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CJOT — Vo1.57 — No.

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Occupational Performance Measures: Â Review Based on the Guidelines for the Client-centred Practice of Occupational Therapy
Nancy Pollock, Sue Baptiste, Mary Law, Mary Ann McColl, Anne Opzoomer, Helene Polatajko

Key Words:

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 the literature. 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.

• Assessment process, occupational therapy • Outcome and process assessment

Nancy Pollock, M.Sc., O.T. (C) is Research Clinician, Occupational Therapy, Chedoke-McMaster Hospitals, 1 200 Main Street West, Hamilton, Ontario, L8N 3Z5 Sue Baptiste, M.H.Sc., O.T. (C) is Director, Occupational Therapy, ChedokeMcMaster 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 -dokeMcastrHopils. Mary Ann McColl, M.H.Sc., O.T. (C) is Assistant Professor, Department of Rehabilitation Medicine , University of Toronto and Director of Research, Lyndhurst Hospital, Toronto. Anne Opzoomer, M.Sc., O.T. (C) is Assistant Professor, Occupational Therapy Program, University of Ottawa. Helene Polatajko, Ph.D., O.T. (C) is Associate Professor, Departments of Occupational Therapy and Education, University of Western Ontario.

CANADIAN OCCUPATIONAL THERAPY FOUNDATION

The Canadian Occupational Therapy Foundation was pleased to provide a research grant to assist the authors with their work.

In 1983, Health and Welfare Canada and the Canadian Association of Occupational Therapists Task Force published the "Guidelines for Client-Centred Practice of Occupational Therapy" (Department of National Health and Welfare & Canadian Association of Occupational Therapists, 1983) describing a conceptual framework for the practice of occupational therapy in Canada. This framework, the Occupational Performance Model "...views an individual's occupational performance as having three areas: self-care, productivity and leisure, predicated on the interaction of the individual's mental, physical, sociocultural and spiritual performance components" (p. 8). In 1987, the Task Force outlined the importance of outcome measures in advancing our profession. Well developed assessments 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 of Occupational Therapists, 1987). The Task Force used the Occupational Performance Model as a basis to investigate available outcome measures in occupational therapy. The task force set out a number of criteria which the outcome measure(s) should meet. Specifically the measure should: a) be based on the occupational performance model. b) focus on performance in self-care, productivity and leisure as the primary outcome.

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time. 1975) is an interviewer administered global measure of health status. j) be scorable. but were included because the focus of this review was on content and philosophy. administration. e) be sensitive to clinical change relevant to occupational therapy goals including development. measured only for their contribution to occupational performance. 13 were not accessible through the literature because they are unpublished or "home grown" assessments. how? If yes. d) consider the client's environment. Several of these measures have not been standardized or formally tested. although those ratings are judged externally through a weighting system. developmental stage. how? Discriminative Predictive Child Adolescence Adult Evaluative Later Years Self yes no Self-Report Nominal Therapist Observation Ordinal Other Interval c) consider performance components (physical. 2 Table 1 O. 1981). Table 2 summarizes the results of the review. Based on the criteria set out in the Task Force report. A percentage score can be calculated for the entire SIP as well as for each category. A total of 136 assessments were identified and 82 of those were excluded as they assessed only performance components. sociocultural and spiritual) as secondary outcomes. Outcome Study Evaluation Form Name of Instrument: Author: Description/Intent: Self-Care: Productivity: Leisure: Environment: Roles: Importance to client: Assesses ability or performance: Purpose: Developmental Stage: Target Population: Culture: Setting: Informant: Structured: Method: Scale: Score Types Available: Source: yes yes yes yes yes yes no no no no no no If yes. Of these. The client checks only those items that she feels describe her behaviour. not on psychometric properties. The SIP is an individualized measure within which the client checks only those items that apply to her situation. restoration and maintenance of function. The first stage of this research project was to update the review done by the Task Force of current measures of occupational performance to determine if a suitable measure or measures existed. mental. A database was designed from this evaluation form and the information entered for subsequent analysis. therefore only 41 could be evaluated.. life roles and motivation. i) be usable in terms of format. I am going out less to visit people). These instruments were reviewed by the Task Force April/avril 1990 . The National Health Research and Development Program of Health and Wel78 fare Canada and the Canadian Occupational Therapy Foundation subsequently funded a project to continue this process and develop an outcome measure for occupational therapy. mental. responsiveness and validity. It is concerned with the impact that sickness has on everyday activities and behaviours. Scoring is based on a weighting system developed through interval scaling procedures (Bergner. The second step in the process was to design evaluation criteria to be used in reviewing the remaining 54 measures. 0 not be diagnosis specific. This paper will describe the review process. Literature searches and input from therapists and academic faculty were used to develop this initial list. h) incorporate measurement properties of reliability. and prevention of disability. a form for evaluation was developed (Table 1). sociocultural or spiritual) were excluded from the rest of the review process. Bobbitt. g) be modular for use in whole or in part. Carter & Gilson. highlight some of the occupational performance measures currently available and assess their correspondence with the Occupational Performance Model. how? If yes. and the research group. Of the 54 instruments reviewed. not based on the 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 therapists.. ease of scoring and client acceptability. The assessments that measured only performance components (physical. The measure consists of 235 statements grouped into 14 categories that describe a situation (eg.CJOT — Vo1. The Sickness Impact Pro fi le The Sickness Impact Profile (SIP) (Gilson et al. and the areas(s) of occupational performance assessed and/ or the performance components assessed were indicated. eight met most of the review criteria and were closely aligned with the Occupational Performance Model.57 — No.T.

The ACTRE provides a comprehensive look at how the client is spending her time and also her performance level and sense of satisfaction with her performance. L R R. The Activity Record The National Institutes of Health Activity Record (ACTRE) (Kielhofner. meaningfulness. The API also records the location. 1985. there is no total score. P. and the level of social interaction involved in the activity. The Status Indicators and the Activity Pattern Indicators measure what the client "does do". Activity Pattern Indicators Rehabilitation Indicators (Diller et al. L SC. P. A. P. 1988) 6.. The three instruments can be used separately or together. L SC. transpo rt ation etc. the lack of a total score limits the useof the ACTRE as an outcome measure. It does not give any indication of the activities most affected by the client's disability or those that are most important to the client. her competence.CJOT — Vo1. P. educational and personal care activities for the previous week. Occupational Pe rf ormance History Interview (Kielhofner & Henry. The outcomes measured are not based specific to occupational therapy. 1988) 5. P. rehabilitation. The Skill Indicators measure what a client "can do". MY client's own situation. The client is asked to rate. selfcare. however the level of detail makes it impractical for clinical use. the perceived difficulty of the activity. As the scores are not cumulative over the entire test. 1986) 4. I.. Activities for each 1/2 hour period during the day are recorded and a series of questions asked about each activity. E A. L SC.57 — No. MY A. on a four-point scale. 1985) 7. P. p. L SC. 1987) 8. and enjoyment in doing the activity. Activity Pattern Indicators (Diller et al.472) is a daily activity log kept by the client. The client documents the frequency and duration of her involvement in social. 1988) 2. L I I Y... 1986) 3. P. 79 .A.L Considerations Developmental Stage C = Y = MY = A = child youth mature years adult R = roles I = importance to client E = environment R. Reintegration to Normal Living Index (Wood-Dauphinee et al. MY P. 1983) are a series of three functional assessment instruments. recreational. 1983) SC. household. MACTAR Patient Preference Disability Questionnaire (Tugwell et al. and the balance of activities in the client's daily routine are examined. Occupational performance is considered.. National Institutes of Health Activity Record (NIH. April/avril 1990 childcare. Activities can be classified as leisure. The information would have limited value in establishing treatment priorities or in monitoring change in the individual. E Y. The API is a highly detailed log of daily activities. pain and fatigue while doing that activity. The Activity Pattern Indicators (API) are most closely aligned to the Occupational Performance model. 2 Table 2 Summary of the Review Measures Performance Areas Assessed SC = self-care P = productivity L = leisure Measure 1. Satisfaction with Performance Scaled Questionnaire (Yerxa et al. The API covers a broad spectrum of activities and provides a detailed description of an individual's daily patterns. Functional Status Questionnaire (Jette et al. MY SC. Although the individual records provide useful information to the client and therapist.. I. but in a general fashion along with many other health status indicators.. Sickness Impact Profile (Gilson et al.L I E A Y. level of assistance required. business.MY A SC.. A A.

values and goals. disposing of garbage) and 22 social/community tasks (eg. The statements in the RNL reflect those domains. and then to priorize which of these activities she would most want to perform without pain or discomfort. distant and community mobility. The ratings indicate the percentage of time in the past six months that the client has been satisfied with her performance of the specified activities. In this way the authors hope that the MACTAR will be more sensitive to small. 1988) is a structured interview designed to gain information about a client's work. This measure comes closest to meeting the criteria outlined by the Task Force. Clients rate 11 statements on a visual analog scale with the anchor phrases "does not describe my situation" and "fully describes my situation".57 — No. coping skills.. 1987) is designed specifically for clients with arthritis. and 80 . The scoring system is computerized and provides a profile for each client highlighting "warning zones" based on his score. roles or functions to the individual client within his own environment. family roles. 1988). and it may not be applicable to all client groups. the RNL assumes a level of insight in the client which would not be present in young children. This information is used in the reassessment to monitor change. find and use social activities vs. It is also based on what the client is actually doing. social activities and the client's own view of his health status. Bu rnett-Beaulieu. clean vegetables. It is not. Twenty-four home management tasks (eg. 1969). The Satisfaction with Performance Scaled Questionnaire Yerxa. those with dementia and some mental health clients. however individualized to reflect the client's roles or environment. Given this inequality. recreational and social activities. The FSQ considers work and social functions. The OPHI consists of 39 questions covering past and present behaviours in the following content areas: organization of daily life routines. It is limited because it is global and so. presentation of self to others were most closely related to reintegration to normal living. interests. daily activity. Keilhofner and Henry (1988) report low levels of reliability between raters. but seem to be at very different levels of complexity. the therapist is required to make a judgement about the client's level of function. going on an interview) are rated by the client on a fivepoint scale. In the reassessment. so the measure is not truly client-centred.CJOT — Vo1. the warning zones have been determined for all clients and thus the measure is not individualized. life roles. work. The MACTAR allows the client to set her own priorities and reflects her own interests. roles and role expectations. The focus is on clients who have recently had an incapacitating illness or trauma. A series of questions determine levels of function in activities of daily living. The RNL was designed primarily to evaluate change in individuals or groups. Unfortunately. does not lead to the development of specific occupational therapy goals.1982. in addition to daily living activities and so provides a comprehensive assessment. the authors determined that indoor. It does not consider the importance of these activities. Marchand & Spitzer. psychological and social or role functions. Stocking and Azen (1988) developed the Satisfaction with Performance Scaled Questionnaire (SPSQ). so it may not be as useful for those with congenital or chronic conditions. measuring client perceptions of her individual situation. As well. As well. The RNL is very much a client-centred assessment. This may limit the scale's responsiveness to change. At present the scale does not use a weighting system so that the activity identified as the highest The Reintegration to Normal Living Index Another assessment of global function status is the Reintegration to Normal Living Index (RNL) (Wood-Dauphinee. perception of ability and responsibility. The fixed list of activities may not be important to individual clients. the client is asked if there has been any change in her ability to do the activities that she had previously listed. It addresses all areas of occupational performance. as well as the client's sense of satisfaction. self-care.. 1986) is a self-administered scale which looks at physical. roles and environment. play and self-care performance. but important changes that occur. 2 The Functional Status Questionnaire The Functional Status Questionnaire (FSQ) (Jette et al.. Moorehead. personal relationships. This assessment is based on the client's perception of her level of satisfaction with her performance in home management and social/community problem solving. eg.. and environmental influences. priority carries the same weight in the score as the lower priority items. the items are equally weighted in the total score. The SPSQ is another example of a clientcentred measure and places most of its emphasis on client satisfaction. Through a content validation process. Williams. Opzoomer. providing a realistic functional picture. The OPHI is based on the Occupational Role History (Florey & Michelman. Each content area is rated by the therapist on a five-point scale ranging from totally adaptive to totally maladaptive. The rating scale requires considerable therapist judgement in converting interview data to scores and this leads to difficulties with reliability.. Although the OPHI considers the client's life roles and his environment. the total satisfaction score may be misleading. These warning zones were developed by a consensus panel of experts and indicate areas of possible concern. The Occupational Performance History Interview The Occupational Performance History Interview (OPHI) (Kielhofner & Henry. April/avril 1990 The MACTAR Patient Preference Disability Questionnaire The MACTAR Patient Preference Disability Questionnaire (Tugwell et al. The client is asked if her arthritis limits her ability to accomplish activities.

Department of Education.. The MACTAR Patient Preference Disability Questionnaire: An individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. A.. Nancy Staisey. D... & Hanna. The Sickness Impact Profile: Development and final revision of a health status measure. & Azen.. & Pollock. 1.. A. 36. S. B. elle fait des recommandations pour l'élaboration d'un nouvel instrument de mesure des résultats en ergothérapie.. Thelma Gill. has shortcomings that prevent them from fulfilling all of the criteria for an occupational therapy outcome measure. Davies. M. S. 2 SUMMARY This review shows that the majority of assessments available to measure outcomes in occupational therapy are still directed at performance components. Burnett-Beaulieu. M.. Gordon. Moorehead. N. however. The Canadian Occupational Performance Measure: An outcome measurement protocol for occupational therapy. K. (1969). 82-87. Grace. L. the Canadian Occupational Performance Measure (Law et al. 69. Cleary. C. C. (1988). Kosecoff. Department of National Health and Welfare and Canadian Association of Occupational Therapists. Florey. The occupational history.. ACKNOWLEDGEMENTS The authors wish to acknowledge the following individuals who have provided valuable advice and assistance during the development of the Canadian Occupational Performance Measure: Sharon Brintnell. C. L. Bobbitt.. Law. Mary Law holds a Career Scientist Award from the Ontario Ministry of Health. This research was funded by grants from The National Health Research and Development Program of Health and Welfare Canada and The Canadian Occupational Therapy Foundation.. Bergner. S.. J. A. Ottawa.. enfin. Each of the assessments. D. American Journal of Occupational Therapy.. O. décrit en détail huit évaluations qui répondent à plusieurs des critères de révision et discute des limites de ces instruments de mesure dans le cadre les Lignes directrices relatives à la pratique de l' ergothérapie axée sur le client. B. M.. I. 301-308. Serge Taillon. Journal of General Internai Medicine. W. 14. R. S. 42.. A. Gilson. Baltimore: Williams & Wilkins. S.. R. R. S. V. ON: Department of National Health and Welfare. D. Ottawa. & Henry. Opzoomer. Stocking. ON: Department of National Health and Welfare. A.R. Fordyce. Concepts in Occupational Therapy. 19. (1982).. 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. Wood-Dauphinee.CJOT — Vo1. (1983). L. D. Baptiste. Barbara Quinn. & Barrett. E. American Journal of Occupational Therapy. R. A. Rubinstein. Yerxa. Carter.. Grant G008003039. Occupational role history: A screening tool for psychiatric occupational therapy. For this reason. 65. B... G.A. W. Canadian Journal of Occupational Therapy.. J. & Vesselagô.. the majority are self-care assessments and very few consider roles and/or the client's environment. (1990). A.. Kielhofner. Baltimore: Williams and Wilkins. Tugwell. 1990) has been designed. S. Department of National Health and Welfare and Canadian Association of Occupational Therapists. H. M. Rehabilitation Indicators Project. Kressel. & Michelman. Young. W. S. 446-451.... Fink.). NIHR. Brown. Kielhofner. Development of the Satisfaction with Performance Scaled Questionnaire. (1975). 329-334. S. M. P. (Ed. H. 23. Jette. Calkins. Assessment of global function: he Reintegration to Normal Living Index. (1988). W.. W. Williams. & Sanderson. Brook. B. & Delbanco. 787-805. Micheline Marrazani. J. Toward outcome measures in occupational therapy (H39114/1987E).. Opzoomer. L. A model of human occupation: Applications of a conceptual approach to occupational therapy.. G. B... incorporating many of the positive features of the assessments reviewed and based on the client-centred practice of occupational therapy. R. McColl. E. 57. Bombardier. REFERENCES Bergner. (1988).. P. (1985). Final report. M. 583-590.. S. Elizabeth Townsend. T. J... & Gilson. Pollard. American Journal of Occupational Therapy. American Journal of Occupational Therapy. The eight assessments reviewed in more detail provide examples of client-centred measures. The Sickness Impact Profile: Development of an outcome measure of health care. Goldsmith. There remains a need in occupational therapy for a valid and reliable outcome measure that assesses the total sphere of occupational performance for the individual client and within her environment. U. E. B.. Archives of Physical Medicine and Rehabilitation. April/avril 1990 81 . (1987). M. (1987). L. T. The Functional Status Questionnaire: Reliability and validity when used in primary care. Simmens.. A. Polatajko. un groupe de travail formé par Santé et Bien-être social Canada et par l'ACE recommandait d'aller de l'avant pour. 489-498. 215-221 Résumé En 1987. Reed. American Journal of Public Health. W. Marchand.. (1983). P. Journal of Rheumatology. content areas reflective of the Occupational Performance Model and a variety of scoring and scaling methods. Buchanan. L. 1304-1310. Sue Laughlin. J. & Spitzer. Jacobs. a new measure.. 143-149.mettre au point une mesure des résultats en ergothérapie compatible avec le modèle axé sur la capacité fonctionnelle. W. S. Bobbitt.. (1981). Guidelines for the client-centred practice of occupational therapy (H39-33/1983E). H. Medical Care. and Elizabeth Yerxa. R.. S. Gilson. L. L. Diller.57 — No. (1986). M. Cette étude présente le processus de révision. (1980). 42.. Development and investigation of the occupational performance history interview. Of those that measure actual occupational performance.. Orazem.