Success With Pediatric Patients

If you were asked to describe successful professional behaviors for working with pediatric patients, what would you include on your list? How would your list compare with those created by other practitioners? Would your list of professional actions include general behaviors related to communication, relationship building, and collaboration with patients? If asked to describe a good clinician that you have worked with, you would likely include things such as the ability to listen well to his or her patients, get along with everyone, or know how to talk to patients.

Photograph by Heather Swanson

Experienced practitioners would agree on many of the behaviors and practices that make up core clinical and technical skills in O&P: appropriate and high-quality impression techniques, modifications, designs, and fabrication. The American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics provides a practice framework by outlining "a contemporary description of the tasks and responsibilities of the orthotic and prosthetic profession" based on practitioner surveys designed to identify "the domains of practice, the specific tasks performed, and the associated knowledge and skills required to perform each task."^1,2

In the areas of practice related to patient function, much progress has been made in defining successful O&P care of adults and children. Researchers and practitioners agree on many aspects of care that should be measured to document functional outcomes, and many clinicians are routinely implementing these measures into their practices. However, it is more difficult to define effective care in domains not directly related to specific clinical skills.

Providing O&P care for children can involve more structural and functional challenges than providing care to adult patients, and often requires a distinct clinical skillset. Communication, motivation, engagement, and other important aspects of the healthcare professional-patient relationship can also be more challenging since the interactions involve multiple caretakers (i.e., family, school personnel, and healthcare professionals) whose roles and perspectives must be considered. This article describes the findings of three research groups that examined the defining elements of successful care in pediatric rehabilitation.

To determine "clinicians' actions associated with the successful patient care process," Kolehmainen et al. examined interview transcripts of 25 occupational therapists who were asked to describe successful and unsuccessful care processes. The specific aim of the research was to identify actions at "different stages of the care process" and "to identify the key actions associated with 'successful' and 'unsuccessful' care processes."³ Success was defined as a "clear and coherent process with easy discharge" and "achieved patient goals and positive patient-clinician relationships."³

Each therapist described two of his or her cases, one considered unsuccessful, and one considered successful. In their descriptions of these cases, the therapists detailed their actions and decisions in managing the care process.³ The researchers coded the transcripts to identify the presence or absence of certain actions and noted when a behavior was clearly associated with a successful or unsuccessful care process. The researchers identified 207 actions and arranged them in six different areas, "assessment, setting goals and planning actions, treatment, review, discharging, and managing processes and relationships" (Table 1). While the authors acknowledge that "all relationships identified are associations only and no conclusions can be made about causality," their findings provide insight into contributing factors of successful care.³

The therapists reported that during assessment, "gathering perspectives from others" helped them understand the patient's challenges. The patient's school and caretakers were described as important contributors to this improved understanding. During the goal setting and planning aspects of the care process, the actions of "identify aims," "take guidance from parents," and "agree [on] plans, roles, and responsibilities/communicate plans to others" were associated with successful care. The failure to agree on "plans, roles, and responsibilities" was associated with unsuccessful care.

The therapists identified involvement of the parents and child during the treatment phase of the process as important to success. This was commonly achieved by "demonstrating activities to the carer and working through activities with the carer...." During the review phase of the care process, the therapists described evaluating the child's progress by "making comparisons between the child's baseline, current performance, and the goal" as important to success.

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As part of managing processes and relationships, the therapists described "keeping others 'onboard' (i.e. engaged in therapy and motivated to implement treatment activities), communicating with professionals and carers (typically to provide information), and persuading others to do what the therapists wanted to be done."³ In this area, the therapists noted that it was important for parents to attend treatment sessions. Not surprisingly, "failing to get others on board" and "negotiating and managing difficulties in relationships" were associated with unsuccessful care.

Di Rezze et al. took a different approach to determine "essential attributes for intervention with children with disabilities."⁴ These researchers were interested in defining general behaviors that support the provision of family-centered service (FCS). FCS "has been described as including service behaviours that assist the family to identify strengths, provide support for families, foster collaboration in services goals, and encourage the participation of all family members." They point out that "specific and observable behaviours within the therapeutic process that should be present in any paediatric rehabilitation intervention that adheres to FCS principles" have not been identified.⁴ Their research purpose was "to generate a list of observable general therapy attributes essential to FCS interventions for children with physical disabilities."⁴

Active ingredients in care are "discrete elements designed to act as causal factors that result in change in patient outcomes."⁴ This includes elements or processes that can impact the treatment outcome but are not specific to any one clinical intervention. These researchers describe the difference between intervention-specific behaviors and general behaviors. Intervention-specific behaviors include clinical skills required to provide the professional service-for O&P, one source that describes these is the ABC Practice Analysis. General behaviors include interpersonal skills that are not specific to any one clinical procedure, but are necessary to perform all of them. Di Rezze et al. point out that to research the outcome of care, all the active ingredients of care must be defined and methods must be developed to "evaluate adherence to these ingredients" during the care process. One of the researchers' goals was to identify important general behaviors so they could be considered when determining whether and why care has been successful. A more thorough understanding of all the features of treatment (both intervention-specific and general) can result in better understanding mechanisms that contribute to success or failure of treatment.

At the time the research was conducted, no validated method existed for observing and assessing general therapy behaviors and how these aspects of care contributed to treatment success. To determine how these general behaviors impact care, a list of behaviors to observe must first be generated. Their study was designed "to generate observable attributes of general paediatric therapy behaviours that are considered to be essential within family-centred rehabilitation intervention sessions for children with physical disabilities."⁴

The researchers used two methods for identifying general therapy behaviors. In one process, eight researchers participated in a Delphi consensus process during which they used a four-point Likert scale to rate general therapy behaviors based on how essential they are to a pediatric therapy session. In a second process, the researchers conducted semistructured interviews with 17 therapists. There was a high degree of consensus among the two groups of participants in this study. Thirty-five attributes related to the behaviors of therapists, clients, and the client-therapist interaction were identified through the Delphi process. The interviews with therapists identified 19 attributes, 17 of which matched the Delphi process items. The researchers' plan was to use these attributes to develop measures to assess behaviors of therapists during intervention studies.

In their article, "Family-Professional Collaboration in Pediatric Rehabilitation: A Practice Model," An and Palisano begin by affirming that collaboration with pediatric patients and their families is both important and challenging.⁵ They report on a systematic review "that indicated that rehabilitation professionals have sought to develop collaborative relationships mainly by providing families therapeutic knowledge and skills. Therapists reported that they spend a significant amount of time reviewing home instructions and teaching handling and positioning techniques to parents, whereas they spend less time focusing on the child's other needs and parental needs and concerns."

This perspective is common in O&P as well-we collaborate with patients and caretakers by performing the specific tasks related to our professional scope of practice. In the language of Di Rezze et al., we tend to focus primarily on the intervention-specific behaviors that contribute to success and may put less emphasis on the general behaviors. In doing so, we may overlook the more important aspects of the care process. Believing that strategies informed by evidence would help professionals (especially those with less experience providing family-centered care) collaborate with families, An and Palisano set out to describe a practice model of family-professional collaboration for pediatric rehabilitation. The model recommends specific strategies and procedures that professionals can use to foster a collaborative process with families, as well as a four-step implementation process (Figure 1).⁵

The model is based on three key principles of collaborative service delivery: family-identified needs, shared responsibility, and family empowerment. Collaboration involves two-way interactions through which families and professionals share knowledge and skill, make shared decisions on goals and intervention, and build capacity in order to foster family empowerment and optimize outcomes. The four-step process involves: (1) mutually agreed-upon goals, (2) shared planning, (3) shared implementation, and (4) shared evaluation.⁵

Goal Setting

An and Palisano recommend using a client-centered interviewing approach when discussing treatment goals with a pediatric patient and his or her family. Asking caretakers in a variety of ways about the child's typical day and listening for specific issues to be addressed can be an effective way to begin this process. Guiding the caretakers in "visualizing a preferred future" places a positive focus on the discussion. Questions such as, "If I saw your child at your home in three months and things were really going well, what would I see?" or "In three months...when you see your child moving around your home, what might make you say, 'Wow, something is different. He is doing well''' can begin the process of defining and agreeing on specific, attainable treatment goals.⁵

Planning

Practitioners can use a scaling question to guide caretakers in making specific plans to accomplish the agreed-upon goals. This method involves the caretaker identifying, on a scale from one to ten, "the number that represents the child's current performance and the number that represents the child's performance at the completion of intervention (the preferred future)...." A score of one indicates low performance and ten indicates high performance. The practitioner can then discuss specific interventions that will be required to help the child move toward the higher performance indicated by the parents' second score.

The use of a Family Routine and Activity Matrix can help identify specific "activities, times, and roles of family members" for achieving the treatment goals.⁵ This process is more specific than the preferred future visualization used during goal setting. The questions asked during this process guide the parents in thinking about and describing specific activities at key points throughout the day that represent particular challenges to the child or provide opportunities to support the child in achieving the established goals. A detailed discussion like this can help the practitioner gain a more accurate understanding of the supports and constraints within each patient's environment.

Implementation and Evaluation

During follow-up visits, practitioners can guide the caretakers by asking for their insights on the effectiveness of the treatment and work out possible solutions to challenges that arose after the last visit. The use of self-report outcome measures and referring to the scaling questions used during the planning stage can facilitate a constructive, solution-focused discussion.

Application to O&P

Objective, quantitative data is not available for many of the general factors that contribute to successful treatment. A consensus process, such as the Delphi and structured interview methods described in the articles reviewed, can yield meaningful information when considering the general behaviors associated with successful patient care. The questions asked at the beginning of this article are a good way for individual practitioners to begin the process of identifying what behaviors can help them work effectively with pediatric patients and their caretakers.

Respondents to the ABC Practice Analysis survey rated the frequency and criticality of specific tasks related to O&P care, several of which can be described as general behaviors. These match the general categories of An and Palisano's practice model for practitioner-family collaboration.

Patient Assessment: Consult with other healthcare providers and caregivers, as appropriate, about the patient's condition in order to formulate a treatment plan as a part of the comprehensive plan of care.

Formulation: Communicate with the patient and/or caregiver about the recommended treatment plan and any optional plans, including disclosure of potential risks, benefits, and limitations in orthotic or prosthetic care.

Follow-up: Obtain feedback from the patient and/or caregiver to evaluate outcome (for example, adherence to wear schedule, comfort, perceived benefits, perceived detriments, ability to don and doff, proper usage and function, and overall patient satisfaction).²

To work effectively with any patient and his or her extended circle of stakeholders, we must consider the general behaviors that contribute to success. During many challenging encounters with patients, the ability to collaborate, form a therapeutic alliance, and communicate effectively contributes more to a successful outcome than the specific O&P task we perform. Practitioners who develop skills in all these areas will provide more effective care.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.

References

1. ABC to Conduct Practice Analysis. www.abcop.org/news-events/CurrentNewsandEvents/2014%20Archive/Pages/ABC-to-Conduct-Practitioner-Practice-Analysis.aspx
2. Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics.
3. Kolehmainen, N., E. A. Duncan, and J. J. Francis. 2013. Clinicians' actions associated with the successful patient care process: A content analysis of interviews with paediatric occupational therapists. Disability and Rehabilitation 35 (5):388-96.
4. Di Rezze, B., M. Law, K. Eva, N. Pollock, and J. W. Gorter. 2014. Therapy behaviours in paediatric rehabilitation: Essential attributes for intervention with children with physical disabilities. Disability and Rehabilitation 36 (1):16-22.
5. An, M., and R. J. Palisano. 2014. Family-professional collaboration in pediatric rehabilitation: A practice model. Disability and Rehabilitation 36 (5):434-40.