Facilitating safe toilet transfers when exploring the topic of the facilitation of safe toilet transfers, it is important to

  • Consider what constitutes a safe transfer
  • Understand how occupational therapy can facilitate transfers and reduce risks
  • Understand and be able to critically appraise toileting equipment through clinical reasoning
  • Use experience and knowledge to support patients and clients.

Firstly, let us consider the definition of safe. This is defined by Merriam Webster (2021) as “free from harm or risk” or “protected from, or not exposed to danger or risk, not likely to be harmed or lost” (Oxford Languages, 2021). An occupational therapist must therefore consider whether any transfer can be classified as ‘safe’, or whether a better description is: the risk in transferring can be reduced to a reasonably practicable level.

The occupational therapy process is defined by the World Federation of Occupational Therapists (2021) as:

assessment, planning, intervention and cooperation.

As part of the assessment or evaluation of a person, an occupational therapist must understand an individual’s occupational profile, undertake an analysis of their occupations and performance in order to target intervention and create the desired outcomes.

Part of this analysis is the review of risks. An element of the unique intervention that an occupational therapist can provide, is the facilitation of risks and Pentland et al (2018) states that it is the role of an occupational therapist to overcome the barriers that prevent people from doing the activities that matter to them and not to see risk as another barrier. Occupational therapists can manage risks in order for people to live meaningful, occupationally based lives.

The Royal College of occupational therapy published guidance for occupational therapists called ‘embracing risk: enabling choice’ in 2018, which encourages practitioners to embrace risk as part of their professional duty. Clinicians are encouraged to review this document and implement its philosophy in their day-to-day practice.

Implementing the occupational therapy process, assessing occupational performance and identifying risk; then leads the clinician to develop an enablement plan which is shared with the client. For example, as part of an initial assessment, it may be identified that
a person is struggling with sit to stand transfers when using the toilet. An activity analysis undertaken verbally with the client, identifies they have difficulty in wiping after using the toilet and are receiving help from a spouse. The enablement plan is developed alongside the client and aims to optimise occupational performance and support appropriate life roles.

In this case, a number of ways in which to optimise occupational performance are evaluated with the client. It is established that the person is extremely unlikely to improve their occupational performance through rehabilitation and therefore, a compensatory approach is required. Evaluation of simpler items that facilitate toilet transfers is undertaken with the client and it is established that a raised toilet seat and a grab rail together with alternative techniques for wiping would not sufficiently reduce risks and promote independence. It is the experience of an occupational therapy practitioner that will sufficiently reduce the risks, promote independence and work alongside the client to find a solution.

The occupational therapy code of conduct states that “you enable individuals to preserve their individuality, self-respect, dignity, privacy, security, autonomy and integrity”. Also, “you empower people to maintain their own health and wellbeing and to manage their own occupational needs, wherever possible”.

Consequently, an occupational therapist needs to make appropriate recommendations to facilitate occupational needs and reduce risks in toilet transfers. Recommendations should be based upon:

  • Client goals
  • Activity analysis
  • Risk assessment
  • Dignity issues
  • The effect of roles on care and intimacy
  • Is the equipment facilitating use of the toilet?

An experienced practitioner should critically appraise compensatory intervention around toileting. This includes evaluating toilet equipment and understanding that compatibility does not always support occupational performance. For example:

  • Does the provision of a combined raised toilet seat and frame support the use of a toilet by other family members? Or
  • When a wheeled shower chair is placed over a wash and dry toilet, is the cleaning action still effective to eliminate the need for additional wiping or drying?

Clinical reasoning in occupational therapy requires the consideration of clients current and future occupational functioning, and how they engage and relate to others in the environment (Scanlon and Brentnall, 2017). However, I would take this further and suggest that robust clinical reasoning involves the appraisal in consideration of the effectiveness of equipment designed to facilitate occupation.

In summary:

  • A safe transfer may not ever be possible, however risks can be managed and reduced.
  • A thorough occupational assessment can facilitate safer transfers and reduce risks.
  • Equipment and adaptations improve occupational performance via a compensatory approach: however, critical appraisal and activity analysis is crucial.
  • It is essential that occupational therapy practitioners are critical thinkers.

References

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