two page paper

Preparing Students for Consultation Roles al1d Systems

Brian J. Dudgeon, Sharon L. Greenberg

Key Words: learning • problem solving • pro- fessional practice

Continuing changes in human services confront occupation- al therapy students with challenges and opportunities not traditionally associated with entry-level practice. Consulta- tion as an approach to occupational therapy practice has become more prominent in many settings. Although consul- tation is normally associated with skilled or expert practice, new pl'actitioners are expected to provide consultation so that an occupational therapy perspective can be incorporated into interdisciplinary and consumer-based service plans. In this article, we review models ofconsultation and propose that issues ofknowledge, interpersonal skifls, and diversity readi- ness are essential to effectively prepare new practitioners for consultation. Problem-based learning is recommended as a technique to expose students to the compleXity and diversity ofissues to be addressed in consultation. Examples of instructional units that demonstrate the functions ofa con- sultant are provided.

Brian J. Dudgeon, MS, OTR, is Lecrurer, Depanmenr of Rehab- iliration Medicine, University of Washington, Box 356490, Seanle, Washingron 98195.

Snaron L. Greenbetg, MOT, OTR, is Seniot Lecrurer, Deparr- menr of Rehabilirarion Medicine, University of Washington, Seatde, \X/ashingron.

This article was accepted ftr publication March 3 J. J998.

D ynamic changes in human services delivery require

careful appraisal and modifications in teaching

skills for practice. Like other health care providers,

occupational therapy practitioners are involved in the

reengineering of health care (Gage, 1995) and recommitment to practice in areas such as education (Powell, 1994), mental health care (Fine, 1990; Paul, 1996), long-term care (Faust & Meaker, 1991; Trace & Howell, 1991), and other compo- nents of community service (Jaffe & Epstein, 1992). Resource conStraints and control, developing technology,

knowledgeable and diverse consumer groups, and emerging

disabilities contribute to changing the landscape of practice.

Shifts in practice have tended to place specialists, such as

occupational therapy practitioners, in roles outside the tra- dition of direct service to clients and their families. Pro-

viding consultation to colleagues and systems has emerged

as a routine expectation of practitioners in various settings

(Jaffe & Ep,stein, 1992; Mayhan, 1993). Because consulta- tion is commonly associated with expertise, students and

new practitioners may be intimidated or mistaken about

their ability to deliver such service. Given the demands of

practice, occupational therapy practitioners must access and use skills needed to perform in consultation roles even as new pracritioners. This reality calls for educators to eval-

uate skill needs and enhance training for consultation roles.

Occupational rherapy educators must influence and

adapt to changing pracrice environments by altering the content, emphasis, and method of instruction. A current

priority is helping students develop and apply different

kinds of clinical reasoning skills (Neistadt, 1996). Edu- cationalliterature has reflected shifts in practice by training

students to be prepared for models of interdisciplinary

pracrice (Giangreco, 1986), group trearment (Srein & Tal- lant, 1988), case management (Klasson, 1989), and other skills [Q bolsrer and extend practice competencies. During

the past several years, consultarion practices have emerged

in various senings, necessitating efforts by educators to pre-

pare students for such service.

In occupational therapy, three broad types of consulta- rion have been described: (a) case or client centered, (b)

education or colleague centered, and (c) system or program

development based (Dunn & Campbell, 1990; Jaffe, 1988). Client-centered concerns are the mOst common use of con-

sulration in occupational therapy. Colleague consultation approaches often emerge from case management challenge.,

and are used to address personnel preparation needs. System,

or program consultation is most commonly associated with new program development (Jaffe, 1988) or wirh busines:i and industry (Bryan, Geroy, & Isernhagen, 1993). Jaffe and Epstein (1992) considered the use of consultation as an inherenr pan of occupational therapy practice, and their

text described principles of consul ration that apply to di··

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verse practice settings and concerns. They noted that occu- pational therapy programs and other health-oriented cur- ricula do not uniformly include course work on either the theory or practice of consultation and that "students must be provided with an expanded theoretical background and the educational support required for the study of consulta-

tion" (p. 719). No specific approaches to teaching consultation in occu-

pational therapy have appeared. The purposes of this article are to explore the nature of consultation and to elaborate on a framework for addressing consultation that enables stu- dents to approach this kind of practice by using approaches that are relevant to the community and culture. We propose instructional methods that will prepare students to recog- nize the opportunities and obligations of consultation and be able to plan and apply consultation strategies in different practice areas. The approach and examples are suggested for classroom or fieldwork training sessions.

Consultation Models

Consultation has been characterized somewhat differently across professions. In medicine, consultation is often char- acterized by an expert or second opinion or a specialist's counseling and recommendation as part of a comprehen- sive care plan (Schein, 1978). In education, consultation is usually described as a collaborative model of problem solv- ing around shared concerns (Idol, Pailucci-Whitcomb, & Nevin, 1986). In occupational therapy, consultation has been characterized by the interaction between two or more parties who engage in collaborative efforts Gaffe, 1988).

The different definitions of consultation reflect con- trasts in styles. Consultations are commonly organized around the triadic, or three-element, model:

1.� The target (or client, who is anyone with the prob- lem)

2.� The mediator (or consultee, who is anyone with potential reinforcers)

3.� The consultant (who is anyone with knowledge) (Tharp & Wetzel, 1969)

Consultation occurs between the consultee and the consultant in order to foster beneficial change in a referred client. The consultant can have either indirect influence, through collaboration with consultees, or direct influence on the client. The nature of decision making about direct or indirect actions by the consultant or consultee varies across consultative relationships. Various approaches to consultation have been described and subsequently con- trasted in the literature. Collaborative, mental health, med- ical, behavioral, and expert consultation have been intro- duced in other disciplines (Babcock & Pryswansky, 1983; Tindal, Shinn, & Rodden-Nord, 1990). On a continuum, the collaborative approach is characterized by partnership and agreement, whereas the expert approach is depicted as the consultant taking control and influencing identifica-

tion of problems and management of interventions. In a discussion of the roles of participants in these various approaches, Tindal et al. (1990) suggested common rela- tionships that can emerge between consultant and consul tee regarding problem identification and intervention actions. Relationships that are formed and followed depend on the relative perspectives, knowledge, skills, experiences, and re-

sources of the consultant, consultee, and client. We modi- fied Tindal et al.'s work and identified four relationship patterns in consultation:

1.� Consultee Lead: In this arrangement, the consul tee has typically identified a problem and then asks the consultant to validate the problem and suggest remediations. The consultation actions result in the consultant making recommendations to a consultee with little follow-up planned by the consultant and the consul tee's discretion in implementing sugges- tions. This relationship may be regarded as a pur- chase of expertise or second opinion, with the con- sultee having control over interventions with clients.

2.� Consultant Lead: In this approach, the consultee calls on the consultant to identify and clarify prob- lems and subsequently direct the program imple- mentation that may involve direct actions with the client or indirect actions through training and di- recting of consultees. This relationship is likened to the medical system wherein a practitioner provides a diagnosis for the problem, prescribes actions ro be followed by various parties, and monitors the clini- cal course.

3.� Partnership: This approach allows the consultant and consul tee to jointly identify the problem, plan remediation, and continue collaboration throughout program implementation and outcome appraisal. Partnership relationships are viewed as cooperative and dynamic, with shifting and changing responsi- bilities over time. The consultant is typically called on to train, guide, and supervise the consultee's implementation of remediation steps and be present to monitor and negotiate changes in consultant and consul tee actions on the basis of the client's responses to intervention. Ongoing services to children in pub- lic schools often involve this kind of relationship.

4.� Programmatic: Consultation in this mode is focused on education as a direct service to a program, agency, or facility. The consultant trains consul tees in identifying problems and planning and imple- menting solution strategies. The consultant may be asked to help clarify team or system challenges and subsequently intervenes through specific instruction to some or all levels of participants in a system. Con- sultation procedures are often linked to a service or business improvement plan.

Occupational therapy practitioners are encouraged most

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often to use collaborative consultation or partnerships. This

avoids the common pitfall of consultation, which is an ex-

pectation by the client, consul tee, or the consultant that the

consultant is the "expert" and must provide solutions Qaffe,

1988). Instead, consultation can be viewed as a technical skill that involves dynamic human relationships in an ever-

changing environment. In collaborative consultation, con-

sultants are seen as more attentive, successful in develop-

ment of strategies, and successful in the application of

meaningful interventions (Babcock & Pryswansky, 1983; Wenger, 1979).

In addition to recognizing relationships within consul-

tation and the interpersonal nature of partnerships, one must acknowledge the systematic nature of the consultation process. Jaffe and Epstein (1992) suggested that the steps of consultation for occupational therapy are much like treat- ment planning stages (see Table 1). Viewing consultation as a process permits students to follow a systematic approach to consultation opportunities, and the comparison of con- sultation planning to treatment planning orients students to the use of knowledge and clinical reasoning processes that they would apply in other service models.

Educational Strategies

Three interrelated themes for organIZIng educational strategies will prepare occupational therapy students for consultation practice: (a) knowledge, (b) interpersonal skills, and (c) diversity readiness (see Table 2). Knowledge of practice, at bOth theoretical and technical levels, forms the basis of the specialization that an occupational therapy practitioner brings to a consultation. Standards of practice, evaluation and treatment approaches, and the evidence- based practice support for those methods are central to the problem-identifIcation and problem-solving contributions made by an occupational therapy consultant. Orientation to practice settings and systems enables the practitioner to be pragmatic in proposing strategies related to planning and carrying out interventions.

Focused development of interpersonal communication skills are likewise needed (Horton & Brown, 1990). Active listening, mutual respect, clear communication without jar- gon, leadership, and teaching skills enable the consultant to demonstrate knowledge of practice and present his or her

Table 1 Procedural Steps to Consultation (Jaffe & Epstein, 1992) Step Purpose ~---- Esrabfiiliing av~iGb~lity - - - - Negotiation Setting up the consultation relationship Establishmenr of trust Developing mutual undersranding

and respect Mainrenance of procedutaJ steps Identifying the problem, goaJ setting,

decision making on s(rarcgies, implementing the program

Evaluation Measuring effecciveness of inrervenrion Tetmination Closing the case, training, or

program-specific plan Renegotiation Informing about opportunity for

additional services

Table 2 Elements To Address in Preparing Students for Consultation Knowledge Interpersonal Skills Diversity Readiness

St';dards of practice Communication Community Ftames of reference Partnership Cultural Evidence-based practice Leadership Resource systems Practice settings and systems Negotiarion

Education and rrainin

ideas clearly. Readiness or openness in acknowledging and

accepting diversity within and among persons and commu-

nities is crucial to effectively analyze problems that may have

prompted the consultation and are equally important in

reaching theoretical and practical agreements about inter- ventlons.

Preparing new practitioners to work in the increasingly diverse communities of the United States is a need and a challenge (Levine, 1987; McCormick, 1987). Occupational therapy students can be inspired and guided toward sensitive practices that confirm existing and new cultures influencing the client, his or her suPPOrt networks, and his or her com- munity. The concept of culture is essential to occupational therapy practice because practitioners view functional per- formance as an interaction of mind, body, and environment (Levine, 1987). Despite claims that culture is an integral part of care, there has been little formal training for practition- ers, and they have tended to rely on their "personal experi- ences and intuition" (Krefting & Krefting, 1991, p. 102).

Chrisman (1991) offered guidelines and practices for care methods that are culture sensitive and result in better acceptance of interventions and outcomes experienced by clients. He suggested that fundamental to culture-sensitive care are knowledge, mutual respect, and negotiation. Be- cause culture is part of the client system, consideration of culture is necessary. Sources of information suggested by Chrisman and other ideas drawn from medical anthro- pology and transcultural nursing (Mattingly & Beer, 1993) can help prepare the occupational therapy student for diver- sity in ethnicity, spirituality, socioeconomic status, and other characteristics of each client, support network, and community. Levine (1987) suggested the use of ethnograph- ic approaches to study community culture, and McCormick (1987) reviewed some relevant cultural characteristics of commonly served populations and suggested key consider- ations for intercultural communication. He stressed effec- tive interviewing skills with culturally relevant adjustments for use of interpreters, time, touch, and personal space.

Knowledge, interpersonal skills, and diversity readiness are interrelated themes and can best be addressed by a con- sultation framework and teaching strategies that address the complexities of practice. Use of case methods (e.g., problem-based learning [PBL}; Barrows, [1986]) is our sug- gested teaching strategy because it can be organized to em- phasize general as well as specifIc components of consulta- tion practices. In the next sections, we offer a framework for consultation planning and illustrate PBL as an instruc-

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tional method for teaching consultation practice.

Teaching a Consultation Framework

Consultation involves analysis of elements and decision strategies that are paired with usual clinical reasoning. In the triadic model, the three component systems would be:

1. The student, who would view himself or herself as the consultant and may consider this as an individ- ual or team role

2.� The consul tee system, which consists of the primary referral source and others who may be called on to clarifY problems as well as organize and implement interventions

3.� The client system, which consists of the client in a case-centered consultation as well as the client's net-

work of support and community

Figure 1 presents a framework for organizing one's approach to consultation.

The first step for the student as a consultant is to estab- lish the consultation relationship with the consultee system. It is important to determine whether one expects a consul tee lead, consultant lead, partnership, or programmatic focus. In most consultation relationships, the student in a consultant's role must clarifY the problem to be addressed and determine whether the team needs to involve additional kinds of con- sultants. The consultant must then determine needs for fur- ther data collection, options and resources available for intervention, and techniques that may be acceptable to the consultee and client system. The consultant and consultee typically collaborate in making decisions about the con- sultant's direct or indirect roles in data collection, planning, and intervention with the client system.

Next, the student consultant would consider two eval- uation actions: one in relation to the client system and the other regarding the consul tee system. Further need for eval- uation of the client system is likely, and the consultant would guide consultees or take on a direct role in gathering information. The consultee and client systems would then

negotiate objective goals for intervention. A parallel evalua- tion activity by the consultant is appraisal of the consul tee system to determine key members, their orientation to the problem, and resources they would make available for inter- ventIon.

As with direct services, consultation may address the problem by intervening with the client, his or her network,

and the community. The most apparent level of service is to the client. Changes in a client's behavior and his or her will- ingness to make changes are at the core of therapeutic goal setting. A client's willingness to modifY habits and alter val- ues and roles are addressed or reflected in his or her actions. There are many ways in which clients deal with health main- tenance or occupational concerns. These include therapeutic activity programs, learning and use of adapted techniques, assistive technology, and environmental modifications.

The contexts, or environments, where the client func- tions are essential to the change process and are directly affected by efforts to capitalize on the client's supporr net- work and community (Dunn, Brown, & McGuigan, 1994). Often, for a client's behavior to change, social expec- tations and supports must be altered or reorganized. Unique to each client is some compilation of interpersonal connec- tions. Grady (1995) described the building of inclusive communities and identified a person's network of support as the building of a personal community. However diverse, fam- ilies are often a common source of such support. Kelley and Thibaut (1978) described the nature of relationships, family members, or other support systems as being interdependent (i.e., the outcomes clients experience are often contingent on and shared with others). Interdependent networks (or inter- reliant systems) require appraisal and the organization of intervention services characterized by educating, training, and advising. Such a network may need to fundamentally change the expectations on the client or make more subtle changes in communication and assistance. Some members of the network may take on new roles and develop new

skills that will enable them to support and sustain an inter- ventJon program.

Figure 1. Consultation framework for an approach to teaching.

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A third intervention component of the client system is

community. Communities are usually identified by area,

common ties, and social interactions (Eng, Salmon, & Mul- Jan, 1992) or the elements of people, places, and their func-

tions (Schuster & Goeppinger, 1996). Community appraisal can address location, population, and social systems, de-

pending on the purposes of evaluation. In client-centered

approaches, use of interviews, visits, and small ethnography

strategies can be initiated to identify the community and

help determine available resource options (Levine, 1987).

In program-based or system-based consultation, communi-

ty appraisal may be more comprehensive. Methods include

surveys, use of community information resources, partici-

pant observation, or an asset-based approach to communi- ty evaluation (Kretzmann & McKnight, 1993).

In relation to the client system, the consultant and con-

sultees must recognize that they do nOt have membership in the client's community, and they should not assume an understanding of the diverse nature of a particular commu- nity. Those elements that define a community are inherent in characterizing culture. The client system reflects culture as a pattern of living that is learned, shared, symbolically transmitted, and dynamically adapted from one generation to the next (Chrisman, 1991). A community has a dominant culture, but clients and networks may demonstrate idio- syncrasies or subcultures that necessitate individual appraisal (Tripp-Reimer, 1984). Cultural evaluation and intervention needs will differ on the basis of the nature of consultation. Interventions at the community level by consultants or con-

sultees may be organized around themes of advocacy, often through community coalitions (Butterfoss, Goodman, & Wandersman, 1993). Use of primary and secondary pre-

vention approaches to community health and well-being is important in occupational therapy consultations with sys- tems or programs Gaffe & Epstein, 1992) and necessitates thorough knowledge of a community's cultural custOmS,

beliefs, and values. A final issue to be addressed by the student as consul-

tant is the decision to pursue either indirect or direct care. The nature of the consultation relationship may dictate which leadership style to select. This decision relates to

effective problem identification and goal setting as well as leadership and negotiation skills. Consultation involves the use of selective leadership. Idol et al. (1986) characterized

these skills as a flexibility in style that communicates either

telling, selling, participating, or delegating. The novice con- sultant is most likely to tell and sell, whereas the expert would be more skilled and comfortable with parrnering and delegating. These styles are similar to Clark, Corcoran, and Gitlin's (1995) description of new and experienced practi- tioners' work with family members to develop a collabora- tive therapeutic relationship that frequently evolved from a style of directing (or advising), to informing (or clarifying), to more client participation in parrnering (active reflec- tion), to caring (support).

Although students may view themselves as novices,

they should be challenged to consider roles in delegating

responsibility to consultees regarding evaluation and inter-

vention. Because they are inexperienced, students tend to

pursue more direct intervention because this style represents

the traditional model that they have been exposed to in the

classroom. Exploring and proposing alternative methods to

influence the client system through consul tees challenges

the student to consider education, training, and supervision

methods. The essence of this challenge is for the student as

a consultant to have a good knowledge of theory and to

demonstrate techniques though intervention planning. They

must then teach practice so that the consultee carries out

desired actions with the client system.

Using PBL To Instruct Consultation Practices

Learning consultation practice involves students in an ambi-

tious interplay of developing and applying knowledge in a manner that is appropriate for the diversity of settings, com- munities, and cultures in which they may practice. Teaching

consultation practice in a way that prepares occupational therapy students for real-life practice and all its uncertainties (Cohn, 1991) while simultaneously providing a back-

ground that encompasses the "underlying theoreticaL, and sometimes idealistic (italics added) principles of [the] pro- fession" (Wittman, 1990, p. 1131) requires deliberate yet flexible teaching tactics.

Case-based approaches, such as PBL, are effective teach- ing strategies for consultation practice because they require active student involvement, an unfolding stOry with multi- ple end points, and modeling of team learning. The PBL

model involves students in three phases of investigation:

1. Problem identification 2. Self-directed study with tutoring

3. Analysis of learning for application to practice

Case-method approaches have been recommended for

other aspects of occupational therapy student preparation to address clinical reasoning skills (Neistadt, 1987, 1996; VanLeit, 1995), client evaluation and treatment planning (Pelland, 1987; Sviden & Saljo, 1993), and ethics (Haddad, 1988). The World Health Organization (1993) advocated PBL approaches because they reflect the practice environ- ment in which professionals malce decisions and take into

account the resources and the constraints facing clients and their communities.

Case-based learning provides an alternative to tradi- tional didactic instruction and can be used to reflect the

complexity of decisions and options practitioners have with- in consultation practice. PBL is a method that uses clinical cases or problems presented sequentially to simulate a process of data collection and decision making that leads to the generation of diagnostic hypotheses, intervention deci- sions, and adjustments to both as part of case management. Cases drawn from teal practice are presented to the student

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with client system infotmation that is often unfamiliar, vague, incomplete, or too abundant. Such cases require that students actively sort data, explore new learning, make deci- sions, and propose actions. An essential ingredient in PBL is the reflective process that occurs during the unfolding case simulation. Students are encouraged to reflect, with evi-

dence of such reflection demonStrated in cooperative learn- ing group work and discussion. Reflective practice is further facilitated and modeled in the tutorials by instructors.

A general sequence for educators who are planning PBL experiences is to propose learning objectives, to select and develop relevant cases' structure and sequence case informa- tion, to outline available resourceS and tutorial assistance, and to seek peer review and feedback on the learning pack- age. Royeen (1995) described design and implementation of PBL materials in occupational therapy education, and VanLeit (1995) suggested using either paper case, videotape case, simulated client, or real client to foster specific types of skills. Hengstberger-Sims and McMillan (1993) offered guidelines for new writers of PBL materials to organize "learning stimulus packages" that can involve either print or visual materials, simulated clients, computer assistance, or a merging of these modes.

Suggestions to approach the learning of consultation skills via PBL designs are presented in the Appendix. These cases represent different practice areas and reRect distinct consultation practice in client-centered, community train- ing, and program development situations. The cases are designed to provide unfolding information so that students explore issues and practice decision making and reflection during several class sessions. We have developed suggestions for instructor or tutor prompts to direct learning; however, the creative aspects of PBL allow for Rexibility. It is crucial for occupational therapy students to realize that case ques- tions may not lead to a "right answer" but should lead to well-justified decisions made on the basis of knowledge, skills, and active reflection applied to the situation. Learning objectives to guide study and reRect the broad application of learning addressed in such simulations are presented. At the end of each case, it is helpful to point out accomplishments and the need for additional study in specific areas. These types of learning approaches have been successful in the final year of the classroom program because they encourage an active, integrative, and reflective group activity. Despite inevitable time constraints that limit tutorial involvement, students have reported that they were prepared to recognize opportunities and make plans for consultation as part of occupational therapy practice.

Conclusion

Entry-level occupational therapy practitioners are likely to be faced with assuming roles as consultants. A framework

for such practice and a problem-solving approach can be taught in classroom or fieldwork training programs. Con- sultation models and procedures and diversity readiness can

be taught in a didactic format, but to fully appreciate the variability of relationships within consultation, students should have the opportunity to experience this role with a PBL approach. We developed case examples that prompt students to plan consultation by requiring the integration and application of theoretical principles, communication skills, and treatment approaches that necessitate demonstra-

tion of clinical reasoning and reflection ....

Appendix

Problem-Based Learning Outlines

PBL 1. Case-Specific Model: Pediauic-School Practice� Aaron is a boy 8 years of age with spinal muscle atrophy. He uses a pow-� ered wheelchair for mobiliry and a computer as a primary means of writ-� ing and information processing. Aaron recenrly moved ro the area from� Texas, and his family members are of Hispanic descent.�

A consultation requesr is received from the direcror of special edu- cation, who is organizing an evaluation for Aaron's enrollment in special education. The child may qualify but may additionally be served through Section 504 of the Rehabilitation Act of 1973 Amendments (Public Law 95-602)/Americans With Disabilities Act of 1990 (Public Law 101-336) (504/ADA) accommodation approach. A written request for occupa- tional therapy consultation indicates goals of optimizing Aaron's partic- ipation and performance in an inclusive second-grade classroom in which he is newly enrolled at an elementary school.

Stage 1: Develop a Consultation Relationship

Insrrucror or ruror prompts: • Suggest a case-specific partnership model. Who are the likely partici-

pants in this partnership (e.g., classroom teachers or others, client and family members, medical care providers)?

• Validate the goal and meaning of fuji inclusion. What level of partic- ipation is anticipated, and are performance expectations different in any way (e.g., teacher's or principal's expectations and client and fam- ily members' ideas and desires for participation and performance)?

• Plan for the use of other consultants. Are assistive technology special- ists available to suggest desired instructional modifICations, or have adaptations already been made (e.g., access information and resources the family members bring to the classroom program; probe about familiariry the classroom teacher and others have with users of assistive technology)?

• Elaboration activiry: If a partnership relationship was not planned, dis- cuss what role the occupational therapy practitioner might take in a different model (e.g., consultee lead) in meeting client needs, the edu- cational needs of participants, and system or program needs.

Stage 2: Evaluation and Intervention Planning

Instructor or tutor prompts: • What sources of data are available for initial evaluation (e.g., referral

documents and srudent records, an interview with the teacher, an interview with family members)?

• Who are the consul tees (e.g., director of special education, classroom teacher, teacher's aide, school principal, resource specialists, others)?

• Who is in Aaron's personal communiry) What do family members regard as their communiry (e.g., impairment and disabiliry issues unique to Aaron: his mother works in the home, his father works in a nearby ciry, his sibling is in fifth grade at the same school, his grand- parents are our of state, his aunt and uncle live in Aaron's neighbor- hood, his family members are new residents in rown, he attends a neighborhood school, he has seen local muscular dystrophy clinic staff members at the children's hospital and has been contacted by the local muscular dystrophy association, he has sought assistance with local assistive technology information and resource referral center, his family members are members of a communiry church)?

•� Discuss data gathering and intervention planning activities (i.e., information need, indirect source(s), direct evaluation plan(s), senso- rimoror skills, hospital clinic notes, evaluation approaches for mobil-

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ity, communication, and self-care skills}. • Discuss managing learning matetials. • Discuss goal setting, intervention planning, and outcOme apptaisal

planning. What occupational therapy approaches are recommended, and what frames of reference are the basis for these strategies? Does evidence-based practice data exist to support these strategies? Who has primary responsibility to implement the program(s}, monitor prog- ress. and appraise outcomes?

Stage 3: Suggest and Plan for Indirect or Direct Interventiom

Instructor or tutor prompts: • Propose actions that are likely to be taken by the client, nerwork, or

community. • Discuss indirect plans. Who will do whar? What education, training,

or supervision do consultees need to perform?

• Discuss direct plans. What direct service, such as regular therapy or training, does Aaron or his family members need? What monitoring or further consultation is recommended?

Study Aims and Objectives

Knowledge: • Explore and describe criteria used to qualify for special education, and

investigate assistive technology components of individualized educa- tion program (IEP) planning.

• Describe 504/ADA principles of reasonable accommodation and un- due hardship.

• Describe concepts of inclusion and inclusive classrooms. • Describe diagnostic features of spinal muscle atrophy and elaborate

on typical impairment and disability experiences with this type of muscular dystrophy.

• Review and specify needs encountered with powered wheelchair con- trol options, seating needs, mobility limits, transportation needs, and safety and maintenance issues.

• Suggest options for using a laptop computer� to complete drawing, writing, and information processing needs in the classroom.

• Identify environmental bartiers that may exist in mobility and com- munication because of Aaron's disability and use of assistive technolo- gy and then suggest environmental and program accommodations ro address these barriers.

Interpersonal skills: • Plan strucrured or semistructured imerviews with the child.� family

members, classroom teachers, or other consul tees. • Organize skilled observations of the child; identify specific contexts and

activities to be included. • Outline strategies for gathering information from indirect sources such

as school personnel, medical care providers, or other consultees. • Suggest arrangements for determining goals relating to Aaron's partic-

ipation and performance in the classroom. • Propose how arrangemems for IEP goals and methods should be ad-

dressed with family members. • Identify potential education and training needs of specific consulrees,

and suggest at least rwo alternatives for providing needed instruction. • Outline written reportS that would be developed as part of consulta-

tion.

Diversity readiness: • Propose sources of information relating to Hispanic culture. • Outline the types of cultural information that might be gathered as

part of this consultation. • Describe how respect would be demonstrated in this culture. • Identify approaches that might best serve negotiation and compromises

regarding proposed intervemions in this culture. • Suggest ways to appraise resources that might be provided� by local

community constituents such as the church, the local muscular dys- trophy association, or othet programs.

PBL 2. Community-Based Training Program: At-Risk Youth Teen Seeking is a gram-funded program designed to facilitate the tran- sition of at-risk and delinquent youths to residential stability and work through employment training. As an occupational therapy practitioner, you work for this agency and evaluate youths to assist with placements

in employment training programs. The Workzone program has devel- oped supported employment training in carpentry, garden works, and housekeeping.

Michelle is a young white woman. 18 years of age, referred to the program rhrough her transitional living center. Michelle has major depression and a history of at least one hospitalization related to an over- dose of illegal drugs. She has been homeless and has been placed at the Scenic House, a ttansitionalliving center, for up to 18 months. To main- tain this benefit, Michelle must complete 40 hours a week of productive engagement in school, jobs, or chores. She has been enrolled in the land- scape program 16 hours per week bur has been arriving late and missing scheduled times. Similar tardiness and lack of follow-through is indicated

at the living center. Conflicts with supervisors at both sites have occurred, and the handling of Michelle's behavior by supervisors is viewed as unsat- isfactory.

The project director is seeking occupational therapy consultation regarding Staff member training to improve youth parricipation and work productivity in the Workzone programs. Michelle is cited as an example when describing the needs of job-site supervisors. Supervision training is identified as a need.

Stage 1: Devewp a Comultation Relatiomhip Instructor or tutor prompts: • Suggest an educational model� of consultation. How could Michelle

be used as a case-specific example of ttaining needs) • A parrnership approach is expected, given the mutual goal of improv-

ing the Workzone program effectiveness. What other levels of con- sultation might be used'

• What contexts for training are available) What period of time is planned for training?

• Are other consultants needed) • Elaboration activity:� How might planning differ if older adults or

retirees were primarily involved as volunteers with teen supervision and training)

Stage 2: Evaluation and Intervention Planning

Instructor or tutor prompts: • What additional information is needed regarding the consultees' sys-

tem) Who are they, and what skiUs do they have (e.g., program direc- tors, employment counselors, job developers, job-site supervisors)?

• What are the job-site supervisor needs in terms of supervising youths (e.g., job-site supervisors are college students with little to no super- vision background; supervisors teach technical job skills to teens through modeling and direct instruction)?

•� What additional information might be needed regarding the client system?

• What do you need to know about Michelle or the types of interac- tions she is having with job-site and transitional living supervisors (e.g., Michelle was asked to leave home by her parents due to incom- patibility over Michelle's religious beliefs involving satanism})

• What else must be learned about Michelle's community (e.g., job programs, transitional housing, a drop-in medical clinic, or other community resources))

• How will changes in performance be monitored)

Stage 3: Suggest and Plan for Indirect or Direct Interventions Instructor or tutor prompts:

• What kinds of training should be provided and to whom (e.g., prob- lem-solving skiUs, interaction skills, asking for help, giving and receiv- ing feedback}l

• How can� Michelle be used as an example in teaching (e.g., can a descriptive or videotape example be used; would Michelle consent to participate; are other training or educational approaches or options available)?

• What direct intervention with Michelle is warranted) • Whar kinds of outcomes are expected) How will this be determined

and by when)

Study Aims and Objectives Knowledge: • Are supervision styles formal or informal? Describe needs that may fit

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best with at-risk or delinquent teens. Outline components and plans for group and individual instruction in supervision.

• Review diagnostic criteria for major depression and differential diag- nosis.

• Describe� common mental health challenges experienced by delin- quent or homeless yomhs.

• Explore the meaning� or at-risk youth and describe common func- tional and social issues that might contribute to this problem.

•� Outline the major life tasks typically faced by adolescents in the American culture.

• Describe theory regarding development of work skills.

Interpersonal skills: •� Outline a planned interview and observation with job-site supervi-

sors. • Suggest key questions to ask Michelle. • Write performance goals for staff member training. • Submit suggestions for training materials or media ideas that could be

considered for long-term program needs.

Diversity readiness: • Explore lifestyles associated with homelessness by outlining common

occupational performance patterns. • Describe typicaJ social, functional,� and health implications of home-

lessness in this area of the COUntry. • IdentifY� community resources and options that might be explored

with Michelle.

PBL 3. Program Development: Long-Term Care Eloquent Care Systems is a private nonprofit organization that owns and operates a congregate care facility system in which occupational therapy contracts for skilled nursing facility programs. The agency is now seek- ing consulrarion from occupational therapy as part of a plan to open 20 new assisted-living units and a program designed for older adults witn chronic obstructive pulmonary disease (COPD). A business plan that identified the increased prevalence, referral pattern, and consumer in- quiries related to this disorder initiated the move.

A request for assistance is sought from occupational therapy regard- ing planning for:

• Environmental design ro promote function and safety • Guidelines for activities� of daily Jiving and independence assistance

programs • Recommendations for community linkages and participation of resi-

dents in other local programs

Stage I: Develop a Cornultation Relationship

Instructor or tutor prompts: • Propose that the consul tee lead in this relationship� and is seeking

from the consultant a series of specific recommendations for facilities and programs.

• What forms will the recommendations take (written, presentation, or both)?

• Elaboration activity: How would your approach differ if a partnership relationship was proposed?

Stage 2: Evaluation and Intervention Planning

Instructor or tutor prompts: • Who are the consultees (e.g., chief executive office-board of directors,

program director, nursing supervisor, resident council)? •� Which residents would be served (e.g., diagnostic levels of COPD,

other cardiopulmonary disorders, community culture, socioeconomic factors, local services)?

Stage 3: Suggest and Plan for Indirect or Direct Interventions

Instructor or tutOr prompts: • What data collection must be carried out and by whom (e.g., needs

evaluations of adults with COPD, common environmental adapta- tions and sUPPOrt needs, activity programs and fitness needs, options for assistance programs)?

• What forms of reportS and follow-up are anticipated (e.g., housing design elements and furnishings, assistance methods, community linkages)?

Study Aims and Objectives Knowledge:

• Appraise organizational planning options in congregate care or long- term-care agencies (e.g., home healtn care, retirement centers, adult family home, assisted living, skilled nursing facilities)

• Review diagnostic information related� to population of adults with CO PO (age, gender, socioeconomic status, ethnicity, impairment ex- periences, common disabilities reponed, artitudes in community).

• Describe use of senior information and assistance programs available in your county.

• SpecifY energy conservation and work simplification principles� to be recommended.

• Outline fitness strategies for chronic healtn impairments and chronic and progressive cardiopulmonary disorders.

• Review and suggest transgenerational design options to accommodate predicable disability issues.

Interpersonal ski lIs: • Suggest language to use regarding assistance needs and goal setting. • Write a dream-building statement for tne planned facility� and pro-

gram and use communication withom jargon. • Outline written report needs. • IdentifY educational initiatives with clients and nerworks, the com-

munity, the board of directors, and staff members.

Diversity readiness: • Propose� methods to appraise ethnic diversity in local referral com-

munity. • IdentifY� sources for information regarding community activity

resources. • Distinguish berween spiritual and religious traditions and resources in

the local community and describe now tnese services may be included in residential support programs.

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