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Hindawi Journal of Aging Research Volume 2018, Article ID 4904379, 13 pages https://doi.org/10.1155/2018/4904379 Research Article The Development of a Design and Construction Process Protocol to Support the Home Modification Process Delivered by Occupational Therapists 1 2 3 Rachel Russell , Marcus Ormerod, and Rita Newton School of Health Sciences, e University of Salford, Salford M6 6PU, UK School of the Built Environment, e University of Salford, Salford M5 4WT, UK School of Health Sciences, e University of Manchester, Manchester M13 9PL, UK Correspondence should be addressed to Rachel Russell; r.c.russell@salford.ac.uk Received 11 September 2017; Accepted 13 December 2017; Published 28 February 2018 Academic Editor: F. R. Ferraro Copyright © 2018 Rachel Russell et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Modifying the home environments of older people as they age in place is a well-established health and social care intervention. Using design and construction methods to redress any imbalance caused by the ageing process or disability within the home environment, occupational therapists are seen as the experts in this field of practice. However, the process used by occupational therapists when modifying home environments has been criticised for being disorganised and not founded on theoretical principles and concepts underpinning the profession. To address this issue, research was conducted to develop a design and construction process protocol specifically for home modifications. A three-stage approach was taken for the analysis of qualitative data generated from an online survey, completed by 135 occupational therapists in the UK. Using both the existing occupational therapy intervention process model and the design and construction process protocol as the theoretical frameworks, a 4-phase, 9-subphase design and construction process protocol for home modifications was developed. Overall, the study is innovative in developing the first process protocol for home modifications, potentially providing occupational therapists with a systematic and effective approach to the design and delivery of home modification services for older and disabled people. “structuralchangestoaperson’shomesotheycancontinueto 1. Introduction live and move, or be moved, safely” (p. 410) [8]. Occupational Current government policy within the UK [1] is encouraging therapists make an important contribution to the home the design and construction industry to build new main- modification process, as their professional skills in “problem stream housing that supports people to successfully age in solving, enablement, prevention and environmental adapta- placeandto reducethe architecturalbarriersprevious design tions” (p. 11) [9] are being used to help health and social care standards have caused since the majority of older and departments within local authorities deliver their legislative disabled people live in homes that are not designed to meet responsibilities for the assessment and provision of home their needs [2–4]. However, current policy recognises the modifications for older and disabled people. social and economic benefits of enabling older and disabled Despite the perceived positive role of the occupational people to remainin their ownhomes by making it a statutory therapist in this field of practice [10] and the fact that home obligation [5, 6] for the assessment and provision of social modifications improve the health and well-being of older care services to achieve this. Home modificationsare one such people [11–13], evidence suggests that some home modifi- service. Whilst home modifications can involve the removal cations fail to meet the client’s needs [14–16] and expectations of hazardous features, such as worn rugs, or changing the [10] and that failing to involve the client (who is usually the behaviour in how activities of daily living are performed [7], older person but may also be the caregiver or relative) in the home modification services in the UK focus on providing decision-making process is a further cause of dissatisfaction 2 Journal of Aging Research [17, 18]. Questions have also been raised about the complexity thecasestudysitesinvolvedintheoriginalresearchcontinued and coordination of the home modification process because of to use the GDCPP after the formal research project was concluded. thenumberofagenciesandprofessionalsinvolved[19–21],with the use of the analogy of a “patchwork of services,” which are relatively “unplanned and uncoordinated” in nature (p. 4) [20]. 3. The Need for an Occupational Therapy It is further suggested that people’s experience of the Design and Construction Process Protocol process and satisfaction with the home modification would improveifoccupationaltherapistshadagreaterunderstanding When providing interventions, the College of Occupational of their role [20, 22, 23], and the lack of available guidance and (erapy states that “any advice or intervention provided standardised assessment tools is seen as a contributing factor should be based upon the most recent evidence available, best [16, 21, 22, 24]. (is issue is further exacerbated by a lack of practice, or local/national guidelines and protocol” (p. 17) design and construction knowledge [8, 20, 25], leading to [36]. (e occupational therapy profession has a number of occupational therapists making the assumption that the generic process frameworks [37–39], and as with the design modification process is simple [26]. Interestingly, evidence and construction industry, these processes help occupational suggests that occupational therapists want a more standardised therapists to structure the evaluation, diagnosis, treatment, approach to the whole modification process [21] and that the and reevaluation phases of therapy. However, the occupa- profession should consider ways to amalgamate the occupa- tional therapy process is generic and applied to the full range tional therapy process into the wider design and construction of interventions such that there is no published process which process [22, 23, 27]. (us, given that occupational therapists makes visible the process required for housing modifications. use the principles of design and construction in interventions (is should be a concern for the profession as practitioners involving modifying the home environment in their everyday have an ethical and professional requirement to make visible practice, the aim of this study was to develop an occupational their practice such that they can demonstrate that the in- therapy design and construction protocol for modifying home terventions they are providing are effective and that the person environments. receiving the intervention is able to understand and consent to all aspects of the treatment that they are receiving [40, 41]. (e assessment for, and the identification of, what home 2. Learning from the Design and modifications are required is a complex part of occupational Construction Industry therapy practice, and practitioners use conceptual models as Interestingly, in the 1990s, the UK design and construction “an organising tool” to help structure and “make sense” of industry faced similar criticisms to those discussed above, this process (p. 57) [42]. (ere is general agreement in the and three key factors were identified [28]. (e first factor is literature [42–44] that the Person Environment Occupation the difficult nature of coordinating a building project re- (PEO) models are the most relevant conceptual model to quiringthe careful planning, management, and coordination practitioners in this field of practice. However, there has been of a number of phases and subphases [28] and coordinating criticism that the traditional PEO models [45–47] do not fully a large number of highly specialised professional groups who capture the concepts occupational therapists require to guide do not typically work alongside each other and only have effective home modification practice [48]. (e Occupational a broad understanding of each other’s role [29]. (e second (erapy Intervention Process Model [38] is used in the re- search reported here, and as such, these criticisms are factor is the flow of information through the various se- quential phases of the process [28] such that it was seen as addressed in three key ways. Firstly, the OTIPM [38] uses important that each professional group understood the value similar terms associated with the built environment literature of information they produced to the other professionals such as “required space,” “required tools,” and “required involved in the project and that they were aware of what actions” and similar terms used in the built environment [49] information needed to flow through to the next phase and when describing the space, equipment, and objects people use also the timing of their information such that subsequent to perform an activity. Secondly, unlike other PEO models phases were not delayed [30]. (irdly, the involvement of end [49], the OTIPM separately operationalises the process for users was identified, thus ensuring that information necessary delivering interventions. (irdly, as with GDCPP [34], the to design and construct a building to meet their needs and OTIPM[38]encouragesoccupationaltherapists nottoproceed requirements was appropriately captured throughout the to the next phase of the process until they have all the necessary project [31, 32]. (ese criticisms led to the development of the information to continue, thereby reducing the risk of planning generic design and construction process protocol (GDCPP) ineffective interventions. [33]. In describing the process, Cooper et al. [34] explain that Despite the professional [41] and ethical requirements [40] the GDCPP breaks down the design and construction process to make visible the core reasoning skills and process used into four phases, and within each phase, there are subphases; within occupational therapy professional practice within the each phase and each subphase are associated with specific UK, there are concerns [50, 51] that very few research studies actions, and these actions are linked to different elements of have evaluated or attempted to describe the home modifica- design and construction. Each phase should be complete tion process and make visible the practice involved. Protocols before moving on to the next phase. Whilst there have been have been used successfully to improve the interventions provided by occupational therapists, for example, to improve no longitudinal follow-up studies investigating the long-term benefits gained from using the GDCPP, it is reported [35] that the clinical reasoning of novice practitioners using a specific Journal of Aging Research 3 Table 1: Respondent inclusion criteria. assessment to identify appropriate interventions to reduce upper limb hypertonia [52]. (e purpose of this study, Inclusion criteria Rationale for criteria therefore, is to develop an occupational therapy design and Occupational (e study is interested in occupational construction process protocol specifically for home modifi- therapy therapy and the use of home modifications cations because protocols “. . . help clinicians focus on what is Involved in using For respondents to be able to comment of important, specify intervention procedures, delineate the home the home modification process, they need theoretical rationale behind treatment, and contribute to the modifications as to have relevant knowledge of using this as evolution of the intervention by explicating the reasoning an intervention an intervention process necessary to solve clinical dilemmas” (p. 712) [53]. Different countries use different terms for UK-based describing concepts within occupational therapy, so UK knowledge was important 4. Methodology A survey strategy [54] was used for this study so that the home modification processes used by occupational thera- separating the response statements into individual activities or actions performed by the respondents in their role and pistscould beunderstoodby analysingthe situationinwhich occupational therapists undertake the process of modifying matching responses to one of the three phases of the OTIPM the home environment. (e specific technique used to collect [38]. (ese three phases of the OTIPM [38] became the the survey data was an online questionnaire, as this approach separate themes for this step of the data analysis. When using provides an effective method of generating knowledge and the a directed content analysis, [59] states that it is important to most efficient way of delivering the survey to a larger sample “remember to stay grounded in the data and remain open to of respondents [54]. the possibility that, ultimately, the data and the framework may be incompatible” [59]. (erefore, codes not matched to (e questionnaires were designed to include both open and closed questions, capturing quantitative data about re- one of the three themes were reviewed. (e second stage of the data analysis involved con- spondent attitudes and experience of the home modification process and qualitative data to capture fact-based information. ceptualising the activities and actions of the respondents during the main phases of the occupational therapy process, Respondents were asked to consider their answers in relation to bathroom modifications as they are the most common as a home modification process. NVivo 10 software was used modification [55]. A pilot study involving five experienced to produce four separate code books. Each book represented occupational therapists was conducted [56] to ensure the one of the themes identified from Step 1 of the directed validityandreliabilityofthedatagenerated,aswellasensuring content analysis and contained the data coded under each that the questions could be understood by the respondents. theme. Once familiar with the content of each book, activities For the main study, purposeful sampling was chosen as an and actions in each code book were matched with similar actions and activities in each of the 10 subphases of the effective way to identify a sample of respondents with specific attributes necessary to generate data [57]. Inclusion criteria, GDCPP [33]. As with the previous stage of analysis, thematic codes not matched to the subphases were reviewed at the end alongside the rationale, are presented in Table 1. (e online questionnaire was advertised through the UK College of of the process. (e outcome of this stage of the analysis was Occupational (erapy monthly e-newsletter to all members a 4-phase, 10-subphase process used by the occupational (approximately 250 members) of the specialist section for therapist to design and construct home modification. housing. Whilst 232 questionnaires were received, only 135 A third stage of the analysis was required to create an met the inclusion criteria. Reasons for exclusion included embryonic home modification process protocol framework. the following: An iterative approach was required to generate the protocol, and a brief description of this process is given below. A (1) Respondent retired from practice framework was developed; along the top of the framework, (2) Respondent worked outside of the UK the headings were used from the 4 phases and 10 subphases (3) Respondent not a qualified occupational therapist of the occupational therapy design and construction process. Running down the far left-hand side were the following (4) Respondent’s main role no longer involved using principles taken from the GDCPP [33]: home modifications as an intervention (i) Description of the phase Data analysis involved three separate stages. Firstly, (ii) Key question a directed content analysis technique was used. Directed content analysis is a useful form of thematic analysis when (iii) Action needed at each phase validating or extending a conceptual theoretical framework, (iv) Outcome of the phase such as the occupational therapy process [58]. (e OTIPM (en, using the actions and activities described by re- [38] acted as a theoretical framework to analyse the data. Data generated from the question“describe your role inthe process spondents in the code books generated at the second stage of the data analysis, the framework was populated. Gaps in the of designing a bathroom modification” were downloaded into NVivo 10. Using the software, each statement from individual framework were populated by referring to An Occupational erapist’s Guide toHome Modification Practice [60] and the respondents was read and reread. Once familiar with the range of statements, the initial coding of the data involved researcher’s knowledge of this field of practice. To improve 4 Journal of Aging Research [33]. In these phases, respondents indicated a number of the trustworthiness of the data included in the framework, the principal researcher was challenged by 2 researchers not actions or tasks involved in analysing how the person was performing theactivityin theexisting environment aswell as involved in this stage of the data analysis and adjustments were made accordingly. professionally reasoning what the person required in the final design. (e themes “conduct an occupational perfor- mance analysis to identify the person(s) PETrequirements” 4.1.Step1Findings. During the thematic analysis, it became and “develop occupational-focused home modification goals evident that an additional phase not captured by the OTIPM and PET based on the person’s PET requirements” were [38] existed within the codes. (is additional phase occurred developed to capture these codes. Similarly, there were three between the assessment and the goal setting phase and the activities described in the GDCPP [33] where no similar intervention phase. Because the respondents performed activity could be found in the code books; thus, no data were a number of actions or tasks that were not associated with coded under the following themes: the initial assessment of occupational need and the setting of goals for the intervention, nor were they related to the in- (i) Outline feasibility tervention itself. Instead, respondents performed a series of (ii) Outline conceptual design activities associated with planning the intervention; thus, the (iii) Production information term “intervention planning phase” was developed to code these responses into a theme. (e findings of this analysis are presented in Table 3 with As an intervention, the home modification is not installed example of responses. by the occupational therapist; however, from the responses, it To be able to compare the subphases of the GDCPP [33] was evident that a number of occupational therapy practi- and the subphases of the home modification process, the tioners were involved in supporting the installation of the results are displayed in Table 4. (e four main phases of the modification. Firstly, their support appeared to be essential for GDCPP [33] were differentiated by colour. By doing this, it ensuring the health and safety of the person, for example, became evident where the lack of congruence occurs be- making the builder aware of any medical conditions which tween the four main phases of the GDCPP [33] and the four could be exacerbated by the construction methods being used main phases of the home modification process. As the aim of to install the modification, for instance, dust exacerbating the this stage of the analysis was to conceptualise the occupa- person’s respiratory condition. Secondly, some of the re- tional therapy practice as a design and construction process, spondents (n �13) indicated that they were involved in giving it was necessary to resolve the issue with the lack of con- adviceonthepositionofequipmentorinpurchasingspecialist gruence between the four main phases so that parallels equipment to be installed as part of the modification. (irdly, between the four main phases of the GDCPP [33] and the some respondents (n �9) indicated that they had a role in OTIPM [38] could be visualised, as illustrated in Table 4. providing the person with emotional support during the installation or acted as an intermediary if issues arose between 5. The Development of the Home Modification the person and the builder. (erefore, using the term “in- Process Protocol tervention implementation” makes distinct that the invention is not the final installed modification alone; it involves a series Step 3 involved the development of a single framework based of activities the occupational therapist is involved with during on the GDCPP [33] and the OTIPM [38]. Across the top of the phase of installing the intervention. Table 2 presents ex- the framework, the 9 subphases developed from Step 2 of the amples of responses coded under each of the phases of the analysis of the data were used to label the headings of in- OTIPM. dividual columns. Populating the framework with content was an iterative process. NVivo 10 software was used to create a code book for each individual subphase of the home 4.2.Step2Findings. In Step 2 of the data analysis, NVivo 10 modification process, with each book containing the written software was used to produce four separate code books. Each responses coded under each of the subphases. (e GDCPP book represented one of the themes identified from Step 1 of Book [33] and the OTIPM Manual [38] guided the devel- the analysis and contained responses coded under each opment of the content for the description of each phase, key theme. (ematic analysis was initially attempted by looking questions needing to be asked at each subphase, and the for similarities between activities in the four main phases of outcome of each subphase. As such, the framework has nine the GDCPP [33]. However, it became apparent that the subphases (0 to 8), and each of these is presented separately. activities within the four main phases of the GDCPP [33] were not congruent with the activities within the four main phases of the OTIPM [38]. To overcome this issue, the 5.1. Subphase 0. Subphase 0, shown in Table 5, has used the activities were coded using the descriptions of the subphase GDCPP principle that a prospective client may not want to of the GDCPP [33] looking for similarities in the responses proceed with a project following an initial discussion of their in each of the four code books. need with the building professional such that the purpose of Using the abovementioned approach to the analysis, it this subphase is to gather data on what has prompted the became evident that two additional phases not captured by person to contact the service and whether involvement from the GDCPP [33] existed in the responses. (ese two sub- an occupational therapist will improve the person’s health phases occurred between subphases 1 and 2 of the GDCPP and well-being. Journal of Aging Research 5 Table 2: Example of responses for the main phases of the OTIPM [38]. Main phase of Direct quote taken from different respondents the OTIPM [38] “Assessing with the person what their needs are in relation to home environment” (R2) “My role firstly involves an OTassessment which takes into account the goals of the individual as regards achieving Assessment and the best bathroom facility for them and/or their care requirements” (R48) goal setting “Carry out an assessment of need, and if the assessed need results in the provision of a bathroom adaptation, would proceed to the next phase of the adaptation process” (R63) “I work with the client and technician to agree on the best possible layout to meet a person’s long-term needs. (is is a joint agreement with client OT, technician and builders all giving input. However, it is my role to advice on installations that may be beneficial and that the client is not aware of existing” (R3) Intervention “Following a functional assessment of needs, my role is to design and plan the layout and facilities in the bathroom to planning meet the individual’s current to long-term needs” (R14) “Using a plan see if intended adaptation fits exploring options, i.e., shape dimensions how the client intends to use it” (R42) “Remaining available through alterations, for site visits and answering questions as and when they arise” (R10) Intervention “Communicating any special needs (e.g. re dust inhalation) to surveyor/contractor” (R56) implementation “Availability for consultation during the building work” (R72) “When work completed to ensure modifications are safe for client, that the work specified has been completed to a high standard and to ensure client completely happy. If not, to assist client to ensure all changes are made to ensure clients safety and ability to enjoy their new facility. Finally, there is a key role in evaluating the provision with the Reevaluation client and or care staff” (R6) “Visiting tenant once work completed to check suitability, demonstrate use of shower and other equipment and to check the adaptations meet the need” (R24) Table 3: Example responses for each of the subphases of the home modification process. Subphase Example of responses “Identifying what problems exist and either what the relevant parties wish to Demonstrate an occupational need within the achieve or providing information of what can be achieved (within public funding person-centred performance context but with acknowledgement of what is available outside of public funding)” (R83) Conceptualise the occupation need as identified “A thorough understanding of persons aspirations and their needs/wishes” (R6) by the person Conduct an occupational performance analysis “Do an initial assessment of the person and their environment looking at their to identify the person(s) PET requirements functional ability and/or the needs of their carer” (R46) Develop collaborative goal(s) and identify person, environment, and task (PET) “Following the assessment OTrecommendations discussed with the person” (R72) requirements for the home modification “I work with the client and technician to agree on the best possible layout to meet Conduct substantive feasibility study for a person’s long-term needs. (is is a joint agreement with client OT, technician and achieving the PET requirement (including builders all giving input. However, it is my role to advice on installations that may funding route) be beneficial and that the client is not aware of existing” (R3) Obtain agreement on the full detailed design of “Approval from service user then written options proposal, specification and CAD the home modification diagrams” (R8) Coordinate and support procurement of the “Referral to District Council or RSL for DFG/minor works funding” (R100) occupation-focused home modification Construct the occupation-focused home “Once work is on site, deal with any queries regarding change of layout due to modification unforeseen problems” (R57) “When work completed to ensure modifications are safe for client, that the work Conduct site visit to check the operation and specified has been completed to a high standard and to ensure client completely maintenance of the occupational-focused home happy. If not, to assist client to ensure all changes are made to ensure clients safety modification and ability to enjoy their new facility” (R6) A further principle of the GDCPP [33] is that the project practitioner may need to involve in later subphases of the manager is aware of which professionals should be involved process. in the process and when. (us, taking this concept and the Subphase 0 has also captured the OTIPM [38] concept of OTIPM [38] concept of identifying who else is involved in making the person aware of the limitations within the the person’s situation, subphase 0 gathers data on who the practitioner’s field of practice. It appeared to be important to 6 Journal of Aging Research Table 4: Conceptualising the occupational therapy home modification process as a design and construction process. Main phase Subphase of the Main phase Terms used in the of the Subphase Activity themes generated from coding home modification of the GDCPP [33] GDCPP [33] process OTIPM [33] Demonstrating Demonstrate an occupational need within 0 0 the need the person-centred performance context Conceptualise the need as identified by the 1 Conception of need 1 Preproject person Evaluation Conduct an occupational performance 2 Outline of feasibility analysis to identify the person(s) PET 2 requirements Develop collaborative goal(s) by identifying Substantive feasibility 3 the detailed PETdesign requirement for the 3 study home modification Modification Preproject Conduct substantive feasibility study for planning Outline conceptual 4 achieving the PET specification (including 4 design funding route) Full conceptual Obtain agreement on the full detailed Modification Preconstruction 5 5 design design of the home modifications planning Coordinate design, Coordinate and support procurement of the Modification Preconstruction 6 procurement, and full 6 occupation-focused home modification implementation financial authority Production Coordinate and support procurement of the Modification Construction 7 6 information occupation-focused home modification implementation Construct the occupation-focused home Modification Construction 8 Construction 7 modification implementation Conduct site visit to check the operation After Operation and 9 and maintenance of the occupational- 8 Reevaluation completion maintenance focused home modification ask this question at this phase, given the theme in the lit- designed to focus on safety and independence or what can erature and the data gathered from respondents, on the or cannot be funded by the practice setting. Instead, the influence departmental policies and resources have on the influence of funding arrangements is considered in sub- phase 4 and the feasibility study. Similarly, as the practi- role of the practitioner. As the GDCPP [33] is concerned with ensuring that all tioner builds a collaborative relationship with the person and new data provide insights into the person’s situation, information is available to support the next phase of the process, the outcome subphase 0 also ensures that the subphase 1 ensures that due consideration is given to the practitioner has all relevant information for the next phase, appropriateness of the intervention in providing the person in particular that the person has given consent. As consent to with the appropriate solution to improve their health and an assessment is an ethical and professional requirement, it well-being. appeared appropriate to include it in this phase so that when the person is first visited, they have already consented to 5.3. Subphase 2. Subphase 2, shown in Table 7, has been a visit and the start of the assessment process. influenced by the OTIPM [38] description of how practi- tioners should analyse occupational performance and participation since it is recommended that the practitioner 5.2.Subphase1. Subphase 1, shown in Table 6, captures the values the OTIPM [33] places on collaborative practice should initially observe the person performing or partici- through the occupational therapy process such that the pating in the occupation, identifying the strengths and person, in collaboration with the practitioner, identifies weaknesses in the person’s performance. Once the practi- the occupation(s) impacting upon their health and well- tioner has these data, the OTIPM [38] describes how the being. practitioner can then analyse the cause of the problem based Since the literature was critical of occupational therapists on the transaction of the person, environment, and task. focusing on safety and function and identifying the need based (is is a two-pronged approach to analysing performance on eligibility criteria, the outcome of subphase 1 assists the and participation because it prevents the occupational therapist making assumptions about the cause of the practitioner to identify what occupation they need to observe in the next subphase of the process. (is reflects ethical problem. (e conceptual model developed as part of the OTIPM [38] guides the type of person, environment, and practice, as the person is not arbitrarily made to perform unnecessary activities based on home-grown assessments occupation data the practitioner needs to collect. It should Journal of Aging Research 7 Table 5: Subphase 0 of home modification process protocol. Table 7: Subphase 2 of home modification process protocol. Assessment Assessment Subphase 0 Subphase 2 phase phase Demonstrate an occupational need within the Identify the person, environment, and task Description person-centred performance context Description elements impacting on occupational performance What is the situation that has prompted contact with the occupational therapist/service? How does the transaction between the person, Is an occupation-focused home modification environment, andtask (PET) factors impacton intervention appropriate for the situation? Key questions occupational performance? Key questions Is the person aware of the limitation in this Should a home modification approach be practice setting? taken? Should a home modification approach be Identify the actions, within the occupation(s), taken? the person(s) does not perform effectively Identity the context of the situation Identify actions, within the occupation(s), the Identify who (persons) is involved in the person(s) does perform effectively Action situation Identify the elements of the person, Identify the tasks involved in the situation environment, and task (PET) [38] that are Identify how resources and other limitations affecting the person(s) occupational Action within the practice setting may affect the performance situation Occupational performance analysis completed Identify how a collaborative relationship with and effective and ineffective elements of the occupational therapist/service could impact performance documented on the situation PET element(s) causing effective or ineffective Referral accepted/declined Outcomes occupational performance documented Key referral (situational) information PETinformationneeded to supportsubphase4 documented documented Outcomes Person(s) aware of limitations within the OT’s Provide advice including referral to alternative field of practice, that is, funding criteria for services home modification Consent to assessment documented 5.4. Subphase 3. Goals are an important part of the occu- pational therapy process since they provide the benchmark Table 6: Subphase 1 of home modification process protocol. on which the occupational therapist and person establish if Assessment the intervention has been successful. (us, the purpose of Subphase 1 phase subphase 3, shown in Table 8, is to identify those goals. Conceptualise the occupational need as GiventhatoneoftheprinciplesoftheGDCPP[33]istocollect Description identified by the person(s) data relevant for the success of later subphases, subphase 3 What is the reported occupation(s) the makes the distinction as to how the modification is improving person(s) needs/wants to address through an health and well-being and whether it is being designed to Key questions occupation-focused home modification? restore, maintain, or acquire performance/participation in the Should a home modification approach be person’s occupation. (us, this question prompts the prac- taken? titioner to consider what impact this decision would have on Identify the specific occupation(s) the person(s) the final subphase of the process. wants/needs/has to do Identify the person(s) occupational priorities Action Identify occupations that cannot be addressed 5.5.Subphase4. (e purpose of subphase 4, shown in Table through occupation-focused home modification intervention 9, is to conduct a feasibility study to identify how the home can be modified to improve the person’s performance or Identify the person(s) occupational priorities participation in the occupation for which it was necessary Outcome Provide advice including referral to alternative services to ensure that the protocol could accommodate a range of regional, policy, and regulatory differences between practice settings. To achieve this, the principles of the be noted that the OTIPM [38] uses the term “task” and not GDCPP [33] were used to develop the question of how “occupation” in the conceptual model, thereby acknowl- contextual issues within the practice setting will influence edging that a practitioner does not objectively observe an the choice of design. Similarly, it was important to ensure occupation; they observe the task part of the transaction that design decisions were made explicit to the person and between the person and the environment. (is is because documented, thus overcoming the difficulty of people not only the person can experience an occupation, since it only always being aware as to why certain decisions have been has meaning and value to them. made. 8 Journal of Aging Research Table 8: Subphase 3 of home modification process protocol. Table 9: Subphase 4 of home modification process protocol. Intervention Intervention Subphase 3 Subphase 4 planning phase planning phase Develop collaborative goal(s) to identify the Conduct a substantive feasibility study for Description detailed PETdesign requirement for the home Description achieving the PET requirements (including modification funding route) Is the person(s) goal(s) for the modification to What design options are there for meeting the restore their occupational PET requirements? performance/participation? What other factors in the person’s occupational maintain their occupational Key questions context will affect the choice of design solutions? performance/participation? Does the design proposal meet the PET Key questions develop their skills or role to perform or requirements outlined in subphase 3? participate in a new occupation? Should a home modification approach be taken? What are the detailed PETdesign requirements Identify that the design has addressed all the for achieving the collaborative goals? requirements identified in subphase 3 Should a home modification approach be Identify that the design meets any other taken? occupational performance context requirements Identify, with the person(s), if the goals for the Identify any practice setting contextual issues home modification are that will influence the person(s) choice of design Actions restoring their occupational solution performance/participation? Identify any potential built environment issues, maintaining their occupational in the existing space, that will impact on the PET performance/participation? requirements being accommodated developing their skills or role to perform or Identify funding requirements for the home participate in a new occupation? modification Identify, with the person(s), how the Professional reasoning on the modification abovementioned approach will impact on the design solution process Actions evaluation phases Document any issues related to the practice Identify the specific “person factors/body Outcomes setting or built environment that prevent the functions” design requirements optimum design solution being provided Identify the specific “environmental” design (e specification related to space, space layout, requirements and tools documented Identify the specific “task” design requirements Identify any occupations(s) that cannot be addressed through an occupation-focused Table 10: Subphase 5 of home modification process protocol. home modification Intervention Subphase 5 Person(s) has collaborated on the goals of the planning phase home modification Obtain agreement on the full detailed design Goals for home modification documented Description and specification of the home modification PETdesign requirements to achieve the goal(s) Outcomes Does the full detailed design provide the documented solution to address the occupational Reablement, rehabilitation, and/or training performance requirements of the person? requirements following the completion of the Do the detailed design plans and specifications home modification documented Key questions provide the person with the information they need to give informed consent? Should a home modification approach be taken? 5.6. Subphase 5. (e development of the content from subphase 5, shown in Table 10, arose from the professional Ensure that the person(s) understands how the design solution addresses their occupational and ethical requirement of practitioners needing to ensure performance requirements that the person has a full understanding of the intervention Identify how any unmet requirements will so that they are able to give informed consent to proceed Actions impact on the occupational performance of the with the intervention, and the questions make overt the need modification for the person to have a full understanding of the design Confirm that the person(s) agrees to proceed before giving informed consent to proceed with the with the design solution intervention. Outcomes Informed consent documented One of the principles of the GDCPP [33] is that it provides an audit trail of the reason why decisions were made at particular subphases of the process. (us, sub- and it makes the information readily available if the phase 5 enables the occupational therapist and person to outcomes of this subphase, or other subphases, are called be accountable for the decisions made during the process, into question. Journal of Aging Research 9 Table 11: Subphase 6 of home modification process protocol. Table 12: Subphase 7 of home modification process protocol. Intervention Intervention implementation Subphase 6 implementation Subphase 7 phase phase Coordinate and support procurement of the Description Construct the home modification Description occupation-focused home modification Is the appropriate support being provided to What information and action are required to the person(s) and building professional Key questions procure the home modification? during the construction phase of the home modification? Key questions Has all the information been obtained for the builder/contractor/others to construct the Provide ongoing support during the home modification? construction of the home modification Identify and communicate information Actions Provide and/or supply tools not part of the required for the procurement of the home construction process modification Provide advice on final positioning of tools Identity and communicate the information Outcomes Modification completed required for the builder/contractor/others to Actions proceed with the construction of the home modification Table 13: Subphase 8 of home modification process protocol. Identify and communicate what ongoing Evaluation support will be required of the occupational Subphase 8 phase therapist/service during construction phase Conduct site visit to check the operation and Funding application/support completed Description maintenance of the occupation-focused home Plans, specifications, product information, modification and health and safety information provided to the builder and/or those involved in Is the home modification operating in the way Outcomes construction of the modification it is intended to? Agree with person and builder support being Does the home modification perform in the Key questions provided by the occupational therapist during way that achieves the goals and requirements construction identified in subphase 3? What can we learn from the process? Provide reablement, rehabilitation, and/or training to enable the use of the modification 5.7. Subphase 6. As with subphase 5, it was necessary to Conduct reevaluation following completion of allow the questions to reflect the different ways modifica- the home modification and compare with tions are funded and for the building professionals to have Actions subphase 2 appropriate information to help them understand why the Provide training on the maintenance of the specific layout and requirement contained in the design plan home modification are important in achieving the person’s goals. (erefore, Complete professional evaluation of the subphase6,Table11,placesadutyontheoccupationaltherapist intervention and what can be learned to provide this information, thereby improving commu- Complete and document the reablement, nication. Also, at subphase 6, the occupational therapist is rehabilitation, and/or training provided no longer given the option to consider if a home modifi- Person(s) provided with information and cation approach should be taken because issues that could documentation needed to manage the home make a home modification inappropriate would have been modification Person(s) satisfied with the performance of the identified by the person and occupational therapist earlier Outcomes modification. Feedback documented in the process. Occupational therapist satisfied with the performance of the modification completed. 5.8.Subphase7. By using the principles of the GDCPP [33], Outcome documented subphase 7, shown in Table 12, reflects the tasks identified by Modification resolves the occupational need identified in subphase 3. Case closed respondents in the questionnaire, where their involvement was required to ensure that the person and builder were both supported during the physical construction phase of the modification. construction process. (e content of subphase 8 was Subphase 7 also ensures that the practitioner provides any influenced by the requirement a number of respondents specialist equipment that is required once the modification is identified in ensuring that the standard of workmanship installed and which could prevent the final modification from met the standards expected from the housing authority. In being used immediately by the person if not provided. the GDCPP [33], the final subphase ensures that the build- ing is handed over ensuring that the end users have an 5.9. Subphase 8. Subphase 8, shown in Table 13, is an im- understanding of how the building operates and needs to portant part of the occupational therapy design and be maintained; thus, this section ensures that the person has 10 Journal of Aging Research is forwarded to the District Council & HIA or Housing a similar understanding in terms of the modification. To capture concepts associated with the OTIPM process [38] and Association to begin the DFG process. I provide technical diagrams and guidelines for the adaptations to ensure the occupational therapy process in general, the questionsand outcomes of subphase 8 reflect the need to evaluate whether they can best meet the client’s needs as well as completing the goals identified in the earlier subphases have been joint site visits with technical officers if required. Once the achieved. Also, subphase 8 provides opportunity for the modification is complete, I am involved with signing off occupational therapist to reflect on their practice. the work. I am also responsible, if relevant, to obtain quotes. (R29) 6. Discussion (e actions of respondent R29 may not directly lead to As a problem-solving profession, the occupational therapy a poorly designed modification, but previous findings [64–66] have noted how departmental policies enacted by occupa- process provides the logical route that the practitioner should follow in order to provide effective interventions [61] such tionaltherapistshavebeenassociatedwithdissatisfactionwith the modification. (us, this finding raises the question as to that practitioners are able to operationalise their professional practice [62]. From the findings of Step 1 of the data analysis, whether practitioners are aware of how departmental struc- it appears that the occupational therapy process was assisting tures and guidance influence their professional practice and respondents to articulate their role in home modifications. the design options presented to the person. Again, this is an For example, the quotes from R6 and R56, presented in important question to answer, given the professional and “Findings” (although their answers differed considerably in ethical responsibility professionals have in ensuring that the terms of the detail provided by each respondent) still provide intervention they provide has been fully explained and ex- evidence of assessment, goal setting, and intervention phases, plored with the person, so the occupational therapist needs to and in the case of R6, an evaluation phase. be able to describe to the person how the intervention they are providing is being influenced by the practice setting. (e thematic analysis also raised theoretical challenges about what constitutes an intervention? (e intervention has Another important finding from the second stage of the analysis was the use of the term “assessment of need” in been traditionally viewed as the completed home modifica- tion [8, 63]. However, it is the skills and knowledge of the which respondents used their professional reasoning skills to occupational therapist during all aspects of the occupational identify occupations (activity) the person is having difficulty therapy process that are essential in the final design and performing or participating in, identifying and analysing performance of the modification, and this raises the question why the person is having difficulty, and analysing and as to whether the occupational therapy profession should identifying if a home modification will address the occu- place greater emphasis on the process being the intervention pational need. From the data collected, it is not possible to rather than the completed modification. Indeed, if the process establish whether in everyday practice respondents make becomes the intervention, then it would be more evident as to a distinction between the different types of professional reasoning necessary to support each aspect involved in the what the intervention is and what training is required to gain theskillstocarryouttheintervention.Bydevelopingoutcome “assessment of need” and what the consequence might be if they do not make the distinction. However, given that one measures that evaluate the process as the intervention, it also allows practitioners to identify which phases of the inter- principle of the GDCPP [33] is to ensure that, where possible, vention were more or less effective and how the process has a subphase does not progress to the next phase until the contributed to the person’s health and well-being. outcome of the previous phase is achieved, the research It has been possible to use the OTIPM [38] and GDCPP suggests that occupational therapists are prematurely pro- [33] to describe the occupational therapy process used by gressing through the process without all relevant data being respondents in this area of practice. However, the outcome collected and analysing as to how it might impact on the subsequent phases. If this is the case, then a process protocol of this does not reflect the actual practice described by respondents, and it appears to differ in one important for home modifications may reduce the risk of this occurring. way, namely, the way respondents combine departmental processes with the occupational therapy process. As an 7. Conclusion example, it can be seen that respondent R29 using both phrases that are associated with the occupational therapy (e purpose of the study was to develop a home modification process (words in red) and the phrases that seem to suggest process protocol by conceptualising the occupational therapy the influence of the systems, structures, and policies within practice involved in home modifications as a design and the respondent’s practice setting (words in blue). construction process, and a number of conclusions can be drawn. Firstly, with data from the questionnaire and guided by As an OT I complete an overview assessment with the the OTIPM [38], it was possible to both visualise and describe service user in their home environment to identify their thisprocess.Whilstinterventionsinvolvinghomemodifications needs. To address these assessed needs (according to the can be described through the occupational therapy process, it FACS criteria), I may be required to provide adaptive was interesting to note that practitioners have an important role equipment and in some cases recommend adaptations. in planning the design of the intervention. Furthermore, the If adaptations are required, I complete a referral for DFG term “intervention implementation” better describes the in- for adaptations which, following my Manager’s approval, volvement of the occupational therapist as they are not directly Journal of Aging Research 11 from this research have shown that each phase of the responsible for the installation of the intervention themselves. (us, the term “intervention implementation” acknowledges protocol is important because the outcomes from each phase can ultimately influence the final performance of, that installing a home modification is a dynamic process and one that the practitioner works with building professionals to and satisfaction with, the modification. (erefore, this achieve. raises the question as to whether the home modification Secondly, by using the occupational therapy process for process is what practitioners should be defining as their home modifications, it was then possible to use the GDCPP intervention? [33] to conceptualise the process as a home modification as Crucially, the necessary skills and knowledge to design four main phases based on the OTIPM [38] and 9 subphases and construct a home modification are not taught in detail based on the GDCPP [33]. (irdly, using the principles of or depth at undergraduate level within occupational the GDCPP [33], it was possible to create a framework therapy education. Once qualified, there are training op- portunities for practitioners, but these tend to be based on for the protocol, and by using an iterative process, it was possible to populate the content of this framework, which the knowledge and skills required to design a particular type of modification or to design a modification for then became the home modification process protocol. (is iterative process was an important part of developing the a particular health condition or disability. Building the protocol because it allowed for the development of the necessary knowledge of the design and construction pro- content based on a conceptual model of practice and for cess should therefore be reviewed within undergraduate issues identified in the literature to be addressed. (us, the education. home modification process protocol potentially should Finally, there is a need to consider how the home mod- ification process protocol could be implemented beyond (1) provide a systematic approach to the process of England, which was the boundary of the research reported modifying the home; here. Home modification is a complex area of practice, and (2) ensure that ethical and professional practice is fol- there is a need to find ways to implement systematic as- lowed by enabling occupational therapists to verbalise sessment, intervention, and evaluation strategies within oc- and visualise their role in the process; reduce the cupational therapy practice [67] (e challenge for further complexity of the current process by identifying the research is that it is difficult for the process to be standardised key questions, actions, and outcome of each phase; as each country provides and funds home modifications in different ways as well as design standards and regulations also (3) improve the effectiveness and efficiency of practice being different in each country [68]. by ensuring that practitioners collect the right in- formation, at the right time; (4) ensure that the person has choice and control through Conflicts of Interest their involvement in all phases of the process; (e authors declare that there are no conflicts of interest (5) guide professional reasoning based on a conceptual regarding the publication of this paper. model of practice; (6) ensure consistency of occupational therapy practice Acknowledgments by accommodating regional, legislative, and regu- latory differences between practice settings; (is study is based on a doctoral thesis, which was supported (7) ensure that financial constraints and other contex- by the UK Engineering and Physical Sciences Research tual issues within practice become a design con- Council, “Russell, R.C., 2016. (e development of a design sideration and not a barrier for accessing funding for and construction process protocol to support occupational a modification. therapists in delivering effective home modifications, Doctoral (esis, University of Salford, UK” [69]. Whilst home modifiications have been a traditional area of practice for occupational therapists, the home modification process protocol is the first time this practice been described as References an occupational therapy design and constuction process. 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