11.9% 24.4% 13.3% 50.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
1 - 3 years 4 - 7 years 8 - 11 years 11 + years
How many years experience do you have in
housing modifications?
142 .
Discussion 5.2.2
The finding that the majority of respondents work within a social care setting was expected, given the predominant role occupational therapists have within social care for assessing and recommending home modifications (Riley et al., 2008). What is surprising is that 11% of respondents work within independent practice. This is interesting because the majority of research conducted in the field of home modifications, both as an intervention and the services providing modifications, in the UK, Europe, and Australasia is predominately with occupational therapists who are providing state funded modifications and as part of the formal health and social care system. Therefore, whilst these studies have considered the professional reasoning skills and needs of occupational therapists within these types of setting, it may be the case that the skills and knowledge needs of practitioners in independent practice may be different.
This finding shows that the majority of respondents had over 8 years of experience. In the research on the use of protocols by Kuipers and Grice (2009), novice practitioners were those with 4 or less years’ experience of using the particular intervention that was being studied. Whilst there has been no specific research that has considered the question as to what makes an expert practitioner within the field of home modifications, using the above research, it could be tentatively argued that the majority of respondents to this questionnaire were above novice level. If considered above novice level, then it would be assumed that those completing the questionnaire were both familiar and experienced with this field of practice.
5.3
Respondents’ understanding of occupational therapy practice in home
modifications
Respondents were asked a series of questions to establish their understanding of their role in the home modification process, and were asked to describe the purpose of a home modification, and to comment on their use of theoretical models and assessment tools in practice. The results of these questions are presented in the following sub-sections.
143 Purpose of a home modification
5.3.1 Findings
To examine respondents’ professional understanding of a home modification, they were asked, in an open ended question, to describe the purpose of modifying the home environment. To assist with the thematic analysis of these responses, NVivo 10 was used to identify the 25 most commonly used words by respondents and these words formed the initial codes. The result of this coding is presented in Table 13.
Word Count Similar Words
Person 105 individual, individuals, person, personal, persons, somebody, someone, someone’s
Independence 104 independence, independent, independence, independently, severe
Enable 75 enable, enables, enabling
Access 61 access, accessibility, accessible, accessing, additional, admission Living 59 dwelling, existing, experience, inhabitant, inhabitants, lives, living,
support, supported, supporting
Carers 52 carer, carers
Disabled 50 disabilities, disability, disabled, disables, impairments Allow 49 allow, appropriate, provide, providing
Safety 45 safely, safety
Housing 43 families, family, homes, house, houses, housing Environment 40 environment, environments
Assist 36 assist, assistance, assisting, assists, attending, support, supported, supporting
Possible 34 possible, potential
Improve 33 additional, better, improve, improved, improving
Adaptations 32 accommodation, adapt, adaptation, adaptations, adapting, adapts, alter, alteration, alterations
Reduce 31 reduce, reduced, reducing
Needs 30 demand, involved, needed, needs, require, required, requirements, 'wants'
Facilities 29 facilities, facility
Occupant 26 occupant, occupants, occupation, occupational, occupations, occupier, resident, residents
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Remain 26 continuance, continue, remain Client 25 client, clients, customer
Daily 25 daily, everyday
Activities 24 activities, activity, participate, participating, participation Increase 23 additional, increase, increased, increasing
Within 22 within
Table 13 Results of initial coding on commonly used words respondents use when describing the purpose of a home modification
Respondents’ answers were then re-read to identify the relationships between the ways that the coded words were used. This second tier of analysis identified five themes which represent how respondents understand the purpose of home modifications. The five themes are listed below, followed by brief description of the theme and then examples of responses.
Theme 1: As an intervention, a home modification improves functional health by enabling a person to safely or independently perform everyday activities of daily living (n=85). In theme 1, respondents discussed the purpose of a modification in terms of improving functional health by maximising the person’s safety or independence whilst performing or participating in activities of daily living. For example, respondents indicated they used a modification for improving independence and reducing the risk of injury whilst performing a personal care task. Interestingly, respondents also discussed the benefits of the home modification to the carer.
“To maximise independence and reduce risk in maintaining personal hygiene and/or to assist carers in supporting service users' in maintaining personal hygiene.” R10
“To improve a person's ability to carry out everyday activities of daily living where the current environment is stopping them or restricting their abilities.” R37
“Enabling a person to maintain their safety and manage any activity of daily living with as much independence as possible.” R51
Theme 2: A home modification improves well-being by giving the person opportunity to develop and/or choice and control over the activities they participate in (n=24)
145
In theme two, respondents discussed how home modifications provide the opportunity to improve concepts associated with well-being such as choice and control over the occupations they want or need to perform and participate in. For example, R11 discusses the home modification in terms of providing a child with the opportunity to “reach their full potential” in the occupations of their choice, whilst R4 discusses how the modification provides the person with the ability to choose and control where in the home environment they want to go.
“To maximise occupational performance and occupational opportunity for all the inhabitants of the dwelling.” R68
“For children there is also the purpose of enabling them to achieve their full potential with a view to being able to sustain their own chosen lifestyle whether this is in the parental home or in their own accommodation.” R11
“Modifications can also give more independence / choice and control over what that person can access with their own environment”. R4
Theme 3: A home modification improves functional health and wellbeing by either reducing or removing design and construction barriers in the environment, or by improving access to facilities in and around the home environment (n=50).
In this theme, respondents discussed how the design and construction of a modification actually improves functional health and well-being. The responses indicated two ways in which this is achieved, either through removing environmental barriers or by improving the access to the different facilities in the home. For example, in the quotes below from R1 and R33 they discuss how the features of the home which are preventing the person from being independent are changed to provide access to facilities. Likewise, R13 discusses the need to reduce the barrier in the home to enable the person to participate in the activity.
“To change the environment that is preventing a person from being independent.” R1
“Reducing environmental barriers to enable individuals to participate in necessary occupations.” R33
“To give clients access to essential facilities in their home.” R13
Theme 4: A home modification not only benefits the person but also reduces carer strain and health and social care costs to society (n=50).
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It was noticeable that respondents not only spoke of the benefit of the home modification for the older or disabled person but also the benefits to the carer. The main benefit appears to be associated with reducing the risk of physical injury or carer strain that might occur when the environment does not support them in their role. However, a number of respondents acknowledge the wider benefits to society of improving the home environment in terms of reducing formal health and social care costs, as can be seen in the response from R121.
“To reduce the level of care needed, to reduce the demand on carers caring for the person and assisting with activities of daily living.” R20
“The purpose of a housing modification is to create an environment that enables the service user to achieve functional ADL to the best of their abilities or to assist their carers to look after them in the safest and most effective manner.” R42
“To enable people to remain independent and safe within their home environment. The ultimate aim is to reduce the level of external support required, to avoid the need for rehousing or some form of residential care, and to allow the person to regain a degree of independent control over their life.” R121
Theme 5: The purpose of a home modification is influenced by the Housing Grants, Construction and Regeneration Act 1996 (n=6)
In a small number of answers, it is possible that the respondents’ understanding of the purpose of a home modification was being influenced by the Housing Grants, Construction and Regeneration Act (1996). Within this legislation the words ‘essential’, ‘necessary and appropriate’ and ‘reasonably practical’ are used to describe when a grant can be awarded and these have appeared in a few of the respondents’ answers to this question.
“To provide access to / use of required facilities for the individual(s) as far as is reasonably practicable and in relation to relevant legislation and eligibility criteria.” R77
“To maximise, re-able, enable, increase safety of the person with a disability and / or their carer(s) to meet essential needs and improve quality of life.” R82
“To enable residents to access use of essential facilities such as bathroom, bedroom etc, and / or to provide suitable facilities if basic provision does not meet their need.” R97
147 Discussion
Being able to articulate the purpose of an occupational therapy intervention is a professional and ethical duty (HCPS, 2013; COT, 2015) and an economic necessity when explaining the value of the intervention to those who purchase the services of occupational therapists (Atwal & Caldwell, 2003; Wilding, 2010). To date the purpose of home modifications has largely been defined by academics in this field of practice. The finding from the thematic analysis is important as the five themes potentially provide a definition based on the experience of practitioners who work in the field of practice. The definition which appears from the thematic analysis is:
‘Home modifications improve functional health by enabling a person to safety and independently perform activities of daily living. Furthermore, a home modification improves well-being by giving the person choice and control over the activities they want, need, or have to participate in. A home modification does this by either reducing or removing architectural barriers in the environment, thus improving access to facilities in and around the home. Home modifications not only benefit the person but can directly benefit the carer or indirectly benefit society by reducing the costs of health and social care.’
Whilst this definition broadly defines the purpose of a home modification, the majority of participants (n=85) associated the purpose of a home modification with independence and safety. Prior studies (Steward, 2000; Heywood, 2004; Aplin, 2013) have shown that where the focus of designing a home modification has been to improve safety and independence, this has resulted in practitioners not considering other important concepts associated with the design and construction of the home modification, such as aesthetics, and how the modification can change the meaning of home. In those prior studies, failure to consider these factors have resulted in dissatisfaction with the modification (Aplin, 2013), and have been a barrier to applying for a home modification in the first instance (Bridges et al., 2007).
Whilst conducting formal cost benefit analysis on home modifications is challenging (Bligh et al., 2016) the following quote demonstrates the cost value this respondent perceives that there is by reducing hospital admission and care costs through the installation of a home modification.
“…to reduce the risk of increased care packages or having to move into hospital or long-term care provisions such as foster placement, care home, residential setting (including schools). Housing
148
modifications can also reduce current care packages or allow someone to access their home environment more easily with reduced risks.” R89
A surprising finding was the small number of respondents who, when describing the purpose of a home modification, used words associated with the current legislation, specifically the Housing Grants, Construction, and Regeneration Act (1996). It is not possible to confirm a relationship between these respondents’ answers and the impact it has on their professional reasoning skills. However, in the review of the literature for this study, Fange et al. (2009) and Sakelleriou (2015b) both raised concerns that legislation was negatively impacting on occupational therapists’ ability to perform their role, particularly with regards to compromising the collaborative relationship and professional reasoning that underpins the profession. The following quote from respondent R43 appears to demonstrate this. The quote begins by suggesting that a suitable solution has to be framed in terms of what can be provided under the definition of the legislation. It appears that if the person identifies a solution that is not congruent with the legislation then the respondent labels this as a ‘wanted a home modification’ rather than a ‘needed a home modification’.
“To provide a suitable housing adaptation to meet the need to the disabled client according to the housing legislation - mandatory access to facilities within the property i.e. washing, kitchen, access, bedroom etc. The word need is very important as clients will often bring in 'wants' into the discussion.” R43
If home modifications are labelled by practitioners as ‘needed’ or ‘wanted’ in this way, then this might provide one explanation for the findings by Sapey (1995) and Heywood (2005). In both these studies research participants received the modification the occupational therapist had recommended, and not the one that the study participant reasoned was the appropriate solution. This resulted in the study participants being dissatisfied with the modification recommended by the occupational therapist.
Respondents use of and attitudes towards conceptual models in practice 5.3.2
Findings
From a pre-determined list, respondents were asked to indicate which conceptual model of practice influenced their professional practice. These results are shown in Chart 3 and they indicate 58% (n=78) of respondents stated that their professional practice was not
149
influenced by a specific theoretical model. Where a model of practice is influencing practice, the most frequent are the Canadian Model of Occupational Performance (Townend et al., 1997; 2002) n=16, followed by the Person Environment Occupation Model (Law, 1994) n=15.