Guided or Directed: How Therapists Describe Their Intervention Approach in an Inpatient Setting

PURPOSE: Research suggests patient outcomes may be influenced by the approaches therapists take in the rehabilitation process. A directed approach emphasizes therapists’ knowledge about how therapy needs to be done. A guided approach maximizes patients’ knowledge to problem solve solutions (functional cognition). Therapists’ approaches at the activity level have not been widely researched. This pilot study sought to differentiate between a guided and a directed approach of therapists working in inpatient rehab.

METHOD: A mixed-design study explored the approaches used by therapists (N = 17) during inpatient rehab interventions. A 19-question survey was used to collect data regarding what happens at the activity level. The researchers designed the survey after a discussion of what directed and guided approaches look like—that is, what the therapists would be doing or saying to the client. Statements were then formulated around action statements. Therapists could respond to the statements on a scale of 1 to 5, with 1 indicating that the therapist never used the approach and 5 indicating that the therapist always used the approach. A response of not applicable was an option. Four days later, a focus group was conducted and data were audio recorded. The focus group took the form of a focused group interview. There were only four questions to center the discussion in a time-efficient manner and elicit quality information about therapist use of the approaches and challenges or benefits of using different approaches.

RESULTS: There were 17 therapists represented, 10 occupational therapists (OTs) and seven physical therapists (PTs) and 15 women and two men. The participants included one certified occupational therapy assistant (COTA), three bachelor’s-level OTs (BSOT), five master’s-level OTs (MSOT), one doctoral-level OT (OTD), three bachelor’s-level PTs (BSPT), one master’s-level PT (MSPT), and three doctoral-level PTs (DPT). Years of practice ranged from 0.25 to 37 yr and averaged 14.6 (SD = 10.9).

Findings suggest that the survey questions were able to differentiate between a guided and a directed approach. Higher scores, theoretically, represent a more guided approach. Survey statements that implied a client-centered approach, such as including client-identified goals in the plan of care, letting the client be involved in the planning process, and using functional activities in treatment, were generally scored high. Statements that asked for the client to be more engaged at the activity level, such as asking the client to initiate, problem solve, review, and give feedback about performance, were generally scored lower.

OT practitioners, on average, scored lower (3.40) than PT practitioners (3.80). OT practitioners with less education (COTA, BSOT) and longer years of practice (average of 30 yr) scored higher (3.51) than the MSOT and OTD practitioners (3.25 and 15 yr in practice). PTs, across educational degree groups, averaged a score of 3.80, with the BSPT and MSPT practitioners scoring slightly higher (3.89) than the DPT practitioners (3.65). Across the combined disciplines, the average survey scores by degree type were bachelor’s, 3.70; master’s, 3.53; and doctorate, 3.50. Analysis of the focus group responses indicated that the therapists recognized the importance of patient-initiated problem solving but were reluctant to give up too much control. Constraints such as the patients’ cognitive abilities, time, and demands of the setting limited therapists’ ability to use a more guided approach.

CONCLUSION: By understanding a guided, a directed, and a combination approach, therapists may become more self-aware of how they can use these approaches. The OT profession has prioritized functional cognition as an important focus of research. How therapists approach intervention at the activity level needs to be more fully understood, studied, and linked to outcomes. Future research should explore the relationships among the types of approaches, patient characteristics, and patient outcomes.

References

Skidmore, E. R., Dawson, D. R., Whyte, E. M., Butters, M. A., Dew, M. A., Grattan, E. S., . . . Holm, M. B. (2014). Developing complex interventions: Lessons learned from a pilot study examining strategy training in acute rehabilitation. Clinical Rehabilitation, 28, 378–387. https://doi.org/10.1177/0269215513502799

Urquhart, J., & Skidmore, E. (2014). Guided and directed cues: Developing a standardized coding scheme for clinical practice. OTJR: Occupation, Participation and Health, 34, 202–208. https://doi.org/10.3928/15394492-20141006-05