July13 2010 meaning gap


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July13 2010 meaning gap

  1. 1. Finding Meaning in our Occupation: Filling the Meaning Gap July 13, 2010 draft (4852 words) Introduction The practice vision for Occupational Therapy is client-centred enablement through occupation (Townsend & Polatajko, 2007), internationally espoused by leaders of our profession (AOTA, 2002; CAOT, 1997, 2007; Christiansen & Baum, 1997; Christiansen & Townsend, 2004; Kielhoffner, 2002, 2004; Law, Polatajko, Baptiste & Townsend, 1997; Law, Baum & Baptiste, 2002; Townsend & Polatajko, 2007; Wilcock, 1999), and Every ooccupational therapist clinicians useknows that occupation ias the basis of our practice. Or do theywe? Since graduating (I, first author, Fran) have increasingly experienced witnessed first-hand the move to increasingly disease-oriented health care and experienced and found that even occupational therapy colleagues devalueding activity-oriented interventions. There wasappeared to be a fear of being seen as keeping people busy, spending time on elemental menial activities, and not being understood acknowledged as a ‘legitimate scholarly’ profession. While Occupational Therapy theory continually championed the use and application of occupation as therapeutic means, the lived experience of occupational therapists’ practice did not always appear to be congruent. An opportunity to investigate the personal experiences of infusing occupation into everyday practice arose when an organizational change occurred in the teaching hospital in which I worked. In the year 2000 three urban Ontario hospitals with distinct and different organizational structures, client populations and occupational therapy departments, merged through a legislated amalgamation. A new program management organizational structure was developed and oOne occupational therapy service was created for the three campuses, with (Fran, first author) as the professional leader. Fran took the opportunity to focused on occupation and occupation-based practice as a unifying concept for the new service. A variety ofVaried, on- going strategies were incorporated within the service are used to foster a culture and process that which promotes reflective practice amongst occupational therapy practitioners, including. Some of these include: dissemination of articles related to occupation-based practice, with structured opportunities for discussion; an annual, individually written opportunity for reflection on practice moment/s, with opportunity to share through sharing with peers and written commentary; and professional development retreats with occupation foci such as occupational science and enabling occupational engagement. A central occupational therapy education council was developed with members drawn from across the three campuses. One of the Another key strategiesy was the development and implementation of the research study described in this paperarticle. Fran and Anne and Fran (the first and second authors) had previously formed a professional relationship, through their common roles and interest in clinical education, mental healthpractice issues, and occupation-based practice, and interprofessional collaborative practice. Anne joined the education council and Fran, aAware of Anne’s shared professional vision, Fran approached her to be a co-PIprincipal investigator for the study. Fran also coordinated a central occupational therapy education council, with an additional five members representing practice areas across the campuses. These representatives were also invited to participate in the study as co-investigators and participants in the participatory action research study.The study participants, occupational therapists in the new centre, provided their perspectives on the incorporation of occupation within their particular clinical practices. Through extensive iterative analysis of the data, the authors (we) discovered that therapists search for meaning in their own occupation of providing occupational therapy. For some therapists the meaning is realized, and for other therapists finding personal meaning in their occupation is elusive. When therapists struggle to find personal meaning and value in their occupation of being an occupational therapist, the a meaning gap is experienced by occupational therapists. More importantly, we identified and will describe herein possible solutions and strategies to address the meaning gap. Background Occupation has been a core concept since the inception of the Occupational Therapy profession (Meyer, 1922), but the role and significance of occupation has shifted over the decades from use as a therapeutic
  2. 2. Finding Meaning in our Occupation: Filling the Meaning Gap medium to enablement (Polatajko, 2001). In Enabling Occupation II, occupational therapy practice is viewed to be driven by theory and process instead of method, and Townsend and Polatajko (2007) envision a future for our profession to be “occupation-based” and “focused on enablement,” so that all people may be “engaged” in “meaningful occupation.” That is, our practice is not defined by tasks and procedures, but by the systematic series of enabling actions that are grounded in occupational theory. Over the years however, occupational therapy practice has been described as narrowed to a component approach of “assessing, fixing, adapting, remediating” specific medical problems (Wilcock, 1991), which is most obvious in teaching hospitals with clinically defined programmatic areas (Baum, Berg, Seaton, & White, 2002; Crabtree, 1998; Jongbloed & Wendland, 2002). Further, research into occupation-based practice has primarily focused on service delivery of specific treatment modalities and its application to particular client populations. Such medical and illness focused models of care and research (Bryen & McColl, 2003; Whiteford, Townsend & Hocking, 2000) lead therapists to translate broad occupational experiences into basic medically measurable components which do not encompass the full scope of enabling occupation (Mattingly & Fleming, 1994; Cockerill, Scott & Wright, 1996), and which may be disconnected from the meaningful occupations that our profession values and endorses. As Hasselkkus (2002) summarized, “occupational therapists are caught up in a balancing act as they strive to function both within the dominant health care paradigm of the human body as machine and within the newly emerging paradigm of the human body as lived experience” (p.92). The current Canadian framework and model for Occupational Therapy practice endorses that partnering with clients to enable meaningful occupation optimizes clients’ enagagement and performance (Townsend and Polatajko, 2007). This assumption may be extended to the occupation of occupational therapists; that is, when we as occupational therapists find our occupation meaningful, we will be engaged and performing optimally at enabling client’s occupation. Meaning in Occupational Therapy literature has been discussed as a broad concept as it is related to understanding the experiences of our clients (Hammell, 2004; Hasselkus, 2002; Wilcock, 1998), and may be understood as a sense of value, purpose and fulfillment in what we do, and how we exist, interact, contribute and envision possibilities. However, there is little research into the meaning that occupational therapists find within their own occupation-based practice experiences. Two recent studies which did examine the meaning of practice in paediatric practice (Trenc Smith & Kinsella, 2009) and in acute physical settings (Robertson & Finlay, 2007) identified that occupational therapists found meaning through making a difference in clients’ lives and working within a supportive, multidisciplinary team. Trenc Smith and Kinsella additionally categorized that meaning was found through relating to clients as human beings, permission to have fun, congruency of values, and an artistry of practice, and participants from Robertson and Finlay’s study also described coping strategies to deal with frustrations and demands of their work. In both studies, participants described examples from typical practice experiences which they reflected to have contributed to meaningful work and interpretation of the participants’ interviews did not explicitly identify gaps in meaning. The premise of this paper is that filling a meaning gap in our occupation as occupational therapists is key to assisting occupational therapists find meaning in their occupation. Method The research method chosen was a modified participatory action research strategy. Participatory action research strategies involve participants in the design and implementation of the research project (Whyte, 1998). The research group consisted of the two co-principal investigators of the research project who were two senior occupational therapists employed at the institution and five staff occupational therapists who were members of the OT educational committee. The five staff occupational therapists were both members of the initial research team and research subjects. There were three phases to the research project. During Phase one ethical approval was received from The Sunnybrook and Women’s College Health Sciences Centre Research Ethics committee (approval #?). The semi-structured interview format was developed by the research group and the first external interviewer (a recently graduated occupational therapist who was not known to the facility) piloted it with an occupational
  3. 3. Finding Meaning in our Occupation: Filling the Meaning Gap therapist from another facility who was not part of the research cohort. The interview format was revised for increased clarity. The interview guide is available from the authors upon request. Participant Recruitment All occupational therapists from the institution were invited to a departmental inservice/retreat on Occupational Therapy and Occupational Science where the research project was launched. Therapists indicated their willingness to be contacted by the external interviewers for a semi-structured interview. Participation was voluntary and anonymous as the research team was not aware of the identities of those who chose to participate or not. Two external interviewers who were recently graduated occupational therapists, who were not employees of the hospital, conducted the semi-structured interviews. Research participants were recruited from all the occupational therapists practicing at the institution during the data collection period following the launch in 2003? until 2005????. 13 subjects consented to be interviewed and audio taped but one individual withdrew consent subsequently and that data was not included in the analysis.12 out of how many possible? Twelve subjects were interviewed. 25% of the sample had worked for less than two years, 25% had worked between 2 and 5 years, 17% had worked between 5 & 10years and 33 % had worked for over 10 years. Subjects identified their area of practice as mental health 33%, ambulatory 17%, long term care 8% acute medical care 42%. The sample size is typical of small scale exploratory qualitative studies. The recruitment period was prolonged by the disruption of normal functioning in the institution caused by SARS. The majority of the interviews were conducted by the second external interviewer because of delays in recruitment due to SARS. All individual interviews were audio taped and transcribed verbatim. Data analysis Data analysis was an iterative process conducted in Phase 1 by the entire research team. Initially open coding of the data broken down into units of meaning followed by synthesis using the Person Environment and Occupation framework to structure the analysis and develop themes. Detailed fieldnotes of the data analysis process and the investigators reflections were kept. As this was an iterative process, in Phase Two, the themes that emerged from the data analysis were shared with the occupational therapists at a second retreat in October 2006. All members of the occupational therapy who attended a half day Occupational Therapy retreat and gave consent participated in focus groups. The normal turnover in the department meant that some of the individuals participating in the focus groups had not been employed at the facility during the initial launch of the project. Three focus groups were held simultaneously. In these focus groups, the research team’s initial thematic analysis was presented and discussed by staff occupational therapists. Focus groups were facilitated by clinicians from other health profession disciplines who were experienced facilitators. The focus groups were audio taped and transcribed verbatim. The focus groups were seen as part of the research strategy to deepen the thematic analysis. .The focus groups provided an opportunity for all participants to learn about the research analysis to date and continue to reflect on their own practice. It also provided an opportunity for member checking to enhance trustworthiness. Member checking is a method of going back to the participants in a qualitative research study and collecting feedback about the resonance of the themes in capturing the participants’ experiences. In addition to participating as an interview subject, the therapists who were researchers/participants were involved in most aspects of the research project including: the project design; the development of the semi structured interview tool; planning and implementing the initial occupational therapy departmental in-service where the research project was launched; participation in initial data analysis and participation in presenting the data at conferences. As this was an iterative process, therapists also participated in planning and implementing of the second retreat during which the focus groups of occupational therapists were held.
  4. 4. Finding Meaning in our Occupation: Filling the Meaning Gap In Phase 3, post focus group, authors continued to analyze the initial transcripts and reflect while the other members of the research team discontinued their participation. There was a decision to reanalyze the initial data as the PEO framework did not fully capture all elements of the transcripts. An additional investigator was invited to join the team the first 3 authors/investigators continued to immerse themselves in the data, reflect and reanalyze the initial transcripts. The fourth author did not do primary re- coding but participated in thematic development. Results One over arching meta theme of the meaning gap emerged through our analysis of the data. This refers to the gap that can occur between how therapists believe occupational therapy should be practiced in an ideal world and how they do practice in the real world. Florence clearly articulates this meaning gap as a struggle between her expectations of herself and the demands and structure of her work on a daily basis. She contrasts her area of focus with a broader understanding of occupation. She also talks about how she “tries to make herself feel better as an OT” by bridging that meaning gap “outside of the regular part of the job” She continues “So we are focused on the occupation of work, you know, or paid employment, whereas as an occupational therapist you want to look at occupation much more broadly.” This meaning gap also emerged when another therapist, Brooklyn, reflected on the relationship/gap between occupation and her role as an occupational therapist in the following way: “I think I facilitate people to become independent but maybe not necessarily in occupations that are significant or important to them.” Other therapists appeared to have found a way to bridge the meaning gap for themselves. They experienced themselves as finding personal meaning and satisfaction within their own occupation despite challenges in their work environment, In Gabrielle’s words, “And so seeing the confidence that’s built from engaging in occupation, seeing that his self-esteem and overall quality of life was improved from engaging in occupation, that’s really—that’s the point to being an OT”. Chloe adds, “If someone is engaged in an occupation that they find personally meaningful and whatever is meaningful to them . . . then that all impacts their health in a positive way”. Four themes emerged from our meta theme of the meaning gap, all of which elaborate different aspects related to the meaning gap. These are as follows: • The Job versus Real OT • Co-creating occupational meaning • Meaning transforms doing • Finding occupational meaning is personal The job” versus “Real OT” The first theme that emerged was “The job” versus “Real OT.” Therapists discussed a clash of expectations between being able to fully realize scope of practice in enabling occupation, and negotiating the expectations of other staff, constraints of the work environment and hospital policies. Ava described the struggle with programmatic demands: We always struggle with being true to our profession and yet being true to the programme that we work in. And very often I think it's hard to say that I've been able to balance both in my clinical practice. Lily spoke of challenges to maintain a focus on occupation within the dominant medical model paradigm:
  5. 5. Finding Meaning in our Occupation: Filling the Meaning Gap So in acute care, especially when it's a very medically focused injury-related type of arena, this type of activity isn't first, not even second, sometimes not even in the whole scope of the day. So that makes it always a battle, sort of, 'well what are you doing? Why are you making this harder for us' all around. Therapists identified various aspects of the meaning gap dilemma, including programmatic demands, time constraints imposed in acute care environments, a medical model focus as opposed to an occupational paradigm, and team members’ limited understanding of their role. Therapists’ strategies to address the dilemma are described under the sub themes of negotiating the team environment and enhancing the understanding of the OT role. Negotiating the team environment Many therapists identified the team environment as an important factor in how they were able to enable occupation with clients. Their perception of support, value and understanding of an occupational focus from the team varied. Gabrielle, felt there was buy in and support from other team members: We have a really strong cohesive, trusting community that I can rely on without a doubt. So, I can trust on anyone on my team that if I'm not there that day, and I wanted to explore something that came out of the COPM, for example,…that someone else on the team will follow through with that. Ava, on the other hand, felt her team members did not understand her focus on occupation. “I think their [the teams] understanding is very much [safe] and independent in function, but that's not what occupation is all about.” Not being understood by the team impacted professional identity and how therapists see themselves. Megan reflected, “with OT’s, some of our things that we do are very common sense things. So it's almost like you have to validate yourself, you have to validate your profession.” Enhancing understanding of the OT role Therapists spoke of challenges they encountered and strategies they developed to enable their own occupation within their teams, including articulating their role through words and actions. Whereas Ava developed and “documented” her “non-traditional,” “unique” “role for this program,” Lily preferred to “educate one-on-one”: We…corral some of the nurses, 'oh yeah, he's got a great nurse today, let's get this pattern going', and then somehow it's harder to change a pattern back if the pattern's existing. So we'll post things behind beds ‘up daily, up and out of the room to see OT, likes to be by the lounge’, so we'll push a lot of that. And usually when the pattern is rolling, then it's hard then for one nurse who has them for three days to suddenly say, 'well they don't really get up on my shift'. Because then everybody says, 'well they do on mine, and they have been for the last two weeks, what do you mean they're not getting up on your shift?' So we try to do it that way, more of a one-to-one.
  6. 6. Finding Meaning in our Occupation: Filling the Meaning Gap In some teams, therapists felt they were “pigeon-holed” into a limited scope. Hanna said, “I think I've tried to really expand my role. I didn't want to just do wheelchairs, and I felt that I could do more.” She continued: When I first started I was getting a lot of referrals for wheelchairs, wheelchairs and more wheelchairs, and… I really worked on, you know, other areas, like going in, like even on the dementia unit, you know, ‘if you guys are having difficulty I can come in and maybe see if there are some strategies that we can try, or you know, adapting to the environment, like different things that have to do with occupation’. And so now I'm actually getting a lot more referrals that are very--there's quite a big variety to them. Co-creating Occupational Meaning The second theme of co-creating occupational meaning refers to the process of interacting with the client to find occupational meaning and enable occupational engagement. For some therapists it represented those moments when they were living most fully their ideal of enabling occupation. In these moments therapists describe experiences of personal occupational fulfillment and meaning as they work with clients. When therapists do not see meaning in the activities or tasks they engage in with clients or when clients do not appear motivated or engaged, the therapists may experience a form of the meaning gap. Lily describes the difficulties when there are challenges in co-creating meaning with a client in the following way: And if the client isn't totally engaged in that as well, that's what I mean about if the motivation isn't there, then I'm the only one who seems to be trying to engage somebody in an occupation. So I find that difficult Jessica gives an example of the process of co-creating meaning with a client: He wanted to live more independently, have his own room, have more privacy, live in a smaller house, and so we supported him through that and it's amazing how just being involved in these self-care occupations how it had a huge impact, not only on his health, his well being, but his quality of life…. And his quality of life, I have to say, has tripled. Power of occupation to make a difference Therapists described the power of occupation to make a difference as an important impact of co-creating occupational meaning. Passion and creativity emerged as an important part of the OT’s experience as they co- create occupational meaning with their clients. This leads the occupational therapists to find more meaning in their own occupation as an OT. Curiosity about the clients’ experiences, and a sense of mutual engagement and reciprocity between the OT and the client were important aspects of co-creating occupational meaning. Florence describes her thoughts with one client where she was wondering about the client returning to a physically demanding job even for me as an occupational therapist I was going, 'I don't know that I want to send this guy back to a heavy job', I was questioning it. But this guy was so motivated and it really challenged me in my thinking of what can a person do… So it was kind of neat, that one, in sort of challenging even me that I was questioning should we be doing this, and yet a highly motivated client can transform your thoughts on occupation.
  7. 7. Finding Meaning in our Occupation: Filling the Meaning Gap Meaning Transforms Doing The theme Meaning Transforms Doing emerged as we recognized that therapists ascribe different meanings to the same intervention, for example self-care. Therapists who view the intervention as meaningful in its potential impact on client occupational engagement, also highly value their identity as occupational therapists. Kiera’s perspective: If patients in this unit don't get a basis of stretching right way…they're not going to be able in the long run to do any other functional activities…it's not necessarily the traditional round of OT, allows us to bridge that gap, and we're able to get into their occupational goals… people that have great outcomes can often go back to work, can lead a normal life, and patients with more complicated outcomes, they tend to not want to get out in public and they tend to not be able to go back to their job, and often times they'll even need more help at home, along with the scarring can also limit the function of that joint.” The following are sub-themes of meaning transforms doing: Meaning is ascribed It is the therapist who invests an intervention with occupational meaning. Gabrielle shares this example: Even if I'm just attending Court with someone because there was some charge related to their mental illness, I know that when Court is through and with whatever consequences they hear from the judge and the lawyers and etc., that eventually that will lead back to them being more able to engage in occupations that are meaningful to them because they'll have a better understanding about consequences of behaviours and what they choose to do and not do…I don't think that there is one day in my practice that I fail to remind myself about occupation. Meaning has to be made visible Therapists who locate their interventions within the context of meaningful occupation can diminish or eliminate the experience of a meaning gap, viewing their practice as occupation-based. Hanna describes a teachable moment: Say Mr. Smith [pseudonym], I'm getting him a wheelchair, and she [the student] sees for Mr. Whoever, that I'm getting him a wheelchair and then another resident I'm getting them a wheelchair, she's thinking 'my god, all this woman does is wheelchairs'. But then I had to like kind of take her aside and say, ‘this person, how are we helping her occupations? What are the things that they are wanting to do?’ Focus on the occupational narrative Exploration of the client’s story, occupational goals, realities, and possibilities helps the therapist understand the meaning of occupation for the individual. Lily speaks of one of her clients: I have a lady right now who's had quite a traumatic injury and it's a spinal cord injury, but she lives independently in the community, she's got lots of clubs and social activities…and suddenly interrupted [by this] event that she isn't sure will allow her to do any of these things again...which really brings me back to that initial rapport building . . .to really see what drives people, what their passions are, why they do those things that they do, how well those things are integrated and why they--did they love it? Was it something that time passed and they just engaged in it? Finding occupational meaning is personal The process of finding occupational meaning appeared to affect and be affected by personal values and therapists frequently used leading words such as “personal bent,” “personal perspective,” “individual sense,” “different view,” and “my experience.” Meaning is personal, so it follows that finding meaning is also a personal process. Megan described that her “individual sense of occupation is very different,” stating, “We learn the same stuff, the same theory, but within each person is what your view of occupation is …So I think it's your individual sense of occupation that sort of guides you where you want to go.” Lily discussed the influence of
  8. 8. Finding Meaning in our Occupation: Filling the Meaning Gap personal “value systems which are kind of cultural”: But that's sort of a personal bias I kind of see because I sometimes hold some value systems which are kind of cultural in some ways, and then I see how that would motivate me to do certain activities that others might question, or to my satisfaction I'm happy doing those in such a way but others might see no reason behind why I would even engage in those things. So that's just personal beliefs, and if I never was to voice them, they would have no idea why my occupations are chosen in such a way. The following three sub-themes emerged within finding occupational meaning is personal. Personal sense of occupation Therapists offered personal definitions of occupation which revealed unique thinking, and which in turn informed how they reflected about practice interactions. Brooklyn viewed occupation as “anything that we do as human beings. It can be self-care, productivity or leisure.” Chloe agreed that occupation is “anything that people do throughout the day, throughout their lives,...it can be very broad,” continuing that “If someone is engaged in an occupation that they find personally meaningful and whatever is meaningful to them and it's something productive, then that all impacts their health in a positive way.” and Wwhen asked if there is anything in her daily work which is not related to occupation, she replied, “Not really. I'm trying to think. It all eventually ties back.” Florence introduced another perspective, that occupation “can also be more passive reflection, although we tend to think of occupation as doing, I think there's also those passive things like reflecting on life. Just even that sense of spirituality could be considered an occupation although I'd say more typically if I think of occupation it is more how we spend our time and engage in activity.” Building Ooccupational perspective is evolving and internally motivated In addition to differing understandings of occupation, therapists’ experiences with developing an occupational perspective also differed. Gabrielle described that her "own understanding of occupation has evolved over time to the point that now I feel very comfortable with it” and through a personal desire to “learn more about occupation” because of “interest and motivation and initiative” that “exists from within.” Therapists employed different strategies to develop an occupational perspective in practice, including formal “monthly reflective practice sessions” and “informal networking” (Daphne), applying for and receiving a Canadian Occupational Therapy Foundation grant to research how her work “is actually making a difference to these individuals” (Ava); attending “rounds,” “in-services,” and “reading on my own time” (Chloe); “spend[ing] more time with therapists just talking through why we are doing what we are doing and not going with the status quo” (Florence); and dedicating a concerted effort to “translate [occupation]…and incorporate it… as a team effort” as well as educate her clinical team about other roles she could fulfil, which resulted in her “getting a lot more referrals” (Hanna). Language creates meaning Some therapists found using occupational language an ongoing process and opportunity for others and selves to learn about occupation-based practice. Ava spoke about the need to “take advantage of opportunities,” through “ Like for instance,…I'd really like to incorporate some other things into my clinical practice based on this whole concept of occupation…I just think,...educating colleagues and sort of sliding that term ‘occupation’ and
  9. 9. Finding Meaning in our Occupation: Filling the Meaning Gap you know, now and then,… if you use the lingo often enough, then they kind of become accustomed to it and know that that's something that's fundamental or part of your practice.” And, Chloe identified the “systemic” role of language “even [in] the assessment form” because “when I'm assessing, I'll like think of like what's the next thing on the form and kind of ask based on that, and if the assessment form used those terms more or reflected that a little more,… like just using the terminology …like what's hindering occupational performance… then I think it influences the way I would kind of like think on a daily basis because it's hard to really in your daily practice to like infuse that into it.” Several therapists identified the role of language in creating meaning for their practice. Therapists experienced different levels of ability and comfort in using occupational language into practice. Gabrielle, who used terms such as “occupational deprivation,” and “occupational motivation” during her interview stated, “I see a lot more exposure to the idea of occupation even in everyday language, replacing a word like functioning with occupational performance. Say what you mean, and if you don't mean occupation and you mean activity or task, say what you mean,” adding, “We don't use, as occupational therapists across the board, consistent language. We don't use occupation when we mean occupation. We say ‘OT’ when we should be saying ‘occupational therapist’ to describe who we are to people.” Similarly, Brooklyn discussed the challenge in incorporating occupational language, stating, “the terminology and the lingo of all that is not really there, you know, we don't talk about that. Occupation is more like the performance [components] and…I don't necessarily see this occupational view in health because it's not really established.” All these therapists inferred that use ofing occupational language hadwas significancet to their everyday practice and the meaning they find in their practice. Lily summarized, : And if we are to engage in it and really be meaningful in it, then our research base should be increasingly embracing...all that new language and terminology. My personal bent is “until there's a language and terminology that's commonly used, there isn't going to be an understanding within the OT field...It's hard to have that language sitting at the bedside trying to make it up.” Gabrielle explains her personal processes of finding meaning, “We all come with different theories and I think that guides us to how we see the world and how we interact with clients…So our theory is different, so I think inherently occupation is central to what I do on a daily basis. But consciously on a different level as well, I think that my thoughts are always on occupation for a client. When I see a client I ask them what their day has been like. When I see a client for the first time I ask them what their routine is like in terms of what they do, how they occupy their time, and when I talk to clients about their treatment time or their goals, that's my focus as well, is on occupation.”