Developing the future occupational therapy workforce in tackling health inequalities, Nottinghamshire County Council

Nottinghamshire’s public health team identified accessibility issues in a needs assessment of women’s refuges. Disabled women are twice as likely to experience domestic abuse. There is evidence that domestic abuse takes away people’s occupational right “to do, be, belong and become what people have the potential to be in the absence of harm” causing occupational injustices and alienation: if survivors’ cannot engage in meaningful occupations part of their identity is taken away from them. 

The council hosted two pre-registration MSc occupational therapy students in their final year within public health to work alongside the domestic abuse team. With support, they completed environmental audits of the accessibility of six refuges and explored how occupational therapy led work could be offered to female survivors while they resided in refuges to improve their health and wellbeing outcomes. The students worked with survivors in one-to-one and group contexts. The one-to-one work involved an adapted assessment designed to assess physical, psychological, cognitive, sensory, and social needs of survivors. The therapeutic group work involved three different groups of women in separate refuges, stress management, arts and crafts, and a family peer support group.

Two women were supported to apply for financial benefits (PIP application) and recommended to buy compensatory equipment to support their activities of daily living. The women were given stress management techniques, more opportunities for meaningful creative occupations, and the opportunity to meet other survivors and to build peer support networks within their refuge.

Feedback from survivors, refuge staff and colleagues in the Nottinghamshire County Council was highly positive. There were small positive changes in the survivor’s perceptions of their abilities to engage in occupations and manage stress over the three weeks of the groups.

“We want the sessions to keep going with you, they’ve been really useful.” – Survivor, feedback from stress group

“The women that attended have fed back that they have started to use the strategies highlighted to them and will keep thinking about it going forward.” –Feedback from refuge manager.

"I have learned that it's good to take time out for yourself and I have enjoyed time with my eldest daughter doing something she loves." – Survivor, from arts and crafts group.

Public health outcomes

• Refuges are more accessible for a wider range of women.
• Additional and local evidence generated in support of trauma informed occupational therapy practice in domestic abuse refuge settings
• Commitment to future student placements

The following case study details the journey of two pre-registration MSc occupational therapy students in their final year on a role-emerging leadership placement within Public Health at Nottinghamshire County Council, specifically working alongside the domestic violence team. It details the work they completed scoping the role for occupational therapy within women’s refuges, where occupational therapists had no previous input. 

It continues to describe the two avenues this work took, one being environmental audits of the accessibility of the refuges and the other how occupational therapy led work could be offered to female survivors while they resided in refuge to improve their health and wellbeing outcomes.

The Allied Health Professional strategy (NHS England, 2022) and UK AHP Public Health Strategic Framework 2019-2024 (AHPF, 2022) identified a role for occupational therapy within Public Health. The idea for a role emerging placement was born from a needs assessment of refuge environments in Nottinghamshire commissioned by public health domestic violence team finding several accessibility issues for people with diverse disabilities. The aim of this placement was to scope out the role for occupational therapy in public health domestic violence services with two objectives, to assess the physical environment of each refuge across Nottinghamshire by conducting environmental audits and to implement the occupational therapy process by working with survivors in groups and on a one-to-one basis.

The rationale is domestic abuse takes away people’s occupational right “to do, be, belong and become what people have the potential to be in the absence of harm” (Wilcock & Hocking, 2015). This can cause occupational injustices including occupational deprivation and occupational imbalance, which can lead to occupational alienation. This can also impact on survivors’ occupational identity, because if they cannot engage in meaningful occupations part of their identity is taken away from them. The starting point for applying occupational therapy in domestic violence came from a project implemented in Wales by Clarke and Jones (2020) seed funded by Elizabeth Casson Trust. This project identified survivor`s occupational needs through the application of occupational therapy theoretical knowledge to practice, and evidenced powerful statistics, including disabled women are twice as likely to experience domestic abuse (Safe Lives, 2023) and an estimated 1.6 million women aged 16 to 74 experienced domestic abuse (Office for National Statistics, 2020).

Environmental objective 

The occupational therapy students undertook environmental audits of all six refuges, with support from their Practice Educators. This required adaptation of an Activity of Daily Living (ADL) assessment to suit the environment they were assessing and involved taking measurements of household facilities and taking pictures to truly represent each refuge. They identified any issues within each refuge that prevented accessibility for those with physical needs or impairments and recommended improvements, which were reasoned, and risk assessed. Those involved in this objective included both students who undertook the audit, the occupational therapy practice educator, refuge managers who provided access to the refuges, and the student’s mentor who was the public health commissioning manager who has reviewed and implemented the occupational therapy students’ recommendations. 

Occupational therapy process 

The occupational therapy students worked with survivors in one-to-one and group contexts. The one-to-one work involved an adapted assessment designed to assess physical, psychological, cognitive, sensory, and social needs of survivors. Two women were supported to apply for financial benefits (PIP application) and recommended to buy compensatory equipment to support their activities of daily living. The therapeutic group work involved three different groups of women in separate refuges, stress management, arts and crafts, and a family peer support group. Both students, led the group work, and the refuge managers and staff helped with the organisation, planning and implementation of the groups. As a result of this work, the women have been given stress management techniques, more opportunities for meaningful creative occupations, and the opportunity to meet other survivors and to build peer support networks within their refuge

Overall, feedback received from survivors, refuge staff and colleagues in the Nottinghamshire County Council was highly positive. Feedback forms were used pre-and-post group sessions, with tailored likert scales to measure outcomes. The results from these showed small positive changes in the survivor’s perceptions of their abilities to engage in occupations and manage stress over the three weeks of the groups. 

Below are some quotes from survivor and refuge staff to give rich qualitative feedback: 

“We want the sessions to keep going with you, they’ve been really useful.” - Survivor feedback from stress group 

“The women that attended have fed back that they have started to use the strategies highlighted to them and will keep thinking about it going forward.” –Feedback from refuge manager. 

"I have learned that it's good to take time out for yourself and I have enjoyed time with my eldest daughter doing something she loves." - Survivor 2 from arts and crafts group. 

Public Health Strategic Commissioning outcomes:

• Working through the occupational therapy students report to implement the environmental recommendations, to make their refuges accessible for a wider range of women.
• Considering how the occupational therapy can add therapeutic value and impact in women’s domestic violence refuges. The work the occupational therapy students have completed, along with the emerging national evidence base, will support the development of a business case for trauma informed occupational therapy practice in domestic violence refuge setting. In turn, and over time the aim is this would support new student placements in this setting.
• Now committed to hosting AHP student placements. Each placement will be planned and designed to address the student’s professional background, and the needs of public health. These placements are dependent on practice educator availability to give a profession specific long-arm supervision model. As this was a university placement the financial cost was minimal, resources for all groups totalled no more than £50.

The key learning points are:

• The breadth of scope for occupational therapy in settings such as domestic violence.
• How the preventative interventions occupational therapists deliver, align with public health values.

Aspects of the placement that worked well were two students working together as a team, the group work, which was received positively, the relationship building with the women and staff in refuges, and the value and impact the environmental audits will have for Nottinghamshire. A challenge was adjusting to a different style of a leadership placement, and autonomy of hybrid working. 

Going forward this occupational therapy role could focus on a range of preventative work packages either in the public health team or specifically placed in the refuges. Areas for further exploration include:

• Working with individuals for housing and equipment needs assessments.
• Recommending or assessing new properties put forward for refuge for access suitability.
• Creating occupational therapy group programmes in all refuges to promote and increase engagement in meaningful activities.