X CICLO Proyecto Empresarial

he  says,  “a  globally  implemented  statistical,  clinical  and  scientific  research   tool  -­  an  international  classification  -­  as  well  as  a  conceptualisation  of   function  and  disability”.    The  current  version  of  the  World  Health  

Organization’s  (WHO,  2001)  ICF  (Figure  5)  combines  the  medical  and  social   models  and  builds  on  the  foundations  of  the  biopsychosocial  model,  

developed  by  George  Engel  in  1977.    

Figure  5:  Conceptual  model  of  the  International  Classification  of  Functioning,   Disability  and  Health  (WHO,  2001)  

In  essence,  the  ICF  provides  a  comprehensive  description  of  a  health-­related   state.    It  comprises  two  parts,  each  with  two  components  (in  brackets):  

namely  part  1:  functioning  and  disability  (body  functions  and  structures;;   activities  and  participation)  and  part  2:  contextual  factors  (environmental  and   personal)  (WHO,  2001).    Each  component  can  be  expressed  in  both  positive   and  negative  terms  with  functioning  being  the  umbrella  term  encompassing   all  body  functions,  activities  and  participation  versus  disability,  which  is  the   counterpart  umbrella  term  for  impairments  (a  problem  in  body  structure  or   function  such  as  a  significant  deviation  or  loss),  activity  limitations  (execution   of  a  task  or  action)  or  participation  restriction  (involvement  in  life  situations)   WHO  (2001).    An  important  point  in  relation  to  contextual  factors  is  the   influence  on  functioning  and  disability  with  environmental  factors  being   external  to  the  person  and  personal  factors  internal  (Welch  Saleeby,  2011).     Environmental  factors  encompass  physical,  social  and  attitudinal  

considerations,  more  specifically,  individual  elements  (physical  and  material   features  of  the  environment  and  direct  contact  with  others)  and  societal   elements  (formal  and  informal  social  structures,  e.g.  work,  rules,  attitudes)   (WHO,  2001).    Moreover,  the  ICF  codes  environmental  factors  as  facilitators   or  barriers  which  in  turn  impact  on  an  individual’s  level  of  functioning.    

Personal  factors  pertain  to  the  person’s  background  or  demographic   considerations  (age  and  gender  for  example),  lifestyle  and  coping  

mechanisms  (Welch  Saleeby,  2011).    As  Figure  5  shows,  the  ICF  clearly   illustrates  the  dynamic  interaction  between  all  components  thus  illustrating   the  inherent  complexity  of  disability  as  a  lived  experience.    Furthermore,  the   ICF  captures  the  interplay  of  a  number  of  elements  which  in  turn  impact  on   the  identified  health  condition  and  the  extent  to  which  activities  and  

participation  enable  the  person  to  function  in  terms  of  what  they  need  and   want  to  do.    The  ICF  coding  for  activities  and  participation  is  based  on  “a   causal  model  of  disablement”  (Chapireau,  2005:309)  meaning  that  the   environment  impacts  on  the  difference  between  ability  and  performance.     This  therefore  is  a  critical  component.  

The  ICF  has  shifted  from  that  of  disease  consequence  to  an  emphasis  on   neutral  components  of  health  (WHO,  2001);;  however,  Bickenbach  (2012)   cautions  that  the  arrows  within  the  model  (Figure  5)  must  not  be  interpreted   as  the  components  being  causal  or  temporally  sequenced.    Instead,  the  ICF   is  etiologically  neutral  in  that,  with  few  exceptions,  “there  are  no  predictable   correlations  between  health  conditions  and  aspects  of  disablement”  

(Bickenbach  et  al.,  1999:1184).    This  is  also  reflected  in  the  ICF’s  ethos  of   universalism  as  functioning  and  disability  are  not  dichotomous,  they  are   continuous  -­  reflecting  decrements  of  functioning  in  the  context  of  the  lived   experience  of  the  health-­related  state.        

Bickenbach  et  al.  (1999)  refer  to  the  concept  of  positive  freedom  and  

emphasise  that  participation  encompasses  enacting  social  roles  and  lifestyle   choice.    These  can  be  compromised  for  people  with  a  disability  if  resources   and  opportunities  are  not  provided.    On  the  theme  of  participation  and  in  the   context  of  the  ICF,  Baylies  (2002:729)  states  that  it  “represents  rights,  

and  physical  through  which  disability  is  contextualised”.    Here,  she  pinpoints   the  notion  of  disability  as  a  social  construction,  influenced  by  the  

environment.    

The  ICF  is  not  without  its  critics.    Arvidsson,  Granlund  and  Thyberg  (2015)   reviewed  16  studies  and  concluded  the  variable  use  of  the  terms  activity  and   participation.    Inconsistent  use  of  the  ICF  principles,  they  caution,  is  

confusing  and  thus  challenging  in  relation  to  sharing  of  knowledge  across   different  disciplines.    Similarly,  Bickenbach  (2012)  argues  that  activity  and   participation  are  accorded  the  same  categories  in  the  ICF  yet  although  given   different  definitions,  on  a  conceptual  level,  the  distinction  is  unclear.      

Terzi  (2005a)  argues  that,  unlike  the  capability  approach,  the  ICF  does  not   consider  matters  of  justice  for  people  with  a  disability  and  Chapireau  (2005)   asserts  that  it  places  more  of  an  emphasis  on  understanding  the  impact  of   the  physical  environment  on  functioning  than  it  does  of  the  societal  

environment.    I  disagree  with  both  Terzi  and  Chapireau.    For  the  purposes  of   my  study  the  ICF  serves  as  a  helpful  and  descriptive  framework  for  situating   students  with  a  disability  in  the  context  of  their  practice  placement  

experiences.    In  other  words,  it  can  be  used  as  a  tool  for  describing  details  of   the  person’s  abilities  and  challenges  experienced  in  the  context  of  their  lived   experiences.    The  ICF  includes  a  broad  spectrum  of  body  functions  and   structures  and  activity  and  participation  domains,  thus  truly  embodying   flexibility  in  consideration  of  the  diversity  of  people’s  lived  experiences.    Of   note,  the  ICF  will  not  reduce  stigma  but  can  be  used  to  highlight  areas  for   action.    Furthermore  I  argue  that  through  familiarisation  with  the  ICF  

framework,  it  can  be  used  to  communicate  with  other  educational  players  in   practice  education  to  illustrate  what  roles  they  can  play  in  reducing  obstacles   and  providing  support  for  students  with  a  disability.      

Thinking  about  impairment,  it  is  a  part  of  disability  but  having  an  impairment   does  not  necessarily  lead  to  activity  limitation  or  participation  restriction.    This   illustrates  the  importance  of  being  aware  of  potential  misconceptions  

disability  and  actual  abilities  which  may  on  occasion  be  detrimental,  for   example,  reinforcing  stereotypical,  negative  views  of  disability.    Table  1   illustrates  my  argument  in  context  regarding  four  of  the  components  of  the   ICF  and  the  dichotomy  between  two  different  types  of  disability  -­  deafness   and  past  history  of  mental  health.  The  WHO  (2002)  used  a  similar  table  and  I   adapted  this  idea  by  adding  the  fifth  column  to  illustrate  a  holistic  overview  of   the  two  disabilities.    The  second  entry  on  mental  health  is  based  on  the  WHO   (2002:17)  table  but  amended  here  for  brevity.    Note,  a  more  detailed  

application  of  the  ICF  in  the  context  of  my  study  findings  is  provided  in   Chapter  5.    

Table  1:  Using  the  ICF  (WHO,  2002:17)  to  illustrate  the  difference  between   two  disability  types,  adapted  by  Jane  M  Hibberd      

HEALTH  

CONDITION FUNCTIONS  &  BODY   STRUCTURES   (impairment)

ACTIVITY  

(limitation) PARTICIPATION  (restriction) CONTEXTUAL  FACTORS

Deafness Most  nerve  cells   in  ear  no  longer   functioning

Unable  to  use   standard   landline  phone

Unable  to  make   or  receive   telephone  calls   independently Environmental:   unawareness  of   specialised   technology  to   enable   telephone  use       Personal:  now   living  alone,   needs  to  be  able   to  use  telephone   independently

Past  history  of   mental  health  

None None Denied  

employment  due   to  employers’   prejudice   Environmental:   attitude  of   interview  panel   unhelpful     Personal:   plummeting  low   mood  as  a  result   of  denied  

employment  

2.1.11  ICF  and  capability  approach  convergences  and  divergences