| dc.description.abstract | Introduction
Decision-making capacity (DMC) is the extent to which an individual is capable of understanding and remembering information and using this to make and communicate their choices regarding their personal, financial and healthcare affairs. Increasing age and life expectancy, alongside the growing incidence of chronic conditions and dementia-related diseases, indicate more older individuals are likely to experience challenges regarding DMC. However, all adults, including those with disabilities, have a right to participate in decisions that may have an impact on their lives. Internationally, equality and human rights policy and legislation protects and upholds these rights. In Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statuary framework for adults who are experiencing difficulties with decision-making. This legislation has significant implications for all health and social care professionals, especially those working with older adults or people with cognitive disabilities. Occupational therapists are frequently involved in and contribute to the assessment of older adults DMC in relation to independent living (IL), yet little is known about the extent of their involvement or the nature of occupational therapists contribution to DMC assessment of older people. The overall aim of this research study was to explore the role of occupational therapy in the assessment of DMC of older people in relation to IL, within an Irish context of practice.
Objectives
This study explored the current involvement of occupational therapists in the assessment of older adults DMC in Ireland, alongside their awareness of, attitudes towards and application of recent legislation regarding DMC and the factors that impact on their engagement in DMC assessment, specifically in relation to IL. Additionally, this study aimed to form a consensus on recommended approaches for occupational therapists in Ireland that address DMC assessment of older adults for IL, from a client-centred, occupation-based perspective, that aligns with current DMC policy and legislation.
Methods
The study was conducted via a four-phased sequential mixed methods design. A combination of qualitative and quantitative approaches was utilised in the three phases of empirical data collection, in conjunction with the scoping review. The design of the study facilitated an iterative and sequential approach to data collection, with each phase emerging as a result of the findings of the previous phase, and findings from all phases were combined in drawing inferences from the overall study. Phase 1 compromised of an online cross-sectional survey among practising occupational therapists, to explore occupational therapy practices regarding DMC assessment in Ireland. This national survey aimed to provide an overview of current occupational therapy practices in DMC assessment within an Irish context by exploring if and to what extent occupational therapists were involved in DMC assessment. The results from Phase 1 indicated that occupational therapists who work with older adults were likely to be involved in DMC assessment and they were most concerned with the DMC domain of IL. Thus, the scoping review conducted in Phase 2 explored DMC assessment approaches for IL among older adults from an international and multidisciplinary perspective. Findings from Phase 1 survey and Phase 2 scoping review informed and shaped the subsequent design and data collection methods in Phase 3. Qualitative focus group interviews were used to explore in detail the assessment practices of occupational therapists in Ireland who were actively involved in DMC assessment with older adults and to identify the challenges encountered by occupational therapists in addressing this area. An interpretive descriptive methodology guided Phase 3 and qualitative data from this phase were analysed using thematic analysis. The issues identified in this phase informed Phase 4, which employed a nominal group technique (NGT) meeting as a structured approach to obtaining consensus on recommended processes for occupational therapists in Ireland to address IL DMC assessment of older adults, from a client-centred, occupation-based perspective, aligning with current legislation. Occupational therapists identified, ranked and rated critical dimensions of assessment of older adults DMC, specifically for IL.
Findings
The survey was responded to by one hundred and seventy-two occupational therapists. Most occupational therapists (65.77%, n=98) reported involvement in DMC assessments, particularly those working with older adults. Occupational therapists were predominantly involved in the contribution to assessments of DMC regarding IL (79.19%, n=118), and to a lesser extent they were involved in assessment of other DMC domains, such as driving (45.89%, n=67), and financial management (44.44%, n=64). Occupational therapists reported using a combination of approaches to inform DMC assessment, including interviews, observations and assessments of cognition and functional performance. Findings indicated that DMC assessment is one of the most complex of occupational therapists practice and a large proportion of respondents were dissatisfied with current DMC assessment procedures in their practice settings. The majority of respondents (91.86%, n=113) emphasised the need for additional training and practice resources to enhance current DMC assessment.
Nine focus groups discussions were conducted with fifty-two occupational therapists, from a range of hospital and community practice settings in Ireland. Findings highlight a good awareness of DMC legislation among occupational therapists, many whom had sought education and training opportunities to enhance their knowledge in this area. However, many practice constraints and resources issues were identified as barriers to occupational therapists implementation of optimal DMC assessment. Occupational therapists identified having a relevant skill set and clear role in contributing to a comprehensive occupation-based and client-centred assessment of older adult s DMC, that is in line with current legislation. The need for further education, resources and guidelines for occupational therapists and other healthcare professionals to better guide DMC assessment and support was highlighted.
A one-day consensus meeting was held with twenty occupational therapists experienced in contributing to IL DMC assessment of older adults from a range of practice settings. Strong consensus was achieved on key triggers that indicate the need for IL DMC assessment, including perceived risk, conflicting stakeholder perspectives on older person s needs, and reduced insight. Strong consensus was also agreed that occupational therapy s contribution to DMC assessment should include observations of function, cognitive assessment, and home-based assessment. Strong consensus was achieved regarding the need to ensure that the older person s will and preference was central within occupational therapy s assessment of DMC for IL. Participants strongly agreed that a responsive and individualised approach to DMC assessment is required to support the person s participation in the process.
Conclusion
The study confirms that occupational therapists have a role to play in assessment of older adult s DMC, particularly regarding IL, within the multidisciplinary context. Overall, the occupational therapists recognised that a thorough assessment of older adults DMC for IL requires a multicomponent and multidisciplinary approach, with consideration of the older person's values and preferences. They emphasised the relevant skill set held by occupational therapists that enables them to make a significant contribution to the multicomponent assessment of DMC for IL. This study provides insight to factors that both challenge and facilitate occupational therapists engagement in assessing and supporting older adults DMC for IL as well as highlighting a potential leadership role for occupational therapy in this area. The findings from this study provide a foundation that will enable the development of resources and guidelines for occupational therapists to consolidate and advance their practice in this area. | en |
