This article proposes a response to the question: what occupational therapy input will best serve to increase occupational opportunities and limit barriers to participation for older people in residential care? Furthermore, the article addresses some of the complexities facing an occupational therapist contracted or employed to provide services within aged care facilities in New Zealand.
Various factors impacting on services informed the conceptualisation of a proposed practice framework for the provision of occupational therapy in residential care facilities. This includes rest homes, private hospitals and secure dementia care units. The need for an evidence-based, systemically targeted approach to service provision is identified in light of the limited resources available to attend to individual residents' occupational needs. In order to maximise health and well being, the framework addresses responsibilities for residents' occupational needs at multiple levels within a residential care organisation.
The rationale for developing the framework was to guide decision making about the occupational therapy role in a residential practice context. By distinguishing three different approaches: direct service delivery (working with residents); educational (working with staff); and policy development (working with management), the framework identifies the building blocks of a viable occupational therapy service. In order to highlight the significance of this, it is useful to explore some of the issues contributing to the current situation in aged care and discuss factors that provide potential solutions.
The imperative to action
In 2006, O'Sullivan and Hocking comprehensively and convincingly addressed the challenging issues facing positive ageing in residential care in New Zealand. They described serious concerns regarding the prevailing climate of occupational deprivation in care situations and identified several barriers to achieving positive health and well being for people in residential care. An expectation of passivity and frailty by staff, economic factors (funding and wages), and limited staff training were examples given. O'Sullivan and Hocking based their argument on literature from a variety of disciplines, which describe the benefits of physical activity, personal control and self efficacy (p. 18), being in a vibrant and cohesive community, and maintaining a sense of self through occupation (p. 19). Similarly in Australia, Snowdon and Fleming (2008) described "grief over loss of opportunities and abilities to take part in valued activities, ... not being involved in helping others, and attending but not taking part in activities" as "factors most highly associated with development of depression" (p. 298). Spurred on by these perspectives, we embarked on a reconsideration of the occupational therapist's role in residential care services for older people, and how occupation could be brought into focus. The first step was to search the professional literature and government policies for insights and support.
Defining health and health care
In order to do justice to quality of life and healthcare issues for older people in residential care, the importance of providing effective occupational therapy services needs to be argued at several levels. In relation to the multiple and complex health-related challenges older people face, it should be acknowledged that the ultimate purpose of healthcare is more than the absence of disease. This has been endorsed by the World Health Organization's (2001) International Classification of Functioning, Disability and Health (ICF). Hocking (2003) described the ICF's proposal in occupational terms as: "helping people to participate in the everyday occupations that give life meaning" (p. 189). Achieving that has been described as "removing obstacles to the achievement of biological or chosen human potentials" (Seedhouse, 1998, p. 6) and, consistent with occupational therapists' understandings of the therapeutic power of occupation, as "human flourishing" (Seedhouse, p. …