Over the last century occupational therapy has developed into an autonomous healthcare profession (WFOT 2007) whose associated professionals are afforded the privilege to ‘exercise judgements for the benefit of others’ (Ilott 2008, p. 178). With professional autonomy, however, comes accountability and all occupational therapists are personally accountable for their professional work (COT 2011). They are responsible for their actions, need to be able to justify their decisions, and accept the consequences for any misjudgements (College of Nurses of Ontario, n.d.). Set in the context of trust, this chapter explores what it means for occupational therapists to be professionally accountable in practice.

What is Professional Accountability?

Simply deconstructed, the term accountability is the ability to give an account of something; to describe or document an action or event. Associated dictionary definitions include the term to ‘bring to account’, meaning to give reason or justify what has been done. Professional accountability can therefore be understood to be the evidence of, and justification for, provision of services under the scrutiny of others. Traditionally, a democratic public has been able to put their trust in professionals with an expectation that they will do their job well for the benefit of others, or at the very least they will not take advantage of, deceive, or exploit others. In her lectures about trust, O’Neill (2002) questions whether modern society is undergoing a crisis of trust in which professionals are no longer deemed to be trustworthy and there is an expectation for professionals to continually provide evidence of their actions. In the current economic climate, there is growing pressure to show effectiveness, to provide indicators of performance and to reach targets. Failing public trust has also brought about an urge to make services more transparent; for professionals to publish facts and figures and make information widely accessible through media and technology. Where there is greater transparency, however, there is greater risk of a breach or abuse of confidentiality, or misinformation and deception.

The consequence of all this is accumulating public mistrust, which leads to sanctions that make government, professionals and institutions ever more accountable. The increase in stringent measures to scrutinize, control and reach managerial targets has created a culture of bureaucracy, which inhibits the performance of the professional and hinders their ability to do the job itself. ‘Professionals … must in the end be free to serve the public rather than their paymasters’ (O’Neill 2002, p. 5). For occupational therapists, there are rising expectations to fulfil processes of accountability which jeopardize therapeutic time with those they serve, thus threatening the fundamental philosophy of person-centredness which should underpin practice. This chapter describes some of the accountability processes that impact on the working lives of occupational therapists in mental health practice and explores ways in which they can adhere to demands for performance and audit, but also stay true to the real work of the profession, providing an efficient, effective and acceptable face-to-face intervention in service users’ lives.

National Standards

Wherever in the world occupational therapists work; whether it is in healthcare, social care or non-traditional, role-emerging settings (Harrod 2007), they will be subjected to fluctuating and evolving working environments (Creek 2003). However many institutional changes they have to endure they are still expected to continuously provide excellent and effective services. To help them reach those high expectations of care, their duties are based on a set of published guidelines.

The World Federation for Occupational Therapists (WFOT) places responsibility for competent, ethical and professional behaviour on each of its associate country’s lead professional organizations. Any authority that has not developed standards for practice in occupational therapy is expected to follow those of the WFOT (2007). Membership countries of the Council for Occupational Therapy in European Countries (COTEC) are all obliged to have a Code of Ethics and Professional Conduct to ensure excellent, safe and equitable services are provided, with the best interests of the public they serve at heart. ‘An overall mission of the Code of Ethics is to promote high professional standards and quality in occupational therapy practice based on person-centred or user-oriented principles and social responsibilities’ (COTEC 2009, p. 9).

Professional accountability will be illustrated in this chapter, by focusing on the systems used to regulate occupational therapists working in the UK. The Code of Ethics and Professional Conduct, published by the UK College of Occupational Therapists (2010a), is used extensively in this chapter to highlight the professional standards that UK occupational therapists are expected to abide by. This code will be similar to codes of conduct published in other countries (albeit expressed slightly differently, perhaps) For non-UK readers, if the precise detail of the UK code is not applicable, the underlying principles undoubtedly will be. Hence, this chapter is suitable for students and occupational therapists across the globe.

TO WHOM ARE OCCUPATIONAL THERAPISTS ACCOUNTABLE?

The issue of who occupational therapists are accountable to is complex and multifaceted. Ultimately, and most importantly, occupational therapists are accountable to the society they serve. The public have rarely questioned the care they receive from healthcare providers and fundamentally believe that, because they are seeing a professional, they will receive a good service. However, this perception has shifted and a few notorious cases in the UK have epitomized the crisis of trust. On the basis that they were ‘trusted’ professionals, nobody suspected family doctor Harold Shipman, or the nurse Beverly Allitt, of killing their patients. These cases prompted more stringent legislation for professional registration in the UK. The legislation intended to protect members of the public and reassure them that appropriate systems were in place to detect and deal with the malicious minority (DH 2004).

Unfortunately, these systems have since failed to protect the public from unacceptable risk and maltreatment, as was the case at Mid Staffordshire NHS Trust. The failings went far beyond a few malevolent individuals and the whole trust fell into a business culture striving for foundation status, instead of a culture that put patients first (Francis 2013). This epitomizes the danger of prioritizing paymasters over individuals and prompted occupational therapists in the UK and beyond, to reconsider their professional responsibilities and revisit relevant ethics and standards guidelines published by their regulating bodies (COT 2013).

Society

In the UK, occupational therapists are now regulated by the Health and Care Professions Council (HCPC). The title ‘occupational therapist’ is protected by law (COT 2010a) and can only be used by those registered with the HCPC. Originally set up in 2001 as the Health Professions Council, and recently reconfigured as the HCPC, this body keeps a register of health professionals who meet a set of standards for health, training, professional skills and behaviour. In order to register, an accredited course must be completed and standards maintained for continued registration. Occupational therapists are also accountable to wider society via the criminal justice system. If a criminal offence is committed they are subject to criminal justice proceedings and could be tried in a criminal court (COT 2011). Indemnity insurance is used to protect occupational therapists from the personal financial cost of this, but the outcome of proceedings may be that an individual is struck off the HCPC register. The UK Code of Ethics and Professional Conduct, though not legally binding, can be used as evidence in any civil or criminal proceedings as a measure of reasonable and acceptable practice. It would be difficult to put up a defence against allegations of negligence if these standards had not been followed. Similarly, it would be difficult to substantiate a claim of unfair dismissal before an employment tribunal if an employer could establish a persistent failure to meet these standards.

Employers

Occupational therapists are accountable to their employers and must work within the terms and conditions of their employment and job description. If they do not, they could face disciplinary proceedings or dismissal. The UK Department of Health has produced a knowledge and skills framework (KSF) – which staff employed by the NHS are required to work to – in order to regulate service quality (DH 2004). The core dimensions require all staff to demonstrate certain standards in communication, development, safety, improvement, quality and diversity. Professionals employed in posts with higher profiles are expected to take on higher levels of proficiency and responsibility; to handle diverse data and work with complex information, to collaborate and develop working relationships, to work safely, and successfully assess and manage risk. Employers will expect occupational therapists to make critical evaluations of outcomes, be able to reflect and review practice, be able to solve problems, have excellent interpersonal skills in order to relate sensitively to others and have an aptitude to learn and undertake self-improvement (HCPC 2013; Higher Education Academy 2008). Employers will also expect employees to keep up-to-date with mandatory training requirements which may include:

■ Fire training

■ Moving and handling

■ Infection control

■ Basic life support

■ Conflict resolution

■ Safeguarding adults

■ Child protection

■ Data protection.

Employers produce local policies to ensure employees work within the framework of national legislation and staff training is just one standard by which NHS services are governed to ensure high standards (see Box 7-1).

BOX 7-1

CLINICAL GOVERNANCE

In the UK, the National Health Service (NHS) has developed a regulatory structure called ‘clinical governance’. It is defined as ‘a framework through which National Health Service organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’ (DH 1998, p. 33). It is an umbrella term that includes working in partnership with service users, carers and the public, to develop and deliver services, manage risk, audit services, ensure services are effective, are based on the best available evidence and ensure that staff are recruited and managed effectively. Healthcare organizations have always had to be financially accountable but with the emergence of clinical governance (DH 1998) came the responsibility for the safety and quality of services. The Health Act (DH 2009) made it a statutory duty to produce an annual Quality Account, which reports to the public about the quality of services delivered. Essence of Care (DH 2010b) aims to support this quality improvement by providing a set of benchmarks to help practitioners identify and share best practice and to develop action plans to remedy poor practice. Although these systems were developed to regulate the NHS many other providers in the UK use them to monitor the quality of their services.

Any frameworks implemented to improve practice will, in principle, raise standards, but, as discussed in the introduction, there may be a conflict between employers’ expectations for undertaking accountability processes (driven by management priorities) and a professional practice in keeping with occupational therapy values and beliefs. In practice, these accountability processes may detract from person-centred working because more time has to be spent in training and governance obligations. (Savage and Moore 2004) which seem only to serve paymasters needs for the purpose of continued commissioning or as defence against a litigious society which no longer has trust in professionals. By maintaining the core values of their profession, occupational therapists should look to training in order to maximize the quality of their service and involve people in the governance process, in order to improve their experience of it (Jones and Stewart 1998).

The Profession

There is an argument that occupational therapists are accountable for what makes their profession unique, particularly in an era where practice is orientated to recovery (Deegan 1988) and more open to influence from the service user movement (WHO 2010). Occupational therapists strive to be person-centred; working ‘with’ people, rather than ‘for’ them (Creek 2003). There is a sense in which occupational therapists should uphold what makes the profession unique. In 2006, the UK’s College of Occupational Therapists (COT) produced ‘Recovering Ordinary Lives’, a ten year strategy aiming to reassert the profession’s belief that occupation is core to health and wellbeing. ‘No Health without Mental Health’ (DH 2011) is the UK Government’s 10-year mental health strategy. The COT response to this document states ‘Occupational Therapy (OT) looks at the person as a whole and takes a personalized approach to recovery; helping patients to get back to work, maintaining social and personal identity, and increasing participation in all areas of life’ (Scott 2011). The Code of Ethics and Professional Conduct (COT 2010a) provides occupational therapists with an accountability framework upon which to base professional standards and behaviours, while remaining person-centred and staying true to occupational therapy values. The code is divided into the following sections:

■ Service user welfare and autonomy

■ Service provision including risk management and record-keeping

■ Personal and professional integrity

■ Professional competence and lifelong learning

■ Developing and using the profession’s evidence base.

These headings have been used to structure discussion over the rest of this chapter.

SERVICE USER WELFARE AND AUTONOMY

Once a therapeutic relationship between a member of the public and a professional has been established, the professional takes on responsibility to ensure the wellbeing of that person. First, someone’s ability to make decisions, in other words their mental capacity, should be assessed. Capacity should be assumed unless proven otherwise and is considered for each individual situation. If a person is deemed to lack capacity, action should be taken in their best interests and in the least restrictive way (Mental Capacity Act 2005) (see Ch. 10 on Ethics, for a wider discussion on mental capacity). When someone is referred to an occupational therapist, it is then important to obtain informed consent for assessment and for further interventions. Gaining consent is not a one-off event but an ongoing process and individuals should be aware that they can refuse intervention at any time (COT 2010a). It is not about signing a piece of paper or giving verbal consent on one occasion only but, as in decisions about capacity, gaining consent is considered for each context.

As far as possible, individuals should be able to make informed decisions about the therapeutic activities they want to engage in. Occupational therapists working in mental health may find times when people lack motivation to engage in an activity because they perceive they will not get any satisfaction from it. For some individuals, the thought of engaging in an activity is worse than the experience of actual engagement (Gard et al. 2003) and therefore it is avoided. It can be difficult to ensure that people are given enough information to make choices about activities, particularly if they are feel overwhelmed by psychiatric symptoms (Gaitskell 1998). After all, how can people make informed choices when they have no experience to base their choice on?

CASE STUDY 7-1

Informed Choice

An occupational therapist works within a long-stay rehabilitation environment. The people she works with have been living within an institution for many years and may have been ‘forced’ to attend industrial therapy units. They have never been able to explore other activities they may have enjoyed nor make informed choices about what activities they want to engage in (O’Brien and Bannigan 2008). The occupational therapist needs to offer a wide variety of activities and use her skills to encourage people to sample these, so that they are able to make informed choices in the future. A individual’s refusal to participate may not be due to their dislike of the activity. It could, instead, simply be a result of how they are feeling on that day. The occupational therapist needs to be patient and persistent, without being coercive, and keep offering opportunities.

SERVICE PROVISION

The service provided by occupational therapists will always be structured around the occupational therapy process; from referral and assessment, to planning, implementation, review and discharge. Creek (2003) offers a more detailed breakdown of this process – presenting occupational therapy as a complex intervention – but the idea of an ongoing cycle of reflection on the therapeutic process and negotiation with people, remains constant. Occupational therapists have a responsibility to ensure that they provide a fair and equitable service in accordance with the law in their country and the Human Rights Act (1998). Many services use referral criteria to assess the need for occupational therapy and prioritize the workload in order to maximize resources. The reality is that occupational therapists work within finite resources and there may be times when service demand exceeds the capacity to meet it. For example, in a given week – when, perhaps, there are staff shortages due to sickness or study/annual leave – there may be such a large volume of referrals to the service that not everyone can be seen in a timely way. In a different week, even with staff at full capacity, there may be more referrals who meet the high priority criteria and those lower down the priority list may not be seen quickly enough. In each situation, those with lower-priority needs may have to wait longer for therapeutic intervention so it is important that decisions are as fair as possible and can be justified against documented criteria. The Occupational Therapy Referral Priority Checklist (Cratchley et al. 2004) is one such document that can be used to screen referrals. It may also be made available in order for people to make sense of any decisions that affect their access to care. This is a good example of transparent decision-making. Consideration may need to be given as to how transparency is achieved, as care records will only document decisions about individual interventions and not service management decisions. A poster displayed in accessible areas may be an appropriate way of publicizing how referrals are prioritized. However, as suggested in the introduction, efforts to provide transparent information can be counterproductive as it can breed suspicion and mistrust (O’Neill 2002). Rather than providing open access information to the public, it may be better to justify decisions discretely to individuals on a needs basis.

A common dilemma for occupational therapists working in mental health, particularly those who are employed as case managers or care coordinators, is that high priority is often given to service users who are assessed as presenting a high risk. Where significant risk is identified, it may be challenging for therapists to find a way of working with individuals on issues other than risk minimization; issues related to people’s occupational needs and quality of life, for example. The following section about risk management suggests possibilities to optimize occupational participation, despite risk.

Risk management

Risk management involves identifying potential hazards or negative incidents and providing adaptive strategies to reduce the likelihood of these occurring, or minimizing harm caused if they do (National Risk Management Programme 2007). Occupational therapists are accountable to the systems designed to ensure that any risks are identified and reduced wherever possible, in keeping with a duty of care to the people they serve and the general public. For example, they have a duty to safeguard children and vulnerable adults with whom they come into contact and need to ensure that abuse is recognized and dealt with effectively. Another important system for those working in mental health in the UK is the Mental Health Act (1983, amended 2007), which is the law designed to assess and treat people in the interest of their own or others’ health and safety. Inevitably, despite attempts to manage risk, incidents do occur and both public and staff will at times be exposed to risk. Therefore, many organizations will have systems for recording incidents and near misses and staff should be clear about what to report and when, in order to identify trends and disseminate information so that practice can be changed to improve safety.

CASE STUDY 7-2

Monitoring Adverse Events to Reduce Risk

A group of occupational therapists working in mental health services for older people had participated in the organization’s incident reporting system since its inception. Whenever an incident or near miss occurred, they filled in a report and submitted it to the risk manager. Once a month, they received information that summarized the incidents that had taken place. This was reviewed in the monthly occupational therapy meeting, so that consideration could be given to how risks could be reduced, both in terms of one-off incidents and regarding any emerging trends. Between February and April, there was an increase in the number of incidents reported in the occupational therapy garden. There were four reports of service users stumbling on the way out to the greenhouse, and one report of a service user falling over in the same place. Further examination of the reports revealed that the reason for the falls was a patio slab that had become raised during the hard frost to create an uneven piece of ground. As a result of this analysis, a requisition was put into the works department and the slab was re-laid to make the ground even again. Consequently, there were fewer incidents and near-miss reports in May, and no service users were reported to have stumbled or fallen on the patio. To ensure that this risk did not occur in other parts of the organization, the Risk Management Department circulated a memorandum highlighting the risk and asking managers to check patio areas.

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