(3) Cue interpretation:

(4) Hypothesis evaluation:

Will go through this case with my supervisor tomorrow

Articulating OT process and reasoning

Throughout the last two days i have been checking in with my supervisor who is on the same ward as me regarding patients that i have seen, what i have done with them and where to next.

I am finding that explaining what i have done has been rather "un organised" and i think this is an area i need to work on.
Its not that i dont know what i have done its putting together sentances and leaving out unnessasary information so that my superviser has a clear picture of what i have done with the patient, what happened, and where to next. I think its just becuase im still settling in and learning about the diagnosis on the medical ward.

For example my supervisor prompts me to talk to her about a particular patient and i dont follow a clear format so i am going to try and make a format to prompt me what to say until i get more competent with reporting the Ot process.

Maybe this..

This patient was referred by.....because....
Primary diagnosis
Secondary diagnosis/Med Hx
Info about social situation
OT input to date
Analysis of assessment/obs/interviews
Contact with other team members
Any discharge plans/referrals
Plan - where to now OT input wise

So i will try this and see how it goes :)


Saturday, February 14, 2009

Beginning at my new job

Well i have spent two days at my new job - learning the processes etc at the DHB, getting orientated and finding my way round. Ive found it easy to fit in with the OT's there because i know a few of them and some of them i trained with.

Havnt had any patient contact really, only sat in on a family mtg, and watched a kitchen assessment. Tomorrow i begin on the medical ward with my senior. So will be a big week where i can start utilsing this blog alot more for clinical reflecting.

I will invite my superviser to come on and read my reflections so she can monitor where my clinical reasoning is at.

I will draft up reflection model questions to stimulate ideas to reflect apon now.


What have i done today/this week that was professionally challenging?

Can you think of a case that was reflecting a medical based model..and how could i change the way i approach situations, problem solve and work with patients to be more holistic?

What was frustrating/enjoyable this week?

How did i work with colleagues in clinical practice and how these interactions have evolved over time?

Think of a clinician/patient relationship that felt client centred? Why did it work so well?

When/how and what information did i seek this week that i was unsure about?

What have i learnt this week?

Think of a problem that you had to solve, how did you go about this/did you need any support or advice?

Sunday, February 8, 2009

Got the rotation job

I was sucessfull in landing a permanent OT position - clincial rotation
Start in a few days time - so exciting

Plan to use this blog for practice reflections weekly - putting a case study on here for supervision preparation - so i can peer review

I can identify knowledge that i require e.g. service questions or diagnosis/impairments

Also it would be good to write down questions that i need answered - if i dont get them asked informally.

Anyway look forward to seeing the first reflection from practice