Professional development enhances the occupational therapy work environment.
Abstract: Continuing professional development requires robust support mechanisms to maximise opportunities for the dissemination of best practice and to ensure sustainability. Accordingly, occupational therapists in a county-wide mental health service created a practice development adviser post and embarked on an academic partnership to support the delivery of evidence-based practice. Professional development surveys were then undertaken in 2005 and 2007 to evaluate the changes to the work environment. These demonstrated that the perceived pressures on standards of work (for example, finite resources and generic role demands) were offset by professional supervision, contact with other occupational therapists and having an occupation-focused model of practice.

Key words: Mental health, work environment, practice development.
Article Type: Report
Subject: Work environment (Management)
Occupational therapists (Practice)
Professional development (Methods)
Authors: Parkinson, Sue
Lowe, Claire
Keys, Katie
Pub Date: 10/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2010 Source Volume: 73 Source Issue: 10
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 240098083
Full Text: Introduction

This paper describes a service evaluation undertaken in a county-wide mental health service to evaluate the impact of strategic practice development initiatives. These hinged on the creation of a Practice Development Adviser (PDA) post to coordinate the professional development of occupational therapists. In turn, the PDA role was underpinned by a pivotal academic partnership, designed to enhance research capacity by establishing and delivering evidence-based practice.

Context

According to the Department of Health (DH 1998), continuing professional development (CPD) is the process by which lifelong learning is maintained, enabling practitioners to develop their full potential in meeting service users' needs. It is regarded as having a crucial role in clinical effectiveness and in delivering patient-centred care (DH 2001) and has been embraced by the College of Occupational Therapists (COT 2005, 2007) and the Health Professions Council (2008) as an integral component of professional conduct for maintaining registration (Plastow and Boyes 2006). In addition to encouraging CPD, national strategies have been built to guide its implementation. These include the strategy for occupational therapists in mental health services (COT 2006), which sets targets for workforce development and recognises the key role of clinical leadership in advancing clinical excellence (DH 2000).

If CPD is to be effective, then leaders must inculcate the belief that change can happen (Dzik-Jurasz 2006) and the gap between theory and practice must be overcome (Kielhofner 2002, Forsyth et al 2005) through the use of innovative posts and partnership working (COT 2002). This view is supported by Jones et al (2005) and Dzik-Juasz (2006), who advocate action learning; Stevens and Roper (2004) and Crist et al (2005), who describe partnerships between academia and practice; and Taylor et al (2002), Kielhofner (2002, 2004, 2008) and Forsyth et al (2005), who call for scholarships of practice. Their shared concern is to build sustainable change with realistic expectations, where theoretical knowledge is tailored to the real needs of practice settings (Khomeiran et al 2006). Such ideals require robust infrastructures:

* Providing opportunities for focused and cohesive research on a large scale (Bannigan et al 2007)

* Allowing group members to support and challenge one another (Dzik-Jurasz 2006)

* Disseminating evidence-based practice (Kitson and Currie 1996).

A professional development infrastructure may be composed of local networks (DH 2001), with uniprofessional groups capable of strengthening 'professional identity and confidence in specialist roles' (Plastow and Boyes 2006, p328). Crucially, however, it must be guided by business plans (Stevens and Roper 2004) and dissemination strategies with procedures in place to measure effectiveness (Kitson and Currie 1996). Yet the hectic pace of many workplaces restricts time for planning, networking and reflection, resulting in unresolved issues becoming ever more challenging (Dzik-Jurasz 2006). Unsurprisingly, this leads to many practice innovations being small scale and lacking in appropriate supports (Kitson and Currie 1996, Higher Education Funding Council for England 2001).

Alsop (2002) noted that workplaces need to provide opportunities to support CPD. Work environments that are unsupportive will have an impact on the health of staff (Kreisburg and Fry 2008) and staff retention (Baumann et al 2001) and, thereby, the quality of care for service users (Kramer and Schmalenberg 2008). It is therefore the duty of managers to reduce stress by promoting healthier workplaces (World Health Organisation 1998) and creating high quality learning environments with the optimum balance of challenge and support (Khomeiran et al 2006). This investment is warranted (Lavoie-Trembelay et al 2005) in order to counteract continuing demands to restructure the health service (Brabant et al 2007). First of all, however, one should conduct a baseline assessment of the environment, identifying the structures and best practices that already exist (Kramer and Schmalenberg 2008).

Environmental analysis and adaptation are considered core skills for occupational therapists (Duncan 2006) because the environment is key to facilitating occupational change (Kielhofner 2008). Specifically:

Such analysis can be assisted by occupational models, which provide structured assessments and taxonomies to classify the environment (Duncan 2006).

Practice evaluation

A full-time occupational therapy Practice Development Adviser (PDA) post for Derbyshire Mental Health Services was recruited to in January 2005. In preparation for a scholarship of practice with the United Kingdom Centre for Outcomes Research and Education (UK CORE) due to be launched in June of that year, the PDA undertook a survey of how the work environment affected practice development. The survey was repeated in 2007 to evaluate the impact of practice development initiatives that were implemented by the PDA, with guidance from UK CORE.

Aims

* To conduct a baseline assessment of the work environment

* To identify best practices and challenges for professional development

* To determine whether professional development initiatives improve the work environment.

Survey tool

It was decided to adapt the Work Environment Impact Scale (WEIS) (Moore-Corner et al 1998). This is a semi-structured interview based on the Model of Human Occupation (MOHO), which is the most widely used occupation-focused model (Kielhofner 2008). Modifications to assessments risk affecting validity and reliability, but were carried out in order to refine the number of items assessed (Table 1).

2005: Ten of the 17 WEIS items were selected in order to reduce the time taken to complete the survey. These were then modified so that:

* 'Appeal of work tasks' was broadened to 'Appeal of profession'

* 'Meaning of objects' focused specifically on 'Meaning of professional model'

* 'Work group membership' shifted to 'Professional links'

* 'Architecture/arrangement' and 'Properties of objects' were subsumed under the heading 'Physical resources'.

The item relating to 'Work role style' was included but discontinued due to a lack of variation in the answers given by participants, who uniformly described their autonomy as strongly supportive of practice development.

2007: The WEIS was modified to allow self-assessment (Fig. 1) and further modifications were made to take into account the lessons learned:

* 'Architecture /arrangement' was reinstated as 'Physical space'

* 'Supervisor interaction' was separated into 'Supervisor interaction' and 'Manager interaction'

* 'Interaction with others' was included, focusing specifically on 'Student contact'.

Sample

All registered occupational therapists in the organisation were included in the sample. In 2005, 69/77 staff were interviewed by the PDA (90%). In 2007, questionnaires were coded to allow identification of the main service areas while preserving the anonymity of individual therapists. These were distributed to key individuals, who actively encouraged their colleagues to return completed assessments to them in sealed envelopes which they forwarded to the PDA, resulting in 61/86 returns (71%).

Data analysis

Quantitative data gathered from the ratings were entered onto Excel spreadsheets and mean ratings calculated. Qualitative comments were also collated, allowing the number of times that each criterion statement was ticked to be counted and key themes to be identified.

Ethical considerations

The Local Research Ethics Committee determined that the staff survey did not constitute research. Ethical principles (COT 2003) were followed, nevertheless: ensuring anonymity in subsequent reports, seeking local approval of the methodology and disseminating the results for the benefit of all.

Findings

In 2005, the survey indicated that the occupational therapists already found their work environment to be mostly 'supportive' or 'strongly supportive' of practice development. By 2007, the ratings for the environment 'interfering' or 'strongly interfering' with practice development had reduced in all three domains ('occupational demands', 'social environment' and 'physical environment') (Fig. 2) and across all individual items, with the exception of 'resources' (Figs 3 and 4). Mean ratings increased for all items other than 'resources' and 'appeal of profession' (Fig. 5), with 12 occupational therapists ticking a criterion statement: 'Some doubts re continuing career in current profession'. Nevertheless, 'appeal of profession' was identified as one of the most supportive items (Fig. 4).

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

Reflection

Baseline assessment

First, it should be noted that the survey in 2005 provided evidence that the organisation offered healthy learning environments with respect to all items. The only concern was the comparative professional isolation described by junior members of staff. It was recognised, for instance, that senior occupational therapists were more likely to work as sole occupational therapists but were typically able to establish contacts in other teams, whereas some less experienced staff had regular contact with just one other occupational therapist. Other than this, three areas explored in the 2005 survey were thought to require increased investigation in 2007:

* The occupational therapists voiced greater appreciation of professional supervision than line management supervision and these two aspects were assessed as separate items in 2007. This confirmed that interaction with professional supervisors was deemed more supportive than interaction with line managers.

* Similarly, when physical space was separated from physical resources a clearer picture emerged, with 'resources' becoming the only item to be rated by the majority as interfering with development. The comments made it clear, however, that this item was still viewed as covering a multitude of issues (finance, training, staffing, therapeutic media and office equipment), indicating that revision to the self-assessment could be made in future.

* Finally, the item regarding 'student contact' was added in 2007, in response to a growing recognition that all occupational therapists have a responsibility to provide practice education opportunities for students (COT 2005). As expected, a proportion of band 5 clinicians who were not yet trained as practice placement educators had reduced contact with students and future professional development initiatives will need to focus on how best to improve this situation.

Best practices and challenges

The issues described in both surveys reflect the findings of other studies, emphasising the importance of best practice in terms of interdisciplinary relationships (Kramer and Schmalenberg 2008) and supervision (Kitson and Currie 1996, Begat and Severinsson 2006), together with the challenges perceived in terms of workload ('task demands') and the physical environment (Brabant et al 2007).

The participants in both surveys tended to equate higher levels of support with having an occupational therapist manager and difficulties were voiced where there had been frequent changes of management as well as concerns that occupational therapy might not be valued by higher management. However, multidisciplinary relationships as a whole were celebrated, with participants chiefly praising team dynamics and only reducing their ratings because of perceived short-staffing:

Other comments expanded upon the challenges of generic working, especially the stress of balancing high levels of care coordination duties with an occupation-specific role (Parker 2001, Pettican and Bryant 2007, Culverhouse and Bibby 2008). A few participants reflected on the benefits of generic roles helping to integrate occupational therapy into the multidisciplinary team, but they mostly commented on their struggle to maintain a professional identity despite the support of a professional model of practice. Indeed, the comments made it clear that 'professional model of practice' was sometimes rated as less than 'strongly supportive', not because the occupational therapists did not value it but because they struggled to implement it in their generic practice. The comments also explained some of the variations between service areas: the highest ratings were most often found in the learning disability service, where participants described varied task demands, a clear occupational focus and the support of their occupational therapist manager.

Professional development initiatives and the work environment

The professional development initiatives introduced by the PDA and the lead academic from UK CORE are listed in Table 2. Following their implementation, the item that was seen as being most strongly supportive was 'professional links', with participants attributing this to professional development initiatives. Their spontaneous comments to this effect were wholly positive and credited their increased satisfaction to the partnership with UK CORE, the role of the PDA and the influence of MOHO:

Despite the success of the professional development initiatives, fewer staff recorded the 'appeal of the profession' as being strongly supportive. This could be partly due to the change from an interview to a self-assessment format, interviews being influenced by interviewer bias. In addition, interviewees may have felt less able to express doubts about their 'appeal of profession' in the presence of the PDA and made more objective ratings during the self-assessment process. It could also be argued that this item was influenced both positively and negatively by professional development initiatives, which conceivably highlighted a discrepancy between ideal and actual task demands. One participant commented:

These results were echoed in the 2009 National Health Service (NHS) Staff Survey (Care Quality Commission 2010), thus reducing concerns that the local occupational therapy surveys might be biased. Analysis of the national survey results showed that occupational therapists in the organisation were more satisfied than most NHS staff in three areas that were closely linked to the original survey, although less satisfied with the quality of work and patient care they could deliver (Table 3).

Conclusion

Professional development initiatives are able to influence positively the working environment of occupational therapists. Practitioners are also influenced by the particular nature of their work setting; for example, whether they have access to occupational therapist managers and whether they are able to limit their care coordination duties to allow increased occupational therapy input for all service users. Further work is therefore required to ensure that best practice is implemented more uniformly across service areas. Moreover, current professional development structures must be maintained to provide ongoing support for occupational therapists to 're-assert the profession's belief that occupation is essential to health and wellbeing' (COT 2006, p2).

DOI: 10.4276/030802210X12865330218302

Acknowledgements

With thanks to Professor Kirsty Forsyth, Director of UK Centre for Outcomes Research and Education, and Keith Wilshere, previously Lead Allied Health Professional at Derbyshire Mental Health Services NHS Trust (now Assistant Director with Humber Mental Health Teaching NHS Trust). Thanks too to Dick Harris, Lead Occupational Therapist, and all the occupational therapists in Derbyshire Mental Health Services NHS Trust who have worked so hard to increase their evidence base, especially those who have served on the Steering Group.

Conflict of interest: None.

Key messages

* Professional development initiatives influence the working environment of occupational therapists positively.

* Continued structured support is required to implement occupation-focused practice.

References

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Bannigan K, Hughes S, Booth M (2007) Research is now every occupational therapist's business. British Journal of Occupational Therapy, 70(3), 95.

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College of Occupational Therapists (2007) Professional standards for occupational therapy practice. London: COT.

Creek J (2003) Occupational therapy defined as a complex intervention. London: COT.

Crist P, Munoz JP, Hansen AMW, Benson J, Provident I (2005) The practice-scholar program: an academic-practice partnership to promote the scholarship of 'best practices'. Occupational Therapy in Health Care, 19(1/2), 71-93.

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Duncan EAS (2006) Foundations for practice in occupational therapy. 4th ed. Edinburgh: Elsevier, Churchill Livingstone.

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Forsyth K, Summerfield Mann L, Kielhofner G (2005) Scholarship of practice: making occupation-focused, theory-driven, evidence-based practice a reality. British Journal of Occupational Therapy, 68(6), 260-68.

Jones K, Brown W, Bunker J, Heywood S, Howard D, Tromp JV (2005) Action learning to provide continuing professional development. Nurse Prescribing, 3(4), 156-58.

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Kielhofner G (2002) Challenges and directions for the future of occupational therapy. Keynote address presented at the 13th Congress of the World Federation of Occupational Therapists. (Final draft.) Stockholm: WFOT.

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Focus on research

Theses donated to the COT Library are available for loan, but are not downloadable. Please contact the Library for details.

Janice Elizabeth Jones

The experience of undergraduate occupational therapy students developing the concept of spirituality in clinical practice.

University of Bradford, 2008. MSc in Health Care Practice.

The interest within the United Kingdom (UK) into the role of the occupational therapist addressing spirituality in practice has increased over the last decade. However, the literature suggests that occupational therapists report being professionally unprepared to addressing spirituality in practice, citing lack of academic preparation as one of the barriers.

Currently, there are no known published UK studies into the experiences of occupational therapy students developing the concept of spirituality during their undergraduate programmes.

Therefore, this study seeks to address the gap in the literature by asking how the teaching of spirituality within an undergraduate programme prepared students for clinical practice. Additionally, in what ways practice placements provided students with the opportunities to explore spirituality with patients.

Semi-structured focus group discussions were carried out with three cohorts of students on an undergraduate occupational therapy programme within the UK. The qualitative data revealed that the students acknowledged that the role of the occupational therapist addressing spirituality was part of holistic, client-centred practice. However, they were unclear about how this role worked out in practice. They identified specific barriers to practice, including the setting and lack of assessments or measurements to justify practice.

The students had difficulty conceptualising spirituality, suggesting that the concept develops over the period of the programme. Additionally, their perceptions were that their academic programme had not helped their development of the concept, and practice placement experience had not consistently helped them in applying theory to practice.

The findings suggest that the development of an effective teaching strategy is needed to ensure that the holistic philosophy of occupational therapy is integrated throughout the programme. Furthermore, studies exploring the concept of spirituality on other occupational therapy programmes would provide a wider understanding of the effectiveness of the preparation that students receive prior to practising.

Additionally, collaboration with practice placement colleagues is suggested to identify strategies to support their development of the concept of spirituality in practice and thus influence the students' practice placement experiences.

Sue Parkinson, (1) Claire Lowe (2) and Katie Keys (3)

(1) Occupational Therapy Practice Development Adviser, Derbyshire Mental Health Services NHS Trust, Ashbourne Centre, Kingsway Hospital, Derby.

(2) Senior Occupational Therapist, Hartington Unit, Chesterfield Royal Hospital, Calow, Chesterfield.

(3) Head Occupational Therapist, High Peak Community Mental Health Team, Buxton.

Corresponding author: Sue Parkinson, Occupational Therapy Practice Development Adviser, Derbyshire Mental Health Services NHS Trust, Ashbourne Centre, Kingsway Hospital, Derby DE22 3LZ. Email: sueparkinson@nhs.net

Reference: Parkinson S, Lowe C, Keys K (2010) Professional development enhances the occupational therapy work environment. British Journal of Occupational Therapy, 73(10), 470-476.

[C] The College of Occupational Therapists Ltd. Submitted: 19 October 2009. Accepted: 21 July 2010.
Analysis of the environment may provide information about the
   causes of problems for the individual, explanations for behaviour
   or ideas for ... modifications (Creek 2003, p38).


Staffing issues have increased pressure and responsibility.

   Interaction with colleagues is very good.


Fab professional links! I feel valued!

   It is brilliant to have such a foundation to our practice and
   boost of confidence.


Satisfied and enjoy role but not enough time for OT specific role.


Table 1. Key domains, items and ratings in the Work Environment
Impact Scale and the formats adapted for the purpose of these
surveys

Key domains        Work Environment            2005 survey
                    Impact Scale--            (interview)--
                    original items            adapted items

Occupational    Time demands             Time demands
demands         Task demands             Task demands
                Appeal of work tasks     Appeal of profession
                Work schedule
                Meaning of objects       Meaning of
                                         professional model

Social          Co-worker interaction    Co-worker interaction
environment     Work group membership    Professional links
                Supervisor interaction   Supervisor interaction

                Work role standards      Work role standards
                Work role style          Work role style
                Interaction with           (discontinued)
                  others

Physical        Rewards
environment     Sensory qualities
                Architecture/
                  arrangement
                Ambience/mood
                Properties of objects    Physical resources
                Physical amenities       (including space)

Key domains       2007 survey (self-
                    assessment)--
                    adapted items

Occupational    Time demands
demands         Task demands
                Appeal of profession

                Meaning of
                professional model

Social          Co-worker interaction
environment     Professional links
                Supervisor interaction
                Manager interaction
                Work role standards

                Student contact

Physical
environment
                Physical space

                Physical resources

Rating                                   Strongly supports    = 4
scale                                    Supports             = 3
                                         Interferes           = 2
                                         Strongly interferes  = 1

Items adapted with permission of Professor Gary Kielhofner on
behalf of the MOHO Clearing House, University of Illinois,
Chicago.

Table 2. Professional development initiatives implemented
between surveys

Areas for              Professional development initiatives
development            implemented by the PDA with guidance
                                   from UK CORE

Supervisor       * Practice Development Adviser appointed to act
interaction        as clinical supervisor for a number of head
                   occupational therapists and clinical
                   specialists

                 * Band 5 group supervision initiated

Professional     * Creation of a strategic infrastructure for
links              occupational therapists, including action
                   learning sets in each service area, with
                   representatives from each forum forming a
                   steering group led by the PDA to drive
                   forward annual practice development strategies

Professional     * Adoption of the Model of Human Occupation
model              launched at trust-wide meeting

Resources        * Funding agreed for a variety of occupational
                   therapy resources and manuals, distributed to
                   all services

Time demands     * Standard report formats agreed to increase
                   efficiency and evidence-based assessments
                   adopted, capable of increasing clinical
                   effectiveness

Co-worker        * Opportunities created for occupational
interaction        therapists to articulate their occupation-
                   specific role, including the creation of an
                   occupational therapy newsletter

Work standards   * Regular professional development sessions
                   organised, quarterly forums for all
                   occupational therapists to share best practice

                 * Accountability and reward structures
                   implemented.

Table 3 Results from National NHS staff survey in 2009
(Care Quality Commission 2010)

Key findings that reflect the results of the local
occupational therapy survey

                                   National average         Local
                                   for mental health     occupational
                                     and learning          therapy
                                   disability trusts        score

Percentage of staff:

1. Receiving job-relevant
training, learning or                     81%                100%
development

2. Feeling there are good
opportunities to develop their            48%                 63%
potential at work

3. Agreeing that they
understand their role and                 45%                 58%
where it fits in

4. Feeling satisfied with the
quality of work and patient
care they are able to deliver             76%                 58%

Fig. 1. Excerpt from self-assessment format.

Item       Rating   Criterion statements                      Comments

Time         SS     [] Able to set own pace
demands             [] Able to prioritise between
                       competing tasks
                    [] Satisfied with time available to
                       complete tasks

             S      [] Mostly able to set own pace
                    [] Mostly able to prioritise tasks
                    [] Mostly satisfied with time
                       available to complete tasks

             I      [] Time is often diverted from tasks
                    [] Difficulty prioritising deadlines
                       and multiple tasks
                    [] Very little satisfaction with time
                       available to complete meaningful
                       tasks

             SI     [] Tasks are constantly interrupted
                       or there are not enough tasks
                       to do
                    [] Unable to prioritise deadlines
                       and multiple tasks
                    [] Dissatisfied with time available
                       to complete essential tasks

SS = strongly supports; S = supports; I = interferes; SI =
strongly interferes.
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