Developing occupational therapists’ capabilities for decision-making capacity assessments: how does a support role facilitate workplace learning?

For the purposes of this study, performing decision-making capacity assessments (DMCAs) was identified as a capability. Essentially, a DMCA assesses an individual’s ability to understand and appreciate the nature and effect of a decision, freely and voluntarily make the decision, and communicate the decision [10‐12]. Healthcare practitioners are increasingly encountering situations where assessing a client’s decision-making capacity plays an integral role in the management of their care [13‐15]. Concerns about capacity may be triggered when clients make choices that put their health, assets, property, self or others at significant risk of harm, and they appear to lack an appreciation of the reasonably foreseeable risks and consequences associated with those choices [12, 16].

DMCAs are considered to be capabilities for the following reasons. Firstly, practitioners need to know that DMCAs are multifaceted, time consuming, intrusive, and may have serious and far-reaching legal, ethical and practical implications for clients [17]. Therefore, best practice is that they are undertaken only if: 1) there is a need for a decision to be made, 2) there is a significant risk of harm, 3) all reversible conditions which may impact on decision-making have been ruled out, and 4) all less restrictive options for managing the risk of harm have been exhausted [18]. Secondly, DMCAs are interprofessional and should involve input from medical and allied health professionals who can undertake holistic evaluations of the psychological, social, cognitive, functional and medical factors, as well as a direct assessment of the person’s decision-making process [18, 19]. Finally, occupational therapists’ contributions to DMCAs are valued [11, 18‐20], particularly where there is a question about an adult’s ability to make decisions about personal matters such as discharge destination or care arrangements [16]. In these situations, occupational therapists can provide supporting evidence regarding a client’s functional abilities, limitations and associated risks of harm, and implement interventions to maximize independence and minimize the risks of harm. Delivering these assessments and interventions requires the integration of specialized and non-routine and non-procedural knowledge and skills, and the development of an extended professional identity which includes contributing to DMCAs. Additionally, occupational therapists need to apply their capability in unfamiliar and varied contexts where each case is unique.

Several studies have demonstrated that medical and allied health professionals often lack the readiness required to perform DMCAs [13, 19, 21‐25]. These findings highlight the need for additional education, training and support. However, existing research tends to focus on implementation strategies, that is, how to best implement DMCA in healthcare settings and the main pedagogic practice adopted, as part of the implementation, was workshops [18, 19]. Whilst their evaluation of the workshops reported an increased understanding of concepts relating to DMCAs, workshops may not fully meet learning needs as they are often decontextualized from authentic practice experiences [26]. Indeed, a further evaluation found that the combination of dedicated resources, timely access to education and mentoring enhanced health professionals’ self-reported ability to confidently, competently and collaboratively conduct DMCAs [25]. However, practical strategies for educators are absent.

In 2013, the occupational therapy department of a large metropolitan state-funded hospital allocated temporary funding for a senior level occupational therapist to develop and implement a dedicated Decision-Making Capacity Assessment (DMCA) Support Role for occupational therapists. The purpose of the DMCA Support Role was to facilitate occupational therapists’ development of knowledge, skills, attitudes and confidence required to contribute to DMCAs. A range of pedagogical practices were implemented as part of a structured workplace practice curriculum. These included direct instruction (1:1 and small group sessions, work shadowing and joint assessments), guided learning (personalized advice and ‘hands-on’ guidance to work through each step of capacity cases), and resources to support learning and clinical reasoning (flowcharts, interview guides and documentation examples). However, it is not clear how the DMCA Support Role may have contributed to occupational therapists’ learning.

Whilst other studies have begun to explore how specific skills, such as prescribing, are developed in the workplace [27, 28], a comprehensive understanding of how the development of capabilities can be facilitated is lacking. This understanding will assist with generating practical strategies for practice-based educators to support the development of other capabilities through practice. Using decision-making capacity assessments as an example, the research described here explores how capabilities, from the learners’ perspective, i.e. occupational therapists, were developed through the practice-based pedagogies enabled by a dedicated support role.

This qualitative interview study, informed by workplace learning theory, aimed to explain from the learner’s perspective how a dedicated support role develops occupational therapists’ capability to contribute to decision-making capacity assessments. A secondary goal was to share our understanding of how capability development can be facilitated in the workplace.

Workplace learning theory explains how practitioners learn in the workplace and can be understood as an interdependent process, where meaningful learning is dependent on the interaction between the available work activities and experiences (i.e. affordances), and the way learners choose to engage with them (i.e. engagement) [32]. The quality of learner engagement with workplace affordances is dependent on their readiness, that is: what they know, can do, and value [32]. Learners can be supported to develop different types of knowledge, including conceptual knowledge (what individuals know), procedural knowledge (what individuals can do) and dispositional knowledge (what individuals value) through establishing a structured practice curriculum and implementing a range of practice pedagogies. Expert guidance can enable individuals to extend their scope of learning beyond what they could achieve through their own efforts [32]. These considerations are important to understand how dedicated support roles contribute to workplace capability development through augmenting the interplay between contextual considerations (i.e. affordances) and individual engagement.

This study was conducted in a large Australian tertiary hospital (750 inpatient beds). Ethical approval for this study was obtained from the Human Research Ethics Committee of the Gold Coast Hospital and Health Service. HREC/16/QGC/324. This research was carried out in accordance with the Declaration of Helsinki. Approximately 65 occupational therapists work within an occupational therapy department that services acute care and rehabilitation settings. Across these settings, occupational therapists receive approximately 350 referrals per year to assist with gathering information to inform DMCAs. These referrals represent a small proportion of total referrals but often consume a disproportionate amount of time due to their complexity. Prior to the establishment of a part-time (0.4 FTE) DMCA Support Role in 2013, there was no specific education or support available to guide occupational therapists’ practice in this area. The DMCA Support Role was established and championed by managers, who allocated a proportion of existing funding to it, with the goal of improving occupational therapists’ capabilities and contributions to DMCAs. It was separated from line management structures and not involved in performance evaluation or management of staff. The persons employed in the DMCA between 2013 and 2017 also worked in other clinical and education roles in the same organization.

Occupational therapists were eligible for inclusion in the study if they had accessed the DMCA Support Role for a period of at least 6 months. Purposive sampling [33] was used to select participants who were likely to provide rich information and a diverse range of perspectives about how the DMCA Support Role influenced their learning [34]. We purposively sampled a mixture of recently graduated, junior and senior occupational therapists, and those working in different practice settings including acute care and rehabilitation. Eligible participants were invited to participate via an emailed letter including a participant information sheet and consent form. Invitations and responses were managed by an independent administrative officer to minimize the influence of social desirability bias on the decision of potential participants to take part. All participants provided informed consent. Participants were recruited until sufficiency was achieved, that is, answering our research question and providing rich insights ensuring transferability to other contexts [35].

Billett’s workplace learning theory [8, 32] informed the development of the interview guide. The interview guide included questions about participants’ personal history of learning about and developing knowledge and skills to contribute to DMCAs, their experiences of engaging with the DMCA Support Role and their perceptions of the influence this support had on their practice. Questions were semi-structured to elicit a broad range of responses.

Individual face-to-face interviews were conducted in early 2017 by two independent senior neuropsychologists working in the same hospital. These interviewers were not involved in the development or implementation of the DMCA Support Role but nevertheless had an in-depth understanding of the complexity of DMCA and an awareness of the purpose of the DMCA Support Role, and thus were able to ask appropriate probing questions. Both interviewers were thoroughly briefed regarding the aims of the research project. Interviews were MP3 recorded, transcribed verbatim by a professional transcribing service and de-identified. Following the completion of their face-to-face interview, participants were also invited to confidentially add any additional comments via a secure online platform.

Thematic analysis was undertaken using a recursive process and following the phases described by Braun and Clarke [36]: 1) becoming familiar with the data by reading the transcripts, 2) generating initial codes, 3) grouping the codes, based on workplace learning theory, and developing themes, 4) identifying patterns in the data through participants ‘indigenous categories’ [37], and 5) defining and naming the themes. Specifically, one author (JM) read and openly coded all transcripts, identifying keywords, concepts and recurring patterns of meaning in the data. Another author (CN) also openly coded a sub-sample of four transcripts. A small number of discrepancies were resolved through discussion and the resulting codes were then applied to all transcripts by JM for consistency. The codes were collated into preliminary semantic themes which were then reviewed and further organized and synthesized using workplace learning theory [32] as a frame of reference. Throughout this process, mind maps were used to conceptualize relationships between themes [36]. All the authors were involved in this final phase of analysis to maintain reflexivity, challenge assumptions and to check the validity to help maintain trustworthiness, credibility and accountability of the findings [38]. The authors participated in regular meetings which helped them to develop their understanding of workplace learning theory and how it applies in the context of this study. Ultimately, all the authors agreed on the final themes. These themes were then also checked and confirmed by a sub-sample of interviewees to be accurate representation of their perspectives.

All participants noted that by engaging with the DMCA Support Role, their learning experiences were structured and sequenced in a progressive way. Most participants reported having no or limited knowledge about DMCAs prior to engaging with the DMCA Support Role, and those who had worked in the department prior to the Support Role being established recalled a lack of information, support and resources. Following an introductory education session, participants described being given opportunities to work through a series of authentic DMCA cases with ongoing graded support. Some participants recalled receiving more intensive support for their first few DMCA cases, followed by decreasing support as their capability and confidence increased over time. However, even more experienced participants continued to access support for complex cases.

Half of the participants reported that the DMCA Support Role supported them to make explicit links and associations between new and existing knowledge. For example, they were asked to reflect on their previous experiences of contributing to DMCAs and to consider the similarities and differences between cases. Further, they were guided to compare the scope of their role in DMCA with the more general occupational therapist role in acute care and rehabilitation settings, and to consider how their knowledge and skills were transferable between these contexts.

Participants described how the DMCA Support Role provided them with different types of guidance depending on their needs and preferences. Most participants described receiving information and direct instructions about what to do and how to do it, alongside in-depth explanations of the reasoning behind why they should be doing it, i.e. in relation to best practice principles and professional values.

In addition to receiving information and instructions directly from the DMCA Support Role, most participants reported that they benefited from having access to resources and artefacts such as written guidelines, flowcharts, case studies, templates and worked examples. While some participants valued direct instructions, others preferred to utilize the Support Role as more of a sounding board to talk through their observations and clinical reasoning, gain a second perspective or seek confirmation of being on the right track. This is illustrated by the following quote:

The advice that I received from the Role tended to be more confirming, … it kind of extended on what I’ve already been thinking … to take you through the next step and to that next level of considering what’s happening. [OT11]

Most participants reported learning from demonstration and modelling of how to conduct an interview, write a report or communicate recommendations with other members of the team. Participants appreciated opportunities to be involved in joint sessions, during which they could observe more complex or unfamiliar steps while still maintaining an active role in the assessment process. Some participants valued receiving feedback and support to reflect on their practice, which helped them to continually improve their knowledge and skills.

Of note, there was variability in how participants engaged with the DMCA Support Role. While some actively sought out support, others were more passive in waiting for the Support Role to initiate contact. A key factor which seemed to influence this was having an appreciation of the seriousness of DMCAs and valuing what occupational therapists can contribute to the management of these cases.

In addition to receiving tailored guidance, participants emphasized the importance of having a supportive and trusting relationship with the DMCA Support Role, which allowed them to feel comfortable asking for help, participating in joint assessments and receiving constructive feedback on their performance along with plans for subsequent improvement. This was facilitated by building rapport, being approachable, normalizing DMCA as a challenging area of practice and separating the DMCA Support Role from line management and performance evaluation processes.

Another important factor reported by most participants was knowing that the Support Role is consistently available, responsive and able to provide timely support when it was needed. This is illustrated by the following quote:

I feel very supported with (the Role). I know that as soon as I get one that may be even looking like (a capacity case), I know that I’m going to have as much support as I need. [OT5]

In these ways, the participants valued being supported as they developed their capability in conducting DMCAs.

This study investigated how capabilities can be developed in the workplace when supported by a dedicated support role. A key strength of this study is that it offers a fresh perspective on practical strategies to support learning through practice which are theory informed. The final themes evolved through regular reflexive discussions between authors which led to a deeper understanding of how learning takes place. Author CN challenged JM to consider how workplace learning theory can illuminate and explain the processes of capability development as influenced by a dedicated support role [44]. Whilst JM in turn possessed an in-depth and rich understanding of the context and data ensured that the findings were confirmable [45] i.e. based on the participants’ perspective.

As with all studies, there are limitations to our work. First, this was a single institution study using a small sample of occupational therapists which is not necessarily representative of the wider population of occupational therapists or other healthcare practitioners. However, using workplace learning theory as an analytical framework enabled a comprehensive understanding of the key features required for capability development [46]. Secondly, the findings of this study were undoubtedly influenced by factors relating to the local environmental context and characteristics of the person who occupied the DMCA Support Role, who was also a member of the research team. Yet potential transferability is enhanced by rich descriptions and purposive sampling [47, 48]. Also, to address the potential for positive bias, participant recruitment and interviewing were conducted by independent investigators, and participants were assured confidentiality.

Third, participants provided self-reports of factors influencing their learning. These self-reports may not be an accurate reflection of their actual learning or changes in their capabilities. However, they are important accounts because they represent the learners’ lived experience of engaging with the DMCA Support Role. This was an initial study to explore participants’ perceptions of how strategies implemented by the DMCA Support Role had influenced their learning.

Whilst this study provides important insights into how a support role can facilitate the development of capabilities in clinical settings, there would be value in conducting similar studies to examine the development of other capabilities within different clinical settings, such as end-of-life care outside of traditional palliative care settings [49]. Follow-up observational studies would be helpful to specifically map the pedagogic practices used and examine the influence of different affordances, such as social and contextual factors [8]. Additionally, further research could evaluate changes in learners’ knowledge, skills, attitudes, and resulting changes in their clinical practices [50]. Finally, there would be value in evaluating the financial sustainability of the model.