Occupational Therapy Process for Patients after Stroke in Thailand

Transcription

1 Örebr University Occuptinl Therpy Schl f Helth nd Medicl Science 15 credit bchelr degree prject wrk Autumn 2014 Occuptinl Therpy Prcess fr Ptients fter Strke in Thilnd - qulittive study Authrs: Lind Olssn Mlin Lundbrg

2 Örebr University Schl f Helth nd Medicl Science Occuptinl Therpy C Type f wrk: 15 credit bchelr degree prject wrk, Occuptinl therpy English title: Occuptinl therpy prcess fr ptients fter strke in Thilnd qulittive study Authrs: Lind Olssn nd Mlin Lundbrg Dte: Wrds: 8309 Summry: Bckgrund: The ccuptinl therpy prcess includes three steps: investigtin, interventin nd evlutin, nd the prcess is lwys influenced by its envirnmentl cntext. Occuptinl therpy is prt f the rehbilittin prcess fr ptients fter strke nd includes interventins fr bth physicl nd cgnitive impirments. In cmprisn t Thilnd s ppultin, there re few ccuptinl therpists nd the cuntry prvides few beds fr strke rehbilittin. After the ptients re mediclly stble, they regulrly return t their hmes nd re tken cre f by their fmilies r reltives. Aim: T describe the ccuptinl therpy prcess fr ptients fter strke t clinic in Thilnd. Methd: Fur ccuptinl therpists were included in the study. A qulittive design ws used, where dt ws cllected thrugh semi-structured interviews nd prticipnt bservtins. Dt ws nlysed ccrding t qulittive cntent nlysis. Results: Tw ctegries were fund: wrking prcedure nd surrunding spects. The first ctegry describes the ccuptinl therpists wrking prcess fr strke ptients nd the secnd ctegry describes hw envirnmentl fctrs ffect the ccuptinl therpy prcess. Cnclusin: The result shw tht the ccuptinl therpy prcess is fllwed nd tht it is influenced by envirnmentl fctrs. The cnclusin is tht ccuptinl therpy fr strke ptients in Thilnd des nt differ frm mny ther cuntries regrding hw they wrk with strke rehbilittin. Keywrds: Occuptinl Therpy, Strke, Rehbilittin, Thilnd 2

3 Örebr Universitet Institutinen för hälsvetenskp ch medicin Arbetsterpi C Arbetets rt: Exmensrbete mfttnde 15 högsklepäng, inm ämnet rbetsterpi Svensk titel: Arbetsterpiprcessen för strkeptienter i Thilnd en kvlittiv studie Förfttre: Lind Olssn ch Mlin Lundbrg Dtum: Antl rd: 8309 Smmnfttning: Bkgrund: Arbetsterpiprcessen består v stegen utredning, åtgärd ch utvärdering ch prcessen påverks lltid v den kringliggnde miljön. Arbetsterpi är en del v rehbiliteringen för ptienter efter strke ch består v interventiner för både fysisk ch kgnitiv nedsättningr. I förhållnde till Thilnds ppultin finns det få rbetsterpeuter ch lndet erbjuder få pltser för strkerehbilitering. Efter tt ptientern är medicinskt stbil återvänder de vnligtvis till sin hem, där de mhänderts v nhörig. Syfte: Att beskriv rbetsterpiprcessen för ptienter efter strke på en klinik i Thilnd. Metd: Fyr rbetsterpeuter inkluderdes i studien. En kvlittiv metd nvändes, där dtinsmling skedde genm semi-strukturerde intervjuer ch deltgnde bservtiner. Dt nlyserdes enligt kvlittiv innehållsnlys. Resultt: Två ktegrier identifierdes: rbetsgång ch miljöfktrer. Den först ktegrin beskriver rbetsprcessen för ptienter sm drbbts v strke ch den ndr ktegrin beskriver hur miljöfktrer påverkr rbetsterpiprcessen. Slutsts: Resulttet visr tt rbetsterpiprcessen följs ch tt prcessen är influerd v miljöfktrer. Slutstsen är tt, i förhållnde till ndr länder, bedrivs rbetsterpi för strkeptienter i Thilnd på ett likrtt sätt. Sökrd: Arbetsterpi, Strke, Rehbilitering, Thilnd 3

4 TABLE OF CONTENTS INTRODUCTION... 5 BACKROUND... 5 Occuptin nd ccuptinl therpy... 5 Strke nd ccuptinl therpy... 6 Strke nd rehbilittin in Thilnd... 7 Rtinle fr the study... 7 AIM... 7 METHODS... 8 Smple... 8 Prticipnts... 8 Dt cllectin... 8 Dt nlysis... 9 Ethicl cnsidertins RESULTS Wrking prcedure Prescriptin Stndrdized methds l setting Tretment Trining rm nd hnd functin Interventins fr phsi Surrunding spects d tmsphere Educte reltives fr hme trining OT rle DISCUSSION Discussin f methds Discussin f results CONCLUSION ACKNOWLEDEMENTS REFERENCES Appendix 1 Interview guide Appendix 2 Observtin prtcl Appendix 3 Evlutin f ccuptinl therpy frm (neurlgicl cnditins) Appendix 4 Ares f ADL 4

5 INTRODUCTION This study is bsed n n interest in hw ccuptinl therpy is cnducted in ther cuntries nd cultures. Strke ptients is cmmn ptient grup within ccuptinl therpy, nd therefre the uthrs wished t get mre knwledge in this re. Cntct with vlunteer rgniztin led t n ccuptinl therpy deprtment in Thilnd, where the study ws cnducted. This study will prvide the Occuptinl Therpy Prgrm t Örebr University with knwledge but ccuptinl therpy in Thilnd nd cn cntribute t n exchnge between Sweden nd Thilnd. BACKROUND Occuptin nd ccuptinl therpy Occuptin is min cncept within ccuptinl therpy (OT) nd ccuptinl therpy ims t enble ccuptin. Occuptin is described s things peple d in interctin with the envirnment nd this interctin cretes mening fr the individul (Förbundet Sveriges Arbetsterpeuter [The Swedish Asscitin f Occuptinl Therpists], 2005). The intentin f ccuptinl therpy is t prvide stisfying life fr ptient (Förbundet Sveriges Arbetsterpeuter [The Swedish Asscitin f Occuptinl Therpists], 2005). Occuptinl therpy prxis fllws prcess, which begins with n investigtin, where the ccuptinl therpist gthers relevnt infrmtin but ptient s needs nd ctivity limittins. Infrmtin but ptient is ften gthered by n interview r bservtin (Rdmski, 2008). Furthermre, the investigtin is fllwed by n interventin, where the ccuptinl therpist in cllbrtin with the ptient, set gls, select tretments nd implement interventins. Finlly, the prcess ends with n evlutin, where decisin if mintining r discntinuing therpy is mde (Rdmski, 2008). The ccuptinl therpy prcess ls includes envirnmentl spects, nd these envirnmentl fctrs lwys ffect the prcess (Rdmski, 2008). Thrugh the ccuptinl therpy prcess, the ccuptinl therpist is respnsible fr creting gd reltinship between herself/himself nd the ptient. The ccuptinl therpist shuld hve the bility t pply different ttitudes in the meeting with ptients, nd shuld be ble t chse the mst pprprite ttitude in the present situtin. Smetimes, severl ttitudes must be pplied in ne ccsin, which is why the bility t shift ttitudes ls is needed (Kielhfner, 2009). Mdel f Humn Occuptin (MOHO) is well-knwn ccuptinl therpy mdel nd it describes hw humns relte t nd re influenced by ccuptin (Kielhfner, 2012). Humn ccuptin is rgnized in three cmpnents: vlitin, hbitutin nd perfrmnce cpcity. Vlitin includes persn s interests nd vlues, which ffects wht is imprtnt nd meningful (Kielhfner, 2012). Hbitutin invlves hbits nd rles. Hbits ccur when persn utmticlly repets n ctivity in specific envirnment r situtin. Rles cntribute t ne s behviur nd ttitude nd persn ften recgnizes herself in severl rles. A persn s physicl nd mentl bility t ccuptinl perfrmnce is clled perfrmnce cpcity (Kielhfner, 2012). Humn ccuptin is ffected by the envirnment, which includes persns, bjects nd plces tht humns interct with. The envirnment cntributes with pprtunities nd limittins tht my supprt r hld bck n individul in ccuptinl perfrmnce. An ctivity lwys ccurs in specific plce, is influenced by nd gets its mening in its physicl nd sciculturl cntext (Kielhfner, 2012). The scil nd physicl envirnment is ls lwys frmed by culture, nd culturl spects shuld be cnsidered in the meeting with ll ptients (Kielhfner, 2008). 5

6 A client-centred prctice is ls centrl within the mdel, nd it ims t find the unique chrcteristics in every ptient nd t invlve ptient in the rehbilittin. The client-centred prctice ls helps the therpist t py ttentin t ptient s situtin nd perspective. Client-centred prctice includes gd reltinship between the ptient nd the therpist. A gd reltinship mens being respectful nd understnding, which supprt ptient in the rehbilittin. Occuptinl therpy shuld be bsed n ptient s feelings, nd her wn chices nd experiences. This wy f wrking tgether with ptient prvides clientcentred reltinship between the ptient nd the therpist (Kielhfner, 2008). Strke nd ccuptinl therpy Strke is cerebrvsculr disese tht reduces r stps the supply f bld t the brin. Strke cn either be n infrctin r hemrrhge nd the size f the injury is termed mjr r minr strke (Svenssn, 2007). At infrct, the injury is usully lclized t specific re in the brin while the hemrrhge is regulrly utspred in the brin tissue. The symptms fter strke vry depending n the size f the injury nd which vessel hs been ffected (Kunnil, 2012). Bth cgnitive nd physicl symptms cn be present. Impirments in upper extremity re cmmn fter strke, where presis is included. Presis mens wekness in ne side f the bdy nd cn either be mild r severe which decides the level f the wekness (Lng, Blnd, Biley, Schefer & Birkenmeier, 2013). Anther cmmn impirment is phsi, which mens rl mtr- nd lnguge impirments (Dlemns, de Witte, Wde & Heuvel, 2010). Aphsi my led t limittins in speking, understnding, reding nd writing. Neglect cn be present fter hving strke, nd ppers s lck f wreness t either right r left side f the bdy (Tgli & Cermk, 2009). Impirment in executive functin cn ls be present fter hving strke. Executive functin is referred t s cmplex cgnitive functin such s plnning, prblem slving nd mnitring (Pulin, Krner-Bitensky & Dwsn, 2013). Physicl nd cgnitive impirments ffect ptient s independence in ctivities f dily living [ADL] (Wdsn, 2008). Occuptinl therpy is prt f the rehbilittin prcess fr ptient recvering frm strke nd the cnstitutin f rehbilittin tem vry depending n the ptient s needs nd resurces (Wdsn, 2008). Occuptinl therpists need t be prt f rehbilittin tem s they hve relevnt knwledge f suitble interventins (Förbundet Sveriges Arbetsterpeuter [The Swedish Asscitin f Occuptinl Therpists], 2005). Occuptinl therpy fr strke ptients shuld be prvided in bth the cute phse nd the fllwing rehbilittin phse (Kunnil, 2012). The ccuptinl therpy prcess fr strke ptients begins with n investigtin f ptient s rles, tsks nd ctivities tht is imprtnt fr the ptient. Therefter, the ccuptinl therpist will investigte the bility t perfrm the rles, tsks nd ctivities nd if disbility in sme re is fund, the ccuptinl therpist will try t find slutins r interventins tht help the ptient t restre, imprve r mintin his r her functins. (Wdsn, 2008). It is imprtnt tht the interventins suit ptient s needs (Förbundet Sveriges Arbetsterpeuter [The Swedish Asscitin f Occuptinl Therpists], 2005). When ptient hs physicl needs, the ccuptinl therpist cn investigte the bility t perfrm ADL, such s dressing, wshing nd tileting (Kunnil, 2012). The ccuptinl therpist cn prvide ptient with ssistive devices tht enble ptient s bilities t perfrm ADL (Kielhfner, 2012). Other cmmn interventins fr strke ptients cn be memry trining nd djustments in the envirnment, fr exmple in ptient s hme (Förbundet Sveriges Arbetsterpeuter [The Swedish Asscitin f Occuptinl Therpists], 2013). Emtinl nd behviurl expressins re cmmn fter hving strke, nd cn smetimes be perceived s negtive feelings. The ccuptinl therpist cn prevent these feelings by encurging nd mtivting the ptient s fr s pssible. 6

7 Reltives hve crucil rle in ptient s recvery fter strke. It is therefre imprtnt t invlve reltives in the rehbilittin s they cn supprt nd tke cre f their wn in the best wy (Kunnil, 2012). The ccuptinl therpist shuld lwys hve hlistic view by including ptient s physicl, psychlgicl nd scil envirnment (Kunnil, 2012). Strke nd rehbilittin in Thilnd Thilnd hs mre thn 250,000 new cses f strke ech yer (Suwnwel, 2014) nd the verge ge when hving strke is 65 yers (Suwnwel, 2014), [crrespnding number in Sweden is 75 yers (Vårdguiden [Helth Cre], 2013)]. The verge life expectncy in Thilnd is 73 yers [crrespnding number in Sweden is 82 yers (pminder, 2012)]. Amng wmen in Thilnd, crdivsculr diseses re the mst cmmn cuse f deth, nd the third leding cuse mng men. Cerebrvsculr diseses, including strke, re verrepresented in crdivsculr diseses nd thereby cnstitute lrge prprtin f mrtlity in Thilnd (Wrld Helth Orgniztin, 2004). During 2011 it ws estimted tht 496,800 peple were strke survivrs crss 6 regins in Thilnd, s the need f rehbilittin is therefre high in Thilnd (Kunnil, 2012). There re 625 ccuptinl therpists in Thilnd nd in regrd t the whle ppultin f 65.4 millin, tht is smll munt (Kunnil, 2012). Crrespnding number in Sweden is 11,000 registered ccuptinl therpists (SACO, n.d.) in ppultin f 9.7 millin (Sttistisk centrlbyrån [Sttistics Sweden], 2014). Strke ptients in Thilnd re treted in hspitl until they re mediclly stble, regulrly perid between three dys nd tw weeks. After this tretment, mst f the ptients return t their hme nd re tken cre f by their fmily members r reltives. The culture f Thilnd vlues the cre f sick nd wek peple (Suwnwel, 2014). The medicl cre in Thilnd priritize the cute phse f strke mre thn the fllwing rehbilittin nd the cuntry prvides few beds fr rehbilittin, which results in lrge number f strke ptients withut rehbilittin (Oupr, riffiths, Pryr & Mtt, 2010). Strke rehbilittin is nt f high pririty becuse f the cuntry s lck f resurces nd the ecnmic situtin (Kunnil, 2012). Rtinle fr the study Accrding t the uthrs knwledge, reserch but ccuptinl therpy nd strke in Thilnd is limited nd therefre nt highly ccessible in dtbses n the Internet. Occuptinl therpy shuld be cnducted in similr wys in ll cuntries, t ensure tht rehbilittin fr strke ptients re f sme qulity. Therefre, reserch f ccuptinl therpy in different cuntries is needed nd cn cntribute t knwledge nd exchnges in ther cuntries rehbilittin prcesses. This study will cntribute t descriptin but ccuptinl therpy fr strke ptients t clinic in Thilnd. AIM The im f this study is t describe the ccuptinl therpy prcess fr ptients fter strke t clinic in Thilnd. 7

8 METHODS A qulittive design ws used, where dt ws cllected thrugh prticipnt bservtins nd semi-structured interviews. Bth interviews nd bservtins were nlysed ccrding t qulittive cntent nlysis (rneheim & Lundmn, 2004). In study bsed n interviews, there is n defined number f prticipnts. Insted it is the cntent tht cunts, which is why it is preferred t hve fewer but mre detiled interviews (Kristenssn, 2014). In this study, fur ccuptinl therpists were interviewed. Accrding t the uthrs, fur interviews were vlued s t pr mteril, which is why these interviews were cmplemented with bservtins. Smple Cnvenient smpling ws used (Kristenssn, 2014), where ll fur ccuptinl therpists t the ccuptinl therpy deprtment were sked t prticipte in the study. All prticipnts in study shuld be infrmed but the im f the study nd lwys hve the right f selfdetermintin in their prticipting (Vetenskpsrådet, n.d.). All respndents were given written nd verbl infrmtin but the study nd their dvntges nd rights in prticipting, nd ll fur greed t prticipte. All prticipnts in this study signed n infrmed cnsent letter frm. Prticipnts Fur ccuptinl therpists were included in the study. They were between 26 nd 49 yers f ge with n verge ge f 37,5 yers. Their wrking experience rnged frm 2 t 26 yers nd ll fur tk their ccuptinl therpy exm in Thilnd. One prticipnt ws mn nd three were femles. Their English lnguge skills vried. All prticipnts wrk t ccuptinl therpy deprtment t generic hspitl, nd the ccuptinl therpists tret ptients with bth cgnitive nd physicl impirments, where strke ptients is cmmn ptient grup. All prticipnts wrk with strke ptients t greter r less extent, but tw f them hve the min respnsibility fr strke ptients nd therefre meet these ptients mre regulrly thn the ther tw. Dt cllectin Dt ws cllected in ccrdnce with ethngrphic design, where bservtins, interviews nd dilgues re the min strtegies used (Pilhmmr, 2014). Dt t this study were cllected by semi-structured interviews ccrding t n interview guide designed fr this purpse (Appendix 1) nd prticipnt bservtins f the ccuptinl therpists wrk with strke ptients. The interview guide fllwed the ccuptinl therpy prcess by the cncepts investigtin, interventin, evlutin nd envirnment. Therefter, questins were creted within ech cncept, which were influenced by MOHO s explntin f therpeutic resning (Kielhfner, 2008). Fr exmple, MOHO describes tht the investigtin include tht the ccuptinl therpist gther infrmtin but ech ptient by using structured r unstructured methds (Kielhfner, 2008) which is why the questin D yu use ny specific methds r instruments during the investigtin f strke ptients? ws creted. Semi-structured interviewing mens tht identicl pen-ended questins re sked t ll the prticipnts nd gives pprtunity fr the interviewer t sk ttendnt questins. Openended questins cntribute t wider nd deeper replies nd re suitble lterntive fr inexperienced interviewers (Kristenssn, 2014), why this frm f interview ws chsen. Becuse f the vried English lnguge skills, n interpreter ws cnsulted t trnslte ll the questins nd replies frm Thi t English nd vice vers. The interpreter ws nt qulified interpreter nd ws cnsulted thrugh the vlunteer rgniztin tht the uthrs trvelled with. The uthrs sked the interpreter but prticipting in the study, nd 8

9 explined the interpreter s rle in the study. Therefter, the interpreter greed t trnslte the interviews. An interpreter shuld be culturlly ccepted, spek the lnguge fluently nd be neutrl (Kvle & Brinkmnn, 2009). The interpreter in this study is Thi nd hd n reltin t the prticipnts r the ccuptinl therpy deprtment. The interview guide ws sent t the interpreter ne week befre the interviews were cnducted s time ws given fr preprtin nd questins. Three f the interviews were perfrmed during the sme dy with few nd shrt breks nd the furth interview ws cnducted three dys lter. One prticipnt ws prevented frm cming t the interview dy, why the frth interview ws cnducted in English, withut n interpreter. The interviews were cnducted in big rm t the ccuptinl therpy deprtment. The prticipnts were sked where t cnduct the interviews, nd they decided tht the deprtment rm wuld be the mst suitble plce. The first uthr, the prticipnt nd the interpreter st rund tble. The interviewer st next t the prticipnt nd the secnd uthr st in the bckgrund. The recrder ws plced t the middle f the tble. Sunds frm building wrkers nd the hspitl s public-ddress system were herd but culd nt be influenced. First, ne f the uthrs presented the im f the study nd the pprximte time f the interview. Befre the interviews were recrded, the prticipnts were sked verblly t cnfirm their prticiptin gin, nd were ls given time t sk questins. The uthrs encurged the prticipnts t freely express their wn thughts nd feelings in their replies. During the interviews, the first uthr interviewed the prticipnts nd the secnd uthr mde ntes nd hndled the recrder. Ntes were mde becuse the uthrs wnted t mke sure tht mteril wuld still be vilble if the recrder wuld stp wrking. Since the recrder wrked in ll interviews, the ntes were nt included in the mteril. In the end f every interview, the prticipnts were given the questin is there nything yu wnt t dd?, nd then the recrder ws turned ff. Averge length f the interviews ws 36 minutes. Observtins in this study were prticipnt bservtins, which mens being present nd shre the prticipnts envirnment (Pilhmmr, 2012). Observtins were mde ccrding t the ethngrphic cmpressed mdel, which mens tht dt is cllected between ne week nd ne mnth (Pilhmmr, 2012). In this study, bservtins f the ccuptinl therpists wrk with strke ptients were mde during perid f tw weeks nd resulted in 12 ccsins. The bservtins were mde t the strke unit, the ccuptinl therpy deprtment nd in crridr utside the ccuptinl therpy deprtment. Befre the bservtins were mde, the uthrs sked the bserved ccuptinl therpists if it ws suitble ccsin t bserve nd sked fr n pprvl. The bservtins were dne ccrding t n bservtin prtcl (Appendix 2), which is shrter versin f the interview guide. Field ntes in the bservtin prtcl were mde in situ (Pilhmmr, 2012) nd questins t the ccuptinl therpists were mde fter the bservtins. Dt nlysis All interviews were trnscribed verbtim nd then nlysed thrugh qulittive cntent nlysis. Qulittive cntent nlysis mens tht similrities nd differences in dt re identified. Fcus in this study ws t nlyse the mnifest cntent in the mteril, which mens tht bvius nd visible cntent is described (rneheim & Lundmn, 2004). The interviews were given cde (Kristenssn, 2014). The bservtins were ls nlysed thrugh qulittive cntent nlysis. Thrugh the nlysis, the uthrs fllwed the steps described by Kristenssn (2014). At first, bth uthrs red ll mteril severl times nd were writing wn ntes. After tht, the uthrs st dwn nd discussed their thughts but the texts. In the secnd step, the uthrs first identified mening units in the interviews nd therefter in the bservtins. This ws dne by cluring ech mening unit with different clured pencils. In the third step the 9

10 mening units were frmed int cndensed mening units. Cndenstin mens shrting mening unit while still preserving the cre (rneheim & Lundmn, 2004). After the cndenstin, the uthrs seprtely cded ech cndensed mening unit nd then discussed nd cmpred their cdes frm bth interviews nd bservtins, nd tgether decided which cdes tht shuld be used. In the furth step, similrities nd differences in ll cdes were identified nd were creted in ctegries. The uthrs sught fr ctegries tht were relted t the study im. The ctegry wrking prcedure includes the steps investigtin, interventin nd evlutin, which re prt f the ccuptinl therpy prcess. Since the prcess is influenced by envirnmentl fctrs, the uthrs sught fr ctegry tht describes these fctrs nd the ctegry surrunding spects ws fund. In the fifth step, the ctegries were summrized int subctegries, where wrd r phrse tht suited between ech cde nd ctegry were chsen. Tble I nd Tble II illustrte hw the cntent nlysis ws cnducted nd hw ctegries nd subctegries were fund in interviews nd bservtins. Tble I. Illustrtin f the cntent nlysis f interviews Mening units I use the Evlutin f ccuptinl therpy (neurlgicl cnditins) befre nd fter tretment, t see the prgressin we hve t tech the ptients reltives t d the exercise t hme we will give them the instructins pper fr ech prblem. Cndensed mening unit Evlutin f ccuptinl therpy (neurlgicl cnditins) is used befre nd fter tretment. Imprtnce f including nd educte reltives. Cde Subctegry Ctegry Use f instrument Prt f OT rle Stndrdized methd Educte reltives fr hme trining Wrking prcedure Surrunding spects Tble II. Illustrtin f the cntent nlysis f bservtins Mening unit Cndensed Cde Subctegry Ctegry Bbth sling fr psitin rm trining in mchine Encurging ttitude by supprt ptients instructive, shw the ptient nd reltives hw t d mening unit Upper extremity functin Different OT ttitudes during interventins Use rm nd hnd Trining rm nd hnd functin Wrking prcedure Attitudes OT rle Surrunding spects Ethicl cnsidertins Vetenskpsrådet s fur ethicl cnsidertins were used: demnd f infrmtin, cnsent, cnfidentility nd the uthrs right f use. Demnd f infrmtin mens tht ll prticipnts re infrmed but the study im nd demnd f cnsent refers t the prticipnts right f self-determintin in prticipting. Demnd f cnfidentility mens tht ll cllected dt shuld be kept in respnsible wy where n unuthrized persns cn rech the mteril, nd the furth demnd but the uthrs right f use mens tht ll cllected dt shuld nly be used fr the study im (Vetenskpsrådet, n.d.). 10

11 In this study, ll prticipnts were verblly infrmed but the study, nd received n infrmed cnsent letter. All cllected dt ws kept in lcked rm, where nly the uthrs hd ccess. All dt ws used nly fr the study. Anther ethicl cnsidertin tht ws mde ws discussin but the risk nd benefits with the study. The benefits with study shuld lwys utweigh the ptentil risks (Plit & Beck, 2012). Dt ws cllected thrugh bth interviews nd bservtins. A risk whether the prticipnts were wrried tht infrmtin frm the interviews nd bservtins wuld differ, ws discussed. They my hve been wrried tht the uthrs nd themselves hd different pinins but hw the ccuptinl therpy prcess fr strke ptients shuld be cnducted. The benefit with this study is tht it will cntribute t descriptin f hw the ccuptinl therpy prcess fr strke ptients is cnducted in Thilnd, nd will therefre cntribute t knwledge f ccuptinl therpy in develping cuntry. RESULTS Anlysis f the mteril resulted in tw ctegries: wrking prcedure nd surrunding spects. Subctegries relted t wrking prcedure were nmed prescriptin, stndrdized methds, gl setting, tretment, trining rm nd hnd functin nd interventins fr phsi. Fr the ctegry surrunding spects, gd tmsphere, educte reltives fr hme trining nd OT rle were chsen s subctegries. Tble III illustrtes the ctegries nd the subctegries. Tble III. Illustrtin f the ctegries nd subctegries Ctegries Wrking prcedure Surrunding spects Subctegries - Prescriptin - Stndrdized methds - d tmsphere - Educte reltives fr hme - l setting trining - Tretment - OT rle - Trining rm nd hnd functin - Interventins fr phsi Results re described in ccrdnce t the ctegries nd the belnging subctegries. Mteril frm interviews nd bservtins re described seprtely under ech ctegry, t clrify which infrmtin tht cmes frm the interviews respectively bservtins. Wrking prcedure This ctegry describes the ccuptinl therpists wrking prcedure fr strke ptients t the deprtment, nd will illustrte prt f the ccuptinl therpy prcess. First, results frm the interviews will be described fllwing by results frm bservtins. Results frm interviews Prescriptin This subctegry illustrtes tht the ccuptinl therpy prcess depends n prescriptin frm the medicl dctr. All prticipnts expressed tht the dctr will be the ne wh decide if ccuptinl therpy is needed nd wht kind f ccuptinl therpy interventins tht they shuld prvide. 11

12 P1: ptients need t meet the dctr first, nd then the dctr will [ ] investigte ll but the ptient nd ll but the functin nd then the dctr will pss the rder t the OT. P2: the dctr will d the investigtin, like wht is the need f this ptient nd wht is need t be dne? After the rdintin, the prticipnts described tht they will mke further investigtin nd design tretment ccrding t the dctr s rder. Stndrdized methds This subctegry describes tht stndrdized methds re used t the deprtment. All prticipnts mentined the Evlutin f ccuptinl therpy frm (neurlgicl cnditins) (Appendix 3), nd described tht ther deprtments t the hspitl ls use this frm. The instrument includes investigtin, interventin, evlutin nd gl setting. Physicl, cgnitive nd sensry bilities re investigted, where the investigtin f ctivities f dily living (ADL) re the mst described prt. ADL include severl res (Appendix 4), where the level f functin in ech re is mesured n scle between 0 nd 15. The scle describes the level f dependence thrugh seven steps, where lw scre men mre dependence in ctivities nd vice vers. The ADL res re relted t the Brthel Index scre, which is prt f the Evlutin f ccuptinl therpy frm (neurlgicl cnditins). After the investigtin, the prticipnts described tht they will nte the ttl munt f ptient s ADL under Brthel Index scre. Apprprite interventins nd selected gls fr ech ptient re ls nted in the frm. P1: The evlutin is but ADL [ ] s bsiclly we fcus n ADL. Tw f the prticipnts wrking t the deprtment describe tht they hve the min respnsibility fr the neurlgicl ptients, nd re thse wh mstly mke the investigtin nd evlutin f the strke ptients. Still, ll prticipnts described this instrument s the ne used fr strke ptients. The Evlutin f ccuptinl therpy frm (neurlgicl cnditins) is signed fter the first meeting with ptient, which cn be either t the ccuptinl therpy deprtment r t the strke unit. The frm is ls signed fter ech evlutin t see ptient s prgressin in n ctivity nd whether the gl is reched r nt. The prticipnts gther infrmtin tht they nte in the frm, thrugh the dctr s infrmtin, bservtins f the ptients nd dilgues with ptients nd reltives. P4: I use the Evlutin f ccuptinl therpy frm (neurlgicl cnditins) befre nd fter tretment [ ] T see the prgressin. Smetimes I sk the ptient if he cn r nt nd smetimes the ptient shw fr me [ ] I bserve. All prticipnts mentined tht they mke evlutin f the strke ptients every mnth. The first, third nd sixth mnth, the results frm the evlutin is reprted t the dctr. l setting This subctegry dels with hw gl setting is cnducted. Results frm the nlysis shw tht shrt-term nd lng-term gls re set, but t this deprtment, the prticipnts described tht fcus is n shrt-term gls. All prticipnts stted tht gls re set in cllbrtin with 12

13 the ptient, dctr nd ther prfessins. ls will be set ccrding t wht ptient needs t recver nd wnts t chieve, which is why the ptient shuld be included in gl setting. P3: We set the gl tgether, but mst f the time, the gl f OT nd ptient is different. We hve t tlk nd discuss, djust the understnding f the ptient, becuse the OT gl is mre [ ] ccrding t the truth nd the ptient s gl is ften drem gl [ ] S we hve t djust it t ech ther. After the gls re set, the gls will be nted in the Evlutin f ccuptinl therpy frm (neurlgicl cnditins), under gl nd prgressin. If ptients rech their gl, the prticipnts describe tht new shrt-term gls will be set. P2: reprt t the dctr nd see if we need t set mre gls r if we need t develp the ctivity. Tretment This subctegry cncerns interventins fr strke ptients tht re used t the deprtment. Interventins fr bth cgnitive nd physicl impirments re described, but the prticipnts mentined mre regrding interventins fr physicl impirments. Fr physicl impirments, interventins fr rm nd hnd functin re the mst described, which im t imprve r mintin bilities in shulder, rm, hnd nd fingers. The fllwing interventins were described s the mst frequently used t imprve rm nd hnd functin: Bbth sling, verhed blnce (OB) helping rm nd hnd trining. P3: fr OT, the tretment tht we mstly give fr strke ptients is the Bbth sling nd the OB helping rm. The prticipnts describe the Bbth sling s sling used t supprt the shulder nd keep it in gd psitin. OB helping rm ws nther described interventin. It ims t imprve muscle strength nd mbility in ptient s shulder nd rm. The prticipnts mentined tht hnd trining is but grss mtr nd fine mtr. Hnd trining is mstly perfrmed thrugh bilterl gripping, but smetimes ptients perfrm hnd trining with ne hnd. P1: Fr the mtr, we will fcus mre n hnd functin [ ] Fr grss mtr, it s mre like yu use the big muscles [ ] fr the fine mtr, we will fcus mre but the fingertips [ ] nd prctice by pick up smller things. Anther interventin described is the r-mtr trining used fr phsi. This interventin mens tht the ccuptinl therpist stimulte ptients muth muscles nd prctice their speking skills. Overll, the prticipnts expressed tht the interventins im t imprve ptient s dily life nd tht they chse interventins cnsidering the ptients interests nd mtivtins. P2: The ctivity will be bsed n ptient s interests [ ] give them psitive ttitude s they cn recver. And let them d the things tht they wnt t d. 13

14 Results frm bservtins Trining rm nd hnd functin As fund in the interviews, the bservtins ls shwed tht interventins fr rm nd hnd functin re cmmn fr strke ptients. Fur interventins fr rm nd hnd functin were fund recurrent in the bservtins: Bbth sling, brd nd stcking cnes, OB helping rm nd rm cycling. As mentined erlier, Bbth sling is used fr psitining nd is supprting bndge. It is used fr hemiplegi nd the sling is plced rund the upper rm f the ffected side. A string is ttched t the bndge nd is tied ver the shulders nd under the ther rm. A supplementry questin but the Bbth sling ws sked t ne f the prticipnts fter the bservtins, nd resulted in the reply tht the Bbth sling is used t prevent subluxtin f the shulder. Brd nd stcking cnes is n interventin where plstic cnes re stcked n ech ther. The ptients mve the cnes ne by ne frm ne pint t nther. The bservtins shw tht this interventin cn be dne thrugh bilterl r ne-hnd gripping, nd the prticipnts explin tht brd nd stcking cnes is used fr trining the shulder nd rm mbility. The interventin ls includes trining in grbbing nd relesing bjects. OB helping rm is trining mchine used fr ptients with hemiplegi. A ptient s ffected rm is plced in n upright psitin, stright ut frm the bdy. The ptient is sitting n chir r in wheelchir during the interventin. The ptients perfrm this interventin by mving the rm frm side t side r up nd dwn, during time f minutes. This interventin is used t imprve muscle strength nd jint mbility in ptient s rm. Thrugh the bservtins, it is fund tht the OB helping rm is used t lmst ll ptients with hemiplegi. Arm cycling is the lst bserved interventin fr rm nd hnd functin. The cycle mchine is plced t tble nd the ptients re sitting n chir. The ptient s ffected hnd is plced n the hndle, by using bndge. Arm cycling is used t imprve muscle strength, jint mbility nd endurnce. During the bservtins, it ws nted tht the ccuptinl therpists t sme ccsins mde interventins mre difficult. Fr exmple, in the interventin brd nd stcking cne, the ccuptinl therpist plced the cnes further wy frm the ptient nd thereby mde the interventin mre difficult. Interventins fr phsi Except the interventins fr rm nd hnd functin, the bservtins shwed tht interventins fr phsi re cnducted. Interventins fr phsi include r-mtr trining nd erly interventins fr speech. Erly interventin fr speech mens trining the ptients cgnitive nd linguistic functins. In the bserved situtins, the ptients first srted sticks by clurs, fllwed by writing nd describing wrds frm pictures tht the ccuptinl therpist shwed. The ccuptinl therpists mstly shwed pictures n bjects fund in the hme envirnment. One prticipnt explined tht these pictures re shwed becuse these re wrds tht ptients ften wnt nd need t fcus n. At the deprtment, tw f the prticipnts hve the min respnsibility fr this interventin, which re the sme prticipnts tht hve the min respnsibility fr the investigtin nd evlutin f strke ptients. Or-mtr trining ws bserved s nther interventin fr ptients with phsi, which ls ws described in the interviews. The r-mtr trining fllws specific trining 14

15 prgrmme nd includes rticultin nd stimultin f the ptients muth muscles. The ccuptinl therpist tret the ptients by giving them mssge rund their muths, nd then the ptients trin rticultin bilities by imitting sunds nd wrds frm the ccuptinl therpist. This interventin is given t ptients t ne ccsin nd the interventin lwys includes tht the ptients nd their reltives get n instructin pper frm the ccuptinl therpist. Furthermre, the ptients tgether with the reltives hve wn respnsibility fr cntinuing the r-mtr trining. Surrunding spects This ctegry describes hw envirnmentl fctrs ffect the ccuptinl therpy prcess. First results frm the interviews re described, which illustrtes tht relxing envirnment s well s including reltives in rehbilittin re imprtnt. Results frm bservtins re then described nd reprts different ttitudes tht the prticipnts use in their wrk with strke ptients. Results frm interviews d tmsphere This subctegry is relted t the envirnment nd describes the imprtnce f hw gd tmsphere ffects ccuptinl therpy rehbilittin. Accrding t ll prticipnts, the rehbilittin prcess shuld be permeted with gd tmsphere, nd the envirnment shuld be relxed t mke ptients, reltives nd stff hppy nd feel gd t the deprtment. T crete this tmsphere, ne prticipnt mentined tht the deprtment hs music nd televisin n. Anther prticipnt expressed tht the ccuptinl therpist lwys shuld hve psitive ttitude rund the ptients. P1: when yu mke the tmsphere relxed, the ptient will be hppy nd they wnt t cme fr the tretment [ ] This is very imprtnt. The prticipnts describe tht gd tmsphere ls includes gd reltinships mng ll included prts nd tht ll persns t the deprtment shuld be seen s friends nd fmily. The prticipnts express tht gd wrking climte will influence the ptients in gd wy. The envirnment t the deprtment is ls described s n pprtunity fr ptients nd reltives t shre experiences nd help ech ther in their situtins. The prticipnts hve experienced tht when reltives shre situtins, they get mtivted t help their wn wh suffered frm strke. Educte reltives fr hme trining This subctegry describes hme trining s prt f ccuptinl therpy. Persns nd plces rund the ptient re prts f the envirnment. A ptient s hme, reltives nd the ccuptinl therpist re therefre included in the envirnment. Chrcteristic fr the interviews, were the imprtnce f including cregivers r reltives in ptient s rehbilittin. This is due t the fct tht lmst ll ptients need t d hme trining fr their prgressin. The prticipnts describe tht they educte ptients, cregivers nd reltives in techniques f trining. Instructins fr trining re lwys given verblly r in n instructin pper. Befre ptient ges hme, they will mke sure tht they knw hw t d the exercise t hme. 15

16 P3: It is very imprtnt t hve the cregiver r reltives with yu becuse we will give them hnd ut pper fr ech prblem. Hw t d the muth mssge, hw t d the hnd mssge [ ] s they cn fllw the instructin [ ] We will mke sure tht the reltives knw hw t tke cre f them. One prticipnt expressed tht the mst imprtnt rle in ccuptinl therpy is t educte nd tech ptients nd their reltives. Thus, ll prticipnts mentined the educting rle t greter r less extent. Results frm bservtins OT rle Results frm the interviews described tht the prticipnts use n educting ttitude in their wrk with strke ptients. Results frm bservtins ls shwed tht ther ttitudes re used. Cmmn ttitudes tht hve been bserved is n encurging nd supprting ttitude, where the ccuptinl therpist hve psitive ttitude, listen nd give their time t the ptients. Other ttitudes tht hve been bserved re n instructive ttitude nd delibertely pssive rle. The instructive ttitude include tht the ccuptinl therpist guide nd give instructins befre nd during interventins. A supplementry questin fter the bservtins resulted in the reply tht ll ptients t the deprtment hve wn respnsibility in their rehbilittin, s the delibertely pssive rle is cmmn t use nd ims t mke the ptients mre independent. DISCUSSION Discussin f methd A cnvenience smpling ws used, where ll ccuptinl therpists t the deprtment were included. A psitive spect when using cnvenience smpling is tht prticipnts re esy t find, while negtive spect cn be tht ll prticipnts wrk in the sme cntext, which my led t less vritin in mteril (Kristenssn, 2014). In this study, ll ccuptinl therpists wrking t the deprtment were included, which leds t representtive nd gd descriptin f hw ccuptinl therpy is cnducted t the deprtment. In this study, ll prticipnts were infrmed but the study im nd the right f selfdetermintin in prticipting. All prticipnts received nd signed n infrmed cnsent letter, nd therefre there were n cmpulsin in the prticiptin. On the ther hnd, the prticipnts my hve discussed the study with ech ther nd my hve ffected nd influenced ech ther t prticipte in the study. The uthrs hve discussed whether the ptients ls shuld be seen s prticipnts in the study nd receive n wn infrmed cnsent letter, since they were included in the bservtins. Thugh, t the time f the dt cllectin, the uthrs did nt hve this in mind. Insted, the uthrs lwys sked the bserved ccuptinl therpist fr permissin t prticipte in ech ccsin, nd relied n their pinin. When this study ws cnducted, the uthrs were vlunteers t the deprtment nd met the ptients regulrly. Therefre, it is pssible t ssume tht the ptients gined trust fr the uthrs nd tht the uthrs becme nturl prt f the deprtment. The dt cllectin, with cmbintin f interviews nd bservtins, gve the pprtunity f describing ccuptinl therpy t the deprtment frm tw ngles. In the interviews, the prticipnts described their wrk t the deprtment frm their wn perspective, 16

17 while the bservtins cntributed with dt frm n utside perspective. Accrding t the uthrs, cllecting dt thrugh bth interviews nd bservtins re seen s psitive. Vgue infrmtin frm the bservtins culd be explined r clrified in the interviews nd vice vers. The uthrs ls chse t describe results frm interviews nd bservtins seprtely, which helps the reder t identify which infrmtin tht cmes frm the interviews respectively bservtins. The interview guide ws mde by the uthrs nd ws discussed with the supervisr befre the interviews were cnducted. T chieve dependbility, n interview guide is useful (Kristenssn, 2014). This study s interview guide cnsidered ll res f the ccuptinl therpy prcess nd helped the uthrs t keep t the subject nd get structure in the interviews. The interview guide nd the bservtin prtcl were influenced by MOHO:s explntin f the therpeutic resning, which helped the uthrs t design the guide nd prtcl ccrding t relevnt terms in ccuptinl therpy. After the interviews were cnducted, the uthrs discussed the questins in the interview guide. The questins regrding the envirnment hd mre t d with the ccuptinl therpists experiences f the envirnment t the deprtment, insted f hw the envirnment is used nd ffect their wrk with strke ptients. Befre the interviews, the uthrs prcticed nd tested the questins in the interview guide n ech ther, t ne ccsin. If it hd been tested mre times, it my hve led t refrmultin f sme f the questins. If similr study is cnducted gin, the uthrs recmmend prcticing mre times nd cnsider if test interview wuld be t prefer. The surrunding envirnment in the interview situtins ws nt the mst ptimum. On severl ccsins during the interviews, sunds frm building wrkers nd the hspitl s public-ddress system disturbed the dilgues, which led t unnturl puses. This my hve led t the fct tht imprtnt mteril ws missed r frgtten. If similr study wuld be cnducted gin, it wuld be better t chse mre quiet nd suitble rm, but in this study, this ws the best pssible ptin. When cnducting the interviews, n interpreter ws used fr three interviews. An dvntge f using n interpreter ws tht the prticipnts gt the privilege f speking their wn lnguge, which prbbly led t brder nd mre detiled replies. Disdvntges my hve been tht the interpreter summrized the replies. Smetimes, the prticipnts nd the interpreter s replies vried in length, which bth uthrs rected t. Therefre, there is pssibility tht summries were mde t sme ccsins. Thus, nne f the uthrs spek Thi, s the vried length in the replies cn ls be due t the differences between the English nd Thi lnguge. T vid this, it my hve been better t cnsult prfessinl nd qulified interpreter. The uthrs ls relised tht n ppintment with the interpreter hd been t prefer befre the interviews were cnducted, where clrifictin f the interview guide nd hw the interviews wuld be implemented, culd hve been discussed. This my hve led t fewer summries. The furth interview ws mde withut n interpreter, which ment tht this prticipnt hd t spek nd express the replies in English, insted f Thi. But this is nt seen s drwbck, becuse this interview went better thn expected nd gve similr replies. Cnducting interviews tkes time nd requires gret del f energy, why it is recmmended nt t cnduct mre thn ne interview in ne dy (Kristenssn, 2014). The uthrs re wre tht cnducting three interviews in ne dy my be t mny, nd recmmend spreding ut the interviews ver mre dys. This my hve ffected the qulity f the interviews, becuse time ws nt given fr the uthrs t reflect nd discuss the interviews (Kristenssn, 2014). In this study, the interpreter ws nly vilble during ne dy, which led t three interviews in ne dy. One uthr cnducted ll interviews nd the 17

18 ther tk ntes. This ws experienced s psitive, becuse it gve the uthrs clerly defined rles nd pprtunities t imprve in their re f respnsibility. Bth uthrs hd gd reltinship t ll prticipnts, since the study ws cmbined with prctice t the deprtment during perid f six weeks. This cntributed t the uthrs understnding f the ccuptinl therpists chsen nd described cncepts nd tht the prticipnts gined trust fr the uthrs. On the ther hnd, negtive spect my be tht the gd reltinship ffected the prticipnts in their replies, becuse they wnted t cntribute t the study s much s they culd. In this study, credibility nd trnsferbility re discussed t enhnce trustwrthiness. Credibility mens tht interprettins frm the interviews shuld be bsed n infrmtin frm the cllected dt (rneheim & Lundmn, 2004). Severl things were mde t enhnce creditbility. Fr exmple, in the nlysis prcess, the uthrs first red nd wrte dwn ntes nd cdes independent frm ech ther, nd therefter discussed the ntes nd cdes tgether. Credibility ws ls incresed thrugh the cmbined methd, by cllecting dt frm bth interviews nd bservtins. This mde the mteril brder nd mre detiled. Fr exmple, the uthrs fund the interventin fr phsi in the bservtins, but this ws prly described in the interviews. If nly interviews hve been chsen, prts f this ctegry my hve been missed. The cmbined methd led t tht the bservtins gve lrger descriptin f used interventins nd creted the ctegry OT rle, which the uthrs cnsider s n imprtnt prt in ccuptinl therpy. A detiled descriptin f hw the nlysis ws cnducted, nd the use f tbles t illustrte the cntent nlysis were ls mde t estblish credibility. Shwing representtive quttins in the findings nd seeking greement with prticipnts cn ls be mde t chieve credibility (rneheim & Lundmn, 2004). In this study, representtive quttins were presented nd fter the nlysis f the interviews nd bservtins, the uthrs sked the prticipnts t cnfirm whether prts in the mteril hd been understd crrectly. In studies with few prticipnts, trnsferbility t ther cntexts cn be difficult t determine (Kvle & Brinkmnn, 2009). The study im ws t describe hw ccuptinl therpy is cnducted t deprtment in Thilnd, s the purpse ws nt t drw cnclusins fr whle ppultin. The uthrs hve discussed whether trnsferbility t ther deprtments in Thilnd cn be mde. There re nly 625 ccuptinl therpists in Thilnd (Kunnil, 2012), nd the prticipnts in this study represent university eductins frm the tw ccuptinl therpy eductins tht the cuntry prvide. Therefre, trnsferbility t ther deprtments in Thilnd cn pssibly be mde. The prbbility tht the ccuptinl therpy prcess fr strke ptients is cnducted in similr wy crss the cuntry cn therefre be high. Discussin f results The result shw tht ll prticipnts hve similr pinins but hw the ccuptinl therpy prcess fr strke ptients shuld be cnducted. Occuptinl therpists t the deprtment fllw the prcess in their wrk with strke ptients, where the ccuptinl therpy prcess begins with n investigtin nd ends with n evlutin. The result ls shws tht the prcess t the deprtment lwys is influenced by envirnmentl fctrs. The im f the study ws t describe the ccuptinl therpy prcess fr strke ptients t clinic in Thilnd. The uthrs chse t include the whle prcess in the study im t get wide nd cmplete representtin f hw strke rehbilittin is cnducted t the deprtment, t the gretest pssible extent during the dt cllectin, which ws perid f tw weeks. Thus, the ccuptinl therpy prcess fr strke ptients re extensive nd include mny spects, s the uthrs re wre f the fct tht there re mre t describe in the ccuptinl therpy prcess. 18

19 The result shws tht the Evlutin f ccuptinl therpy frm (neurlgicl cnditins) is used during the whle prcess. The Brthel Index scre is prt f this frm, nd severl studies hve shwn tht Brthel Index is frequently used methd in the investigtin nd evlutin f strke ptients. One study (Wlf & Rgnstd, 2013) indictes tht Brthel Index is ne f the mst cmmn ssessments t use fr strke ptients. Akbri et l. (2011) describes tht Brthel Index cnsists f 15 items relted t ADL ctivities, while nther study (Bergström et l., 2012) describes 10 items f ADL ctivities. In this study, the Brthel Index cnsists f 10 items (Appendix 4). The munt f the ADL items in Brthel Index vries, nd seems t be djustble. Wlf et l. (2013) emphsize tht the Brthel Index is useful fr investigtin nd evlutin f physicl impirments, but mre limited fr cgnitive impirments. In this study, the result shws tht Brthel Index scre is supplemented with prts fr investigtin nd evlutin f cgnitive nd sensry impirments. Result illustrtes tht ccuptinl therpy fr strke ptients ften include interventins fr rm nd hnd functin, such s brd nd stcking cnes nd rm cycling. This is similr t nther study (Chnubl et l., 2012), which ws cnducted in Thilnd, where Chnubl et l. describe plstic cne stcking nd rm cycling s tw cnventinl interventins within ccuptinl therpy. Assistive devices ims t imprve n individul s functin nd independence in ctivities, nd is frequently used by strke ptients (Chiu & Mn, 2004). One study (ustfssn & Ytes, 2008) describes tht hemiplegic supprt slings cn be used t prevent subluxtin nd shulder pin fr strke ptients. Result frm this study shw tht Bbth slings re cmmnly used fr strke ptients with hemiplegi, nd the ccuptinl therpists t the deprtment use the sling t prevent subluxtin nd t keep the shulder in gd psitin. Hwever, the Bbth sling is the nly ssistive device tht hs been identified. This my depend n the shrt perid f cllecting dt r tht the ccuptinl therpists chse t describe the Bbth sling in the interviews, becuse t the deprtment, this ssistive device is cmmnly prescribed fr the strke ptients. This study fund tht ccuptinl therpists t the deprtment cnduct interventins fr ptients with phsi. Thugh, fter survey f vilble rticles mde by the uthrs, n result but the interventin r-mtr trining ws identified. Articles but interventins fr speech bilities were fund, but the interventin seems t be cnducted by speech therpists, rther thn by ccuptinl therpists. The pr result f the survey my depend n which terms tht were used r tht few studies but these interventins hve been cnducted. Educte reltives fr hme trining ws fund s n essentil prt f ccuptinl therpy. Hme trining requires tht ptients nd their reltives get infrmtin but hw t perfrm trining t hme. Therefre, the ccuptinl therpists need t educte the ptient nd his r her reltive, by giving infrmtin but ech interventin. One study (Rchette et l., 2007) describes tht supprt frm the fmily nd reltives hve centrl rle in the rehbilittin f strke ptients, nd tht infrmtin, eductin nd supprt shuld be given t the reltives. Hlmqvist et l. (2014) fund in nline questinnire study tht eighty-fur per cent f the fur hundred nd five included ccuptinl therpists, expressed tht they felt tht rehbilittin re dependent n reltives. Fr exmple, sme f the ccuptinl therpists in their study, replied tht cllbrtin with reltives re prtly dne by giving infrmtin t reltives nd discussing with reltives hw t supprt ptient. The feeling tht rehbilittin is dependent n reltives my be shred by the ccuptinl therpists included in this study, becuse they express the educting rle t gret extent. Fr exmple, ne prticipnt expressed tht the mst imprtnt rle in ccuptinl therpy is t educte reltives. The educting rle ws ls identified in the bservtins, which supprts the expressins frm 19

20 the ccuptinl therpists. Tw f the included ccuptinl therpists hve the min respnsibility fr strke ptients, which my hve ffected the result f this study. Fr exmple, during the interviews, the mre experienced ccuptinl therpists gve mre detiled replies in the step evlutin, thn the ther tw. The uthrs discussed whether the result hd been brder nd deeper if ll fur ccuptinl therpists wrked with strke ptients, t the sme extent. Thus, the im f this study ws t describe the ccuptinl therpy prcess fr strke ptients t clinic in Thilnd, nd in this deprtment the distributin f wrk is rgnized in the described wy, nd therefre give rel picture f hw the prcess fr strke ptients is cnducted. CONCLUSION The result shws tht the ccuptinl therpy prcess is fllwed nd tht it is influenced by envirnmentl fctrs. The cnclusin is tht the ccuptinl therpy prcess fr strke ptients in Thilnd des nt differ frm mny ther cuntries regrding hw they wrk with strke rehbilittin. Further reserch but hw ccuptinl therpy is cnducted in Thilnd is needed. This study describes the ccuptinl therpy prcess fr strke ptients t ne deprtment. T get wider picture f ccuptinl therpy fr strke ptients in Thilnd, the uthrs suggest tht studies n mre deprtments shuld be cnducted. Cmprtive studies but ccuptinl therpy fr strke ptients cn be mde nd will cntribute t n exchnge f knwledge between different cuntries. 20