Building a workplace culture of occupation-based practice in a tertiary health service

Jennifer Wort, Matthew Thorpe, Zoe Ellis, Danielle Hitch, Karen Kessner and Sue Giles

Occupation is the foundation of our profession’s unique expertise and contribution to care. Despite the challenges of the past three years, the profession has continued to support “the right of all people to engage in the occupations they need to survive … and that contribute positively to their own wellbeing and the wellbeing of the communities”1. The key to our ability to uphold these rights for our consumers is our commitment to occupation-based practice.

However, it can be difficult in practice to enact our fundamental values and principles, and long acknowledged barriers to occupation-based practice cause both frustration for therapists and suboptimal outcomes for our consumers2. The importance of occupation-based practice is especially urgent in tertiary care settings, as occupational therapy is the only health profession focused on occupation in relation to the person and their environment. However, the fast-paced and medicaloriented nature often leaves therapists providing reductionist or abbreviated services. This disconnect between our ambitions and realities potentially distresses staff, impacting recruitment and retention.

For more than a decade, the Occupational Therapy department of Western Health in Melbourne has worked to sustain a culture of occupation-based practice by developing strategies that ensure occupation remains at the centre of everything we do. This commitment to occupation-based practice has informed the culture of the department, and data from internal focus groups suggests it has contributed to the engagement and retention of staff. By sharing our strategy, we hope to provide colleagues around Australia with examples to draw upon in their own practice.

In the Australian context, Di Tomasso et al characterised occupation-based practice as having “occupation as the foundation within the assessment, intervention and evaluation phases of the occupational therapy process”3. A key characteristic of occupation-based practice is its deep integration or embedding within daily practice, which is combined with accountability or governance processes that allow us to remain ‘true’ to its espoused values. Consistent evidence of its presence should be explicit within professional documentation, and in the language used by OTs with their colleagues and consumers.

Explicitly enacting occupation-based practice can enable opportunities for consumers to engage in authentic occupations, which enhance their engagement in therapeutic processes4. It can also help to identify instances of ‘gap filling’, where OTs take on generic tasks and roles that don’t make the best of their unique skills and abilities. Greater clarity around what is and isn’t within the scope of OTs can prevent the dilution of their contribution to tertiary healthcare, enable clinicians to work more effectively at the top of their scope5 and have a positive influence on recruitment, retention and workplace wellbeing.

Our occupation-based strategy

Western Health is committed to empowering and supporting our clinicians to be occupation-based practitioners. To act on this commitment, the following multidimensional strategy was developed from Wilcock’s dimensions of ‘doing, being, becoming, and belonging’6, supported by our Senior Leadership Team and the Culture Committee. The strategy was also founded on the Sustainability Wheel7, which is an evidence-based assessment tool for embedding sustainability into process. The strategy aims to clearly communicate the unique contribution of occupational therapy to care, and counter frequently heard claims that it was “just like physio” or “just common sense”.

Doing occupation-based practice

The Sustainability Wheel7 provided a framework for developing occupationbased practice activities within Western Health. There are four elements to the wheel – fostering commitment, clarifying expectations, building momentum for change and instilling capacity for change. Existing activities were mapped to each element, along with gaps in the current approach that required further development.

Using this tool, it became apparent to the team that doing occupation-based practice involves operating within four interdependent domains: Education, Communication, Demonstration and Evaluation. As shown above in Figure 1, Western Health now has specific strategies and tools to enable doing across all areas of our service.

Purpose: To establish occupational identity with occupational therapists, colleagues and community.

• Story telling via case studies

• Promotion of self as occupational beings

• Regular review of practice methods

• Consulting with experts for professional development

• Seeking opportunities for public communication to promote occupation-based practice outside of Western Health (i.e., conference presentations, articles)

• Journal club

• Internal Occupational Therapy newsletter

Purpose: To provide tangible examples of the occupation-based practice strategy.

• Explicit presence in competencies, supervision, recruitment and leadership initiatives

• Active participation in Allied Health research, quality and innovation opportunities

• Communicating occupational therapy roles appropriately to various audiences

• Monitoring perception of occupational therapy within team meetings and multidisciplinary contexts

• Culture committee developments

• Living and breathing vision statements

These strategies and associated tools enable the review and refinement of practice using formal and informal channels. They also promote innovation that aligns with occupation-based practice and culture. For example, ‘scripts’ were developed to consistently guide the documentation of occupation-based clinical reasoning and expertise. Western Health also uses observed practice for peer evaluation and support, providing opportunities for demonstration of the application of occupational therapy values to daily practice.

Being an occupation-based practitioner means staying true to our values as OTs and adhering to the following non-negotiable principles (see Figure 2 on next page).

These values were identified through much work, discussion, and reflection within all cohort areas, across the care continuum. Constant reflection on these nonnegotiables occurs through multiple avenues including orientation, culture committee

Purpose: To record and provide tangible evidence of occupation-based practice.

• Timely and clear records of all occupational therapy activities

• Formalised policies and procedures (e.g., prompt in supervision tool, documentation)

• Biennial documentation audits of occupational language

• Occupation-based practice embedded within business plan directives

• Departmental branding with a logo

Purpose: To instil the Reflection, Action and Evaluation spiral within the occupation-based practice strategy.

• Use of occupation-based outcome measures over time to measure change

• Benchmarking against other tertiary health services

• Multiple supports for reflective practice

• Action plans based on past initiatives and learning

• Staff and student satisfaction surveys

• Implementation of observed practice activities, celebratory events, professional development, and supervision. An example of these iterative opportunities includes explicit prompts for the discussion of values and culture within initiatives such as buddy programs and professional development.

For occupation-based practice to become ‘just how we do things around here’, the implementation of this strategy has helped to develop a sustainable, embedded culture. A key aspect of becoming an occupationbased service has been supporting OTs throughout the organisation to stand their ground around our non-negotiables. This is particularly important to reduce the tendency for OTs to be seen as ‘jacks of all trade’ and be asked to fill gaps in service provision with support that could be offered by multidisciplinary colleagues. Our OTs can now recognise and clearly articulate their expertise and value and feel less pressure to do generic tasks just to be helpful.

Four critical factors have guided our implementation of this strategy: vision, leadership, ownership and structures, procedures, and tools. This strategy has been enacted in a number of ways, many of which address multiple factors. One example was the establishment of a culture committee comprised of staff from all clinical areas to explicitly champion occupation-based practice. Amongst other achievements, the committee has implemented processes and expectations related to the sharing of patient stories. These stories challenge and illuminate practice norms, both to spark inspiration and enable peer learning. This approach has been embedded into procedures through the presence of clinical storytelling as a standing item in meeting agendas. The committee has also facilitated regular occupation-based practice forums, led initiatives to explicitly recognise best occupation-based practice through acknowledgements and awards, and identified opportunities to publish and share our organisational strategy more broadly (including this article).

The occupation-based practice strategy continues to evolve in response to the ever-changing demands of the health, community, and socio-political context in which we practice. What has not changed; however, is our commitment to embed occupation-based practice aligned with our core professional values and nonnegotiables into everything we do. Developing and maintaining this approach has enabled positive changes for both our patients and staff. The development of the strategy and its associated tools and resources has been a massive undertaking for the entire workforce, but there is no doubt that our investment in occupationbased practice is paying off. Our colleagues now have a better understanding of the value of occupational therapy, and our clinicians report greater confidence, satisfaction and clarity around explaining their role to others. All of which leads to a happier workforce, more effective service, and better outcomes for our patients.

Jennifer Wort: Formerly a Grade 3 Occupational Therapist for Acute Care

Matthew Thorpe: Current manager of Western Health Occupational Therapy service

Zoe Ellis: Grade 3 Occupational Therapist for Inpatient Aged Care

Danielle Hitch: Senior Research Fellow with Deakin University and Western Health

Karen Kessner: Formerly a Grade 3 Occupational Therapist for Inpatient Aged Care

Sue Giles: Former manager of Western Health Occupational Therapy service

The occupation-based strategy at Western Health shows it is possible within a fast-paced tertiary health service to ensure occupationbased practice is embedded in service delivery and service planning and delivers improved outcomes to patients and staff alike. Our service belongs to a community with one of the fastest growing populations in the country, with associated high demand for access and flow, and the multiple challenges of low socioeconomic status and significant resource constraints. Maintaining an occupation-based focus helps us to belong to our community, as we offer personalised and culturally appropriate assessments and interventions that make a real difference in daily life.