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Journal of Agromedicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wagr20
Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers a
b
Carla S. Wilhite OTD & Linda Jaco MS a
Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico, USA
b
Seretean Wellness Center, Oklahoma State University, Stillwater, Oklahoma, USA Published online: 24 Jun 2014.
To cite this article: Carla S. Wilhite OTD & Linda Jaco MS (2014) Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers, Journal of Agromedicine, 19:3, 325-332, DOI: 10.1080/1059924X.2014.916641 To link to this article: http://dx.doi.org/10.1080/1059924X.2014.916641
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Agromedicine, 19:325–332, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1059-924X print/1545-0813 online DOI: 10.1080/1059924X.2014.916641
Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers
Downloaded by [Tufts University] at 16:46 08 October 2014
Carla S. Wilhite, OTD Linda Jaco, MS
ABSTRACT. Limited attention has been devoted to the cultural and practice competencies needed by occupational therapy and physical therapy professionals who provide services to farming families impacted by chronic health or disability issues. Agricultural occupational safety and health should represent a continuum of services responsive to individuals, families, and agricultural communities across a life span and range of health status changes. Physical rehabilitation professionals have a key role in impacting an agricultural producer’s sense of self-efficacy and capacities for returning to agricultural living and work. However, demonstration of competency is essential in providing person-centered rehabilitation services of assessment, evaluation, treatment planning, interventions, referrals, and discharge issues. The paper highlights methods utilized by a state AgrAbility program and a former National AgrAbility Project to develop a model of continuing education programming for occupational and physical therapists that evaluate and treat agricultural workers after acute injury or exacerbation of chronic health conditions. KEYWORDS. Agricultural health, competency, continuing education, disability, occupational therapy, physical rehabilitation, physical therapy, professional competence, secondary injury prevention
INTRODUCTION Agricultural production is one of the nation’s most hazardous industries.1 Nationally, it is estimated that about 288,000 agricultural workers have an impairment creating a disability in the workplace.2 Ample literature demonstrates a need for competency-based practices by health care providers who work with agricultural populations and have resulted in programs educating doctors and nurses in preventive and acute care issues of agricultural workers.3−13 Hinojosa and Blount14 describes competency as developing
pertinent knowledge, skills, and attitudes to perform a behavior or task to a specific criterion. Yet, agriculture as a work activity is often poorly understood by health care providers.3 However, rehabilitation therapists have a large potential impact on the injured, ill, or disabled agricultural worker’s sense of self-efficacy and perceptions of their ability to return to work or living situation. Anecdotal information from farmers and ranchers receiving AgrAbility services supports an assertion that many health care workers, especially those with limited knowledge of farm occupations and culture, have often discouraged
Carla S. Wilhite is affiliated with the Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico, USA. Linda Jaco is affiliated with the Seretean Wellness Center, Oklahoma State University, Stillwater, Oklahoma, USA. Address correspondence to: Carla S. Wilhite, OTD, Department of Pediatrics, University of New Mexico, UNM Health Sciences Center, HSSB Room 140 MSC09 5240, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA (E-mail: [email protected]). 325
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the individual from returning to agricultural work. AgrAbility programs across the United States have demonstrated this discouragement is not always warranted, and many agricultural workers with disabilities have returned to a high level of satisfactory participation in farming occupations.15 AgrAbility is a discretionary grant program administered by the United States Department of Agriculture National Institute of Food and Agriculture, with a core focus on providing education, networking, and assistance to return agricultural worker with disabilities back to the workplace.16 Educational emphasis is considered the primary means by which AgrAbility Projects will harness “human capital [to focus on] . . . accommodating disabilities and avoiding secondary injuries in persons with disabilities”16 who work in production agriculture. Thus, it is important for AgrAbility to direct educational efforts toward professionals who will interact with farmers with disabilities and whose services will have a large long-term impact on the farmer’s subsequent return to living and working on the farm. In 2003, at a National AgrAbility Workshop in Nebraska, the Oklahoma AgrAbility Project presented a white paper on the need for addressing the competency of occupational and physical therapy practitioners (among other professions) to provide services to farmers and ranchers with disabilities. As a result, an ad hoc working partnership developed between then National AgrAbility Project Partners (the University of Wisconsin and National Easter Seals) and approximately six state AgrAbility Projects. The work partners agreed that agricultural occupational safety and health represents a continuum of services responsive to individuals, families, and agricultural communities across a life span and range of health status changes. A complete continuum of care includes recovery and rehabilitation of agricultural workers who choose to return to agricultural vocations after debilitating illness, injury, or disability.
REVIEW OF LITERATURE A literature review was conducted using the search databases CINAHL, PubMed, and the
National Ag Safety Database. Search terms included occupational therapy, physiotherapy, physical therapy, agriculture, agricultural health, competency, attitudes of health personnel, rural health, physical rehabilitation, needs assessment, and farmers and disabilities in varying combinations to uncover articles on the rehabilitation issues of farmers and ranchers. No articles were found within the domains of occupational therapy and physically therapy that address the physical rehabilitation issues of the farming population. However, a number of articles devoted to the cultural competency and practice competencies needed by health care providers, such as nursing,3,5,6−11,13 were uncovered during the process. These articles were utilized extensively as a model for the process in developing a continuing education curriculum for physical rehabilitation professionals. Additional resources were found through informal networking with state and national leaders in AgrAbility and resulted in finding nonpublished educational programs in Illinois17 and Australia18 that address disability and farming, but had not been widely distributed. In addition, Breaking New Ground at Purdue University19−21 has produced selfpublished texts on assessment for handicap accessibility to farm work environments and selection of assistive technologies that are extensively used by AgrAbility staff. However, the texts were not created as part of a continuing education and competency effort per se. Also, the National Institute for Occupational Safety and Health (NIOSH)-funded Iowa Center for Agricultural Safety and Health12 (I-CASH) provides an hour of rich content on farming with a disability in an annually delivered curriculum for health care professionals. The development of these programs and resources indicates that there is a perceived need for competency in the physical rehabilitation of farmers. The acknowledgement highlights the need for research and evidence-based programming in the area of physical rehabilitation issues of agricultural workers. Evidence-based practice involves making clinical decisions using the best available research evidence, clinical expertise, and client preferences.22 To date, most professionals working with agricultural workers with disabilities have had to rely on their
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Wilhite and Jaco
own experiences, abilities, and client preferences alone without any supportive evidence in the published literature. The purpose of the paper is to describe the combined efforts of the Oklahoma AgrAbility Project, the National AgrAbility Project– Wisconsin (at the time of the work), and National Easter Seals in developing an evidence-based continuing education for physical rehabilitation health care professionals, beginning with education for occupational and physical therapists who directly treat agricultural workers with complex medical issues. This paper will detail establishing a foundation for developing further evidence-based practice and competencies for working with chronically ill or disabled farmers or ranchers. The work partners started with three primary questions: 1. Do occupational therapy/physical therapy (OT/PT) professionals already have a sufficient knowledge about agricultural living and work environments? 2. Are OT/PTs already providing culturally relevant treatment and interventions to the agricultural population (i.e., therapeutic media, adaptive equipment/assistive technology)? 3. Are OT/PTs able to make appropriate discharge plans for injured or ill agricultural workers (i.e., resource identification, referrals, transition services, AgrAbility services)? The initial questions were designed under the general rubric of conducting a needs assessment, which is to identify, first of all, whether the target audience needs the education and, second, if there are gaps in knowledge to be addressed with educational programming.23,24 The needs assessment is an important precursor step before activities and programs are designed. Occupational therapy and physical therapy both follow a process of referral, screening, assessment, evaluation, treatment, and discharge during which knowledge, skills, and attitudes are critical at each step in providing optimal services. Therefore, questions regarding competencies across the process were essential probes for gaining information and advice from panelists.
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The needs assessment process is a wellaccepted tool for organizations, nonprofits, or communities to efficiently improve processes and planning within the entity.24−27 In this example, the needs assessment was conducted volitionally by members of the AgrAbility community of state projects and national partners, about knowledge contained within the community, and the advice subject experts would have about the competencies they have developed in working with farmers with disabilities. The purpose of talking between the projects and partners allowed the sharing of information in order to obtain the knowledge, make it explicit, and thereby more efficiently plan and pursue the grant objective of educating health professions.
MATERIALS AND METHODS Purpose The purpose of the information gathering was to identify the knowledge, skills, and attitudes already held by occupational (OT) and physical (PT) therapy professionals associated with AgrAbility projects. These professionals are regarded as having experiences that contain the knowledge needed to project the learning needs of OTs and PTs who need to provide agriculturally competent services to farmers and ranchers with disabilities. The advice and information gleaned from the panelists was used to develop a continuing education program for other OT and PT professionals.
Design The working group used a Developing a Curriculum Process, a Needs Assessment with a Likert scale survey, and rank ordering procedure in order to gather the information. The partners developed the instruments used to gather information, with assistance from staff with program evaluation expertise from the University of Wisconsin Department of Biological Systems and Agriculture. Drafts of the instruments were reviewed for bias and clarity in order to minimize influencing the subjects giving information and advice.
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Subjects OTs and PTs working with AgrAbility and other AgrAbility staff with expertise in direct service provision who agreed to share information and give advice to the working partners.
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Procedures The partners initiated the first programmatic step toward creating an evidence-based education program by learning about the selfperceived competencies already developed by OTs and PTs who work closely with agricultural populations. The partners generally followed the steps of planning and implementing an educational program as detailed by Donham and Venske3 for I-CASH in developing its formal and validated agricultural occupational nurse training course in 1997 and consulting texts on developing curriculum.23
DACUM Prior to presenting the white paper to the AgrAbility community, the Oklahoma AgrAbility Project obtained preliminary information about competencies via a panel of six OTs who were working with AgrAbility projects. Although referrals for PTs were requested from state AgrAbility Projects, none were identified as working with AgrAbility at this point in the information gathering. Each therapist voluntarily agreed to participate in advising a Developing a Curriculum (DACUM) style process.24 A DACUM is a small-group tool typically used by a profession or trade for developing a curriculum and was deemed a good fit for obtaining information the working partners needed for future planning. The DACUM involves talking to the professionals about what they do in terms of “duties, tasks, knowledge, skill, traits and in some cases the tools the worker uses. The information is presented in graphic chart form and can include information on critical and frequently performed tasks and the training needs of workers.”25 The DACUM is proven to be an efficient and
relatively low-cost basis for creating curriculum, training needs, and competency development. The DACUM process typically begins with developing an expert panel of high-performing workers; in this case, the group of OTs identified within the AgrAbility community. Since the group was geographically dispersed, it was improbable to convene in person. The strategy was modified instead and the group was facilitated by the author asynchronously by e-mail, telephone, or online discussion group. In many ways, the hybrid strategy conformed closely to a focus group.22,26,27 Each therapist was provided with a set of questions intended to elicit their advice about the competencies they believed requisite to their practice with agricultural workers and communities. Each therapist was interviewed on the questions by the author. At this point, the DACUM group defines and describes their job. The therapists were asked about years of practice, years of practice with agricultural workers, a description of their agricultural practice setting, roles and responsibilities within their agricultural health practice, and their background, experience, or affiliation with farming. Deeper questioning yielded whether entry-level education had prepared them for rural or agricultural health, if they had any fieldwork experiences in rural or agricultural health, and whether they had required additional learning in order to work in agricultural health, and what essential skills were necessary to work in agricultural health practices in their opinion. A second round of discussion occurred as responses were shared within the group and ample time was given to discuss and validate the shared information. The sum of the process resulted in describing the duties, tasks, knowledge, skills, and traits (i.e., competencies) involved in the job as perceived by the panel.22 The final results were tabled in an Excel spreadsheet and shared with the forum participants and the work partners. After the DACUM process, other approaches, such as systematic research or observational analysis, are often carried out to provide statistically verifiable information. However, at this time, these approaches have not been used to further define the work competencies of OTs and PTs in rehabilitating farmers.
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Survey After reviewing the results of the DACUM, the National AgrAbility Project–Wisconsin developed an additional needs assessment survey tool by utilizing the information presented by the DACUM. The needs assessment reorganized and expanded the information into eight topic areas. A total of 20 AgrAbility professionals who were OTs, PTs, and other AgrAbility direct service experts took part in the panel to provide information and advice to the working group. A needs assessment is a planning tool that is used to improve education/training or to identify what a particular group of persons lack in order to achieve more satisfactory performance.24 The professionals rated the level of importance of knowledge and skills related to serving the agricultural population on a 5-point Likert scale (very high importance, high importance, moderate importance, low importance, and very low importance) across eight domains: farming today, agricultural safety, case management, assessment skills, treatment strategies, assistive technology, and farm culture. Each section allowed for “other” responses and openended comments. Examples of group responses are reported in the findings section. Finally, the group rank ordered the ratings of the knowledge and skills in order of importance. One last step of information gathering was conducted by National Easter Seals and consisted of determining the relative competency therapists already believed they held in regard to agricultural rehabilitation issues. This involved surveying a group of willing OTs and PTs attending national conferences for their respective disciplines. The survey asked questions about training, level of experience, and perceived competence in treating agricultural workers (see Results and Discussion).
Data Analysis The plan for recording, storing, and reducing the data was carried out by each work partner with primary responsibility for the procedures. The informational data were shared
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across partners so further planning and decisionmaking could occur in developing a continuing education program for OTs and PTs.
RESULTS AND DISCUSSION Analysis of the initial DACUM focus group determined that OTs already working in agricultural health specified competencies needed for this area of practice. On average, the clinician’s averaged 21.8 years in practice, and 10 years in agricultural practice. All six participants had previous experience with farming (living or working on farms). In regard to knowledge, therapists reported one must be able to transfer fundamental frameworks of their primary practice disciplines (OT or PT) to an agricultural setting. However, one must also draw on relevant knowledge from other disciplines (i.e., occupational health, ergonomics, agricultural safety, assistive technology, etc.). In regard to skills, the therapists believed one must possess general assessment and treatment skills and be able to apply them in agricultural health contexts. One must also develop advanced-level skills in activity analysis, ergonomics, and agricultural safety awareness, as well as build an extensive knowledge base of available farm equipment, farm technologies, adaptations, and environmental modifications that can be utilized as assistive technologies or accommodations for the agricultural worker with a disability. When referring to professional attitudes, the therapists believed one must have a client-centered philosophy and clearly understand farming culture and its relationship to farm work and community participation. In addition, the therapist must be flexible, creative, and resourceful as well as demonstrating “going the extra mile” to provide services. An example of “going the extra mile” was adapting therapeutic exercises to fit within the work routine of the individual farmer versus expecting the farmer to make multiple visits to outpatient therapy clinics every week. The second data-gathering effort (needs assessment survey and rank ordering) was carried out by National AgrAbility–Wisconsin.
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The panel first rated the eight topic areas for level of importance. In regard to farming, the majority of the panel rated the farm work environment, physical demands, seasonal demands, and impact of disability as “very high” or “highly” important. The business aspects of farming, health insurance issues, and crop management were rated as “moderately” or of “low” importance. The majority of the panel also rated knowledge of agricultural safety as being of “very high importance” as well as work environment and preventing secondary injuries. In regard to assessment, the majority of the panel reported the ability to complete farm task or job analysis as “very high” or “high” in terms of importance, as well as ergonomics skills. The panel also rated the need to individualize treatment strategies for farmers as “very high” and “high” importance, as well as understanding assistive technology for the farm, and farm culture. Next, the expert panel ranked the most important topics in the physical rehabilitation of agricultural workers as the physical demands of farming (95% said “very high”), respect for the farming way of life/culture (90% ranked as “very high”), and assuming that farming with a disability is feasible (85% ranked it as “very high”). The least important topic area for all respondents was the business aspect of farming (accounting, marketing, etc.), rated at 5% “very high” or “high” by the panel, moderately important by 35% of the panel, and “low” or “very low” by 55% of the panel. Perhaps the most interesting results were found in the competency survey of practitioners by National Easter Seals staff at an American Occupational Therapy Association conference. As reported by National Easter Seals, the OTs rated themselves as “low” on their knowledge of agriculture, yet a surprising number of the same respondents indicated that they had a high level of skill in being able to competently treat farmers with acute and chronic health conditions and disabilities. After thorough discussion by the working partners, the confounding responses were interpreted as evidence that some therapists did not know they lacked competency in the area of rehabilitation of agricultural workers. Although requested, the raw data from National
Easter Seals were not shared with the other partners of the working group, and were lost to follow-up after a change in National AgrAbility Project partners. The synthesis of the information learned among the partners moderately confirms the original questions of the study. In sum, although OTs and PTs graduate with entry-level skills in the physical rehabilitation process, additional skills and advanced knowledge are required to practice with farmers and ranchers with disabilities. Most of the panelists report numerous activities to gain this knowledge, including training in agricultural health, reading agricultural health journals, training in industrial ergonomics, and years of experience working directly with the agricultural population. Secondly, if the therapists do not have knowledge about agricultural culture and agricultural work, their treatment interventions are not likely to be as farmcentered and tailored to the farmer as it should be. Thirdly, if practitioners lack the knowledge and skills outlined by the panelists, they also likely do not know about the existence of AgrAbility, how to refer clients to AgrAbility, or referral to other agricultural health organizations upon discharge. Based on the totality of information, learning goals and objectives were created in the topic areas of physical demands of farming, farming culture, farming with a disability, farm assistive technologies, and resources and referral information. A pilot course was developed with input by the working partners. An educational training was hosted and offered to multiple state AgrAbility projects to implement the pilot curriculum, including Oklahoma, Kansas, Nebraska, Colorado, and West Virginia. The National AgrAbility Project (formerly of the University of Wisconsin) provided multiple media resources, slides, articles, key notes, and input to substantially improve the course offerings. In 2008, the curriculum and National AgrAbility Project– Wisconsin, plus two state AgrAbility Projects, were accepted as approved providers of the course by the American Occupational Therapy Association (AOTA), meeting the AOTA’s stringent guidelines for continuing education credit approval. Colorado and Nebraska AgrAbility
Wilhite and Jaco
have both reported to the author that participants rate an increased competency through pre/post surveying, and in the case of Colorado, the increase in competency reaches the threshold of significance (Dr. Robert C. Fetsch, Colorado State University-Extension Services, personal communication).
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CONCLUSIONS In conclusion, several limitations in developing the educational program effort must be acknowledged. First, the program development was constrained by the lack of empirical and qualitative research on physical rehabilitation as part of the continuum of care for agricultural workers in the broader field of agricultural health and safety. Second, the reliability and validity of all the data-gathering instrument items were not established. However, their targeted use in developing exploratory data for analysis was necessary for initiating a beginning to the process. Thirdly, the methods for gathering the data used a hybridization of strategies that may have influenced the quality and integrity of the information gathered. No statistical procedures were performed beyond averaging the Likert scale data. For these reasons alone, the resulting curriculum and its products should be viewed with caution until future research-based studies can be done. Therefore, the educational curriculum in its current form represents a rough starting point for the field, not an end point. The author feels strongly that a basis for further inquiry and research into the confluence of agriculture, disability, and physical rehabilitation is explicitly clear and necessary and in conformation with World Health Organization28 directives on health. The interview questions as well as tabled information and data can be obtained from the author. The goal of information gathering by the working group was substantially met by sampling the knowledge within AgrAbility projects and the advice from experts in the field. As a result, several probable knowledge gaps by general OTs and PTs were confirmed, and an educational effort is underway to ameliorate these practice gaps.
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REFERENCES 1. Bureau of Labor Statistics. Census of Fatal Occupational Injuries. Available at: http://www.bls.gov/ iif/. Accessed February 7, 2013. 2. Willkomm T. Farming and ranching with a disability. National Agricultural Safety Database Web site. Available at: http://nasdonline.org/static_content/ documents/1832/d001767.pdf 2004. Accessed February 7, 2013. 3. Donham K, Venzke JK. Agricultural occupational health nurse training and certification: addressing the need for occupational health professionals in agricultural environments. J Agromedicine. 1997;4:105–116. 4. Fragar L. Policy issue: agricultural health and safety in Australia. Aust J Rural Health. 1996;4:200–206. 5. Greaves IA, Olson DK, Shutske J, Kochevar L. An agricultural seafety and health information needs assessment for rural service providers. J Agromedicine. 1994;1:43–58. 6. Hodge BD, Ackerman S, Evans C, Erb T, Cook MLW. An occupational health nursing education program: relevance to nurses in non-occupational practice settings. AAOHN J. 2002;50:257–261. 7. Lee BC. Agricultural health and safety: opportunities for nursing research. J Agromedicine. 1994;1:75–80. 8. Lundvall, AM, Olson DK. Agricultural health nurses: job analysis of functions and competencies. AAOHN J. 2001;49:336–346. 9. Malloy C. Agromedicine: an opportunity for nursing. J Agromedicine. 1994;1:85–88. 10. Martin SR. Agricultural safety and health: principles and possibilities for nursing education. J Nurs Educ. 1997;36:74–78. 11. Randolph SA, Migliozzi AA. The role of agricultural health nurse: bringing together community and occupational health. AAOHN J. 1997;41:429–433. 12. Wheat JR, Donham KJ, Simpson WM. Medical education for agricultural health and safety. J Agromedicine. 2001;8:77–92. 13. Winters J. Primary prevention of agricultural injuries: use of standardized nursing diagnosis, interventions, and outcomes. AAOHN J. 2002;50:271–274. 14. Hinojosa J, Blunt ML. National speaking: professional competence. Am J Occup Ther. 1998;52:699–701. 15. Meyer RH, Fetsch RJ. National AgrAbility Project impact on farmers and ranchers with disabilities. J Agric Saf Health. 2006;12:275–291. 16. United States Department of Agriculture National Institute of Food and Agriculture (USDA-NIFA). Assistive technology program for farmers with disabilities: request for Application. Available at: http://www.csrees.usda. gov/fo/agrabilitystateandregionalprojects.cfm. Accessed September 2, 2013. 17. Brunson L, Aherin RA, Petrea R, Brusnighan D. Rehabilitation Needs in Agricultural Contexts: Issues in Illinois. Urbana, IL: University of Illinois; n.d.
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18. Boughton KS, Fragar L, Davis GM. Return to Work on the Farm: Rehabilitation Services for Injured and Disabled Farmers and Farm Workers. Sydney, Australia: University of Sydney-Australian Centre for Agricultural Health and Safety; 1999. 19. Breaking New Ground. Conducting Agricultural Worksite Assessments. West Lafayette, IN: Purdue University; 2005. 20. Breaking New Ground. Improving Farmstead Accessibility. West Lafayette, IN: Purdue University; 1994. 21. Breaking New Ground. Identifying, Selecting, and Implementing Assistive Technology in the Agricultural Workplace. West Lafayette, IN: Purdue University; 1992. 22. Law M, MacDermid J. Evidence-Based Rehabilitation. 2nd ed. Thorofare, NJ: Slack; 2008.
23. Kern D, Thomas P, Howard D, Bass E. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: The Johns Hopkins University Press; 1998. 24. Peterson DJ, Alexander GR. Needs Assessment in Public Health: A Practical Guide for Students and Professionals. Hingham, MA: Kluwer Academic Publishers; 2001. 25. Dacum.org. What is DACUM? Available at: http:// www.dacum.org/. Accessed May 20, 2014. 26. Morgan DL. Focus Groups as Qualitative Research. 2nd ed. Newbury Park, CA: Sage Publications; 1996. 27. Creswell JW. Qualitative Inquiry and Research. Thousand Oaks, CA: Sage Publications; 1998. 28. World Health Organization. International Classification of Functioning, Disability, and Health. 1st ed. Geneva, Switzerland: World Health Organization; 2001.
Journal of Agromedicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wagr20
Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers a
b
Carla S. Wilhite OTD & Linda Jaco MS a
Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico, USA
b
Seretean Wellness Center, Oklahoma State University, Stillwater, Oklahoma, USA Published online: 24 Jun 2014.
To cite this article: Carla S. Wilhite OTD & Linda Jaco MS (2014) Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers, Journal of Agromedicine, 19:3, 325-332, DOI: 10.1080/1059924X.2014.916641 To link to this article: http://dx.doi.org/10.1080/1059924X.2014.916641
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Agromedicine, 19:325–332, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1059-924X print/1545-0813 online DOI: 10.1080/1059924X.2014.916641
Continuing Education in Physical Rehabilitation and Health Issues of Agricultural Workers
Downloaded by [Tufts University] at 16:46 08 October 2014
Carla S. Wilhite, OTD Linda Jaco, MS
ABSTRACT. Limited attention has been devoted to the cultural and practice competencies needed by occupational therapy and physical therapy professionals who provide services to farming families impacted by chronic health or disability issues. Agricultural occupational safety and health should represent a continuum of services responsive to individuals, families, and agricultural communities across a life span and range of health status changes. Physical rehabilitation professionals have a key role in impacting an agricultural producer’s sense of self-efficacy and capacities for returning to agricultural living and work. However, demonstration of competency is essential in providing person-centered rehabilitation services of assessment, evaluation, treatment planning, interventions, referrals, and discharge issues. The paper highlights methods utilized by a state AgrAbility program and a former National AgrAbility Project to develop a model of continuing education programming for occupational and physical therapists that evaluate and treat agricultural workers after acute injury or exacerbation of chronic health conditions. KEYWORDS. Agricultural health, competency, continuing education, disability, occupational therapy, physical rehabilitation, physical therapy, professional competence, secondary injury prevention
INTRODUCTION Agricultural production is one of the nation’s most hazardous industries.1 Nationally, it is estimated that about 288,000 agricultural workers have an impairment creating a disability in the workplace.2 Ample literature demonstrates a need for competency-based practices by health care providers who work with agricultural populations and have resulted in programs educating doctors and nurses in preventive and acute care issues of agricultural workers.3−13 Hinojosa and Blount14 describes competency as developing
pertinent knowledge, skills, and attitudes to perform a behavior or task to a specific criterion. Yet, agriculture as a work activity is often poorly understood by health care providers.3 However, rehabilitation therapists have a large potential impact on the injured, ill, or disabled agricultural worker’s sense of self-efficacy and perceptions of their ability to return to work or living situation. Anecdotal information from farmers and ranchers receiving AgrAbility services supports an assertion that many health care workers, especially those with limited knowledge of farm occupations and culture, have often discouraged
Carla S. Wilhite is affiliated with the Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico, USA. Linda Jaco is affiliated with the Seretean Wellness Center, Oklahoma State University, Stillwater, Oklahoma, USA. Address correspondence to: Carla S. Wilhite, OTD, Department of Pediatrics, University of New Mexico, UNM Health Sciences Center, HSSB Room 140 MSC09 5240, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA (E-mail: [email protected]). 325
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the individual from returning to agricultural work. AgrAbility programs across the United States have demonstrated this discouragement is not always warranted, and many agricultural workers with disabilities have returned to a high level of satisfactory participation in farming occupations.15 AgrAbility is a discretionary grant program administered by the United States Department of Agriculture National Institute of Food and Agriculture, with a core focus on providing education, networking, and assistance to return agricultural worker with disabilities back to the workplace.16 Educational emphasis is considered the primary means by which AgrAbility Projects will harness “human capital [to focus on] . . . accommodating disabilities and avoiding secondary injuries in persons with disabilities”16 who work in production agriculture. Thus, it is important for AgrAbility to direct educational efforts toward professionals who will interact with farmers with disabilities and whose services will have a large long-term impact on the farmer’s subsequent return to living and working on the farm. In 2003, at a National AgrAbility Workshop in Nebraska, the Oklahoma AgrAbility Project presented a white paper on the need for addressing the competency of occupational and physical therapy practitioners (among other professions) to provide services to farmers and ranchers with disabilities. As a result, an ad hoc working partnership developed between then National AgrAbility Project Partners (the University of Wisconsin and National Easter Seals) and approximately six state AgrAbility Projects. The work partners agreed that agricultural occupational safety and health represents a continuum of services responsive to individuals, families, and agricultural communities across a life span and range of health status changes. A complete continuum of care includes recovery and rehabilitation of agricultural workers who choose to return to agricultural vocations after debilitating illness, injury, or disability.
REVIEW OF LITERATURE A literature review was conducted using the search databases CINAHL, PubMed, and the
National Ag Safety Database. Search terms included occupational therapy, physiotherapy, physical therapy, agriculture, agricultural health, competency, attitudes of health personnel, rural health, physical rehabilitation, needs assessment, and farmers and disabilities in varying combinations to uncover articles on the rehabilitation issues of farmers and ranchers. No articles were found within the domains of occupational therapy and physically therapy that address the physical rehabilitation issues of the farming population. However, a number of articles devoted to the cultural competency and practice competencies needed by health care providers, such as nursing,3,5,6−11,13 were uncovered during the process. These articles were utilized extensively as a model for the process in developing a continuing education curriculum for physical rehabilitation professionals. Additional resources were found through informal networking with state and national leaders in AgrAbility and resulted in finding nonpublished educational programs in Illinois17 and Australia18 that address disability and farming, but had not been widely distributed. In addition, Breaking New Ground at Purdue University19−21 has produced selfpublished texts on assessment for handicap accessibility to farm work environments and selection of assistive technologies that are extensively used by AgrAbility staff. However, the texts were not created as part of a continuing education and competency effort per se. Also, the National Institute for Occupational Safety and Health (NIOSH)-funded Iowa Center for Agricultural Safety and Health12 (I-CASH) provides an hour of rich content on farming with a disability in an annually delivered curriculum for health care professionals. The development of these programs and resources indicates that there is a perceived need for competency in the physical rehabilitation of farmers. The acknowledgement highlights the need for research and evidence-based programming in the area of physical rehabilitation issues of agricultural workers. Evidence-based practice involves making clinical decisions using the best available research evidence, clinical expertise, and client preferences.22 To date, most professionals working with agricultural workers with disabilities have had to rely on their
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own experiences, abilities, and client preferences alone without any supportive evidence in the published literature. The purpose of the paper is to describe the combined efforts of the Oklahoma AgrAbility Project, the National AgrAbility Project– Wisconsin (at the time of the work), and National Easter Seals in developing an evidence-based continuing education for physical rehabilitation health care professionals, beginning with education for occupational and physical therapists who directly treat agricultural workers with complex medical issues. This paper will detail establishing a foundation for developing further evidence-based practice and competencies for working with chronically ill or disabled farmers or ranchers. The work partners started with three primary questions: 1. Do occupational therapy/physical therapy (OT/PT) professionals already have a sufficient knowledge about agricultural living and work environments? 2. Are OT/PTs already providing culturally relevant treatment and interventions to the agricultural population (i.e., therapeutic media, adaptive equipment/assistive technology)? 3. Are OT/PTs able to make appropriate discharge plans for injured or ill agricultural workers (i.e., resource identification, referrals, transition services, AgrAbility services)? The initial questions were designed under the general rubric of conducting a needs assessment, which is to identify, first of all, whether the target audience needs the education and, second, if there are gaps in knowledge to be addressed with educational programming.23,24 The needs assessment is an important precursor step before activities and programs are designed. Occupational therapy and physical therapy both follow a process of referral, screening, assessment, evaluation, treatment, and discharge during which knowledge, skills, and attitudes are critical at each step in providing optimal services. Therefore, questions regarding competencies across the process were essential probes for gaining information and advice from panelists.
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The needs assessment process is a wellaccepted tool for organizations, nonprofits, or communities to efficiently improve processes and planning within the entity.24−27 In this example, the needs assessment was conducted volitionally by members of the AgrAbility community of state projects and national partners, about knowledge contained within the community, and the advice subject experts would have about the competencies they have developed in working with farmers with disabilities. The purpose of talking between the projects and partners allowed the sharing of information in order to obtain the knowledge, make it explicit, and thereby more efficiently plan and pursue the grant objective of educating health professions.
MATERIALS AND METHODS Purpose The purpose of the information gathering was to identify the knowledge, skills, and attitudes already held by occupational (OT) and physical (PT) therapy professionals associated with AgrAbility projects. These professionals are regarded as having experiences that contain the knowledge needed to project the learning needs of OTs and PTs who need to provide agriculturally competent services to farmers and ranchers with disabilities. The advice and information gleaned from the panelists was used to develop a continuing education program for other OT and PT professionals.
Design The working group used a Developing a Curriculum Process, a Needs Assessment with a Likert scale survey, and rank ordering procedure in order to gather the information. The partners developed the instruments used to gather information, with assistance from staff with program evaluation expertise from the University of Wisconsin Department of Biological Systems and Agriculture. Drafts of the instruments were reviewed for bias and clarity in order to minimize influencing the subjects giving information and advice.
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Subjects OTs and PTs working with AgrAbility and other AgrAbility staff with expertise in direct service provision who agreed to share information and give advice to the working partners.
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Procedures The partners initiated the first programmatic step toward creating an evidence-based education program by learning about the selfperceived competencies already developed by OTs and PTs who work closely with agricultural populations. The partners generally followed the steps of planning and implementing an educational program as detailed by Donham and Venske3 for I-CASH in developing its formal and validated agricultural occupational nurse training course in 1997 and consulting texts on developing curriculum.23
DACUM Prior to presenting the white paper to the AgrAbility community, the Oklahoma AgrAbility Project obtained preliminary information about competencies via a panel of six OTs who were working with AgrAbility projects. Although referrals for PTs were requested from state AgrAbility Projects, none were identified as working with AgrAbility at this point in the information gathering. Each therapist voluntarily agreed to participate in advising a Developing a Curriculum (DACUM) style process.24 A DACUM is a small-group tool typically used by a profession or trade for developing a curriculum and was deemed a good fit for obtaining information the working partners needed for future planning. The DACUM involves talking to the professionals about what they do in terms of “duties, tasks, knowledge, skill, traits and in some cases the tools the worker uses. The information is presented in graphic chart form and can include information on critical and frequently performed tasks and the training needs of workers.”25 The DACUM is proven to be an efficient and
relatively low-cost basis for creating curriculum, training needs, and competency development. The DACUM process typically begins with developing an expert panel of high-performing workers; in this case, the group of OTs identified within the AgrAbility community. Since the group was geographically dispersed, it was improbable to convene in person. The strategy was modified instead and the group was facilitated by the author asynchronously by e-mail, telephone, or online discussion group. In many ways, the hybrid strategy conformed closely to a focus group.22,26,27 Each therapist was provided with a set of questions intended to elicit their advice about the competencies they believed requisite to their practice with agricultural workers and communities. Each therapist was interviewed on the questions by the author. At this point, the DACUM group defines and describes their job. The therapists were asked about years of practice, years of practice with agricultural workers, a description of their agricultural practice setting, roles and responsibilities within their agricultural health practice, and their background, experience, or affiliation with farming. Deeper questioning yielded whether entry-level education had prepared them for rural or agricultural health, if they had any fieldwork experiences in rural or agricultural health, and whether they had required additional learning in order to work in agricultural health, and what essential skills were necessary to work in agricultural health practices in their opinion. A second round of discussion occurred as responses were shared within the group and ample time was given to discuss and validate the shared information. The sum of the process resulted in describing the duties, tasks, knowledge, skills, and traits (i.e., competencies) involved in the job as perceived by the panel.22 The final results were tabled in an Excel spreadsheet and shared with the forum participants and the work partners. After the DACUM process, other approaches, such as systematic research or observational analysis, are often carried out to provide statistically verifiable information. However, at this time, these approaches have not been used to further define the work competencies of OTs and PTs in rehabilitating farmers.
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Survey After reviewing the results of the DACUM, the National AgrAbility Project–Wisconsin developed an additional needs assessment survey tool by utilizing the information presented by the DACUM. The needs assessment reorganized and expanded the information into eight topic areas. A total of 20 AgrAbility professionals who were OTs, PTs, and other AgrAbility direct service experts took part in the panel to provide information and advice to the working group. A needs assessment is a planning tool that is used to improve education/training or to identify what a particular group of persons lack in order to achieve more satisfactory performance.24 The professionals rated the level of importance of knowledge and skills related to serving the agricultural population on a 5-point Likert scale (very high importance, high importance, moderate importance, low importance, and very low importance) across eight domains: farming today, agricultural safety, case management, assessment skills, treatment strategies, assistive technology, and farm culture. Each section allowed for “other” responses and openended comments. Examples of group responses are reported in the findings section. Finally, the group rank ordered the ratings of the knowledge and skills in order of importance. One last step of information gathering was conducted by National Easter Seals and consisted of determining the relative competency therapists already believed they held in regard to agricultural rehabilitation issues. This involved surveying a group of willing OTs and PTs attending national conferences for their respective disciplines. The survey asked questions about training, level of experience, and perceived competence in treating agricultural workers (see Results and Discussion).
Data Analysis The plan for recording, storing, and reducing the data was carried out by each work partner with primary responsibility for the procedures. The informational data were shared
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across partners so further planning and decisionmaking could occur in developing a continuing education program for OTs and PTs.
RESULTS AND DISCUSSION Analysis of the initial DACUM focus group determined that OTs already working in agricultural health specified competencies needed for this area of practice. On average, the clinician’s averaged 21.8 years in practice, and 10 years in agricultural practice. All six participants had previous experience with farming (living or working on farms). In regard to knowledge, therapists reported one must be able to transfer fundamental frameworks of their primary practice disciplines (OT or PT) to an agricultural setting. However, one must also draw on relevant knowledge from other disciplines (i.e., occupational health, ergonomics, agricultural safety, assistive technology, etc.). In regard to skills, the therapists believed one must possess general assessment and treatment skills and be able to apply them in agricultural health contexts. One must also develop advanced-level skills in activity analysis, ergonomics, and agricultural safety awareness, as well as build an extensive knowledge base of available farm equipment, farm technologies, adaptations, and environmental modifications that can be utilized as assistive technologies or accommodations for the agricultural worker with a disability. When referring to professional attitudes, the therapists believed one must have a client-centered philosophy and clearly understand farming culture and its relationship to farm work and community participation. In addition, the therapist must be flexible, creative, and resourceful as well as demonstrating “going the extra mile” to provide services. An example of “going the extra mile” was adapting therapeutic exercises to fit within the work routine of the individual farmer versus expecting the farmer to make multiple visits to outpatient therapy clinics every week. The second data-gathering effort (needs assessment survey and rank ordering) was carried out by National AgrAbility–Wisconsin.
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The panel first rated the eight topic areas for level of importance. In regard to farming, the majority of the panel rated the farm work environment, physical demands, seasonal demands, and impact of disability as “very high” or “highly” important. The business aspects of farming, health insurance issues, and crop management were rated as “moderately” or of “low” importance. The majority of the panel also rated knowledge of agricultural safety as being of “very high importance” as well as work environment and preventing secondary injuries. In regard to assessment, the majority of the panel reported the ability to complete farm task or job analysis as “very high” or “high” in terms of importance, as well as ergonomics skills. The panel also rated the need to individualize treatment strategies for farmers as “very high” and “high” importance, as well as understanding assistive technology for the farm, and farm culture. Next, the expert panel ranked the most important topics in the physical rehabilitation of agricultural workers as the physical demands of farming (95% said “very high”), respect for the farming way of life/culture (90% ranked as “very high”), and assuming that farming with a disability is feasible (85% ranked it as “very high”). The least important topic area for all respondents was the business aspect of farming (accounting, marketing, etc.), rated at 5% “very high” or “high” by the panel, moderately important by 35% of the panel, and “low” or “very low” by 55% of the panel. Perhaps the most interesting results were found in the competency survey of practitioners by National Easter Seals staff at an American Occupational Therapy Association conference. As reported by National Easter Seals, the OTs rated themselves as “low” on their knowledge of agriculture, yet a surprising number of the same respondents indicated that they had a high level of skill in being able to competently treat farmers with acute and chronic health conditions and disabilities. After thorough discussion by the working partners, the confounding responses were interpreted as evidence that some therapists did not know they lacked competency in the area of rehabilitation of agricultural workers. Although requested, the raw data from National
Easter Seals were not shared with the other partners of the working group, and were lost to follow-up after a change in National AgrAbility Project partners. The synthesis of the information learned among the partners moderately confirms the original questions of the study. In sum, although OTs and PTs graduate with entry-level skills in the physical rehabilitation process, additional skills and advanced knowledge are required to practice with farmers and ranchers with disabilities. Most of the panelists report numerous activities to gain this knowledge, including training in agricultural health, reading agricultural health journals, training in industrial ergonomics, and years of experience working directly with the agricultural population. Secondly, if the therapists do not have knowledge about agricultural culture and agricultural work, their treatment interventions are not likely to be as farmcentered and tailored to the farmer as it should be. Thirdly, if practitioners lack the knowledge and skills outlined by the panelists, they also likely do not know about the existence of AgrAbility, how to refer clients to AgrAbility, or referral to other agricultural health organizations upon discharge. Based on the totality of information, learning goals and objectives were created in the topic areas of physical demands of farming, farming culture, farming with a disability, farm assistive technologies, and resources and referral information. A pilot course was developed with input by the working partners. An educational training was hosted and offered to multiple state AgrAbility projects to implement the pilot curriculum, including Oklahoma, Kansas, Nebraska, Colorado, and West Virginia. The National AgrAbility Project (formerly of the University of Wisconsin) provided multiple media resources, slides, articles, key notes, and input to substantially improve the course offerings. In 2008, the curriculum and National AgrAbility Project– Wisconsin, plus two state AgrAbility Projects, were accepted as approved providers of the course by the American Occupational Therapy Association (AOTA), meeting the AOTA’s stringent guidelines for continuing education credit approval. Colorado and Nebraska AgrAbility
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have both reported to the author that participants rate an increased competency through pre/post surveying, and in the case of Colorado, the increase in competency reaches the threshold of significance (Dr. Robert C. Fetsch, Colorado State University-Extension Services, personal communication).
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CONCLUSIONS In conclusion, several limitations in developing the educational program effort must be acknowledged. First, the program development was constrained by the lack of empirical and qualitative research on physical rehabilitation as part of the continuum of care for agricultural workers in the broader field of agricultural health and safety. Second, the reliability and validity of all the data-gathering instrument items were not established. However, their targeted use in developing exploratory data for analysis was necessary for initiating a beginning to the process. Thirdly, the methods for gathering the data used a hybridization of strategies that may have influenced the quality and integrity of the information gathered. No statistical procedures were performed beyond averaging the Likert scale data. For these reasons alone, the resulting curriculum and its products should be viewed with caution until future research-based studies can be done. Therefore, the educational curriculum in its current form represents a rough starting point for the field, not an end point. The author feels strongly that a basis for further inquiry and research into the confluence of agriculture, disability, and physical rehabilitation is explicitly clear and necessary and in conformation with World Health Organization28 directives on health. The interview questions as well as tabled information and data can be obtained from the author. The goal of information gathering by the working group was substantially met by sampling the knowledge within AgrAbility projects and the advice from experts in the field. As a result, several probable knowledge gaps by general OTs and PTs were confirmed, and an educational effort is underway to ameliorate these practice gaps.
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23. Kern D, Thomas P, Howard D, Bass E. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: The Johns Hopkins University Press; 1998. 24. Peterson DJ, Alexander GR. Needs Assessment in Public Health: A Practical Guide for Students and Professionals. Hingham, MA: Kluwer Academic Publishers; 2001. 25. Dacum.org. What is DACUM? Available at: http:// www.dacum.org/. Accessed May 20, 2014. 26. Morgan DL. Focus Groups as Qualitative Research. 2nd ed. Newbury Park, CA: Sage Publications; 1996. 27. Creswell JW. Qualitative Inquiry and Research. Thousand Oaks, CA: Sage Publications; 1998. 28. World Health Organization. International Classification of Functioning, Disability, and Health. 1st ed. Geneva, Switzerland: World Health Organization; 2001.
