'Patient' or 'professional'? Negotiating accommodations and identity in fieldwork education.

INTRODUCTION: Despite legislation mandating accommodation policies in postsecondary education, support for students with disabilities is often not implemented within health and human services (HHS) education programs, particularly in fieldwork settings. As part of a Canada-wide study exploring the experiences of disabled students in 10 HHS programs, we examined how HHS students described their experiences accessing accommodations in fieldwork to understand how conceptions of disability relate to students' fieldwork experiences. Using a critical disability studies framework, we explored how HHS fieldwork education understands disability, accommodations and professional competence and what those understandings reveal about the discrepancy between mandated accommodations and what happens in practice. METHODS: Thirty-five students requiring accommodations in HHS fieldwork education participated in interviews. Through a critical interpretive analysis of interview data, we developed first-person composite narratives to show the richness and complexity of the students' diverse, yet similar, subjective experiences with fieldwork accommodations. FINDINGS: Two composite narratives demonstrate how conceptions of disability incommensurate with professional competence expectations influenced student experiences with disclosing disability and obtaining accommodations in fieldwork. Fear of stigma and having one's competence questioned, or having accommodation requests denied for being misaligned with professional expectations, demonstrate how HHS fieldwork education and practice are upheld by ableist systemic structures. DISCUSSION: The dominant medical model of disability in HHS education creates institutional barriers that require students to constantly (re)construct their 'professional' identity in relation to their 'patient' identity. This patient-professional identity construction relates to HHS professional competency standards and assumptions about what makes a 'good' professional. Suggestions include reworking competency standards and implementing critical pedagogical approaches to teach future and current HHS professionals to question both personal and practice assumptions. With institutional backing, such changes may support diversity within HHS and a culture shift toward more equitable education and health care.

Negotiating legitimacy and belonging: Disabled students' and practitioners' experience.

INTRODUCTION: People with disabilities are underrepresented in health professions education and practice. Barriers for inclusion include stigma, disabling discourses, discriminatory programme design and oppressive interactions. Current understandings of this topic remain descriptive and fragmented. Existing research often includes only one profession, excludes particular types of disability and focuses on one aspect of the career journey. To expand understanding, we examined the recurrent forms of social relations that underlie the participation of disabled individuals in learning and practice contexts across five health professions. METHOD: We analysed 124 interviews with 56 disabled health practitioners and students. Participants were interviewed up to three times over 1.5 years. Using constructivist grounded theory, authors used a staged analytic approach that resulted in higher level conceptual categories that advance interpretations of social processes. Finally, the authors compared and integrated findings among students and practitioners. RESULTS: Participants experience challenges to their sense of legitimacy and belonging as health providers. They describe tensions within the health education and practice between the commitment to inclusion and the day-to-day realities experienced by disabled participants. We identified six distinct, but related, conditions underlying these tensions: (i) validity and transparency of competencies' evaluation; (ii) the social and physical contexts; (iii) integration of inclusive practices; (iv) boundaries between personal and professional identities; (v) vulnerability to authority figures; and (vi) dynamic person-level factors. DISCUSSION: If we are to commit to health practitioners and students with disabilities experiencing an overall sense of legitimacy and belonging, priority needs to be given to system-level practices and policies to support inclusion. Attention to the day-to-day marginalisation of students and practitioners with disabilities in the health professions is also needed. Additionally, inclusive and transparent delineation of competency requirements is needed. Finally, educational actions are needed to increase understanding of disability in the health professions, with particular attention to promoting social relations that foster collective responsibility for supporting inclusion.

Social support experiences of students and clinicians with disabilities in health professions.

Social support is vital in promoting the health, well-being, and performance of students and clinicians in health professions. Health settings' demanding and competitive nature imposes unique challenges on students and clinicians with disabilities. This paper aims to explore the trajectories and experiences of social support interactions amongst students and clinicians with disabilities in health professions. In a qualitative longitudinal study, 124 in-depth semi-structured interviews were conducted with 27 health students and 29 health clinicians with disabilities. Data analysis was informed by grounded theory as an adapted analytic approach involving constant comparisons. A few main characteristics of social support and trajectories in which social support is negotiated emerged from the data: (1) The need to be accepted and not questioned when asking for support, (2) Support interactions that do not heighten otherness, (3) Failure to acknowledge the challenges, (4) Interactions that support the process of disclosure (5) Interactions that allow mobilization of social support without strain or an extra effort. These findings have important implications for designing more supportive health professions, educational programs, and workplaces for people living with disabilities.

Barriers and facilitators for Indigenous students and staff in health and human services educational programs.

Indigenous Peoples are underrepresented in many of the Health and Human Services Educational Programs (HHSEP, e.g.: Nursing, Social Work). As various studies have reported the benefits of diversifying HHSEP, the barriers and facilitators of increasing the number of Indigenous Peoples in these professions must be identified. The purpose of this exploratory study is to identify and understand the barriers and facilitators Indigenous Peoples face when entering, learning or working in HHSEP. A narrative approach was used in the facilitation of culturally safe sharing circles with Indigenous students and staff to collect perspectives based on their individual experiences in HHSEP. Inductive thematic analysis was used to identify emerging themes in participant experiences and the impact of those experiences on participation in learning and working at the university in these educational programs. Results from this exploratory study identified current academic structures and ideologies rooted in colonialism, that act as barriers for engagement and inclusion of Indigenous students, staff, and clinical and academic faculty. These findings shaped the main themes of this study including negotiation of identity in different spaces, negotiating colonial structures in HHSEP, and negotiating changes and transitions in HHSEP. We anticipate these preliminary results will act as a catalyst for uncovering further changes to be made regarding attitudes, procedures, and practices present in an academic environment that limit the inclusion of Indigenous Peoples in HHSEP.

Disabled healthcare professionals' diverse, embodied, and socially embedded experiences.

Disabled people are underrepresented within healthcare professions, although their participation has potential benefits for them personally, and for broader society. Disabled peoples' participation in healthcare professions is limited by assumptions about disability. Little research explores how healthcare professions can be organized to support disabled peoples' employment. Within a critical realist paradigm influenced by grounded theory, this study used interviews to explore the experiences of 56 disabled healthcare clinicians and students, and advance a conceptual taxonomy of disability experience within healthcare professions. Participants describe their experiences of disability in the healthcare professional context in terms of characteristics and dimensions of disability-how characteristics interact with factors within healthcare training and practice environments. We profile two particularly salient dimensions of the disability experience: visibility and onset of disability. These are developed to describe complexity and specificity of the experiences of individuals negotiating the healthcare context. Among participants there is extensive heterogeneity related to the experience of disability in healthcare professional contexts. Despite some having similar disability characteristics, no two individuals experience the same combination of characteristics and dimensions of disability. Given the complexity of experiences for disabled healthcare professionals/students, a taxonomy for conceptualizing this experience is presented. Readers are encouraged to consider the taxonomy through which they might conceptualize individual, embodied, and socially embedded experiences of disabled healthcare professionals and students. Stakeholders involved in healthcare professions and education should consider this shift in perspective, with a view to increasing access of disabled people to health professional practice.

"I Can Understand Where They're Coming From": How Clinicians' Disability Experiences Shape Their Interaction With Clients.

Students and clinicians with disabilities are underrepresented in the academic health programs and professional clinical settings. Disability studies foregrounds the unique ways of knowing and being that clinicians with disabilities can offer. Based on a larger grounded theory study of the experiences of students and clinicians with disabilities, this article examines the role that clinicians' abilities to draw on their personal experiences of living with a disability have on their interactions with clients. The analysis of semistructured interviews with 55 students and clinicians with disabilities from different fields contributes to the development of a theory of epistemic connection. The theory is informed by the following three themes: (a) building rapport through understanding, (b) from understanding to advocacy and creative approaches, and (c) between professionalism and disability. The findings emphasize not only the importance of diversifying the health care workforce but also incorporating disability epistemology into the health care culture.

A randomized controlled trial to evaluate the feasibility of the Wii Fit for improving walking in older adults with lower limb amputation.

OBJECTIVE: To assess the feasibility of Wii.n.Walk for improving walking capacity in older adults with lower limb amputation. DESIGN: A parallel, evaluator-blind randomized controlled feasibility trial. SETTING: Community-living. PARTICIPANTS: Individuals who were ⩾50 years old with a unilateral lower limb amputation. INTERVENTION: Wii.n.Walk consisted of Wii Fit training, 3x/week (40 minute sessions), for 4 weeks. Training started in the clinic in groups of 3 and graduated to unsupervised home training. Control group were trained using cognitive games. MAIN MEASURES: Feasibility indicators: trial process (recruitment, retention, participants' perceived benefit from the Wii.n.Walk intervention measured by exit questionnaire), resources (adherence), management (participant processing, blinding), and treatment (adverse event, and Cohen's d effect size and variance). Primary clinical outcome: walking capacity measured using the 2 Minute Walk Test at baseline, end of treatment, and 3-week retention. RESULTS: Of 28 randomized participants, 24 completed the trial (12/arm). Median (range) age was 62.0 (50-78) years. Mean (SD) score for perceived benefit from the Wii.n.Walk intervention was 38.9/45 (6.8). Adherence was 83.4%. The effect sizes for the 2 Minute Walk Test were 0.5 (end of treatment) and 0.6 (3-week retention) based on intention to treat with imputed data; and 0.9 (end of treatment) and 1.2 (3-week retention) based on per protocol analysis. The required sample size for a future larger RCT was deemed to be 72 (36 per arm). CONCLUSIONS: The results suggested the feasibility of the Wii.n.Walk with a medium effect size for improving walking capacity. Future larger randomized controlled trials investigating efficacy are warranted.

Implementing a collaborative coaching intervention for professionals providing care to children and their families: An exploratory study.

The growing complexity of healthcare requires family and interprofessional partnerships to deliver effective care. Interprofessional coaching can enhance family-centred practice and collaboration. The purpose of this study was to explore the acceptability and feasibility of collaborative coaching training to improve family centredness within acute paediatric rehabilitation. Using a participatory action design, service providers (SPs; n = 36) underwent a 6-month coaching programme involving coaching workshops, learning triads, and tailored sessions with a licensed coach. The feasibility and acceptability of coaching on SPs' family interactions and care was explored. Measure of Processes of Care (MPOC) and MPOC-SP, a coaching skills questionnaire, and focus groups were used to evaluate the acceptability of coaching training. We found that structured coaching training was feasible and SPs reported significant improvements in their coaching skills; however, MPOC and MPOC-SP scores did not reveal significant differences. Qualitative themes indicated that clinicians are developing coaching competencies and applying these skills in clinical practice. Participants perceived that the coaching approach strengthened relationships amongst colleagues, and they valued the opportunity for interprofessional learning. Findings suggest that coaching offers promise as an approach to facilitate successful patient outcomes and improve processes of care. Preliminary findings indicate that interprofessional coaching training is acceptable, feasible, and can significantly improve SP coaching skills and improve team cohesion. Further research to study the effects of coaching on interprofessional care using validated outcome measures and to assess the impact on service delivery is recommended.

Measuring Participation for Children and Youth With Power Mobility Needs: A Systematic Review of Potential Health Measurement Tools.

OBJECTIVES: To identify and critically appraise potential participation measurement tools for children aged 18 months to 17 years with power mobility (PM) needs. DATA SOURCES: Searches in 9 electronic databases identified peer-reviewed publications in English to January 2015, along with hand-searching included bibliographies. STUDY SELECTION: The Preferred Reporting Items for Systematic reviews and Meta-Analyses statement was followed with inclusion criteria set a priori. Keywords and subject headings included participation and measurement terms with descriptors of young people who are potential PM candidates. Publications describing measurement properties of English-language tools were included if the items included ≥ 85% content related to participation and described at least 2 participation dimensions. DATA EXTRACTION: Two reviewers reached consensus after independently screening titles and abstracts, identifying full-text articles meeting criteria, extracting data, and conducting quality ratings. Tool descriptions, clinical utility, and measurement properties were extracted. Study quality and measurement properties were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments checklist and the McMaster Outcome Measures Rating Form. DATA SYNTHESIS: Of 1330 titles identified, 138 peer-reviewed publications met study inclusion criteria. Fifty tools were identified, of which 20 met inclusion criteria. Evidence supporting reliability and validity varied considerably. Two tools had responsiveness evidence, an important measurement property when evaluating change. Quality ratings were strongest for internal consistency and content validity. Ratings were downgraded because of small sample sizes and a limited description of missing data or study conditions. CONCLUSIONS: While potential tools emerged (Assessment of Preschool Children's Participation, Preferences for Activities of Children, Child and Adolescent Scale of Participation, Child Engagement in Daily Life, Canadian Occupational Performance Measure, Questionnaire of Young People's Participation), none were judged best suited for use with children having PM needs. Further empirical studies with this population are needed before recommending use for PM applications.

Picture This: Exploring the Lived Experience of High-Functioning Stroke Survivors Using Photovoice.

An increasing number of high-functioning stroke survivors are present with minimal functional impairments and are often discharged with reduced access to community reintegration. Our objectives were to explore the lived experience of high-functioning stroke survivors and to identify gaps in community and rehabilitation services. Photovoice was used with five high-functioning stroke survivors to photo-document their experiences. A modified inductive thematic analysis was used, and meanings behind the photographs were elicited through four focus group sessions followed by photography exhibitions. Five themes emerged: lack of understanding and consideration for persons with disability, emotional and behavioral impacts after stroke, self-reliance and dependence on others, importance of appropriate and accessible services, and financial determinants of quality of life. By including service users' voices; investing in adapted, community-based programs; and providing educational programs for creating attitudinal change among service providers, the polarization between who can and cannot access services will be reduced.

Male-to-female transitions: Implications for occupational performance, health, and life satisfaction.

BACKGROUND: People who undergo a gender transition process experience changes in different everyday occupations. These changes may impact their health and life satisfaction. PURPOSE: This study examined the difference in the occupational performance history scales (occupational identity, competence, and settings) between male-to-female transgender women and cisgender women and the relation of these scales to health and life satisfaction. METHOD: Twenty-two transgender women and 22 matched cisgender women completed a demographic questionnaire and three reliable measures in this cross-sectional study. Data were analyzed using a two-way analysis of variance and multiple linear regressions. FINDINGS: The results indicate lower performance scores for the transgender women. In addition, occupational settings and group membership (transgender and cisgender groups) were found to be predictors of life satisfaction. IMPLICATIONS: The present study supports the role of occupational therapy in promoting occupational identity and competence of transgender women and giving special attention to their social and physical environment.

Important elements of measuring participation for children who need or use power mobility: a modified Delphi survey.

AIM: To identify and reach consensus on important elements of measuring participation in everyday life for children who need or use power mobility. METHOD: A panel (n=74) of parents, therapists, and researchers with pediatric power mobility and participation expertise completed an online modified Delphi survey. Three rounds determined important elements of participation for two groups: early childhood (18mo-5y) and school-aged (6-12y). 'Elements of participation' defined the 'who, what, where, and how' of measuring participation, generated from a literature review and participants' suggestions. Consensus was set a priori as ≥80% agreement. RESULTS: Consensus was reached on 21 out of 48 elements of participation important to measure for our population: eight elements for the younger group and 18 elements for the older group. When ranked by importance, four of the top five elements were common across both age groups. INTERPRETATION: For children using power mobility, measuring participation in a variety of settings is critical, along with considering both the child's and family's participation. Evaluating child engagement and enjoyment of participation are priorities, as is measuring barriers and facilitators. For school-aged children, evaluating child and parent reports of participation are essential. These elements can guide tool selection and/or development.

Effectiveness of a summer camp intervention for children with developmental coordination disorder.

BACKGROUND: Developmental coordination disorder (DCD) significantly affects a child's motor abilities and negatively impacts their self-efficacy and participation in physical activity. Using a task-specific approach and cognitive strategies in a group setting, we designed a summer camp intervention for children with DCD. AIMS: Our purpose was to examine the effectiveness of the summer camp in meeting child-chosen functional motor goals and increasing self-efficacy and participation. METHODS: This mixed methods study examined performance and satisfaction of child-chosen goals, self-efficacy, and participation of 11 children before and after the camp. Survey and interview data from three children and nine parents were collected to supplement quantitative findings. RESULTS: Statistically significant improvement in performance and satisfaction of child-chosen goals was noted. While no measureable changes in self-efficacy and participation were observed, parents and children reported positive benefits to camp participation, including the confidence to try new activities, being with other children with DCD, and learning more about the disorder. CONCLUSION: The intensive, group-based summer camp may offer a valuable alternative to improve the functional skills of children with DCD, while providing other notable benefits.

The development of the Pediatric Motivation Scale for rehabilitation.

BACKGROUND: Clinicians recognize that client motivation is key to optimizing rehabilitation; however, they are limited in its assessment by a paucity of motivation measures. PURPOSE: This paper presents the preliminary psychometrics of the Pediatric Motivation Scale (PMOT) designed to measure motivation from a child's perspective. METHOD: Content validity of the PMOT was measured through expert feedback (n = 12), and field testing ocurred with 41 children, 21 in rehabilitation and 20 healthy. Pearson product-moment correlations were used to analyze subscale correlations, test-retest reliability, and convergent validity with the Pediatric Volitional Questionnaire (PVQ). Internal consistency was measured using Cronbach's alpha. FINDINGS: Preliminary psychometric evaluation indicates strong internal consistency for PMOT total (α = .96) and subscales (α = .79-.91). The PMOT and PVQ moderately correlated in the rehabilitation subsample (r = .71, p < .01); no correlation was found in the healthy subsample (p > .05). Test-retest reliability was excellent (r = .97). IMPLICATIONS: This study provides preliminary psychometric evidence of the PMOT for children undergoing rehabilitation. These pilot findings warrant ongoing scale development.

The effects of motivating interventions on rehabilitation outcomes in children and youth with acquired brain injuries: a systematic review.

PRIMARY OBJECTIVE: To systematically review the evidence of the effects of motivating rehabilitation interventions on outcomes in children with acquired brain injury (ABI). METHODS: A literature search of six databases was conducted to identify intervention studies published until July 2013. The American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) systematic review methodology was used as a framework. Two reviewers independently extracted data and assessed level of evidence and quality of studies. RESULTS: Of 891 records initially retrieved, 166 were screened by abstract and 31 by full text; 10 studies comprised of five randomized controlled trials, two case series and three single subject research design studies met the inclusion criteria. Studies fell into three intervention categories: (1) token economy based interventions; (2) virtual reality (VR); and (3) memory and attention interventions. CONCLUSIONS: A paucity of evidence has examined the effects of rehabilitation interventions with a motivational component. Token economies can significantly enhance memory and response inhibition performance in children with ABI. VR systems are motivating, yet findings are limited by the lack of use and availability of psychometrically evaluated measures of motivation. Findings point to the need for further research to evaluate the effects of motivation-based interventions.

Culture as a variable in health research: perspectives and caveats.

To augment the rigor of health promotion research, this perspective article describes how cultural factors impact the outcomes of health promotion studies either intentionally or unintentionally. It proposes ways in which these factors can be addressed or controlled in designing studies and interpreting their results. We describe how variation within and across cultures can be considered within a study, e.g. the conceptualization of research questions or hypotheses, and the methodology including sampling, surveys and interviews. We provide multiple examples of how culture influences the interpretation of study findings. Inadequately accounting or controlling for cultural variations in health promotion studies, whether they are planned or unplanned, can lead to incomplete research questions, incomplete data gathering, spurious results and limited generalizability of the findings. In health promotion research, factors related to culture and cultural variations need to be considered, acknowledged or controlled irrespective of the purpose of the study, to maximize the reliability, validity and generalizability of study findings. These issues are particularly relevant in contemporary health promotion research focusing on global lifestyle-related conditions where cultural factors have a pivotal role and warrant being understood.

Digital citizenship of children and youth with autism: Developing guidelines and strategies for caregivers and clinicians to support healthy use of screens.

LAY ABSTRACT: Children and youth with autism use screens in their daily lives and in their rehabilitation programs. Although parents and clinicians experience specific challenges when supporting positive screen time use of children and youth with autism, no detailed information for this group exists. Therefore, this study aimed to develop clear guidelines that are agreed by expert clinicians and parents of children and youth with autism. Using a method called Delphi, 30 experts-20 clinicians and 10 caregivers, who have experience working with or caring for children and youth with autism were invited to complete a series of three surveys. In each round, the experts had to rate their agreement with statements regarding screen time management. The agreement level was set to 75%. The final themes to be included in the guidelines were accepted by more than 75% of the panel. The final guidelines included six main sections: (1) general principles, (2) considerations for timing and content of leisure screen time use, (3) strategies for caregivers and clinicians to monitor and regulate screen time use, (4) behaviors to monitor for screen time overuse, (5) additional guidelines for clinicians, and (6) resources. The new guidelines developed in this study can provide potential guidance on how to further the development of digital citizenship for children and youth with autism and provide strategies to families to help manage screen time use.

Complementary contribution of parents and therapists in the assessment process of children.

BACKGROUND/AIM: Traditional developmental models assume that the underlying capacities of children contribute to their participation. In this framework, preschoolers who are referred for occupational therapy services usually undergo an assessment intended to identify capacities in certain domains. Contrary to this, newer ecological models assume that child participation is a consequence of a multidimensional interaction between personal and environmental factors. As a result clinicians are increasingly focusing their assessment on performance and participation. This study aimed to assess the correlation between children's performance skills, their capacities and participation; and to explore whether parents' observations, alongside therapist observations and standardised assessments, contribute to an enhanced understanding of child participation. METHOD: Participants included 188 parents and their children, aged 4-6 years, with and without mild developmental difficulties. Data were collected using standardised assessments for child capacities, and questionnaires completed by parents and occupational therapists regarding child participation and performance skills. RESULTS: Significant correlations were found between parent assessments of child performance skills and child participation, but not with child capacities. The opposite was found to be true for occupational therapist assessments of child performance skills which were found to correlate with child capacities, but not with participation. Additionally, an interaction effect was found for both groups. Occupational therapists reported higher performance skills as compared to parents, but the difference was only significant for children without mild difficulties. CONCLUSION: As suggested by ecological models of child participation, the findings highlight the importance of parent-therapist collaboration in the assessment process of children.

Inclusive Community Aquatics Programming for Children with Developmental Challenges: A Community Participatory Action Research.

BACKGROUND: Children who are neurodiverse have traditionally been segregated from their peers in community-based programs, despite evidence of health benefits of inclusive education. OBJECTIVES: This community-initiated project aims to explore barriers and facilitators to inclusive aquatics programming for children with developmental and/or mental health challenges. METHODS: Using a participatory-action research methodology, semi-structured interviews and focus groups were conducted with 14 participants from various stakeholder groups, including parents of children who are neurodiverse, helping professionals, and community programmers. RESULTS: Participants described unique definitions of inclusion, from integration with neurotypical peers, to individualized goal-setting and achievement. Major facilitators include adequate resources, flexibility around accommodations, and motivated staff. Major barriers include social stigma, financial limitations, and lack of communication between caregivers and service providers. CONCLUSIONS: Participants felt strongly about the need to improve inclusion practices within aquatics-and other community-based-programs. Increased collaboration between families, community programmers, and helping professionals can foster better inclusion and outcomes for children who are neurodiverse. By incorporating various perspectives into the design of future programs, program administrators can ensure more equitable access such that all children are able to participate.

Profiling the Research Activities of Canadian Occupational Therapy and Occupational Science Faculty Members.

Background. There is a lack of knowledge on the scope and nature of the research by faculty members in occupational science (OS) and/or occupational therapy (OT) programs in Canada. Purpose. To describe the research activities of faculty members in these programs and directions. Method. A cross-sectional survey was distributed to 173 faculty members across all 14 Canadian OT that addressed: 1) research topics and methods, 2) populations, and 3) funding. Findings. Based on respondents (N = 121), research is focused on a range of topics and populations with most conducting qualitative research. Many conduct research examining the effectiveness of interventions, with few respondents focused on OS research. Federal and provincial grants agencies were the largest source of funding. Implications. Research topics studied were not always proportional to practice although emerging areas were being investigated that can expand the evidence base and scope of practice. Despite limited occupation-specific funding options, respondents were accessing funding from varied sources. Collaborations among faculty members, clinicians, and individuals with lived experience can create priorities for future OS and/or OT research in Canada.