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Transcript of Occupational Performance Measures: Â Review Based on the Guidelines for the Client-centred...
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C J O T — V o 1 . 57 — N o. 2
Occupational Performance M easures:Â Review Based on the Guidelines
for the C lient-centred Practice ofOccupational Therapy
Nancy Pollock, Sue Baptiste, Mary Law,
Mary Ann McColl, Anne Opzoomer, Helene Polatajko
Key Words:• Assessment process,
occupational therapy
• Outcome and process
assessment
Nancy Pollock, M.Sc., O.T. (C) is Re-
search Clinician, Occupational Therapy,
Chedoke-McMaster Hospitals, 1 20 0 MainStreet West, Hamilton, Ontario, L8N 3Z5
Sue Baptiste, M.H.Sc., O.T. (C) is Direc-
tor, Occupational Therapy, Chedoke-
McMaster Hospitals.
Mary Law, M.Sc., O.T. (C) is Assistant
Professor, Departments of Medicine and
Clinical Epidemiology and Biostatistics,
McMaster University and Research
Manager, Occupational Therapy, Che
M a s t
Mary Ann McColl, M.H.Sc., O.T. (C) is
Assistant Professor, Department of Reha-
bilitation M edicine , University of Toronto
and Director of Research, Lyndhurst
Hospital, Toronto.
Anne O pzoomer, M .Sc., O.T. (C) is Assis-
tant Professor, Occupational Therapy
Program, University of Ottawa.
Helene Polatajko, Ph.D., O.T. (C) is As-
sociate Professor, Departments of Occu-
pational Therapy and Education, Univer-
sity of Western Ontario.
ABSTRACT
In 1987, Health and Welfare Canada
and the Canadian Association of
Occupational Therapists Task Force
recommended that work go forward to
develop an outcome measure for
occupational therapy which reflects the
Occupational Performance Model. The
first step in this process was to review
critically those outcome measures
which assess occupational performance
and that are currently available in theliterature.
This paper will present the review
process, describe in more detail eight
assessments that fulfilled many of the
review criteria, discuss the limitations
of these measures using the "Guidelines
for the Client-centred Practice of
Occupational Therapy as the
framework, and make recommendations
for the development of a new outcome
measure for use in occupational
therapy.
The Canadian Occupational Therapy Foun-
dation was pleased to provide a research grant
to assist the authors with their work.
In 1983, Health and Welfare Canadaand the Canadian Association of Occupa-
tional Therapists Task Force published
the "Guidelines for Client-Centred Prac-
tice of Occupational Therapy" (Depart-
ment of National Health and Welfare &
Canadian Association of Occupational
Therapists, 1983) describing a conceptual
framework for the practice of occupa-
tional therapy in Canada. This frame-
work, the Occupational Performance
Model "...views an individual's occupa-
tional performance as having three areas:self-care, productivity and leisure, predi-
cated on the interaction of the individual's
mental, physical, sociocultural and spiri-
tual performance components" (p. 8).
In 1987, the Task Force out l ined the im-
portance of outcome measures in advanc-
ing our profession. Well developed as-
sessments can assist in demonstrating the
effectiveness of our programs, improving
the quality of patient care, and clarifying
our role (Department of National Health
and Welfare & Canadian Association ofOccupational Therapists, 1987). The Task
Force used the Occupational Perform-
ance Model as a basis to investigate avail-
able outcome measures in occupational
therapy. The task force se t out a number of
criteria which the outcome measure(s)
should meet. Specifically the measure
s h o u ld :
a) be based on the occupational per-
formance model.
b) focus on performance in self-care,
productivity and leisure as the pri-
mary outcome.
CANADIAN
OCCUPATIONAL
THERAPY
FOUNDATION
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c) consider performance components
(physical, mental, sociocultural and
spiritual) as secondary outcomes,
measured only for their contribu-
tion to occupational performance.
d ) consider the client's environment,
developmental stage, life roles and
motivation.
e) be sensitive to clinical change rele-
vant to occupational therapy goals
including development, restoration
and maintenance of function, and
prevention of disability.
0 not be diagnosis specific.
g) be modular for use in whole or in
part.
h ) incorporate measurement proper-
t ies of reliability, respon siveness and
validity.
i) be usable in terms of format, ad-
ministration, time, ease of scoring
and client acceptability.
be scorable.j)
CJOT — Vo1.57 — No. 2
Name of Instrument:
Author:
Description/Intent:Self-Care:es no
Productivity:es no
Leisure:es no
Environment:es no
Roles:es no
Importance to client:es no
Assesses ability
or performance:
Purpose:
Developmental Stage:Target Population:
Culture:
Setting:
Informant:
Structured:
Method:
Scale:
Score Types A vailable:
The National Health Research and De-velopment Program of Health and Wel-
Source:
If yes, how?
If yes, how?
If yes, how?
fare Canada and the Canadian Occupa-
tional Therapy Foundation subsequently
funded a project to continue this process
and develop an outcome measure for oc-
cupational therapy.
The first stage of this research project
was to update the review done by the T ask
Force of current measures of occupational
performance to determine if a suitable
measure or measures existed. This paper
will describe the review process, high-
light some of the occupational perform-
ance measures currently available and
assess their correspondence with the
Occupational Performance Model.
Review Process
The first step in the review process was
to generate a list of assessments covering
all developmental levels and client types
currently available to occupational thera-
pists. Literature searches and input from
therapists and academic faculty were used
to develop this initial list. These instru-ments were reviewed by the Task Force
and the research group, and the areas(s) of
occupational performance assessed and/
or the performance components assessed
were indicated. The assessments that
measured only performance components
(physical, mental, sociocultural or spiri-
tual) were excluded from the rest of the
review process. A total of 136 assess-
ments were identified and 82 of those
were excluded as they assessed only per-
formance components.
The second step in the process was to
design evaluation criteria to be used in
reviewing the remaining 54 measures.
Based on the criteria set out in the Task
Force report, a form for evaluation was
developed (Table 1). A database was
designed from this evaluation form and
the information entered for subsequent
analysis.
Of the 54 instruments reviewed, 13
were not accessible through the literature
because they are unpublished or "home
grown" assessments, therefore only 41
could be evaluated. Of these, eight met
mo st of the review criteria and were closely
aligned with the Occupational Perform-
ance Model. Several of these measures
have not been standardized or formally
tes ted , but were inc luded because the focus
of this review was on content and philoso-
phy, no t on psychom etr ic propert ies . Table
2 summarizes the results of the review.
The Sickness Impact Pro fi le
The Sickness Impact Profile (SIP)
(Gilson et al., 1975) is an interviewer
administered global measure of health
status. It is concerned with the impact that
sickness has on everyday activities and
behaviours. The measure consists of 235
statements grouped into 14 categories that
describe a situation (eg., I am going outless to visit people). The client checks
only those items that she feels describe
her behaviour. Scoring is based on a
weighting system developed through in-
terval scaling procedures (Bergner, Bob-
bitt, Carter & Gilson, 1981). A percentage
score can be calculated for the entire SIP
as well as for each category.
The SIP is an individualized measure
within which the client checks only those
items that apply to her situation, although
those ra t ings a re judged externa l ly througha weighting system, not based on the
Table 1
O.T. Outcome Study E valuation Form
Discriminativeredictivevaluative
Child
dolescence
dult
ater Years
Selfherapistther
yes no
Self-Reportbservation
Nominalrdinalnterval
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CJOT — Vo1.57 — No. 2
Table 2
Summary of the Review Measures
Performance Areas
Assessed
Considerations Developmental
Stage
SC = self-care R = roles C child
P productivity I importance Y youth
L leisure to client MY = mature years
E = environment A adult
Measure
1. Occupational Pe rformance History Interview SC , P,L R, I, E Y,A,MY
(Kielhofner & Henry, 1988)
2. Functional Status Questionnaire SC, P, L A
(Jette et al., 1986)
3. Sickness Imp act Profile SC, P, L R A, MY
(Gilson et al., 1986)4. Reintegration to Normal Living Index SC, P, L R, I, E A, MY
(Wood-Da uphinee et al., 1988)
5. Satisfaction w ith Performance
Scaled Questionnaire P, L I Y, A
(Yerxa et al., 1988)
6. National Institutes of Health Activity Record SC, P, L I A, MY
(NIH, 1985)
7. MACT AR Patient Preference
Disability Questionnaire SC, P, L I A
(Tugwell et al., 1987)
8. Activity Pattern Ind icators SC , P,L E Y, A, MY
(Diller et al., 1983 )
client 's own situation. Occupational per-
formance is con sidered, but in a general
fashion along with many other health status
indicators . The outcom es measured arenot based specif ic to o ccupational ther-
apy.
Activity Pattern Indicators
Reh abilitation Indicators (Diller et al.,1983) are a series of three functional as-
sessment instruments. Th e S kill Indica-tors measure what a cl ient "can do". The
Status Indicators and the Activity PatternIndicators measure what the client "does
do". T he three instrum ents can be usedseparately or together. The Activity Pat-
tern Indicators (AP I) are mo st closelyaligned to the Occupational Performance
mo del. The AP I is a highly detailed log of
daily activities. The client docum ents the
frequency and duration o f her involve-ment in social, recreational, household,
childcare, rehabilitation, business, educa-
tional and perso nal care activities for the
previous week. The API also records the
location, level of assistance required, and
the level of social interaction involved in
the a ctivity.
The A PI covers a broad spec trum o factivities and provides a detailed descrip-
tion of an individual's daily patterns,
however the level of detail makes it im-practical for clinical use. It does not give
any indication of the activities most af-fected by the client's disability or those
that are most impo rtant to the client. The
information wou ld have limited value inestablishing treatment priorities or in m oni-
toring change in the individual.
The Activity Record
The National Institutes of H ealth Activ-
i ty R ecord (AC TRE ) (Kielhofner , 1985,p.472) is a daily activity log kept by the
client.
Activities for each 1/2 hour periodduring the day are recorded and a series of
questions asked about each activity. The
cl ient is asked to rate , on a fou r-pointscale, pain and fatigue while doing thatactivity, her competence, the perceived
difficulty of the a ctivity, meaningfulness,
and enjoyment in doing the activity. Ac-
tivities can be classified as leisure, self-care, transpo rtation etc., and the balanceof activities in the client's daily routineare examined. As the scores are not cumu-
lative over the entire test, there is no total
score.
The ACTRE provides a comprehensive
look at ho w the client is spending her time
and also her performance level and senseof sa t i sfact ion wi th her perform ance.Although the individual records provide
useful information to the client and thera-
pist, the lack of a total score limits theuseof the ACT RE as an outcome m easure.
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CJOT — Vo1.57 — No. 2
Th e Functional Status
Questionnaire
The Functional Status Questionnaire
(FSQ) (Jette et al., 1986) is a self-admini-
stered scale which looks at physical, psy-
chological and social or role functions. Aseries of questions determine levels of
function in activities of daily living, work,
social activities and the client's own view
of his health status. The scoring system is
computerized and provides a profile for
each client highlighting "warning zones"
based on his score. These warning zones
were developed by a consensus panel of
experts and indicate areas of possible
concern.
The FSQ considers work and social
functions, in addition to daily living ac-tivities and so provides a comprehensive
assessment. It is also based on what the
client is actually doing, providing a real-
istic functional picture. Unfortunately, the
warning zones have been determined for
all clients and thus the measure is not
individualized. It does not consider the
import ance of these activities, roles or
functions to the individual client within
his own environment.
The MAC TAR Pat ientPreference Disability
Questionnaire
The MACTAR Patient Preference Dis-
ability Questionnaire (Tu gwell et al ., 1987)
is designed specifically for clients with
arthritis. The client is asked if her arthritis
limits her ability to accomplish activities,
and then to priorize which of these activi-
ties she would most want to perform with-
out pain or discomfort. This information
is used in the reassessment to monitor
change. In the reassessment, the client is
asked if there has been any change in her
ability to do the activities that she had
previously listed.
The MACTAR allows the client to set
her own priorities and reflects her own
interests, roles and environment. In this
way the authors hope that the MACTAR
will be more sensitive to small, but impor-
tant changes that occur. At present the
scale does not use a weighting system so
that the activity identified as the highest
priority carries the same weight in the
score as the lower priority items. This
may limit the scale's responsiveness to
change.
The O ccupational Performance
History Interview
The Occupational Performance History
Interview (OPHI) (Kielhofner & Henry,
1988) is a structured interview designed
to gain information about a client's work,
p la y a n d s e l f- c a re p e r f o rma n c e . T h e O PH I
is based on the Occupational Role History
(Florey & Michelman,1982; Moorehead,
1969). The OPHI consists of 39 questions
covering past and present behaviours in
the following content areas: organization
of daily life routines; life roles; interests,values and goals; perception of ability and
responsibility; and environmental influ-
ences. Each content area is rated by the
therapist on a five-point scale ranging
from totally adaptive to totally maladap-
tive.
Although the OPHI considers the
client's life roles and his environment, the
therapist is required to make a judgement
about the client's level of function, so the
measure is not truly client-centred. The
rating scale requires considerable thera-pist judgement in converting interview
data to scores and this leads to difficulties
with reliability. Keilhofner and Henry
(1988) report low levels of reliability
between raters.
The Reintegration to Normal
Living Index
Another assessment of global function
status is the Reintegration to Normal
Living Index (RNL) (Wood-Dauphinee,
Op zoomer, W il liams , Marchand & Spi tzer ,
1988). The RNL was designed primarily
to evaluate change in individuals or groups.
Clients rate 11 statements on a visual
analog sca le with the ancho r phrases "does
not describe my situation" and "fully
describes my situation". Through a con-
tent validation process, the authors deter-
mined that indoor, distant and community
mobility, self-care, daily activity, recrea-
tional and social activities, coping skills,
family roles, personal relationships, and
presentation of self to others were most
closely related to reintegration to normal
living. The statements in the RNL reflect
those domains.
The RNL is very much a client-centred
assessment, measuring client perceptions
of her individual situation. It addresses all
areas of occupational performance, roles
and ro le expectations, as well as the client 's
sense of satisfaction. This measure comes
closest to meeting the criteria outlined by
the Task Force. It is limited because it is
global and so, does not lead to the devel-
opment of specific occupational therapy
goals, and it may not be applicable to all
client groups. The focus is on clients who
have recently had an incapacitating ill-
ness or trauma, so it may not be as useful
for those with congenital or chronic con-
ditions. As well, the RNL assumes a level
of insight in the client which would not be
present in young children, those with
dementia and some mental health clients.
The Satisfaction with
Performance Scaled
Questionnaire
Yerxa, Bu rn ett-Beaulieu, Stocking and
Azen (1988) developed the Satisfaction
with Performance Scaled Questionnaire(SPSQ). This assessment is based on the
client's perception of her level of satisfac-
tion with her performance in home man-
agement and social/community problem
solving. Twenty-four home management
tasks (eg., disposing of garbage) and 22
social/community tasks (eg., going on an
inte rv iew) are rated by the client on a five-
point scale. The ratings indicate the per-
centage of time in the past six months that
the client has been satisfied with her per-
formance of the specified activities.
The S PSQ is another example of a c l ien t -
centred measure and places most of its
emphasis on client satisfaction. It is not,
however individualized to reflect the
client's roles or environment. The fixed
list of activities may not be important to
individual clients. As well, the items are
equally weighted in the total score, but
seem to be at very different levels of
complexity, eg., find and use social activi-
ties vs. clean vegetables. Given this ine-
quality, the total satisfaction score may be
misleading.
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C J O T — V o 1 .5 7 — No. 2
S U M M A R Y
This review shows that the majority of
assessments available to measure out-com es in occupa t ional therapy are s t i ll
directed at perform ance com ponents . Of
those that measure actual occup at ional
performance, the majori ty are self-careassessments and very few consider roles
and/or the client 's environment.
The eight assessments reviewed in more
detail provide examples of client-centred
measures, content areas reflective of the
Occupat iona l Performance Model and a
variety of scoring and scal ing method s.
Each o f the assessmen ts , however , has
shortcom ings that prevent them from ful-
fi ll ing al l of the cri teria for an occ upa-
t ional therapy outcome measure.
There remains a need in occupat ionaltherapy for a val id and rel iable o utcome
measure that assesses the total sphere of
occupat ional perfo rman ce fo r the indi -
vidual client and within her environment.
For this reason, a new measure, the Cana-
dian Occupational Performance Measure
(Law et al., 1990) has been designed,
incorporat ing many of the posi t ive fea-
tures of the assessments reviewed and
based on the client-centred practice of
occupational therapy.
REFERENCES
Bergner, M., Bobbitt, R. A., Carter, W. B.,
& Gilson, B. S. (1981). The Sickness
Impact Profile: Development and final
revision of a health status measure. Medi-
cal Care, 19, 787-805.
Department of National Health and Welfare
and Canadian Association of Occupa-
tional Therapists. (1983). Guidelines for
the client-centred practice of occupa-
tional therapy (H39-33/1983E). Ottawa,ON: Department of National Health and
Welfare.
Department of National Health and Welfare
and Canadian Association of Occupa-
tional Therapists. (1987). Toward outcome
measures in occupational therapy (H39-
114/1987E). Ottawa, ON: Department of
National Health and Welfare.
Diller, L., Fordyce, W., Jacobs, D., Brown,
M., Gordon, W., Simmens, S., Orazem, J.,
& Barrett, L. (1983). Final report,
Rehabilitation Indicators Project. NIHR,
U. S. Department of Education, Grant
G008003039.
Gilson, B. S., Gilson, J. S., Bergner, M.
Bobbitt, R. A., Kressel, S., Pollard, W. E.,
& Vesselagô, M. (1975). The Sickness
Impact Profile: Development of an out-
come measure of health care. American
Journal of Public Health, 65, 1304-1310.
Florey, L. L., & Michelman, S. M. (1982).
Occupational role history: A screening
tool for psychiatric occupational therapy.
American Journal of Occupational
Therapy, 36, 301-308.
Jette, A. M., Davies, A. R., Cleary, P. D.,
Calkins, D. R., Rubinstein, L. V., Fink,
A., Kosecoff, J., Young, R. T., Brook, R.
H., & Delbanco, T. L. (1986). The Func-
tional Status Questionnaire: Reliability
and validity when used in primary care.
Journal of General Internai Medicine, 1,
1 43 - 1 49 .
Kielhofner, G. (Ed.). (1985). A model of
human occupation: Applications of a
conceptual approach to occupational
therapy. Baltimore: Williams & Wilkins.
Kielhofner, G., & Henry, A. D. (1988).
Development and investigation of the
occupational performance history inter-
view. American Journal of Occupational
Therapy, 42, 489-498.
Law, M., Baptiste, B., McColl, M.A.,
Opzoomer, A., Polatajko, H., & Pollock,
N. (1990). The Canadian Occupational
Performance Measure: An outcome meas-
urement protocol for occupational
therapy. Canadian Journal of Occupa-
tional Therapy, 57, 82-87.Moorehead, L. C. (1969). The occupational
history. American Journal of Occupa-
tional Therapy, 23, 329-334.
Reed, K. & Sanderson, S.R. (1980).
Concepts in Occupational Therapy. Balti-
more: Williams and Wilkins.
Tugwell, P., Bombardier, C., Buchanan, W.
W., Goldsmith, C. H., Grace, E., &
Hanna, B. (1987). The MACTAR Patient
Preference Disability Questionnaire: An
individualized functional priority ap-
proach for assessing improvement in
physical disability in clinical trials inrheumatoid arthritis. Journal of Rheuma-
tology, 14, 446-451.
Wood-Dauphinee, S. L., Opzoomer, A.,
Williams, J. I., Marchand, B., & Spitzer,
W. O. (1988). Assessment of global func-
tion: he Reintegration to Normal Living
Index. Archives of Physical Medicine and
Rehabilitation, 69, 583-590.
Yerxa, E. J., Burnett-Beaulieu, S., Stocking,
S., & Azen, S. P. (1988). Development of
the Satisfaction with Performance Scaled
Questionnaire. American Journal of
Occupational Therapy, 42, 215-221
ACKNOWLEDGEMENTS
Th e authors wish to acknowledge the
following individuals who have provided
valuable advice and assistance during the
d ev e lo p m en t o f the Canadian Occupa-tional Performance Measure: Sharon
Brintnell, Thelma Gill, Sue Laughlin,Micheline Marrazani, Barbara Quinn,
Nancy Staisey, Serge Ta i l lon, E l izabeth
To wnsend, and Elizabeth Yerxa.
This research was funded by grants
f rom The Nat iona l H eal th R esearch and
Development Program of Health and
Welfare Canada and The Canadian Occu-
pat ional Therapy Foundat ion. Mary Law
holds a C areer Scient is t Award from the
Ontario Ministry of Health.
Résumé
En 1987, un groupe de travail formé par
Santé et Bien-être social Canada et par
l'ACE recommandait d'aller de l'avant
pour - mettre au point une mesure des résu l-
tats en ergothérapie compatible avec le
modèle axé sur la capacité fonctionnelle.
La première étape de ce processus a été de
faire une revue critique des instruments
de mesure des résultats qui évaluent la
capacité fonctionnelle et dont fait état la
littérature actuelle.
Cette étude présente le processus de
révision, décrit en détail huit évaluations
qui répondent à plusieurs des critères de
révision et discute des limites de ces in-
struments de mesure dans le cadre les
Lignes directrices relatives à la pratique
de l' ergothérapie axée sur le client; enfin,
elle fait des recommandations pour
l'élaboration d'un nouvel instrument de
mesure des résultats en ergothérapie.