1. Practice guideline
Occupational therapists’ use of occupation-focused practice in secure hospitals
  Royal College of Occupational Therapists
Specialist Section - Mental Health, Forensic Forum
CPD Session: PowerPoint, notes and group activities
The slides and information in this CPD session can be used as a template, but can also be adapted to reflect local need and priorities.
The overall aim of this resource is to support a continuing professional development session to explore the practice guideline Occupational therapists’ use of occupation-focused practice in secure hospitals (Royal College of Occupational Therapists 2017).
The resource comprises this PowerPoint presentation and notes which can be used for a one-hour facilitated workshop, or for individual self-directed learning.
There are some interactive activities which are intended to be used to encourage reflection on current practice and to explore some areas in more detail.
Pre-requisite materials:
Guideline document: Occupational therapists’ use of occupation-focused practice in secure hospitals (RCOT 2017)
Implementation tools i.e.
Audit Form.
Quick Reference Guide.
It is essential that workshop facilitators familiarise themselves with the full guideline document and implementation tools in advance.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists.
This PowerPoint may be copied and adapted for non-commercial use

2. Learning outcomes
To explore aspects of the practice guideline recommendations in relation to current practice.
To develop an understanding of the importance of using practice guidelines to inform practice.
To explore and develop an understanding of the RCOT Audit Form available to use with the evidence-based recommendations.
Slide 3 Practice question
Slide 4 Guideline objective
Slide 5-6 Methodology and recommendation grading
Slide 7 Recommendation areas:
Volition
Habituation (Activity 1 and 2)
Performance capacity
Environmental considerations
Slides 8-18 Evidence overview and list of the recommendations
Slides Impact of the guideline (Activity 3)
Slide 23 Practice guideline resources
Information used in the session is taken from the full practice guideline document and the audit tool.
Activities 1 and 2 can potentially be applied to any of the recommendation areas. Choose the one that you think would yield as much discussion as possible by the group in order that they may take plenty of ideas away to think about.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

3. Practice question:
What evidence is there to support the use of occupation in occupational therapy in secure hospitals with patients over the age of 18?
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

4. Objective of the guideline
To provide specific recommendations to support the use of occupation-focused occupational therapy in secure hospitals. The guideline is relevant to high, medium and secure hospitals.
Emphasise that the guideline focuses on occupation-focused practice for adults, aged 18 and over, and covers all aspects of severe mental illness, personality disorders and learning disability.
The setting is high, medium and low secure units.
Specific index offence interventions are not covered, e.g. anger management and sex offender treatment.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

5. Methodology 1. Guideline development group established
2. Guideline scope defined involving stakeholders
5. Critically appraise articles
4. Screen findings
3. Literature search
6. Development of practice guideline recommendations
7. Peer review, stakeholder and service user consultation
A topic selected for guideline development needs to have a sufficient evidence-base, and a proposal must be approved by the Royal College of Occupational Therapists’ Practice Publications Group.
The Royal College of Occupational Therapists’ guideline development process is rigorous and is Accredited by the National Institute for Health and Care Excellence.
Stakeholder, service user and carer engagement and involvement is fundamental to the development of a guideline.
1. Establish the Guideline Development Group
2. Define the scope and practice question(s)
3. Literature search
4. Screen findings
5. Appraisal and grading of the evidence
6. Formulate the recommendations and write the guideline
Peer review and consultation involving stakeholders (includes occupational
therapists as end users) and service users
8. Ratification by the COT Practice Publications Group
9. Publication and implementation
10. Review – within 5 years, replicates steps 3-8.
11. Publication of 2nd edition
9. 1st edition published by COT 2012
8. Final draft approved by COT Practice Publications Group
10. Review undertaken
11. 2nd edition published by RCOT 2017
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

6. Evidence-based recommendations
Recommendations are based on the evidence available within 41 critically appraised papers.
Each recommendation is assigned:
A strength scoring 1 or 2 (Strong or Conditional).
A quality grading A, B, C or D
(High, Moderate, Low or Very Low).
Each article of evidence identified which met the scope inclusion criteria, from the original search (2001–2011) and review search ( ), was critically appraised by two members of the guideline development group, and a quality of evidence grading subsequently determined based on that assessment.
The quality of evidence grading reflects the typical hierarchy given to study design. For example the highest level (A) reflects consistent results from randomized controlled trials, whilst the lowest (D) includes studies such as case studies or expert opinion. Higher level studies are perceived as being less susceptible to bias.
The strength of the recommendation is scored as either strong (1) or conditional (2). This is based on the benefits and risks of the evidence. A strong recommendation indicates that benefits appear to outweigh the risks for the majority of the target group, where as a conditional or suggested recommendation, means that the risks and benefits are more closely balanced or there is more uncertainty.
The majority of the 41 items of evidence were assessed as low grade and were predominantly cohort and qualitative studies. None of the evidence was graded as high (A). 4.9% was graded as moderate (B), 63.4% as low, and 31.7% as very low (D). Seventeen of the 20 recommendations are graded as strong.
Each recommendation is specific and is based on the appraised evidence. Details about the studies referenced can be found in the evidence tables section (Appendix 6) of the full guideline.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

7. Recommendation areas Model of Human Occupation Framework: Volition;
Habituation;
Performance capacity;
Environmental considerations.
The recommendations are based on the synthesis of the best available evidence. It should be noted that the guideline will only reflect that evidence and cannot, therefore, be inclusive of all aspects of the role of occupational therapy within secure hospital settings.
Recommendations, based on the evidence, were developed in four key areas reflective of the Model of Human Occupation Framework:
Volition
Habituation
Performance capacity
Environmental considerations
Point out that the recommendation categories reflect the concepts associated with the Model of Human Occupation (Kielhofner 2008) as currently this appears to be the most frequently used and cited in relation to forensic occupational therapy. Highlight, however, that this serves as a useful framework but is not meant to be prescriptive.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

8. Volition
Volition
It is recommended that occupational therapists always take into account the gender-specific needs of patients with whom they are working.
(Baker and McKay 2001 [C])
1 C
2. It is recommended that occupational therapists consider the occupational life history of patients, including that at the time of the index offence, and its influences on occupational performance, life satisfaction and criminogenic lifestyle.
(Lindstedt et al 2005 [B])
1 B
3. It is recommended that occupational therapists establish, as part of their assessment, patients’ perspectives of their occupational performance and social participation, and work with those perceptions in planning care.
(Lindstedt et al 2004 [B])
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

9. Volition contd. Volition
4. It is recommended that occupational therapists work collaboratively with patients to identify and develop care pathways which are recovery-focused.
(Clarke 2002 [C]; Walker et al 2013 [D])
[Statement amended, new evidence 2017]
1 C
5. It is recommended that occupational therapists recognise the specific
intrinsic value of occupation to individual patients.
(Craik et al 2010 [C])
6. It is recommended that occupational therapists facilitate meaningful
occupational choices for patients.
(Craik et al 2010 [C]; Cronin-Davies 2010 [C]; Mason and Adler 2012 [C]; Morris 2012 [C]; O’Connell et al 2010 [D]; Stewart and Craik 2007 [C])
7. It is recommended that occupational therapists ascertain patients’
aspirations towards paid employment at the earliest opportunity, and
during rehabilitation.
(McQueen 2011 [C])
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

10. Patient perspectives - volition
Direct consideration of what interests and enthuses me is important, as it also allows for a good initial relationship and discussion to be individualised.
‘Aspirations’ could more specifically relate to a person’s outlook generally rather than only to paid employment.
Sometimes activities are done to aid independent living skills but repetition leads to boredom and disinterest.
Meaningful - Yes, but also relevant to their recovery needs. Activity and progress should be time framed and phased, so progress and skill development can be measured and to ensure things don’t drift, lose meaning and focus.
Slide 10 provides some perspectives from service users provided as part of the guideline review consultation.
Activity 1
Prior to showing the next slide 11, ‘Habituation’ Activity 1 can be carried out.
Tell the group that the next section deals with habituation.
Split the group into pairs and ask them to discuss what they think would be covered/recommended in this section. Prompt them to think about their own practice in this area, and highlight examples of what they consider best practice.
Following discussion, ask the pairs to share 1-2 examples with the group; you might want to record on a flipchart the groups’ suggestions to refer back to these ideas when you show the recommendations.
On completion of the activity present the recommendations for habituation on slide 11.

11. Habituation Habituation
8. It is recommended that occupational therapists consider patients’
roles (past, present and future) within treatment planning and
interventions.
(Schindler 2005 [C])
1 C
9. It is recommended that occupational therapy facilitates a range of
interventions that enable patients to engage in structured and
constructive use of time throughout the week, including weekends and
evenings.
(Bacon et al 2012 [D]; Castro et al 2002 [C]; Farnworth et al 2004 [C];
Jacques et al 2010 [D]; Stewart and Craik 2007 [C])
Activity 2
Once the recommendations have been presented, the questions below can be used to encourage the group to talk about the recommendations in relation to their own suggestions:
Do they cover the best practice examples they identified?
Why might these not be the same?
You may want to refer back to the methodology of creating an evidence-based guideline and how it is based on the published literature - evidence-based practice guidelines support practice, but can only reflect current evidence.
It may be important to emphasise that just because their own examples are not covered, this does not necessarily mean they are not best practice. Occupational therapists also need to adhere to other service standards, consider the service user’s perspectives and apply their clinical judgement and reasoning when providing occupation-focused interventions for adults in a secure hospital.
The Audit Form can now be used to further consider the habituation recommendations.
Ask the pairs/small groups to discuss one or more of the recommendations, sharing their current practice in relation to the recommendation and how they would evidence this. If the recommendation is not current practice then they should look at what an action plan might consist of to implement that recommendation.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

12. Patient perspectives - habituation
It’s really important to help us identify the patterns and history of our engagement and why this is relevant.
Consider productivity according to past and present - asking patient why this may have differed in order to help us understand the relevance and importance of changed behaviour/engagement .
Consideration of habituation formed as a result of medication, and /or sleep pattern. Help needed to support patients to work on identifying these patterns in their daily routine and collaborate on how these can be overcome and why breaking them is beneficial to the patient and their recovery.
Slide 12 provides patient perspectives related to their review of the habituation recommendations.

13. Performance capacity Performance capacity
10. It is recommended that occupational therapists routinely used
standardised outcome measures to assess and demonstrate
patients’ progress.
(Clarke 2003 [D]; Fan 2014 [D]; Fitzgerald 2001 [C]; Green et al 2011 [C]; Kottorp et al 2013 [C]; McQueen 2001 [C]; Williams and Chard 2016 [D])
[New evidence 2017]
1 C
11. It is recommended that occupational therapists consider prevocational training, real work, or supported employment as part of occupation-based intervention opportunities for patients.
(Cox et al 2014 [D]; Garner 1995 [D]; McQueen 2011 [C]; Smith et al 2010 [D]; Völlm et al 2014 [D])
[Statement amended, new evidence 2017]
The next two slides focus set out the performance capacity recommendations.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

14. Performance capacity contd.
12. It is recommended that occupational therapists consider the use of
healthy living programmes and exercise as activity to benefit health
and wellbeing.
(Bacon et al 2012 [D]; McQueen 2011 [C]; Prebble et al 2011 [D]; Tetlie
et al 2008 [C]; Tetlie et al 2009 [C]; Teychenne et al 2010 [C])
1 C
13. It is suggested that occupational therapists include social inclusion
programmes as part of their intervention to improve occupational
functioning.
(Fitzgerald 2011 [C])
2 C
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

15. Patient perspectives - performance capacity
Work needed on initial admittance on patients’ fears and anxieties…this is overlooked by staff and in my experience is a barrier for the majority of patients.
Collaboration with patients to identify methods best used to help them understand/learn and identify their own progress are important…..
Narratives…the importance of these is desperately underestimated…
Key for me…and not enough attention paid to [this] in secure care is the identification and appreciation of an individual's past and present skills and qualities. This would help to avoid deskilling and lack of confidence in doing things we used to be very competent at.
Slide 15 reflects a sample of views on performance capacity shared by patients who participated in the guideline review consultation.

16. Environmental considerations
14. It is recommended that occupational therapists fully value the therapeutic use of self as being integral to the positive engagement of patients in occupations.
(Evans et al 2012 [C]; Mason and Adler 2012 [C]; Tetlie et al 2009 [C])
[Statement amended, new evidence 2017]
1 C
15. It is recommended that occupational therapists ensure that risk
assessment is a dynamic process, in which judgements are made on an
ongoing basis in collaboration with patients and members of the
multidisciplinary team.
(Cordingley and Ryan 2009 [C])
16. It is suggested that occupational therapists recognise the role and
contribution of family and friends in the recovery of patients.
(Absalom et al 2010 [C]; Fitzgerald et al 2012 [D])
[Statement amended 2017]
2 C
The final set of recommendations relate to the MOHO area of environmental considerations.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

17. Environmental contd. Environmental considerations
17. It is recommended that occupational therapists consider the impact of the environment on quality of life and occupational engagement.
(Craik et al 2010 [C]; Fitzgerald et al 2011 [D]; Long et al 2008 [C]; Long et al 2011 [C]; Morris 2012 [C])
1 C
18. It is suggested that occupational therapists liaise with a range of
community services to facilitate replication of patients’ pro-social
behaviours developed during an inpatient stay.
(Elbogen et al 2011 [D]; Lin et al 2009 [C]; Lindstedt et al 2011 [C])
2 C
19. It is recommended that occupational therapists demonstrate their
competencies (skills and training) to facilitate identified therapeutic
groups, enhancing the confidence and participation of patients.
(Mason and Adler 2012 [C])
20. It is recommended that occupational therapists articulate, to patients
and the multidisciplinary team, their role and the contribution of
occupational therapy to the overall treatment performance.
(Cronin-Davis 2010 [C])
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

18. Patient perspectives - environment
Risk assessment: should be geared towards ultimately empowering patients to take responsibility for their risk and therefore the risk assessment. Therefore that should be the goal in preparation for independent living or life outside of hospital. Encourage patients to work towards driving this and not just being a partner in it!
The work achieved by OT with patients is so important but this work can be progressed during the time between sessions with other staff…sharing OT knowledge with other front line staff is important for patient recovery… Better introductions required by OTs when meeting patients for the first time….
Allow time to read the patients perspectives on the environment.
Activity 3 – can be carried out before moving onto the next slides
Divide into groups again and ask them to consider what they think the impact of these guidelines will be for themselves, their service managers, the users of their service, and the commissioners of services.
Obtain feedback from the groups before going through the suggested impacts on slides

19. Impact of practice guideline for you: the practitioner
Challenges / affirms your current practice.
Provides evidence-based recommendations to inform and support your practice.
Raises awareness of benefits and risks and organisational and financial barriers.
Provides a vehicle for you to audit your practice.
Assists in communicating your role to members of the multidisciplinary team.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

20. Impact of practice guideline for managers
Provides evidence of the need for occupation-focused occupational therapy for adults in secure hospitals.
Provides a structure to audit the work of occupational therapists within the service to improve service quality.
Provides a vehicle for justifying service provision.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

21. Impact of practice guideline for commissioners
Articulates the need for occupational therapy interventions within secure hospital services.
Provides recommendations developed by a NICE Accredited process.
Can help educate commissioners to identify learning needs for the workforce.
Audit form provides a mechanism to review service delivery in accordance with the evidence.
NB: Highlight the significance of the guideline having been developed by the RCOT Guideline Development process which is NICE Accredited, e.g.
RCOT practice guidelines developed using the NICE Accredited guideline process are clearly visible in search results on NICE Evidence.
Guidelines developed via a NICE Accredited process are eligible for consideration as evidence in the development of NICE Quality Standards.
Provides robust evidence-based recommendations that can demonstrate to commissioners the benefits of occupational therapy for the community on whose behalf they are commissioning services.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

22. Impact of practice guideline for patients
The recommendations reinforce the fundamental importance of the patient perspective.
In being adopted by services and occupational therapists, the guideline should improve the consistency and quality of intervention for users of services.
Gives assurance that practitioners use the available evidence to support interventions.
Finish by reiterating the importance of a practice guideline in informing work with patients, focusing on empowering the patient to fully engage and take responsibility of achieving individual goals. You may wish to reflect on some of the patient perspectives shown in earlier slides.
Conclude the session by summarising some of the key areas of discussion and messages from the guideline recommendations.
Ask each participant to share a thought about the recommendations and to identify something they are going to do following the session.
If applicable, you may also want to identify how as a service you are going to complete and monitor the Audit Form.
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists

23. Practice guideline resources
Royal College of Occupational Therapists (2017) Occupational therapists’ use of occupation-focused practice in secure hospitals: practice guideline. 2nd ed. London: RCOT.
Audit form.
Quick Reference Guide.
Guideline implementation tips.
Resources are available from the College’s website at:
RCOT Implementation Toolkit/CPD Session
© 2017 Royal College of Occupational Therapists