Emily Sosa

OC TH 6960

Reflective Diary

Date of Experience: June 3rd and 5th, 2019

1) Factual Strand:

One critical incident that took place during my first Level II fieldwork—within a

pediatric home health setting—occurred during week four. It was significant to my

development and ability to take part in a difficult conversation with the caregiver of a

young patient. It involved primarily the mother of the child, my clinical instructor, myself

and to an extent, a nurse providing care to the child during the day. The patient is three

years old, attending preschool for two hours, five days per week, had been receiving

occupational therapy (OT) services with this agency for six months and was due for re-

evaluation. Following his re-evaluation, the child showed no progress on goals or the

standardized testing values from his initial evaluation. He demonstrated no interest in

age and client-appropriate play activities and interventions provided by the occupational

therapist. He was only interested in watching television during our visits and would cry

and remain inconsolable when it was off.

The mother was not present during any OT sessions, only his regular daytime

nurse was available face-to-face. At the end of his re-evaluation, my clinical instructor

discussed with the nurse, potential to discharge the patient around this time from OT

services, due to his lack of progress and active participation in therapy. During the next

scheduled visit, both the nurse and the child’s mother were present. The mother was

upset that the OT was considering discharging her son from services. She also
expressed that she was upset that she had to hear this from the nurse and was not

informed by the therapist and that she did not understand why we were “giving up” on

her son. My instructor acknowledged her concern, presented the progress/evaluation

results and she and I both discussed with the mother, “Episodes of Care” and how it

may be more appropriate for her son to have a break from OT during his transition into

preschool. We informed her that at school he will experience opportunities to build

important play and social skills, as well as continue to have opportunities for other

successes in current physical and speech therapies.

2) Retrospective Strand:

During the incident I felt unsure of my place in handling the situation,

uncomfortable, slightly defensive and also empathetic toward the mother, given the

frustration she was feeling about her son being discharged from OT services. While I

was only a participant in several sessions with this patient, I discovered that team-based

care needs to consistently involve all caregivers—weekly or even session-by-session.

Pediatric therapy processes have more positive and achievable outcomes when home

programs are provided and all caregivers are actively involved and/or aware of progress

or lack thereof during the process.

I realize the mother was upset because she felt an important decision regarding

her child was made without her input. When medical professionals and therapists are

telling her that her child needs and qualifies for certain services, she felt abandoned

when a skilled therapist deduced that the child was not improving, despite her provision

of services. My behavior during the incident contributed to the knowledge provided to

the mother and about “Episodes of Care”. This child is going to have lifelong conditions
that impact his ability to participate and function in meaningful tasks. However, lifelong

therapy is not necessary for him to make progress and be successful.

3) Substratum Strand:

In former pediatric curriculum and fieldwork, I was taught that caregiver/parent

involvement is absolutely vital in the occupational therapy process. In some

circumstances, a small child with high needs may have multiple health professionals

involved in their care, who are often seen as the “experts” by caregivers. The parent in

my situation, appeared to take the “back seat” in the therapy process and allowed

therapists to do the work they deemed necessary to support him, until discharge was a

looming possibility. Regardless of the degree of her involvement in OT sessions the

past six months, my clinical instructor and I know the value and true expert perspective

this mother has of her own child and what she believes is important to support their

roles within their family unit.

Discussion with the mother reinforced that her son was doing well with other

therapies and building up tolerance and a routine at preschool. He may just not be

ready for the task demands and sociability that is required to meet the goals and

objectives that were projected in OT. I learned that the perspectives of caregivers vary

from that of the OT at times and successful sessions require collaboration to meet the

needs of the child/family and to increase occupational participation.

4) Connective Strand:

This experience was the first I had with a parent that was truly upset with the

therapy process and therapist. I realize that I only played a small part in it, as it was

fairly early on in my fieldwork. For my future practice, I need to be more proactive in

getting caregivers involved in therapy sessions, when appropriate and when it will be

most beneficial to the patient receiving OT. I also need to be more dutiful about

providing reports to caregivers and simple activities or home programs for them to carry

out with their child. In order to build trusting relationships with patients and families, I

need to let them know I am there as a support and allow for productive, even difficult

conversations to occur if needed. It is my role to inform them of what the therapy

process might look like early on and whenever re-evaluation takes place. My action plan

will therefore be:

a) Reinforce the important role that caregivers have to practice skills learned in

therapy during activities at home, when I am not there. This needs to occur at the

beginning and throughout the entire process. Provide opportunities for their

success as well as the child’s/patient’s.

b) Check in with caregivers weekly (or as needed) about their thoughts and

questions concerning the therapy process.

c) Look for inservices that provide skills and training for handling difficult

conversations professionally and effectively.

d) Document all interactions with caregivers, as well as their involvement in

sessions.