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In each setting and specialism that I have worked as an Occupational Therapist (OT), the adoption of routine has been key to the recovery, rehabilitation or general maintenance of an individual's health and/or well-being. In this article, I encourage you to consider, reflect on, or be reminded of the value of routines and rituals - for both you and those you support in practice...
routine
/ru: ˈti:n/
noun
a sequence of actions regularly followed
repeated behaviours that become second nature and require little conscious thought
Personal practice experiences of utilising routine
At an acute community 'rapid response' service
By collaboratively adjusting medication timings, ensuring an appropriate frequency of welfare checks and structuring personal care support, older adults were kept safely in their home environment - rather than admitting them to hospital unnecessarily. By making (often minor) adjustments to how they went about their day, rates of falls and medication errors would reduce and clinical observations could be increasingly stabilised. This might also rely on the provision of adaptive equipment to carry out activities of daily living (ADLs), but it would ultimately make engaging in necessary occupations safer and easier.
At an inpatient brain injury rehabilitation unit
Post-stroke routine was crucial to orientation (time and place) and to restoring patient's cognitive abilities. Devised by a multidisciplinary team of therapists, a daily timetable incorporated occupation both as a means and an end*. This included set breakfast periods, when patients were encouraged to eat and drink in the dining room - providing context, orientation and social connection, within an appropriate physical environment.
Early rehabilitation also involved gathering information from friends and family about the person's usual personal care routine, then accommodating for and encouraging these preferred methods and orders of task completion.
In doing this, interventions exercised social and communication skills, as well as addressing cognition - including working memory and executive functioning (divided attention, planning, sequencing, problem-solving, etc).
* Occupation as Means vs Occupation as Ends:
Occupation as Means | Using the engagement and performance of occupations as intervention. |
Occupation as Ends | The outcome of the intervention or goal is the ability to perform or engage in occupation. It does not necessarily mean the use of occupation was used directly as an intervention. |
[Gray, 1998]
For young people struggling with their mental health
"Many people don’t realise just how much their routine - sleep, eating, exercise, work, how you like to do things - impacts their mental health until they’ve had their routine disrupted." - Dr Gold (Gilbert, 2023)
Incorporating meaningful activity and social opportunity into daily routines provided a much-needed volition-boost, distraction from negative or unhelpful thought cycles and a chance to re-connect. The community-based mental health charity facilitated peer support, allowing teenagers to learn resilience tools and tips from others going through similar experiences. Planned meaningful activity, in a safe, after-school environment, included fortnightly art classes, evening discussion groups and weekly yoga sessions.
Often linked to a reduced motivation to engage in normal daily routines, the self-care practices of those affected by mental ill health often break down. This potentially has knock-on effects to physical health, hygiene and self-esteem, among other domains. In turn, this may impact on an individual's social and/or work life. Factors are inter-connected, but routine intertwines all aspects of our lives.
Adopting daily routines removes the stress of decision-making. For example, if your routine is to eat a bowl of cereal when you wake up, less valuable time is spent deciding what to have for breakfast. That frees up brain power for more important decisions as the day progresses, that deserve more of our energy and stress (Van Raalte, in Gilbert, 2023).
Within a paediatric disability service
I have explored elements of routine management with parents of children, including those with autism spectrum disorder (ASD), where behaviour that challenges can also impact on the wider family's daily life. Adapting showering or bathing methods, attending after-school clubs and staggering mealtimes are just a few examples of how triggering behaviours might be avoided or reduced. This often involves liaising with family members and other healthcare professionals, to establish if a child is sensory-seeking or sensory-avoidant, then making minor adjustments to the execution of ADL(s).
Alongside referring to a sensory advice service - and sometimes making home adaptations - parents can be empowered to support their child's daily routine. Goals might focus on engagement in an activity with greater ease, independence and/or safety.
In an outpatient neurorehabilitation centre
I currently work with patients, often on intensive packages of rehabilitation, following a range of neurological conditions, including stroke, traumatic brain injury (TBI) and spinal cord injury (SCI). In neurologic rehabilitation, repetition is required to maximise levels of improvement and brain reorganisation, to facilitate an individual maintaining and making greater functional gains. Animal studies in neuroplasticity have shown that approximately 400-600 repetitions per day of a difficult functional task are needed before the brain reorganises. This means that...
'If an individual is working on a functional task such as grasping, it will take 400-600 repetitions of grasping per day to help drive neuroplasticity and cause changes in the brain' (Kimberly et al, 2010).
And the link to routine? Well, whilst face-to-face occupational therapy and physiotherapy sessions might last two-to-three hours per day, how my clients engage in activity outside of the clinic will be just as key to their speed of progress and potential. Working with them on a functional home exercise programme (HEP), that fits realistically into their current routine, will help embed techniques, skills and abilities learnt in OT sessions.
Away from clinical practice, I am sure you are more than aware of the power of routine (or a lack of it), as we coped with change throughout the coronavirus (COVID-19) pandemic. Regularised routines 'can buffer the adverse impact of stress exposure on mental health' (Hou et al, 2020), something that affected us all, to varying degrees.
This relatively recent experience is highlighted in a piece by Megan Edgelow, who explores the influence of 'doing' on the quality of daily life - a concept that every occupational therapy professional holds close to their heart! I reference Megan, Assistant Professor at Queen's University, at the end of this article, but I would like to share her main points with you.
Click the three statements below:
Routines support cognitive function
Routines promote health
Routines provide meaning
[Edgelow, 2022]
How could you build on your own routines?
Do you think you - or those you support in occupational therapy practice - could do with improved or adjusted routines? Take a look at these small steps, that might help cognitive functioning, promote better health and/or provide greater meaning in daily life:
Decide on a regular time to wake in the morning and go to sleep at night; aim to keep to this most days of the week. Choose a familiar, low-stimulation 'wind-down' activity to precede going to bed (avoid screen time!)
Organise your day with a timer or smart phone app; put tasks you want to do into your schedule.
Start a new leisure occupation or hobby, or take up an old one. Need ideas? Consider playing an in/outdoor sport, engaging in arts and crafts, playing a musical instrument or singing in a choir.
Make physical activity manageable, with local walks or bike rides a few times a week. Or consider walking or cycling your commute to work, rather than driving or getting the bus (if this is realistic for you).
In summary...
Routines are powerful tools! Whilst the notion can sound mundane, research shows that implementing them can support better physical and psychological health, as well as social connection and wellbeing.
Occupational therapists and therapy assistants can use routine to support patients and clients in their recovery, or to maintain a level of health and/or cognitive functioning. As occupational deprivation and disruption of the coronavirus pandemic passes, we all have the chance to evaluate routines that we want to keep and the meaningful occupations we need in our daily lives, to stay happy, healthy and productive.
References
Edgelow, M. (2022) What you do every day matters: The power of routines. The Conversation. Available from: https://theconversation.com/what-you-do-every-day-matters-the-power-of-routines-178592 [Accessed 23 March 2022].
Gilbert, K. (2023) 3 Expert-Backed Tips for Building Mental Health Routines That Stick (online). Peloton: The Output. Available from: https://www.onepeloton.co.uk/blog/mental-health-routine/ [Accessed 8 August 2024].
Gray, J. (1998) Putting occupation into practice: Occupation as ends, occupation as means. American Journal of Occupational Therapy. 52(5)3, pp.354-364.
Hou, W.K., Lai, F.T.T., Ben-Ezra, M. and Goodwin, R. (2020) Regularizing daily routines for mental health during and after the COVID-19 pandemic. Journal of Global Health. 2020; 10(2): 020315. doi:10.7189/jogh.10.020315.
Kimberly, T.J., Samargia, S., Moore, L.G., Shakya, J.K. and Lang, C.E. (2010) Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. Journal of Rehabilitation Research and Development. 2010; 47(9): 851-62. doi: 10.1682/jrrd.2010.02.0019.
Nakamura, J. and Csikszentmihalyi, M. (2009) Flow Theory and Research. The Oxford Handbook of Positive Psychology. 2 ed. July 2009. DOI: https://doi.org/10.1093/oxfordhb/9780195187243.013.0018.