Archive for category: Occupational Therapy At Work


Provider Consent in Health Care – No Also Means No

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

In my previous blog, “Client Consent in Health Care — No Means No,” I spoke of the importance of client consent.   No means no.  But what is often forgotten in health care, is that consent goes both ways.  While a client has the right to “choose their provider,” this just means they can decline to be treated by, say, me. Or the next person.  But that doesn’t mean they can go down a random roster of professionals to find the best fit.  Why?  Because their ability to “choose their provider” is trumped by the provider also being able to “choose” them as well.

There are three main situations when a provider may say “no” to a client:

Skills and Availability – The provider would be expected to decline if they lack the skills, knowledge, or expertise (“the competencies”) to treat the clients’ presenting problems.   Taking on a client outside their skillset is unsafe for them professionally and for the client and their outcomes.  This also applies to them already having a full complement of clients such that they don’t have the space to do the work within what is needed or expected.

Conflict – Providers cannot consent to provide services to someone if this places them in a conflict, which can happen if they know the individual, or if being their provider would violate an employment agreement or contract (i.e. if you meet them at Company A, you can’t then work with them at Company B).  If the provider indicates a conflict, even if it seems minor to others (i.e. “I knew them in high school”), this must be respected.  Note that the nature of the conflict does not need to be disclosed.  Saying “I am in conflict” is enough.

Safety – The provider can also decline if providing services would be unsafe for them (physically, emotionally, environmentally).  While some jobs are inherently unsafe by nature, health professionals are not required to put themselves at risk when working.  This is especially true in the community where we are isolated and not protected by the surroundings of say a hospital or clinic space, where there are others (and buttons) to aid us quickly if needed.

As I said before, consent is a deal-breaker.  Always.  As occupational therapists, there are rules, laws, and regulatory matters to consider before taking on any client.  Working with vulnerable and exposed people (emotionally, mentally and physically) requires providers to take consent seriously and this goes both ways when clients choose us, and when we choose them.


Client Consent in Health Care – No Means No

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

My grandmother is in her 90’s and up until recently, lived in a retirement home.  She is legally blind and deaf, so communication is very difficult for her, but where she lacks in sight and hearing she excels in cognition, missing little and being able to direct her own needs.

As with many people of advancing age, while she can bathe herself, this is a safer process with an attendant.  She has been fortunate to be eligible for public services and receives care in the mornings.  During a recent review of her care schedule, the facilitator asked her if she was comfortable with a male attendant.  She responded with a “no” and that her “late husband was the only man to see her undressed and she would like to keep it that way.”

The next day two care providers showed up.  One was “in training” and he was a man.  My grandmother was upset by this, but like many people of her generation that feel that public services are such a “gift,” she felt that for “training purposes” she would compromise her comfort and tolerate the presence of a man during her shower.

The next day the same man showed up alone.  “I am here to shower you today.”  I am not sure how the conversation went, but it ended with her deciding to let the man shower her, with her telling him “well, this is probably just as uncomfortable for you as this is for me, so let’s get this over with.”

As an occupational therapist, but also as her granddaughter, this is upsetting.  She was asked for consent regarding a male provider and declined.  This should be in her record.  They proceeded anyway.  As a business owner, I understand that staffing and capacity are challenging and based on my own work experience with finding and keeping personal care workers for clients, the human resource issues are real.  But consent is consent and she did not provide it.  One could argue that “in the moment” consent was “implied” (she didn’t ask the man to leave), or “provided” (she let him proceed), but an “in the moment” comment of “let’s get this over with” is not consent but surrender.  She was vulnerable, confronted, and knew that a “no” meant “no shower today.”  Showers, like privacy, are also important to her.

The ability to “Consent” (to anything) is an important human right.  Exercising this is our duty to ourselves.  We are reminded of this quite topically in the “#MeToo” movement, but the reach of the “no means no” concept needs to be wider.  In health care especially, consent is paramount in the acceptance and deliverance of services.  No must mean no.

Consent is a deal-breaker.  Always.  Not only are there preferences and “feelings” about this important topic, but there are rules, laws, and regulatory matters to consider.  Working with vulnerable and exposed people (emotionally, mentally and physically) requires providers to take consent seriously and this goes both ways when clients choose us, and when we choose them.

For my grandmother, we contacted the agency and reminded them of her preferences.  We asked that no men arrive for showering and that they need to do better to not put her in these vulnerable and uncomfortable situations.  If they cannot accommodate, we will need to elect another service agency, or fund private care for her such that we are not exposing her to these experiences, even if “free.”

Stay tuned for my next blog on this topic, where I will review the second side of consent as yes; providers get to consent too.



Snow Removal O-Tip of the Week: Snowblower Safety Considerations

Our O-Tip of the week series we will be providing valuable “OT-Approved Life Hacks” to provide you with simple and helpful solutions for living. 

For the month of February, our O-Tip series will help you to practice safe and efficient snow removal this winter.

If you are fortunate enough to have a snow blower you have less heaving lifting to do, however, there are still dangers that this more efficient method can pose.   Here are some tips to ensure you are being safe while blowing snow:

  • Do not let children operate the machine
  • Do not wear loose clothing which could get caught in the machinery
  • Pace yourself – even when snow blowing you can overexert yourself in the cold, leading to the risk of heart attack
  • Operate the machine only outside as inside a shed or garage could put you at risk for carbon monoxide poisoning
  • Add fuel outdoors, before starting, and never add fuel while the machine is running
  • Never leave it unattended when it is running

Reducing Risk of Strain Due to Repetitive Movements

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

Repetitive activity using improper posture and body mechanics can result in excess energy expenditure, fatigue, pain and even injury or damage to muscles and joints over time.  Therefore, it’s important to know the proper body mechanics required when completing everyday tasks and activities, at home, at play or at work or school.

The following episode of our Occupational Therapy Video Series:  OT-V discusses how to ensure you are using proper body mechanics with respect to:

·    workspace design

·    lifting and repetitive muscle use

·    excessive standing

·    excessive sitting

·    hand movements

·    excessive energy output.

Take a look to learn how an OT can help you improve body mechanics and reduce the risk of injury and pain in the long-term.  Remember to subscribe to our YouTube channel for access to this and other great OT-V videos!


How Emotionally Intelligent Are You?

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

I have four daughters – three in high school and one in University.  That is a lot of estrogen in our house.  Yet it is an interesting time for our family – as our girls are navigating the perils of adolescence, I too am finding myself in a stage I am calling “adultescence” whereby my thoughts, feelings, and emotions are changing as theirs are.  This creates an interesting ebb and flow of all of us learning together what it all means as a teen girl to “grow up” and as an adult to start “letting go”.

I had one of those adultescent “aha” moments the other day with one of my teen daughters.  She is very socially driven and relationships are very important to her.  Over the last few months, as school has resumed, she has been struggling with some of her friendships.  One girl just suddenly stopped responding to messages, one takes pleasure in forwarding hurtful messages, and another treats my daughter as the weekend “last resort”.  In talking to my daughter about these events, my “aha” moment came when I realized that my daughter, already, is highly emotionally intelligent.  She has the ability to put herself in the position of others and regulates her own behavior (so far) on how she would feel as the recipient.  This is a gift for her but puts her at a relationship disadvantage as many of her peers are not there yet.   She “feels” in a relationship like she is 25, but is trying to rationalize the emotional behavior of kids 16 and 17.

According to psychology today, Emotional Intelligence includes three skills:

1. Emotional awareness, including the ability to identify your own emotions and those of others;

2. The ability to harness emotions and apply them to tasks like thinking and problem solving;

3. The ability to manage emotions, including the ability to regulate your own emotions, and the ability to cheer up or calm down another person.

Emotional intelligence then includes:  self-awareness, self-regulation, motivation, empathy, and social skills.  It can affect: personal relationships, workplace (or school) performance, physical and mental health, and how you deal with situations such as loss or disability.

The good news is that experts believe that emotional intelligence can be learned, even in adults.  How do you know if you are emotionally intelligent?  Perhaps reflect on your relationships – are you able to sustain positive and loving bonds with others?  Can you empathize and relate to people during their struggles, and do they know that you “get it” and are emotionally available to them?  Do you regulate your own behavior based on how others might feel if you act a certain way, or say certain things?  Before sending that text, email or calling someone in anger do you consider how you want them to “feel” following your interaction?  Do you take pleasure in being right even if that makes others feel bad?  If you want to test your level of emotional intelligence, or raise your emotional IQ, take a quiz to see where you’re at:  Emotional Intelligence Quotient Quiz.

Do you think you need to improve in this area?  Some suggestions include:

·    practice mindfulness – in social situations, at work, at home with family relationships.

·    Stay in touch with your feelings through journaling or meditation “check-ins”.

·    Connect your feelings to the situation and try to separate the person from their behavior.

·    Check your thoughts – how you think can become how you feel, and the good news is you can change how you think!

·    Communicate with others and don’t be afraid to be vulnerable to those close to you to help sort through feelings, thoughts and emotions.

·    And if you can, don’t take the comments of others personally.  Their thoughts about you do not need to become the thoughts you have about yourself.


Originally posted November 2016


Occupational Therapy and Heart Health

Being diagnosed with heart disease is a life-altering event, often requiring permanent lifestyle changes.    Occupational therapists can help people to recover from the initial incident, to rebuild a life of function, and to promote change that will help with prevention.

Learn more about how Occupational Therapy can assist those recovering from heart disease in the following infographic:




Breaking the Stigma: Sexuality and Disability

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

Co-written by Lauren Halliwushka, Occupational Therapist

Unfortunately, in the ongoing quest for an inclusive and equal-opportunity society, “sex” still sells. What used to be in printed material (magazines, newspapers, and fliers) has turned into an online buffet of images that are posted by people of themselves (often filtered, patched and “enhanced”), by people of others (with and without consent), and by photographers, companies and others whose job is to capture the attention of, and entice millions of people, to buy a product, service or idea. The goal of these “sexy” images is to tap into our intrinsic human need and desire for sexuality by adhering to the societal expectations of what is attractive. 

It has only been in the last few years that the concept of “attractive” is changing. Models are increasingly featured in many different shapes, sizes, ethnicities and some campaigns (thank you Dove) are about “natural” beauty.  But despite this small move in the direction of selling with images of “various types of people” presented as “real”, there is one more similarity in advertising that we often overlook. The models are able-bodied, or to use a totally arbitrary term, they would be considered “normal”. 

Why then do we rarely see individuals with disabilities featured in sexually enticing advertisements? It goes back to society’s assumptions of what beautiful and sexy is. Disabled people, through their history of being marginalized, institutionalized, segregated, or otherwise pitied have not been routinely associated with ‘attractive” as a concept. We need to work together to continue to change this perception and to remove the stigma.

Individuals with disabilities are sexual beings. Like you and me, they also have urges, desires, needs, and fantasies. However, a subset of the general population doesn’t think so. According to a systematic review of qualitative articles, a prominent misconception among a sample of the general public is that individuals with disabilities are asexual. Biologically this is odd because individuals with disabilities undergo the same maturation processes as everyone including puberty, reproduction and hormonal surges. Yes, approximately 1% of individuals are asexual but this is all people, not just those with disabilities. Another common misconception is that individuals with disabilities are only attracted to other individuals with disabilities. Inter-abled couples do exist, and relationships can form before or after a disabling event. Compared to inter-racial couples, however, inter-abled are not as common. Why? Well, it is thought that individuals with disabilities may be unconsciously internalizing the stigma and perspectives of society, which further negatively impacts their self-esteem, self-efficacy, motivation, and perceived sexual autonomy. This claim is supported by a qualitative study that gained the perspectives of individuals with disabilities on the topic of sexuality. A significant theme that emerged is the innate belief that their sexuality was not equal to or desired by individuals without disabilities. As such, they were reluctant to pursue inter-abled relationships due to fear of rejection, the partner resenting their disability and the possibility of the partner falling into a caregiver role.

In addition, stigma unknowingly creates various systemic barriers that further reinforce societal and self-stigma among individuals with disabilities, creating a negative counter-productive cycle. There is plenty of literature that highlights the ineffectiveness or inaccessibility of sexual education within secondary schools for individuals with both visible and invisible disabilities. Sexual education focuses on “normal” (that ugly word again) people. Hence, from a young age, we are setting up individuals with disabilities for failure by reinforcing self-stigma and neglecting to acknowledge their sexual being.

Regarding the healthcare system, a study suggests that only 6% of licensed health care professionals engage in frequent discussions about sexuality with patients/clients with half of them stating they avoid the topic due to embarrassment. Keep in mind, this statistic is regarding all individuals, disability or not, which is even more surprising given that sexuality is a crucial component of someone’s health and – more importantly – intrinsic to human nature. No wonder individuals with disabilities are adopting self-stigma if health care professionals shy away from this topic.

This is not about changing what you see as attractive. This is about challenging the opinion that individuals with disabilities are not capable of being sexy and can’t (or shouldn’t or don’t) engage in sexual behaviors. Not only are all people, disabled or not, able to engage in any and all sexual behaviors, but they also have wants, needs and desires like the rest of us. Healthcare professionals that shy away from, or avoid, this topic should consider discussing this aspect of health with patients/clients when appropriate by adopting a comfortable strategy (such as the ex-PLISSIT model).

If you have personally felt, or still feel, the self-stigma surrounding sexuality, please discuss it with a trusted family member, friend or healthcare professional. Specifically, Occupational Therapists are trained to be open about this concept and to problem solve the barriers to sexuality and engagement in sexual activity as a very important “occupation (aka life role)” for all of us.

If you are interested in reading more, I recommend The Ultimate Guide to Sex and Disability by Dr. Miriam Kaufman.

Remember: Disability is extremely broad and can impact people in multiple ways. As with all people, consent is always required when engaging in any sexual activity.




1 Sinclair, J., Unruh, D., Lindstrom, L., & Scanlon, D. (2015). Barriers to Sexuality for Individuals with Intellectual and Developmental Disabilities: A Literature Review. Education and Training in Autism and Developmental Disabilities, 50(1), 3-16. Retrieved June 18, 2018.

2Miller, A. M. (2015, May 4). Asexuality: The Invisible Orientation? Retrieved from

3Esmail, S., Darry, K., Walter, A., & Knupp, H. (2010). Attitudes and perceptions towards disability and sexuality. Disability and Rehabilitation, 32(14), 1148-1155. doi:10.3109/09638280903419277

4McDaniels, B., & Fleming, A. (2016). Sexuality Education and Intellectual Disability: Time to Address the Challenge. Sexuality and Disability, 34(2), 215-225. doi:10.1007/s11195-016-9427-y

5Jones, L., Bellis, M., Wood, S., Hughes, K., McCoy, E., Eckley, L., . . . Officer, A. (2012). Prevalence and risk of violence against children with disabilities: A systematic review and meta-analysis of observational studies. The Lancet, 380, 899-907. doi:10.1016/S0140-6736(12)60692-8.

6Dukes, E., & McGuire, B. E. (2009). Enhancing capacity to make sexuality-related decisions in people with an intellectual disability. Journal of Intellectual Disability Research, 53(8), 727-734. doi:10.1111/j.1365-2788.2009.01186.x

7Haboubi, N. ,. J., & Lincoln, N. (2003). Views of health professionals on discussing sexual issues with patients. Disability and rehabilitation, 25(6), 291-296

8 Taylor, B., & Davis, S. (2006). Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard, 21(11), 35-40. doi:10.7748/ns2006.


My Animals Support Me, But Are Not Support Animals

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

Every day I benefit from the love of my animals.  In fact, being an animal owner is not only part of my lifestyle, but has absolutely become part of who I am.  My animals provide me with love, comfort, they calm me and make me smile and laugh.  I have one at my feet right now and he is the one that tends to keep an eye on me – never too far away, watching, waiting, and looking for moments to connect with me, steal some cuddles or give me a quick wag to show his support.  My animals also provide comfort and security to my children and it is not uncommon to see a kid doing homework or relaxing in her room while surrounded by her four-legged beasts much like Snow White.  However, like children, animals are not always easy and at times can be all-consuming, frustrating, and difficult to manage.  Pets are not for everyone, especially during times of trauma, transition, or change.  In the end, my dogs provide me and my family with a “service”, but these are far from “service animals”.  I will explain.

Pets are animals that we keep inside to provide us all the comforts and joys that animals can provide.  Sure, we take them outside, but that is equally for their benefit as it is for ours (dog parks, nature walks, doggie play dates).  Maybe to the vet, groomers or to visit with dog-friendly friends.  But pets are typically a hot mess in public spaces.  My dogs are wonderful at home and are trained to be good here, but If I took one of them to a restaurant he would pretend to be looking for some affection while simultaneously snatching the steak off my plate, or diving to grab that roll that landed on the floor.  He would be underfoot and anxious, nervous of the chaos and commotion.  And in getting him into the restaurant he would not hesitate to chase a squirrel across the road while dragging me as the leash holder into traffic with him.  After all he is a pet; he is not trained in how to properly manage public spaces.

True service animals are pets, sure, because they provide all the supports of an animal at home.  But they are also exceptionally well trained to behave in public.  They can navigate public spaces with focus, comfort and ease because they have experience here, and know what is expected.  They are not distracted by squirrels or steak and get used to being so attentive to their owners such that affection from strangers when out of the home is not something they crave.  They are trained to react to situations with consistency and based on what the owner needs – they will not jump on someone in an elevator, bark, urinate in the lobby, or wrap their leash around someone’s leg.  They won’t bite anyone because they are screened as non-aggressive and are trained to have restraint (unless they are a trained guard dog in which case they provide owner protection on appropriate command).  Service animals provide just that – a “service” to someone in need.  They are not just “pets in a vest out in public.”

In Ontario, owners of service animals, in addition to donning the animal in a vest, are required to carry a “prescription” to explain that they need the dog in public spaces.  This “prescription” can be written by a health professional, and to protect the privacy of the animal owner, is often discrete and vague (“requires the service animal for medical reasons or reasons of mental health”).  Many people with these scripts won’t look or act disabled on the surface, hence the need for supporting documentation.  Unfortunately, with service and support dog vests available online, the note becomes necessary to prove a need and to allow the owner of an establishment to be comfortable having the animal inside.

As occupational therapists, we can provide these scripts and notes to owners of service and support animals.  In many settings, we also assist people to obtain funding for the animal and its training.  What we need to understand, however, is the responsibility that comes with this.  Should the animal misbehave at home or in public and harms someone or the owner, the prescriber of the animal could prove liable as the one indicating the animal was needed and was suitable for the purposes of service and support.  To protect ourselves from this, there are things we should consider:

1.      Ensure the animal is not a pet in the first place.  Confirm that the animal is trained, has been vetted to be suitable, and can handle the important responsibilities that come with wearing a service animal vest.  The best way to do this is to ensure the animal was provided by a reputable facility that works with animals for this purpose.  A list of such facilities in Ontario is included below.

2.      Ensure your note has an expiry date.  An open-ended script that could be carried for years or decades does not ensure that you are referring to “this animal” at “this time”.  Consider dating your script to ensure it is reviewed perhaps annually like other processes that involve our signature (parking permits, tax forms, etc.).

3.      Recognize that supporting the funding for someone to obtain or purchase an animal could also be considered a “script” whereby you are taking ownership for this animal as a service dog.  If you complete a letter of recommendation, complete with funding support, that could be enough for someone to carry with them, written by an “occupational therapist” as proof of the need.

4.      In the cases of mental health, consider the value of having this prescribed by a psychologist, psychiatrist or psychotherapist if warranted.  Consider your own knowledge, skills, and experience with the client and their disability in recommending this type of need.  Ensure there is an appropriate diagnosis of mental health which is best obtained from a registered mental health professional.

In researching for this blog, I was provided a very informative and helpful document written by a Psychologist, Registered Dog Breeder, and Executive Director of Hope Heels Service Dogs: Dr. Aanderson.  This resource is also included below.  This document explains service animal laws across Canada, and clearly outlines the differences between a guide dog, service or support dog and pet.  It provides a decision tree to help professionals like myself navigate the important conversation with clients regarding the use of a service dog, and how this differs from a pet, in deciding whether to “prescribe” this or not.

I am sure many of us have witnessed an animal in a public space that was wearing a vest and misbehaving.  In one instance, someone in an elevator with me said to the owner of a vested “support animal” that was climbing on people “there is no way that is a service dog.”  The owner just exited the elevator without responding.  Service animal or not, it is an abuse of process and blatant disregard to the training and time that goes into true service animals to try and present a pet in this way.  Service animals provide an immense amount of support to those they are trained to help.  As professionals, we have a responsibility to continue to safeguard the true use of these animals, the programs that train them and the people that need them.  Consider using Dr. Aanderson’s guide before providing written support for these valuable four-legged aids to daily living.


Aanderson Service Dog Prescriber Guidelines

Service Dog Providers in Ontario – Current as of October 2019



Improve Safety in Your Bathroom

Let’s discuss the most dangerous room in the home: the bathroom. For those with limited mobility, or seniors, it is important to consider the fall risks that exist in the bathroom to ensure that people are safely able to go about daily routines. In the video below we will review bathroom hazards and will discuss the many suggestions an Occupational Therapist may make after a home assessment.

We hope you enjoy this video from our Occupational Therapy Video (OT-V) series and can use some of our tips to stay safe at home!


Disability and Weight Management: Helping You Tip the Scales in the Right Direction

Julie Entwistle, C.Dir. (c), MBA, BHSc (OT), BSc (Health / Gerontology)

I find that while many of my clients initially lose weight following trauma (hospital food diet); eventually the net impact of a disability is often weight gain.  This is often the result of many factors – most interacting to make the solution difficult to isolate.  Medication side-effects, altered routines, reactive eating, friends and family that provide unhealthy sympathy foods, increased use of fast food because preparing meals is difficult, inactivity, depression, and even hormonal and physiological changes to the body as a result of the trauma.

But we do know that 70% of weight management is diet and assuming this is true, then the solution to weight management should be simple – you can’t eat it if you don’t buy it.  Purchasing unhealthy food is the first step to a weight problem.  And weight problems in disabled people are exponential.  Everything becomes harder – transfers, walking, completion of daily tasks, caregiving, and many pieces of equipment have weight limits that when exceeded result in equipment failure.

What is even more problematic is the role of the caregiver in the maintenance of weight in the person they are caring for.  When people cannot shop for food and cannot cook, then helping them to maintain weight becomes the job of the caregiver.  Just buy and prepare healthy foods – perhaps food prescribed by a nutritionist or dietician.  However, often caregivers rely on the disabled person to dictate the food choices but if people are emotionally eating, or eating out of boredom, then the caregiver cannot always rely on the individual to make the best decisions.  Often raising awareness about healthy eating starts with asking people to track what and when they are eating and drinking.  Then, problems can be identified, and a list of doable solutions can be developed. 

In one instance, in helping a client with weight loss as a functional goal, we discovered through tracking that she was barely eating breakfast and lunch but was consuming all of her calories from 5-10 pm.  We made the goal that, over time, she would consume breakfast, lunch, two snacks and dinner, and would stop eating after 7 pm.  Within a few short months, she lost 30 pounds, and this greatly improved her mobility and tolerances for activity.  Another client discovered through tracking that he was consuming far too many large bottles of pop a day.  By changing his large bottle to a smaller one, and eventually to only one pop per day and the rest water, he was able to drop 20 pounds.  In both cases, the problems, solutions, and commitment to change were made by my clients (with my guidance and support), making the results far more meaningful and lasting.  Further, the client was shown a framework for how to check and modify eating habits should they deteriorate again in the future.