page proof instructions and queries · received: 27 april 2015; accepted: 17 december 2015...

Page Proof Instructions and Queries

Journal Title British Journal of Occupational Therapy (BJO)

Article Number 630329

Greetings and thank you for publishing with SAGE We have prepared this page proof for your review Please respond to each of the below queries by digitally marking this PDF using Adobe Reader

Click ldquoCommentrdquo in the upper right corner of Adobe Reader to access the mark-up tools as follows

For textual edits please use the ldquoAnnotationsrdquo tools Please refrain from using the two tools crossed out below as data loss can occur when using these tools

For formatting requests questions or other complicated changes please insert a comment using ldquoDrawing Markupsrdquo

Detailed annotation guidelines can be viewed at httpwwwsagepubcomrepositorybinariespdfsAnnotationGuide-

linespdf

Adobe Reader can be downloaded (free) at httpwwwadobecomproductsreaderhtml

No Query

Please confirm that all author information including names affiliations sequence andcontact details is correct

Please review the entire document for typographical errors mathematical errors and anyother necessary corrections check headings tables and figures

Please confirm that the Funding and Conflict of Interest statements are accurate

Please ensure that you have obtained and enclosed all necessary permissions for thereproduction of artistic works (eg illustrations photographs charts maps other visualmaterial etc) not owned by yourself Please refer to your publishing agreement for furtherinformation

Please note that this proof represents your final opportunity to review your article prior topublication so please do send all of your changes now

AQ 1 Please provide the city for affiliations 3 4 6 and 10

AQ 2 Please provide an update for the reference Hughes etal (submitted)

Research Paper

Occupational therapy roles and responsibilitiesEvidence from a pilot study of time usein an integrated health and social care trust

Mark Wilberforce1 Jane Hughes2 Ian Bowns34 Joanne Fillingham5Faye Pryce6 Eileen Symonds7 Katie Paddock8 and David Challis910

AbstractIntroduction Occupational therapists undertake a broad spectrum of activities yet no mechanism exists to record how workingtime is distributed across them This is a hindrance to research evaluation and evidence-based practice

Method A new diary schedule was piloted by 151 qualified and assistant-grade practitioners working in multiple adult health andsocial care settings in an integrated NHS and Social Care Trust in England Time use relating to 37 occupational therapy tasks wasrecorded in 30 minute intervals for one week

Results Almost 5000 hours of activity were recorded For the average working week 39 of time was spent in direct care withclients 31 involved undertaking indirect casework such as liaison and administration whilst a further 22 was in teamserviceactivity Only modest differences were observed between qualified and assistant-grade respondents whilst occupational therapistsin traditional social care roles spent significantly longer in liaison and administrative duties Individual tasks capturing lsquotherapeuticactivityrsquo accounted for just 10 of practitioner time

Conclusion The new diary tool is a viable data collection instrument to evaluate practice and the impact of service redesignHowever further work is needed to evaluate its measurement properties in more detail

KeywordsOccupational therapy diary-study time-use integration specialist tasks social care

Received 27 April 2015 accepted 17 December 2015

Introduction

The role of occupational therapists has evolved over time

In the UK they were first employed within local authorities

in the late 1960s and early 1970s primarily to meet new

responsibilities in the provision of equipment and housing

adaptation services under new legislation Their role broa-

dened throughout the 1980s and 1990s as successive

reforms sought to expand community care and reduce resi-

dential home placements requiring occupational therapists

and allied practitioners to increasingly promote and sup-

port independent living at home Subsequently a ground-

swell of concern emerged concerning timely access to

equipment and adaptations and a lack of a tiered response

between those with high and low level needs resulting in

pressure for change within community-based occupational

therapy services (Audit Commission 2000 2002)

More recently a new policy and practice landscape has

since emerged in England with three inter-related themes

particularly relevant to this research First the occupational

therapy role has developed with the evolution of specialist

assessments for example through the introduction of the

Single Assessment Process in older peoplersquos services

(Department of Health 2001a Sutcliffe et al 2008) and

the occupational therapy assessment in transition reviews

as young people with learning disabilities and complex

needs move to adult services (Sloper et al 2010) Second

reforms aimed to improve access to equipment stores

1NIHR Doctoral Research Fellow Personal Social Services Research Unit

University of Manchester Manchester UK2Lecturer Personal Social Services Research Unit University of Manchester

Manchester UK3Director Public Health Priorities Limited UK 14Honorary Research Fellow Personal Social Services Research Unit

University of Manchester Manchester UK5Clinical Fellow to the Chief Allied Health Professions Officer NHS England

UK6Acting Professional Lead Staffordshire and Stoke-on-Trent Partnership

NHS Trust UK7Retired Occupational Therapist formerly Head of Service for Rehabilitation

and Enablement at Birmingham City Council Birmingham UK8Research Assistant Personal Social Services Research Unit University of

Manchester Manchester UK9Director and Professor of Community Care Research Personal Social

Services Research Unit University of Manchester Manchester UK10Associate Director NIHR School for Social Care Research UK

Corresponding authorMark Wilberforce NIHR Doctoral Research Fellow Personal Social Services

Research Unit University of Manchester Manchester M13 9PL UK

Email markwilberforcemanchesteracuk

British Journal of Occupational Therapy

1ndash8

The Author(s) 2016

Reprints and permissions

sagepubcoukjournalsPermissionsnav

DOI 1011770308022616630329

bjosagepubcom

Integrated Community Equipment Services combined NHS

and local authority resources and provided free provision to

those with an assessed need for all items under 1000

(Department of Health 2001b) Finally a growing empha-

sis has been placed on key cross-professional themes with

direct consequences for practitioners These include pre-

ventative care with an expansion of such services advo-

cated in Caring for our Future (Cm 8378 2012) and NHS

Englandrsquos (2014) forward strategy document as a way of

reducing reliance on crisis support The growth of inter-

mediate care has additionally challenged traditional occu-

pational therapy roles (Grant et al 2007) Importantly

how NHS and local authorities manage boundaries

between services has changed with occupational therapists

playing a key role in integrated care through multi-disci-

plinary working (Health Service Journal 2011)

Despite the fundamental impact that such changes may

have on the occupational therapy role surprisingly little is

known about the breadth of their activity the aspects of

the role that account for most time nor about differences

in time-use across settings between qualified and assis-

tant-grade staff or between individual practitioners In

Hughes et al (submitted)2 the development of a diary

schedule for use by occupational therapists was described

and appraised This article presents the results of a pilot of

this through an analysis of the distribution of working

time spent by responding occupational therapists and

assistants in an integrated health and social care Trust in

England

Literature review

Evaluations of how activities and responsibilities are chan-

ging in light of the above-described reforms are relatively

scarce Nevertheless two broad groups of literature can be

discerned First many references have explored the impact

of multi-professional working on the role and in particu-

lar the generic versus specialist content of occupational

therapy in community health services For example

detailed accounts of multi-disciplinary work supporting

people with mental health problems and learning disabil-

ities have been undertaken (Harries and Gilhooly 2003

Lloyd et al 2004 Parkinson et al 2009) However the

schedules used in these studies each encountered difficulty

in making the subjective distinction between generic and

specialist occupational therapy activities which hampered

their utility and ability to influence practice (Parkinson

et al 2009) Furthermore whilst local authority occupa-

tional therapy services were integrated with other public

services (eg health or housing) in some areas there

remained a predominance of single-agency delivery never-

theless (Riley et al 2008) suggesting the need for a

broader focus of research to reflect the diverse settings in

which practitioners work

A second body of literature has explored specific policy

and practice change including the implementation of the

Single Assessment Process (Ridout and Mayers 2006)

intermediate care services (Grant et al 2007) self-assess-

ment (Tucker et al 2012) personalisation (London-Willis

et al 2012) and the expansion of telecare and assistive

technology (Nelson and Senker 2006 Riley et al 2008)

Related research also investigated how service change

impacted upon the role of qualified vis-a-vis assistant-

grade practitioners (Mackey 2005 Nancarrow and

Mackey 2005)

Taken together the literature is limited to narrow

methodological approaches mostly comprised of small

qualitative studies or surveys in single organisations It is

largely restricted to services in England and focused on

perceptions and opinion rather than objective change The

body of evidence is conspicuous by its lack of generalis-

ability caused in part by the absence of standardised

measurement tools available to assist researchers seeking

to evaluate reform The literature review conducted as part

of the instrument development (Hughes et al submitted)

identified no suitable mechanisms for recording the full

range and content of occupational therapy activities

across health and social care settings

Yet diary tools have been repeatedly used in adult social

care Most commonly the schedules have been used with

social work teams in local authorities (eg Weinberg et al

2003) but examples also exist in community mental health

services (eg Tucker et al 2008) hospital-based social

work (eg Jacobs et al 2006) continuing healthcare and

intermediate care settings (eg Challis et al 2012) Those

studies also demonstrated that diary data have multiple

uses as a means for simply describing practitioner roles

and responsibilities for evaluating change (eg over time

or compared to a control group) and in providing a basis

for costing new or existing activities When linked with

other data (eg other job characteristics caseload charac-

teristics) diary tools also provide a means for exploring a

wider range of research questions

Method

This study aimed to pilot a new diary tool to demonstrate

its potential utility to research and practice Specifically

the diary tool was used to determine how qualified and

assistant-grade practitioners invested their time and to

investigate any association between time use service set-

ting and qualification status

Setting

It was undertaken in partnership between the Personal

Social Services Research Unit at the University of

Manchester and the Staffordshire and Stoke-on-Trent

Partnership (SSOTP) NHS Trust in England The latter

was established in 2011 bringing together community

health services previously delivered by three separate

NHS organisations across nine districts and boroughs

and adult social care services for adults previously pro-

vided by the county council The Trust serves a large

county (population 852000) with below-average levels of

social deprivation and average health profile and an

urban area (population 250000) with above-average

levels of social deprivation and ill-health

2 British Journal of Occupational Therapy 0(0)

Participants

All practitioners within the SSOTP NHS Trust undertak-

ing an occupational therapy role in adult care settings were

invited to participate Box 1 summarises the service sectors

in which they were based Prior to fieldwork the

Professional Head of Allied Health Professionals within

the Trust undertook internal communications to increase

awareness of the research Together with the Professional

Lead for Occupational Therapy a comprehensive list of

all occupational therapy practitioners was compiled from

the Trustrsquos IT system and supplemented with manual

checks The diary tool schedule was printed with a partici-

pant identification number that was matched by the

SSOTP NHS Trust to an individual practitioner and sub-

sequently sent to the correct person Each participant

received an envelope containing their diary tool complete

with covering letter guidance a participation information

sheet and a freepost envelope addressed direct to the

research team at Manchester

Instruments and analysis

The paper-based diary tool was designed for self-comple-

tion and comprised an anonymised diary grid (Mondayndash

Friday 8 amndash7 pm) divided into 30 minute intervals

together with a list of 37 activity codes The activities were

organised into four sections those undertaken face-to-face

or via telephone with service users and their families

(lsquodirect carersquo) those relating to individual service users

but not undertaken with them (lsquoindirect carersquo) those relat-

ing to wider organisational duties (lsquoteamservice workrsquo)

and other tasks Further detail on the task-list and their

development are presented in Hughes et al (submitted)

Participants were asked to record their time-use for each

30-minute interval using the activity code list or lsquootherrsquo

where no appropriate code was available Previous diary

study research with community practitioners suggests that

a 30 minute interval provides an appropriate balance

between accurate recording and respondent burden (eg

Weinberg et al 2003) Accompanying instructions

explained that where they undertook more than one activity

in any interval they should enter the code relating to the

activity that took the most time Further participants were

asked to complete the diary throughout the day to avoid

inaccurate recollection later Data collection lasted one

week However where an individual was away on annual

or sick leave they were asked to complete it for the corres-

ponding day in the following week

Participants completed the diary study in mid-

November 2013 If a response was not received by the

end of November the non-responder received an email

reminder and shortly after a second email or telephone

contact Fieldwork closed in mid-December 2013 Data

were entered by a single researcher with a sample corro-

borated by a second author with any uncertainties (eg

issues of legibility andor information provided in open

text) resolved in discussion with the wider research team

Analysis was undertaken in SPSS (v20) and was predom-

inantly in the form of cross-tabulation of frequencies and

percentages with statistical tests of association underta-

ken where relevant

Ethics

Ethical scrutiny was provided by the University of

Manchester Research Ethics Committee 3 (Reference

13119) Local NHS permission was granted by the

SSOTP NHS Trust and the study was adopted by the

Primary Care Research Network

Results

All practitioners within the Trust undertaking an occupa-

tional therapy role were invited to participate in the diary

tool pilot Two hundred and forty-four schedules were dis-

tributed and 151 were returned representing a response rate

of 62 Table 1 presents the response profile for the study

More returns both proportionately and in absolute terms

were received from qualified than assistant-grade practi-

tioners and from those based in community compared to

intermediate care and hospital settings Twelve schedules

were received from lsquootherrsquo service sectors Eighty-one and

67 respondents were in full-time and part-time posts

respectively The returned schedules provided time-use

information for an aggregate of 4879 hours

The proportion of the working week spent on each of

37 activities included in the pilot schedule is presented in

Table 2 Almost a fifth of the average working week was

Table 1 Response rate and sample size

Invited(n)

Responses(n)

Responserate ()

Qualificationstatus

Qualified 160 111 694

Assistant-grade 83 40 482

Servicesector

Community primary care 57 45 789

Community social care 63 40 635

Intermediate care 69 35 556

Hospital-based services 43 23 535

Other 12 8 667

Total 244 151 619

One qualification status was missing

Box 1 Service sectors included within the research study

Community services ndash primary care Includes primary community rehabilitation teams pain manage-

ment and neuro-rehabilitationCommunity services ndash social care Includes community sector OT teams and equipment servicesIntermediate care Includes community intervention services and early discharge

teams as well as ward-based intermediate careHospital services Includes rheumatology musculoskeletal service stroke rehabilita-

tion falls service limb fitting and a wheelchair teamOther services Includes hospice-based palliative care and paediatrics

Wilberforce et al 3

spent recording case notes and other office-based paper-

work (activity 25) with almost all respondents recording

at least some time spent on this activity When combined

with general administration (activity 36) a quarter of

worked hours were accounted for Client-related travel

accounted for a further 8 of the working week on aver-

age and amounted to over a quarter of all worked time

for a small number of staff Four of the five activities

accounting for the greatest amount of time were under-

taken away from the client (ie activities outside of direct

care) The fifth activity assessment of the home environ-

ment was the most commonly reported direct care activity

and accounted for just over 5 of the working week

on average

Twenty-seven of the activity codes were used by fewer

than half of respondents (hence a corresponding median of

zero hours) Little time was spent on activities relating to

adaptations during the pilot week For example just

10 respondents reported spending any time specifying

and planning adaptations and only 16 spent time under-

taking Disabled Facility Grant applications Further only

14 respondents recorded time assessing needs relating to

vocational or social participation and few lsquootherrsquo assess-

ments were identified Only 31 respondents reported clin-

ical supervision during the study period Although

27 codes were not used by most respondents a number

were required by some individuals to describe significant

proportions of their work For example lsquodelivering

Table 2 Proportion of the working week spent on each of 37 activities included in the pilot schedule

ACTIVITY Mean () Median () Max ()N usingcode

1 Pre-assessment information gathering 265 130 2055 84

2 Assessment activity home environment 556 329 3708 110

3 Assessment activity manual handling 194 0 2941 56

4 Assessment activity physical function 356 184 2917 84

5 Assessment activity vocational andor social participation 035 0 980 14

6 Assessment activity generic for multi-disciplinary team 116 0 2941 26

7 Assessment activity other (eg carer driving) 045 0 1744 21

8 Care planning 175 0 1739 57

9 Providing advicetrainingskills development 123 0 1825 48

10 Delivering therapy supporting basic ADL 314 0 7451 61

11 Delivering therapy supporting instrumental ADL 075 0 893 32

12 Delivering therapy physical therapy 236 0 3158 46

13 Delivering therapy supporting psychological health 120 0 4634 34

14 Equipment inspection fitting joint visits demonstration 174 0 3333 65

15 Adaptations planning inspection joint visits 081 0 1075 28

16 Monitoring and review 204 0 1944 58

17 Client-related travel 779 698 2826 113

18 Equipment specification ordering and related paperwork 388 267 2255 114

19 Equipment liaison with providers professionals agencies 126 0 1189 60

20 Adaptations specification and planning 018 0 646 10

21 Adaptations securing finance (eg DFG) and paperwork 050 0 1175 16

22 Adaptations liaison with other professionals and agencies 057 0 1125 29

23 Referral to other services and practitioners 140 0 1519 69

24 Client-related liaison with other practitionersagencies 439 245 2241 103

25 Recording case notes and other office-based paperwork 1829 1571 8434 147

26 Clinical supervision 086 0 990 31

27 Triageallocation of new referrals on behalf of the team 392 127 3167 81

28 Supervising others staffstudents 136 0 2819 36

29 Service development activities 276 0 4094 42

30 Personal professional development and training 542 0 4938 62

31 Training others staffstudents 082 0 2208 18

32 Audit data collection and performance measurement 138 0 1833 46

33 Team meetings 382 214 2022 88

34 Travel (ie to and from meetings at other offices) 201 0 1818 67

35 Travel (not covered above) 151 0 2785 46

36 General administration (not covered above) 611 267 7241 98

38 Other 103 0 3137 23

ADL activities of daily living DFG disabled facilities grantsActivity 37 (lunch) excluded


therapy supporting basic ADLsrsquo accounted for around

three-quarters of one practitionerrsquos activity whilst

lsquodelivering therapy supporting psychological healthrsquo and

lsquopersonal professional development and trainingrsquo were

each required to describe around half of the activity for

some others Conversely the activity with the lowest max-

imum use by any individual was lsquoadaptations specification

and planningrsquo though this still accounted for almost 7

of one individualrsquos week

Table 3 shows the proportion of the working week spent

on activities grouped within the broad themes outlined

above The largest proportion of time was spent on direct

care tasks and together with indirect care client-related

activity accounted for 70 of the average working week

Only modest differences were observed between qualified

and assistant-grade respondents The former spent margin-

ally more time undertaking direct care although this differ-

ence did not reach statistical significance Time spent by

service sector revealed more pronounced differences

(ANOVA Ffrac14 315 pfrac14 0016) Specifically respondents in

intermediate care spent significantly more time in direct care

activities than those in social care (Post-hoc test pfrac14 0015)

the latter being the only service sector in which respondents

spent more time in indirect than in direct care

By combining time spent on different individual tasks

the diary data can be used to explore activities under other

thematic headings For example two distinct categorisa-

tions of assessment were identified for further analysis

activities most likely to require the specific skills possessed

by occupational therapists (lsquoOT specificrsquo) and those more

general assessment tasks common to other professional dis-

ciplines (lsquowider assessment activityrsquo) Table 4 shows that

over a quarter of the average working week was spent on

the latter compared to just over a tenth on the former The

data provide some evidence that qualified staff spent more

time undertaking occupational therapy-specific activities

than assistant-grade counterparts although the test statistic

was outside conventional significance thresholds (t-test

tfrac14 186 pfrac14 0065) With respect to wider assessment

activities the data suggest differences between sectors

(ANOVA Ffrac14 287 pfrac14 0025) Most notably respondents

in primary care services seemed more likely to undertake

these activities than respondents in social care (Post-hoc

test pfrac14 0070)

Three other themes relating to the support of service

users were also identified lsquotherapeutic activitiesrsquo lsquoequip-

mentadaptationsrsquo and lsquocare planning monitoring and

reviewrsquo (Table 5) On average less than one tenth of the

average working week was spent on each Assistant-grade

practitioners spent significantly more time on therapeutic

activities than their qualified counterparts (t-test tfrac14 1988

pfrac14 0049) whilst the reverse was true for time spent on time

care planning monitoring and reviewing (t-test tfrac14 2431

pfrac14 0016) Significant differences in time spent on thera-

peutic activities (ANOVA Ffrac14 987 plt 0001) equipment

and adaptations activities (ANOVA Ffrac14 1062 plt 0001)

and to a lesser extent care planning monitoring and review

activities (ANOVA Ffrac14 253 pfrac14 0043) were also observed

by service sector Respondents in social care services again

stood apart spending least time undertaking therapeutic

activities more time arranging equipmentadaptations and

least time care planning monitoring and reviewing

Finally time spent on training and the work environment

was also categorised under three themes lsquomulti-disciplinary

workingrsquo lsquotraining and development activitiesrsquo and lsquooffice-

based administrationrsquo (Table 6) The latter accounted for

just under one third of the average working week whilst

time spent working in a multi-disciplinary context and in

training and development activities accounted for over

10 each Qualified practitioners spent more time on aver-

age than assistant-grade respondents on multi-disciplinary

working (t-test tfrac14 2013 pfrac14 00459) whilst spending less

time on office-based administration (t-test tfrac14 3753

plt 0001) Significant differences in time use were also

apparent by service sector With respect to multi-disciplin-

ary working (ANOVA Ffrac14 461 pfrac14 0002) respondents in

intermediate care undertook significantly more time in this

than those in other sectors (multiple post-hoc tests not

shown) Further respondents in social care services spent

significantly less time on training and development

than those in primary care (ANOVA Ffrac14 268 pfrac14 0034

Table 3 Proportion of the average working week spent on four

activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721

Assistant-grade 3659 3297 1774 1269

Servicesector

Communityprimary care

4111 2579 2415 896

Communitysocial care

2777 3918 2320 985

Intermediate care 4443 2864 1900 792

Hospital-basedservices

4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866

Direct care (activities 1ndash17) indirect care (18ndash26) teamservice work(27ndash34) other (35 36 38)

Table 4 Proportion of the average working week spent on

assessment activities ()

OT specificassessment

Widerassessmentactivity

Qualificationstatus

Qualified 1220 2605

Assistant-grade 924 2765

Servicesector

Community primary care 1126 3175

Community social care 1188 2223

Intermediate care 1144 2391

Hospital-based services 1059 2703

Other 1188 3361

Total 1142 2648

Specialist assessment (activities 2ndash5) generic assessment (1 6 7 2527)

Wilberforce et al 5

Post-hoc test pfrac14 0021) but more time undertaking admin-

istrative duties (ANOVA Ffrac14 577 plt 0001 Post-hoc test

pfrac14 0013)

Discussion and implications

The changing roles of occupational therapists is of signifi-

cant domestic and international interest with potential

consequences for service users efficient use of resources

and is likely to have consequences for practitioner welfare

(Lloyd et al 2004) Yet few evaluative tools enable

researchers and service managers to assess how practi-

tioner time-use is changing This paper together with

Hughes et al (submitted) describes the development and

piloting of a diary tool to describe the work of occupa-

tional therapists in a variety of community settings The

schedule was piloted in a single NHS Trust and the find-

ings should be interpreted in this context The particular

benefit of undertaking the study in the SSOTP NHS Trust

was its integration of practitioners employed in former

social services teams with primary care and other hospital

(non-acute) based services allowing contrasts to be drawn

across a range of sectors In addition given that the inte-

gration of such services was contemporaneous with the

study the research offers the Trust a baseline picture of

time use against which to monitor future trends

Almost 5000 hours of practitioner activity were

included in the pilot For the average working week

39 was spent in direct care with clients whilst 31

was undertaking indirect casework and a further 22 in

service development activity The appropriate balance

between direct and indirect care has been a topic of

some debate due to concern that health and social care

reforms has proceduralised service delivery at the expense

of service usercarer contact (Carey 2008) Nevertheless

these findings are rather similar to the findings of a study

of health visiting practice conducted in the late 1990s in

which respondents spent on average 41 of their time in

direct client contact 27 on lsquoclient-relatedrsquo activity with

the remainder on travel administration and so on (Crofts

et al 2000) Furthermore the pilot suggested that practi-

tioners from the present sample spent more time in direct

care than practitioners in social care teams (Jacobs et al

2013 Weinberg et al 2003) and specialist mental health

services (Tucker et al 2008) Yet the data clearly suggest

that occupational therapists in traditional social care sec-

tors spend less time in direct care and more time in indir-

ect care than those in other sectors In part this is a

Table 6 Proportion of the average working week spent on training and activities relating to the work

environment ()

Multi-disciplinaryworking

Training anddevelopment activities

Office-basedadministration

Qualification status Qualified 1497 1220 2775


Service sector Community primary care 1054 1365 2690




Other 697 1385 3526

Total 1400 1175 3019

Multi-disciplinary working (activities 1 6 14 15 19 22ndash24) training and development (28ndash32) office-based admin-istration (18 20ndash23 25 32 36)

Table 5 Proportion of the average working week spent on provision of assistance ()

Therapeuticactivities

Equipmentadaptations

Care planningmonitoringand review

Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834

Therapeutic activities (activities 9ndash13) equipmentadaptations (14 15 18ndash22) care planning monitoring and review(8 16 23 24)


consequence of specific activities such as paperwork and

liaison activities needed to apply for Disabled Facilities

Grants However other differences may be systemic a

legacy of the practices and administrative systems

common in traditional social service departments estab-

lished prior to integration with the host Trust

The pilot also found that less than 10 of the average

working week was spent on lsquotherapeutic activitiesrsquo one of

the roles expected to be a central component of an occu-

pational therapistrsquos duties Data also suggested that

respondents in the host Trust spent over twice the time

undertaking wider assessment activities as they did on

occupational therapy-specific assessment These findings

possibly reflect the breadth of skills possessed by occupa-

tional therapists and the multi-disciplinary nature of their

work However the results also raise questions about

whether occupational therapists have moved too far

away from rehabilitative forms of support and towards

the delivery of compensatory approaches in arranging

equipment and adaptations and coordinating the input

of other providers Given the current strategic emphasis

towards prevention and self-care (NHS England 2014)

and the College of Occupational Therapistsrsquo previous

statement that the majority of casework should be focused

on specialist occupational therapy interventions (Pettican

and Bryant 2007) the findings here perhaps hint at cause

for concern However these studies are not immune from

definitional ambiguities that have bedevilled similar

research (Parkinson et al 2009) For example what con-

stitutes a lsquospecialistrsquo occupational therapy task (from other

lsquogenericrsquo roles they may undertake) and what constitutes

lsquotherapeuticrsquo activity is clearly a subjective matter Results

should be interpreted with this in mind

The diary data enable an inspection of variation as well

as simple arithmetic averages and these suggest a poten-

tial use of the diary data for practitioners to reflect on their

own time use It is notable that a small number of

respondents appeared to have unusual patterns of activity

For example whilst most respondents did not report

undertaking any service development activities for one

individual this was the equivalent of two full working

days in the reference week It may be that some respond-

ents were undertaking a discrete time-limited element of

service development work for the Trust or that it was an

idiosyncratic week for some individuals Nevertheless

such tools offer practitioners the potential for reflection

on the breadth of their work For this reason it is import-

ant to retain a task list of good descriptive detail even

though a comparatively large number of codes were not

required by the majority of practitioners they were almost

all necessary to describe a significant proportion of work

(between a tenth and a third) for at least one individual

The research presented in this report engaged over 150

practitioners and managers at different levels and a sense

of enthusiasm for the study permeated each activity

Despite the consequent professional endorsement it is

important to reflect on the limitations of the research

The diary tool was only designed for use in adult care

settings and the (accidental) inclusion of a small number

of practitioners in paediatric settings should not infer an

ease of transfer to those working with children Further

the diary tool has not been tested in all adult settings with

adult mental health and learning disability services being

notable exceptions Nevertheless it is encouraging that the

study has found that a single diary tool is viable across a

broad range of settings and for both qualified and assis-

tant-grade practitioners The response rate of 62 is rea-

sonable but cannot rule out significant differences

between respondents and non-respondents Practitioners

were required to identify a single dominant activity for

each half-hour slot and the entire time period was attrib-

uted to that particular activity This alone is likely to have

led to an underreporting of activities that occupied only a

few minutes at a time such as telephone contacts with

clients or other service providers and consequent over-

reporting of other activities Some activities undertaken

simultaneously would also be underrepresented

Further research is needed to develop and test the diary

tool in more detail Structured data collection tools should

be assessed against a range of established measurement

properties The results go some way in establishing the

toolrsquos validity (whether it measures what it seeks to meas-

ure) although an extension to other settings including

acute hospitals adult mental health and learning disability

services is desirable Furthermore the research does little

to assess its reliability (whether it performs equally well in

repeated administrations) Specifically intra-rater (does

the same individual use the tool consistently at different

times) and inter-rater (do different individuals record the

same activity consistently) reliability needs to be estab-

lished An example of such testing might include providing

vignettes describing hypothetical activities and asking

multiple respondents how they would code that time

using the diary tool Until such testing is complete the

diary tool should be used cautiously with due regard to

these limitations

Conclusion

The lack of standardised instruments available to docu-

ment and measure the activities of occupational therapists

is a hindrance to research evaluation and evidence-based

practice This paper reports the results of a pilot study

seeking to test the validity and utility of a new diary sched-

ule of practitioner time-use The diary tool proved to be

simple to administer and generated information with face

validity and thus may be suitable to evaluate practice and

policy reform However further work is needed to inspect

its measurement properties in more detail

Key findings

Diary tools offer a robust mechanism for exploring

practitioner time-use

39 of time was spent in direct care with clients

Administrationliaison accounts for more time in social

care roles

Wilberforce et al 7

What the study has added

A new diary tool collected reliable data on occupa-

tional therapist time-use The results suggested little

difference between qualifiedassistant-grade staff but

social care roles spent more time in administration

liaison

Acknowledgements

The authors would like to thank all participating occupational ther-

apists Hazel Mackey and Janice Lovatt of SSOTP NHS Trust and

Elizabeth White of the College of Occupational Therapists for their

support

Research ethics

Ethical approval was obtained from the University of Manchester

Research Ethics Committee 3 (Reference 13119) on 5 August 2013

Declaration of conflicting interests

The authors confirm that there is no conflict of interest

Funding

This article presents independent research funded by the NIHR

School for Social Care Research The views expressed in this article

are those of the authors and not necessarily those of the NIHR

School for Social Care Research or the Department of Health

NIHR or NHS

References

Audit Commission (2000) Fully Equipped The Provision of

Equipment to Older or Disabled People by the NHS and

Social Services in England and Wales London Audit

Commission

Audit Commission (2002) Fully Equipped 2002 Assisting

Independence London Audit Commission

Carey M (2008) Everything must go The privatization of state

social work British Journal of Social Work 38(5) 918ndash935

Challis D Clarkson P Hughes J et al (2012) National evaluation

of the common assessment framework Volume 2 Service deliv-

ery and outcomes Findings Discussion paper M269

Manchester Personal Social Services Research Unit

Crofts D Bowns I Williams T et al (2000) Hitting the target

The equitable distribution of health visitor caseloads Journal

of Public Health Medicine 22(3) 295ndash301

Department of Health (2001a) National Service Framework for

Older People London DH

Department of Health (2001b) Guide to Integrating Community

Equipment Services London DH

Grant M Ward G Dring P et al (2007) Intermediate care

An occupational therapy perspective International Journal

of Therapy and Rehabilitation 14(3) 130ndash134

Harries P and Gilhooly K (2003) Identifying occupational ther-

apistsrsquo referral priorities in community health Occupational

Therapy International 10(2) 150ndash164

Health Service Journal (2011) Why occupational therapists have

a vital role in integrated care Health Service Journal 17

November Available at httpwwwhsjcoukresource-centre

best-practicequality-and-performance-resourceswhy-occupa

tional-therapists-have-a-vital-role-in-integrated-care5039080

article (accessed 15 September 2015)

Hughes J Wilberforce M Symonds E et al (submitted)

Practitioner roles and responsibilities development of a stan-

dardised measure of time use British Journal of Occupational

Therapy Submitted April 2015

Jacobs S Hughes J Challis D et al (2006) Care managersrsquo time

use Differences between community mental health and older

peoplersquos services in the United Kingdom Care Management

Journals 7(4) 169ndash178

Jacobs S Abell J Stevens M et al (2013) The personalisation of

care services and the early impact on staff activity patterns

Journal of Social Work 13(2) 141ndash163

Lloyd C McKenna K and King R (2004) Is discrepancy between

actual and preferred work activities a factor in work-related

stress for mental health occupational therapists and social

workers British Journal of Occupational Therapy 67(8)

353ndash360

London-Willis J Couldrick L and Lovelock L (2012) The person-

alisation of adult social care Occupational therapistsrsquo percep-

tions British Journal of Occupational Therapy 75(3) 128ndash133

Mackey H (2005) Assistant practitioners Issues of accountabil-

ity delegation and competence International Journal of

Therapy and Rehabilitation 12(8) 331ndash338

Nancarrow S and Mackey H (2005) The introduction and evalu-

ation of an occupational therapy assistant practitioner

Australian Occupational Therapy Journal 52(4) 293ndash301

Nelson R and Senker P (2006) The preventative technology

grant Benefits and dangers Occupational Therapy News

14(11) 22ndash23

NHS England (2014) Five Year Forward View London NHS

England

Parkinson S Forsyth K Durose S et al (2009) The balance of

occupation-focused and generic tasks within a mental health

and learning disability occupational therapy service British

Journal of Occupational Therapy 72(8) 366ndash370

Pettican A and Bryant W (2007) Sustaining a focus on occupa-

tion in community mental health practice British Journal of

Occupational Therapy 70(4) 140ndash146

Ridout A and Mayers C (2006) Evaluation of the implementation

of the single assessment process and its impact on occupa-

tional therapy practice British Journal of Occupational

Therapy 69(6) 271ndash280

Riley J Whitcombe S and Vincent C (2008) Occupational

Therapy in Adult Social Care in England Sustaining a High

Quality Workforce for the Future London DH

Sloper P Beecham J Clarke S et al (2010) Models of Multi-

Agency Services for Transition to Adult Services for Disabled

Young People and those with Complex Health Needs Impact

and Costs York Social Policy Research Unit

Sutcliffe C Hughes J Abendstern M et al (2008) Developing

multidisciplinary assessment ndash exploring the evidence from a

social care perspective International Journal of Geriatric

Psychiatry 23(12) 1297ndash1305

Tucker S Hughes J Burns A et al (2008) The balance of care

Reconfiguring services for older people with mental health

problems Aging and Mental Health 12(1) 81ndash91

Tucker S Hughes J Brand C et al (2012) Providing community

equipment and adaptations in adult social care Lessons from

an evaluation of the use of self-assessment in five English local

authorities Research Policy and Planning 29(1) 21ndash35

Weinberg A Williamson J Challis D et al (2003) What do care

managers do A study of working practice in older peoplersquos

services British Journal of Social Work 33(7) 901ndash919


AQ1

AQ2

AQ1

AQ2

Research Paper

Occupational therapy roles and responsibilitiesEvidence from a pilot study of time usein an integrated health and social care trust

Mark Wilberforce1 Jane Hughes2 Ian Bowns34 Joanne Fillingham5Faye Pryce6 Eileen Symonds7 Katie Paddock8 and David Challis910

AbstractIntroduction Occupational therapists undertake a broad spectrum of activities yet no mechanism exists to record how workingtime is distributed across them This is a hindrance to research evaluation and evidence-based practice

Method A new diary schedule was piloted by 151 qualified and assistant-grade practitioners working in multiple adult health andsocial care settings in an integrated NHS and Social Care Trust in England Time use relating to 37 occupational therapy tasks wasrecorded in 30 minute intervals for one week

Results Almost 5000 hours of activity were recorded For the average working week 39 of time was spent in direct care withclients 31 involved undertaking indirect casework such as liaison and administration whilst a further 22 was in teamserviceactivity Only modest differences were observed between qualified and assistant-grade respondents whilst occupational therapistsin traditional social care roles spent significantly longer in liaison and administrative duties Individual tasks capturing lsquotherapeuticactivityrsquo accounted for just 10 of practitioner time

Conclusion The new diary tool is a viable data collection instrument to evaluate practice and the impact of service redesignHowever further work is needed to evaluate its measurement properties in more detail

KeywordsOccupational therapy diary-study time-use integration specialist tasks social care

Received 27 April 2015 accepted 17 December 2015

Introduction

The role of occupational therapists has evolved over time

In the UK they were first employed within local authorities

in the late 1960s and early 1970s primarily to meet new

responsibilities in the provision of equipment and housing

adaptation services under new legislation Their role broa-

dened throughout the 1980s and 1990s as successive

reforms sought to expand community care and reduce resi-

dential home placements requiring occupational therapists

and allied practitioners to increasingly promote and sup-

port independent living at home Subsequently a ground-

swell of concern emerged concerning timely access to

equipment and adaptations and a lack of a tiered response

between those with high and low level needs resulting in

pressure for change within community-based occupational

therapy services (Audit Commission 2000 2002)

More recently a new policy and practice landscape has

since emerged in England with three inter-related themes

particularly relevant to this research First the occupational

therapy role has developed with the evolution of specialist

assessments for example through the introduction of the

Single Assessment Process in older peoplersquos services

(Department of Health 2001a Sutcliffe et al 2008) and

the occupational therapy assessment in transition reviews

as young people with learning disabilities and complex

needs move to adult services (Sloper et al 2010) Second

reforms aimed to improve access to equipment stores

1NIHR Doctoral Research Fellow Personal Social Services Research Unit

University of Manchester Manchester UK2Lecturer Personal Social Services Research Unit University of Manchester

Manchester UK3Director Public Health Priorities Limited UK 14Honorary Research Fellow Personal Social Services Research Unit

University of Manchester Manchester UK5Clinical Fellow to the Chief Allied Health Professions Officer NHS England

UK6Acting Professional Lead Staffordshire and Stoke-on-Trent Partnership

NHS Trust UK7Retired Occupational Therapist formerly Head of Service for Rehabilitation

and Enablement at Birmingham City Council Birmingham UK8Research Assistant Personal Social Services Research Unit University of

Manchester Manchester UK9Director and Professor of Community Care Research Personal Social

Services Research Unit University of Manchester Manchester UK10Associate Director NIHR School for Social Care Research UK

Corresponding authorMark Wilberforce NIHR Doctoral Research Fellow Personal Social Services

Research Unit University of Manchester Manchester M13 9PL UK

Email markwilberforcemanchesteracuk

British Journal of Occupational Therapy

1ndash8

The Author(s) 2016

Reprints and permissions

sagepubcoukjournalsPermissionsnav

DOI 1011770308022616630329

bjosagepubcom





























England

Literature review

































Mackey 2005)





























Method







Setting















Participants


























































ken where relevant

Ethics






Results


















Invited(n)

Responses(n)

Responserate ()

Qualificationstatus



Servicesector





Other 12 8 667

Total 244 151 619







Wilberforce et al 3














on average

















































33 Team meetings 382 214 2022 88




38 Other 103 0 3137 23














































test pfrac14 0070)







































activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721


Servicesector


4111 2579 2415 896


2777 3918 2320 985



4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866






Qualificationstatus

Qualified 1220 2605


Servicesector





Other 1188 3361

Total 1142 2648


Wilberforce et al 5



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2





























England

Literature review

































Mackey 2005)





























Method







Setting















Participants


























































ken where relevant

Ethics






Results


















Invited(n)

Responses(n)

Responserate ()

Qualificationstatus



Servicesector





Other 12 8 667

Total 244 151 619







Wilberforce et al 3














on average

















































33 Team meetings 382 214 2022 88




38 Other 103 0 3137 23














































test pfrac14 0070)







































activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721


Servicesector


4111 2579 2415 896


2777 3918 2320 985



4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866






Qualificationstatus

Qualified 1220 2605


Servicesector





Other 1188 3361

Total 1142 2648


Wilberforce et al 5



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2

Participants


























































ken where relevant

Ethics






Results


















Invited(n)

Responses(n)

Responserate ()

Qualificationstatus



Servicesector





Other 12 8 667

Total 244 151 619







Wilberforce et al 3














on average

















































33 Team meetings 382 214 2022 88




38 Other 103 0 3137 23














































test pfrac14 0070)







































activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721


Servicesector


4111 2579 2415 896


2777 3918 2320 985



4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866






Qualificationstatus

Qualified 1220 2605


Servicesector





Other 1188 3361

Total 1142 2648


Wilberforce et al 5



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2














on average

















































33 Team meetings 382 214 2022 88




38 Other 103 0 3137 23














































test pfrac14 0070)







































activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721


Servicesector


4111 2579 2415 896


2777 3918 2320 985



4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866






Qualificationstatus

Qualified 1220 2605


Servicesector





Other 1188 3361

Total 1142 2648


Wilberforce et al 5



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2












































test pfrac14 0070)







































activity themes ()

Directcare

Indirectcare

Teamservicework

Othertasks

Qualificationstatus

Qualified 3919 3076 2285 721


Servicesector


4111 2579 2415 896


2777 3918 2320 985



4251 3108 1829 812

Other 4002 3604 1814 580

Total 3850 3135 2150 866






Qualificationstatus

Qualified 1220 2605


Servicesector





Other 1188 3361

Total 1142 2648


Wilberforce et al 5



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2



pfrac14 0013)













































environment ()










Other 697 1385 3526

Total 1400 1175 3019






Qualificationstatus



Servicesector





Other 783 332 903

Total 869 884 834


































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2
































































































these limitations

Conclusion











Key findings





care roles

Wilberforce et al 7






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2






liaison

Acknowledgements




support

Research ethics





Funding





NIHR or NHS

References




Commission











































353ndash360












14(11) 22ndash23


England


































AQ1

AQ2

AQ1

AQ2

page proof instructions and queries · received: 27 april 2015; accepted: 17 december 2015...

Documents