See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/13183923

Developing Guidelines for Client-Centred Occupational Therapy Practice

Article  in  Canadian Journal of Occupational Therapy · May 1990

DOI: 10.1177/000841749005700205 · Source: PubMed

CITATIONS READS
29 302

3 authors, including:

Elizabeth A Townsend Sharon G. Brintnell

Dalhousie University University of Alberta
62 PUBLICATIONS   1,792 CITATIONS    55 PUBLICATIONS   468 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Cultural and Psychosocial Elements Impacting on Disaster Recovery: Response in Indonesia View project

Compassion Fatigue of Canadian Health Professionals View project

All content following this page was uploaded by Elizabeth A Townsend on 20 August 2015.

The user has requested enhancement of the downloaded file.


Developing Guidelines for Client-Centred
Occupational Therapy Practice
KEY WORDS:
• Client-centred practice
(occupational therapy)
• Conceptual framework
• Quality assurance, occupational
therapy
Elizabeth Townsend, M.Ad.Ed., O.T. (C)
is an Assistant Professor at the
School of Occupational Therapy,
Dalhousie University, Halifax, Nova
Scotia B3H 3J5. She was a member of
Guidelines Task Forces, 1979-1989. She
is now the Chairperson of the new Cana-
dian Association of Occupational
Therapists Client-Centred Practice Com-
mittee
Sharon Brintnell, M.Sc., O.T. (C) is a
Professor in the Department of Occupa-
tional Therapy, Faculty of Rehabilitation
Medicine, University of Alberta, Edmon-
ton, Alberta T6G 2E1. She was a member
of Guidelines Task Forces, 1979-1989.
She now chairs mental health and audio-
visual projects arising from the Guide-
lines
Nancy Staisey, Ph.D, O.T. (C) is a Psy-
chologist Consultant with Price Water-
house Management Consultants, 180
Elgin Street, Suite 1100, Ottawa, Ontario
K2P 2K3. She was the Researcher and
Consultant for Volume 111 of the
Guidelines, "Toward Outcome Measures
in Occupational Therapy"
April/avril 1990
Elizabeth Townsend, Sharon Brintnell, Nancy Staisey
ABSTRACT
The Canadian Guidelines for the client-
centred practice of occupational
therapy are national, generic, consen-
sus guidelines developed to address
growing concerns inside and outside the
profession for assuring the quality of
health services. From 1979 to 1987,
successive Task Forces, sponsored by
the Department of National Health and
Welfare and the Canadian Association
of Occupational Therapists, developed
three volumes of guidelines. A pivotal
guideline in Volume 1 is a conceptual
framework of occupational therapy's
central concern: occupational perform-
ance within an individual's physical,
cultural and social environment.
Volume 1 also outlines stages in the
process of client-centred occupational
therapy practice, and specific assess-
ment and program planning guidelines.
Volume 11 covers issues, concepts and
fundamental elements of intervention,
as well as specific guidelines for
intervention, discharge, follow-up and
evaluation. Volume 111 reviews issues in
outcome measurement given occupa-
tional therapy's primary, concern for
occupational performance. The authors,
members of the Task Forces, provide an
overview of the development of and
their hopes for the Guidelines. Uses
and influences of the Guidelines have
not been formally documented. How-
ever, projects are arising from the
Guidelines and a new CAOT Client-
Centred Practice Committee is propos-
ing an updating process for the three
volumes.
CJOT — Vo1.57 — No. 2
The publication of three volumes of
Canadian Guidelines for client-centred
occupational therapy practice was a mile-
stone in the profession's development.
Canada has produced the only nationally-
based, generic guidelines which define
and relate process and outcome issues for
quality assurance in occupational ther-
apy. The Guidelines were developed as a
response by Canadian therapists to na-
tional and international trends in health
service delivery. Since the 1960's, the
following five factors have been particu-
larly compelling for Canadian health
professionals to look critically at the
quality of their services:
1. increasing prevalence of chronic
disease and the need for individuals
to accept a greater responsibility for
their own health;
2. proliferation of technological ad-
vances in investigation, diagnosis and
treatment now available to health care
professionals;
3. heightened sophistication and effec-
tiveness of mass communication
techniques which have resulted in a
more astute and critical consumer
population;
4. acceleration of adaptive changes now
occurring in many of the human serv-
ice areas with the resulting emphasis
on health maintenance, prevention
and early disease detection;
5. insurgence of economic concern by
governments about the ever-increas-
ing high cost of health care which
will dictate greater accountability of
the service delivery by health care
professionals.
69
CJOT — Vo1.57 — No. 2
(Department of National Health and
Welfare and Canadian Association of
Occupational Therapists, 1983, p.1).
This article is an overview of the his-
torical development of the three volumes
of Canadian Guidelines for client-centred
practice in occupational therapy. The
authors reflect on the Task Forces' hopes
and current projects for putting the Guide-
lines to practice.
Historical Development
Development of the first volume of
Guidelines began formally in 1979 when
Health and Welfare Canada and the Cana-
dian Association of Occupational Thera-
pists (CAOT) convened a national Task
Force. However a number of Canadian
and American projects in the 1960's and
1970's, defining occupational therapy
competencies and standards, were instru-
mental in laying the groundwork. For
instance, since the 1960's, CAOT has
collaborated with Statistics Canada to
develop guidelines for the national work-
load measurement system (WMS) now
used in most health institutions. In 1973,
CAOT standards for hospital-based occu-
pational therapy services were adopted by
the Canadian Council on Hospital Ac-
creditation. A 1977 CAOT Task Force
identified generic occupational therapy
competencies in an Occupational Thera-
pist-Occupational Profile. Occupational
Therapy Profile Guidelines were devel-
oped by the Quebec Department of Labour
and the Corporation Professionnelle des
Ergothérapeutes du Québec. The Ameri-
can Occupational Therapy Association
(AOTA) Continuing Competency Project
developed standards for job performance
and continuing education (Department of
National Health and Welfare and Cana-
dian Association of Occupational Thera-
pists (DNHW & CAOT), 1983, pp. 2-3).
By the late 1970's, AOTA was developing
specific practice guidelines for occupa-
tional therapy with people with specific
medical diagnoses. At this time, CAOT
began to discuss the development of guide-
lines which would reflect practice in this
country. The Executive and members of
the Board of Directors saw in guidelines a
resource for developing and monitoring
quality assurance programs, and for de-
70
fining the profession's effectiveness in
client-centred practice.
In 1978, the President of CAOT wrote
to the Department of National Health and
Welfare (DNHW) about its Clinical Guide-
lines Program after learning that the
Department was providing assistance to
other health professions. After a second
inquiry in 1979 by the Chairman of the
Council of Practice and Executive mem-
bers of CAOT, representatives from the
DNHW convened the first Task Force on
Client-Centred Guidelines. This, and two
successive Task Forces, were coordinated
by Eve Kassirer, a medical sociologist
with the Health Services Directorate of
the Department. Each Task Force was
comprised of occupational therapists se-
lected as expe rts by CAOT to represent
each region of Canada, clinical and aca-
demic perspectives, and a range of areas
and settings for client-centred practice.
The first Task Force also included a
medical gerontologist, and a representa-
tive each from the Canadian Psychiatric
Association and the Canadian Medical
Association (a corresponding member).
The second Task Force included a neu-
rologist and the Canadian Psychiatric
Association representative who had par-
ticipated on the first Task Force. By the
third Task Force, occupational therapists
were on their own. From extensive litera-
ture review, a survey of client-centred
outcomes in occupational therapy prac-
tice, and (often heated!) debate, the Task
Forces produced three volumes of Guide-
lines. The first two volumes, following
Donabedian's (1966) sequence for devel-
oping quality assurance guidelines, de-
scribe the process of client-centred prac-
tice. The third volume summarizes out-
come issues and reports on a study of
outcomes in Canadian client-centred
practice.
Process Guidelines for
Client-centred Practice
A Generic Conceptual Framework
and Stages in the Process of Practice
Volume I, Guidelines for the Client-
Centred Practice of Occupational Ther-
apy (DNHW & CAOT, 1983), laid the
groundwork for the other two volumes by
defining a generic conceptual framework
for client-centred practice. Beginning at
its first meeting in December 1979, a nine
member Task Force reviewed current lit-
erature on occupational therapy, quality
assurance, quality of care, standards and
competencies in health professions, medi-
cal sociology and other related topics.
From this mass of information, the Task
Force outlined a conceptual framework
which recognized four beliefs as generic
to client-centred occupational therapy
practice. Ageneric framework was sought
as an overriding guideline within which
therapists could use specific frames of
reference appropriate to their clients, work
settings and modes of practice. The con-
ceptual framework was built on the occu-
pational therapy belief in the worth of the
individual as an important and active
participant in her/his own therapeutic
relationship. It reinforces occupational
therapists' traditional holistic view of the
individual constituted of and integrated in
mind, body and spirit. In recognition of
the profession's philosophical roots, the
framework emphasizes occupational
therapy's central belief in the therapeutic
use of activity/occupation interpreted as
"purposeful task engagement" (p.10).
Finally, the framework acknowledges that
occupational therapists' therapeutic use
of activity/occupation takes place within
a developmental perspective which im-
plies recognition of the life stage and role
demands of the client. In summary, the
conceptual framework is based on a na-
tional statement of occupational therapy
belief that an individual's holistic physi-
cal, mental and spiritual health is pro-
moted through active participation in
performing tasks, or directing others on
one's behalf, in developmentally appro-
priate, purposeful activity/occupation.
These beliefs underlie the generic model
of occupational performance (Figure 1)
which depicts a performance-oriented
view of health. The model is the overrid-
ing guideline defining occupational
therapy's domain of interest in health: an
individual's ability to integrate everyday
activity/occupation into an holistic, de-
velopmentally appropriate way of life
which that individual defines as purpose-
ful. The model recognizes four perform-
ance components: mental, physical, socio-
cultural and spiritual. Each individual
integrates performance components in
April/avril 1990

ways which enable her/him to achieve
three areas of occupational performance:
self-care, productivity (developmentally
defined as play, paid or unpaid occupa-
tion) and leisure. A critical element of the
model of occupational performance is the
recognition that integration and execution
of occupational performance, including
all components and areas, is defined and
shaped by the individual's social, physical
and cultural environment. An individual
achieves occupational performance
through active participation, either
performing or directing others, in her/his
own integration of self-care, productivity
and leisure. Occupational performance is
an holistic, integrated way of life which
an individual has uniquely defined as
purposeful. In achieving occupational
performance, each individual both
influences and is influenced by her/his
environment.
The guideline of a generic conceptual
framework paved the way for another
overriding guideline: the process of client-
Figure 1
INTERACTING ELEMENTS OF THE INDIVIDUAL
IN A MODEL OF OCCUPATIONAL PERFORMANCE •
ENVIRONMENT
(social, physical, cultural)
leisure®
spiritual ®
SOCIAL
ENVIRON-
MENT
THE INDIVIDUAL
cultural®
productivityA
PHYSICAL
ENVIRONMENT
Printed with permission from: Department of National Health and Welfare Canada & Canadian
Association of Occupational Therapists. (1983). Guidelines for the client-centred practice of
occupational therapy. (H39-33/1983E). O tt awa, ON: Department of National Health and Welfare.
Page 9.
April/avril 1990
centred occupational therapy practice to
promote occupational performance. The
purpose of client-centred occupational
therapy practice is "to prevent disability;
and to promote, maintain or restore occu-
pational performance" (p.xvi). Through-
out the process of client-centred practice,
the purpose of occupational therapy is to
help individuals singly or collectively,
directly or indirectly through advocates
or assistants, to change the self and/or the
environment. Occupational therapists
focus practice with those whose occupa-
tional performance is at risk or already
disrupted.
The Task Force defined seven stages
required to ensure quality in the process of
client-centred practice. The process be-
gins when people become clients of occu-
pational therapists. Occupational thera-
pists respond to the needs of others, not by
soliciting services, but through referral
mechanisms which vary with the occupa-
tional therapy - client context. The occu-
pational therapy response is not prescribed
self care°
physicals
CULTURAL
ENVIRON-
MENT
o Performance components
e Areas of occupational performance
le Adapted from Read and Sanderson, 1980
CJOT — Vo1.57 — No. 2
by others but is determined as the occupa-
tional therapist and client collaborate in
the assessment of the individual and her/
his environmental context for daily liv-
ing. Program planning for intervention
requires collaboration between the client
and therapist with attention to the
individual's needs in present or antici-
pated living situations.
Intervention is the core of client-centred
practice. Since the purpose of practice is
to help others change, intervention is not
static or reducible to recipe-like technical
solutions. Intervention is dynamic, a
continually evolving pattern of interac-
tion and action in some way involving the
client, the therapist and all those with
whom a client relates to reach her/his
potential for occupational performance.
Therapists intervene with clients in one-
to-one relationships or in groups. In-
creasingly, therapists in client-centred
practice intervene indirectly via interme-
diaries such as homemakers, personal care
attendants, volunteers and members of a
client's family, school, work or leisure
community. To complete the process of
practice, therapists terminate contact with
clients through some type of discharge.
Where possible, therapists attempt to fol-
low up to check on progress after active
intervention. The final stage, evaluation,
points to the individual therapist's re-
sponsibility for formal or informal review
of the both the process and the results of
involvement with each client.
These generic conceptual framework
and process of practice guidelines now
appear simple and obvious. However, the
Task Force struggled with the literature
and ideas (juggling reading and writing
with full time employment as any com-
mittee member knows!) for almost two
years before arriving at a satisfactory
consensus. Having defined the concep-
tual framework and process of practice,
the Task Force proceeded, in the third
year, to write Specific Assessment and
Program Planning Guidelines. Interven-
tion (as readers will appreciate from the
few comments above on this stage of
practice) is complex. Time moved on.
The Task Force decided to go to press and
to devote the major portion of a second
volume to issues particularly important to
the intervention stage of practice.
71
CJOT — Vo1.57 — No. 2
Intervention, Discharge, Follow
Up and Evaluation
Volume II, Intervention Guidelines for
the Client-Centred Practice of Occupa-
tional Therapy (DNHW & CAOT, 1986),
continued from Volume I. Beginning in
1984, an 11 member Task Force com-
prised of eight people from the first Task
Force and five new appointees, reviewed
literature on motivation, interpersonal
relationships, ethics, health professional
teams, learning and education, interven-
tion methods, and more. The writing for
this volume began with overriding, ge-
neric guidelines on the major issues,
concepts and elements associated par-
ticularly, although not exclusively, with
intervention. Two issues, professionali-
zation and the team concept in occupa-
tional therapy, were highlighted as they
define relations with other professionals.
Two main concepts governing inter-
vention were given special emphasis:
adaptation and activity. Adaptation is a
central, unifying concept in client-centred
occupational therapy practice. It is based
on "philosophical assumptions that inde-
pendence is better than dependence, inter-
nal locus of control is better than external
locus of control, and individuals have a
right to seek a meaningful existence and
fulfilment of potential through purpose-
ful interaction" (p.9). The adaptation
process requires a "readiness for change
and involves analysis of function, prob-
lem solving, learning, biological change
and decision making" (p.9). Adaptation is
often interpreted as individuals adjusting
themselves to cope with situations which
put them at a disadvantage. However, in
the model of occupational performance,
the individual is seen as influencing as
well as being influenced by the environ-
ment. Therefore, client-centred practice
is guided to promote adaptation, not only
of the self, but also of the environment
where environmental change will enhance
an individual's possibility for independ-
ence, a sense of internal control and a
purposeful existence. Activity/occupa-
tion, another central unifying concept in
occupational therapy was summarized as
"the core of the occupational therapy
process" (p.10), either as "a frame of
reference or as a means to explore func-
tion, increase skills, or promote adapta-
72
tion in intervention....The term activity
may represent specific tasks related to the
three areas of occupational performance.
Activity may also represent less tangible
aspects of human occupation required for
a balanced lifestyle or interaction with the
environment" (p.10). The selection and
adaptation of activity for therapeutic pur-
poses then requires collaboration with the
client or client's representative(s). Activ-
ity selection is a complex process of con-
sideration of the individual's physical,
mental, social and spiritual development.
Selection takes into account the
individual's ability and personal sense of
purpose in all aspects of cultural and social
life.
The Task Force defined five fundamen-
tal elements as permeating all stages but
particularly intervention. Spirituality
reflects the mind-body-spirit paradigm
historically recognized by occupational
therapists. Spirituality represents the need
to explore meaning in life and is central in
assessment of and intervention in occupa-
tional performance. Spirituality also
provides a basis for motivation which
represents one's intrinsic sense of pur-
pose and energy. Motivation is the inte-
gration of spiritual, socio-cultural and
mental components of occupational per-
formance. The therapeutic relationship,
developed as a dynamic interaction around
activity/occupation, is fundamental to
occupational therapy intervention.
Through this relationship, the therapist
expresses genuineness, non-judgemental
attitude and empathy to build trust be-
tween therapist and client. The client and
therapist engage in a teaching learning
process associated with adaptation and
development of independence in occupa-
tional performance. Learning is broadly
conceptualized to include reflection for
self knowledge, attitudinal and interper-
sonal learning, and skill/behavioural learn-
ing for competent performance. Underly-
ing all intervention is an ethical frame-
work defining professional behaviour.
Ethical dilemmas are those in which
behaviourial choices depend on interpre-
tation of rights and responsibilities of
therapist and client given the legal and
moral expectations of the situation.
By 1986, the Task Force had also writ-
ten Specific Intervention, Discharge,
Follow Up and Evaluation Guidelines.
Particularly important was the outlining
of four specific, generic intervention goals.
Occupational therapists restore function
as in the traditional rehabilitation ap-
proaches in which the expected changes
are gains in occupational performance.
Therapists also maintain function, a criti-
cal recognition of client-centred practice
where the expectation is slowing func-
tional losses associated with disease or
the aging process. Therapists develop
function, i.e. promote functional gains, in
those whose genetic or social conditions
have limited the usual development of
occupational performance. Finally, occu-
pational therapists have historically played
a role in health promotion, particularly to
prevent dysfunction "by modifying a
health threatening lifestyle by restoring or
developing or maintaining health patterns
of work or play" (p.27).
Case Illustration
The Task Forces recognized that the
value of generic guidelines is their tre-
mendous flexibility - necessary for a di-
verse, broad-based profession such as
occupational therapy. However, the Task
Forces also knew how difficult it is to
bring generic guidelines to life in real
practice situations. Their response to the
anticipated difficulty in applying the
guidelines was to construct (with the help
of two Nova Scotia therapists) a generic,
typical case illustration recognizable to
the majority of client-centred practitio-
ners who, in the 1980's, worked in institu-
tional, health settings. In Volume I, a
referral was simulated for "Mr. Jones", a
45 year old widowed male and former
carpenter who has been hospitalized but
plans to return to his home. Generic
process and conceptual framework guide-
lines were illustrated as follows:
1. referral focuses on Mr. Jones' physi-
cal performance problems associated
with an above knee amputation and
mental performance problems ex-
pressed through sullen, angry and
resistant interactions and suicide
threats;
2. the therapist works with Mr. Jones to
arrive at an assessment of these diffi-
culties; the therapist gathers infor-
mation from interviews, medical
April/avril 1990

records and assessment of task func-
tioning; assessment information is
documented as a set of conclusions
and recommendations;
3. using the model of occupational per-
formance, assessment findings in self-
care, productivity and leisure (areas
of occupational performance) were
identified; although only physical and
mental performance components
were identified in the referral, the
therapist explores the socio-cultural
component by assessing the man's
relationship with his daughter (with
whom he lived prior to hospitaliza-
tion), his community involvement,
his friendships and his own attitudes
towards being a non-employed, dis-
abled man; assessment of the spiri-
tual component addresses his vision
of himself in the future, his sense of
purpose in life, his beliefs as they
contributed to his sense of worth, his
sense of life and death (especially
considering his threat of suicide) and
his source of apparent anomie;
4. in program planning, one possible
goal, to explore emotional status
through activity, was outlined to il-
lustrate planning of time, frequency,
personnel, activity, resources and cost
associated with pursuing this goal in
one-to-one intervention in a hospital
setting; this goal provides a link with
evaluation at the end of the process of
practice.
The case continued in Volume II illus-
trating generic concepts, fundamental
elements and specific goals of interven-
tion, as well as specific discharge, follow
up and evaluation considerations:
1. adaptation was discussed as primar-
ily emotional and socio-cultural while
physical adaptation to being an
amputee was considered as secon-
dary;
2. activity/occupation selection was sug-
gested as a review of photo albums
and carpentry to aid emotional ex-
pression through memory stimulus
and a sense of productive well-being
associated with Mr. Jones' former
occupation;
3. spirituality, motivation, therapeutic
relationship, teaching learning
April/avril 1990
process, and ethics, were illustrated
through a brief analysis of Mr. Jones'
sense of future and possible happi-
ness, the potential for developing his
relationship with his daughter, his
learning about feelings and adapting
to the loss of his wife, and ethical
questions about discussing confiden-
tial information about his suicide
thoughts with his daughter;
4. intervention goals, to develop func-
tion and to prevent dysfunction, were
illustrated throughout the interven-
tion processes of interaction, docu-
mentation, re-evaluation, program
modification and team communica-
tion;
5. as Mr. Jones' relationship with his
daughter strengthens, the therapist's
hospital contact is terminated with
development of a discharge plan
documented and coordinated with the
daughter and social worker;
6. the therapist arranges to make a home
visit and to continue hospital out-
patient follow up by coordinating
schedules with Mr. Jones, his daugh-
ter, and his social worker;
7. evaluation of the process of care was
through a chart audit to ensure that all
stages were completed with docu-
mentation meeting a standard for
content and frequency of entry; out-
come evaluation was suggested as an
informal comparison of Mr. Jones'
ability to express emotion related to
the loss of his wife at the beginning
and end of the occupational therapy
contact.
Toward Outcome Guidelines
Following Donabedian's (1966) se-
quence for developing quality assurance
guidelines, Volume III, Toward Outcome
Measures in Occupational Therapy
(DNHW & CAOT, 1987) defined key
issues for outcome measurement associ-
ated with occupational therapy. A seven
member Task Force, with five original
and two new members, was a consulting
body to a contract researcher. The third
volume of Guidelines viewed outcomes
in light of the four intervention goals: to
develop, restore or maintain function or to
prevent dysfunction. The Task Force
began by defining objectives for outcome
CJOT — Vo1.57 — No. 2
measurement to: (p.1)
1. improve quality of care by providing
the clinician with information on
client outcomes which are useful for
practice decisions;
2. demonstrate the effectiveness of oc-
cupational therapy to those funding
these services;
3. demonstrate the effectiveness of oc-
cupational therapy to other care
givers;
4. clarify the role of occupational
therapy.
In reviewing outcome literature, the
Task Force found itself working on the
leading edge of outcome measurement
although, in practice, occupational ther-
apy had focused most, to that time, on
structural measures of quality such as
staff, facilities, etc. The generic guide-
lines of Volumes I and II provided a con-
ceptual framework for developing out-
come guidelines. Based on the model of
occupational performance, the primary
outcome of concern to occupational ther-
apy is individual occupational perform-
ance within the context of that individual's
physical, cultural and social environment.
However, the very nature of client-centred
occupational therapy practice, helping
people to achieve occupational perform-
ance as they interact with their families
and community members, confounds
measurement of the influence of occupa-
tional therapy on individual occupational
performance. While measurement of out-
comes in occupational performance is the
concern of occupational therapy, outcome
changes in occupational performance
cannot be necessarily nor fully attributed
to occupational therapy intervention.
By defining client-centred outcomes in
terms of occupational performance,
changes in performance components or
areas of occupational performance are
significant only to the extent that they are
translated into overall change in occupa-
tional performance defined as important
by the client. Occupational performance
outcome expectations are different with
every client. They vary with the unique
physical, cultural and social environment
of the client and with the client's roles and
responsibilities in that unique environ-
ment. In other words, a gain of 5 degrees
in range of movement, an improvement in
73
CJOT — Vo1.57 — No. 2
meal planning ability, or an environmental
change are significant only if they con-
tribute to a client's vision of occupational
performance. While goals (and outcomes)
defined in terms of specific performance
components, areas of occupational per-
formance or environmental factors are
necessary, critical steps along the path to
occupational performance, these steps are
not sufficient as the primary outcome.
In November 1986, in order to capture
the current emphasis on particular out-
comes in client-centred practice, the Task
Force surveyed 200 Canadian occupa-
tional therapists randomly sampled from
CAOT membership records. The thera-
pists who were included in the sample
represented a variety of areas of practice
and settings. Of the 78% of therapists
who responded, 97% were female. Re-
spondents had an average of 11 years of
occupational therapy experience. Most
respondents (75%) held bachelor level
degrees and worked full time (64%) in
programs other than psychiatry (80%).
They worked with clients of all ages in a
mixture of settings (pp. 31 & 32).
Therapists were asked to rate 58 per-
formance items, organized using the per-
formance area and component categories
of the model of occupational perform-
ance. Ratings provided responses to two
questions:
1. as a result of your therapy how fre-
quently do you see changes or im-
pacts in your clients?
2. what is the importance of changes, as
they contributed to overall function-
ing?
The results indicated that current prac-
tice is directed at outcomes in the per-
formance areas of self-care and leisure to
a greater degree than in household man-
agement and productivity. In terms of per-
formance components, practice focuses
on physical, mental and socio-cultural
components to a greater degree than on
the spiritual component. (p.38)
When asked to describe their caseload,
most responded with diagnostic (strokes)
or anatomical categories (hands) as op-
posed to disability categories despite re-
cent trends in the profession to move
away from diagnostically-based practice.
(p.36)
74
Table 1'
Guidelines Distribution
ENGLISH
Volume I (Model & Process)
Volume II (Intervention)
Volume III (Outcome)
' Distribution to December 31, 1989, courtesy of L. Perreault, Publications Unit, Health
Services Directorate, Department of National Health and Welfare. Distribution numbers for
Volumes I and II in French have been estimated from Department records, Task Force minutes,
and personal communication with M. Marazzani.
Putting the Guidelines
to Practice
The goal in producing the Guidelines
series has been to provide occupational
therapists with Canadian documents which
support them to develop and maintain
high quality services and to define their
domain of concern in client-centred prac-
tice. Successive Task Forces hoped that
they were providing a national, unifying
framework to focus occupational therapy
efforts to develop, implement and evalu-
ate quality services consistent with our
professional philosophy and abilities. Ten
years ago, initial Task Force members
hoped that the conceptual framework
would help therapists, despite their clien-
tele or work setting, to articulate their
interest in function or disability in terms
of concern for occupational performance.
They hoped that process guidelines would
support therapists as they hire personnel
and work with team members to establish
policies and procedures for every stage
from referral to evaluation. As members
of the second Task Force wrote guidelines
on the issues, concepts and fundamental
elements of intervention, they hoped to
raise professional awareness of the im-
portance of spirituality, interpersonal re-
lationships, ethics, motivation, and our
responsibility to collaborate with clients
as facilitative teachers-learners, not as
authoritative, technical experts. In the
third Task Force, members hoped to help
therapists link their goals to outcomes
consistent with the conceptual framework
of occupational performance. By sum-
marizing the issues of outcome measure-
ment in relation to occupational therapy
and occupational performance, they hoped
to encourage therapists to reflect on the
FRENCH
8163 2387
3346 1300
6404 1440
purpose of their contact with clients and
the ways in which the quality of service is
made accountable. At this point, use of the
Guidelines depends "on individual need
and is limited only by individual creativ-
ity" (DNHW & CAOT, 1986, p.51). Fif-
teen possibilities were listed in Volume II
to suggest ways of putting the Guidelines
to practice. They challenged therapists to
create applications for program accredi-
tation, workload measurement, perform-
ance appraisal, public relations, and, of
course, quality assurance. Workshops
have been conducted by Task Force
members to facilitate this process and to
develop specific clinical protocols for
quality assurance.
The outcomes Task Force recommended
action for development of outcome meas-
urement tools. It recommended develop-
ment of tools compatible with the model
of occupational performance and usable
in outcome research in hospital, commu-
nity and other settings. Acting on that
recommendation, the Canadian Occupa-
tional Therapy Foundation (COIF) re-
ceived funding from the DNHW to pro-
duce a self instructional package (SIP) to
assist clinicians to develop clinical proto-
cols from the Guidelines. The SIP will
include a video tape and a manual. In
addition, the Department, including the
National Health Research Development
Program, NHRDP, and COTF co-funded
a fourth Task Force and research team to
develop an outcome measurement tool,
the Canadian Occupational Performance
Measure (COPM) based on the Guide-
lines. In 1989, the Department approved
funding for a fifth Task Force, the Work-
ing Group on Occupational Therapy
Mental Health Services. These projects
are all in progress.
April/avril 1990

All three volumes of Guidelines have
been widely distributed, in English and
French, by the DNHW at no cost to recipi-
ents. Using the CAOT address list, copies
were sent to each person who was regis-
tered with CAOT at the time each volume
was published. Copies were sent to major
health facilities, social programs and a
variety of administrators, researchers and
interested persons. Anyone can order, at
no charge from DNHW, any number of
copies to distribute to team members,
conference delegates, students consider-
ing a career in occupational therapy, or
others. In December 1989, distribution
was as listed in Table 1.
What effect have the Guidelines had?
Have any of the Task Force hopes been
realized? One criterion for evaluation is
the ongoing demand for copies of all three
volumes. Prompted by the initial distri-
bution, book reviews, international con-
ference presentations, and promotion
through the World Federation of Occupa-
tional Therapists, the DNHW receives
Canadian and international correspon-
dence requesting single or multiple cop-
ies. Approximately 95% of requests are
from occupational therapists with the
remaining requests from physiotherapists,
nurses and health administrators inter-
ested particularly in the outcome Guide-
lines.
Another criterion of impact is the extent
to which the Guidelines have infiltrated
Canadian occupational therapy practice.
The President of the Association of Cana-
dian Occupational Therapy University
Programs (ACOTUP), in April 25, 1989
correspondence with the President of
CAOT, summarized responses to a survey
concerning use of the Guidelines. The six
programs which had responded to that
date stated that the three documents "are
used extensively throughout the 3(4) years
of training" in the theoretical and clinical
courses. Since the Guidelines are part of
education, these programs stressed the
need for updating to reflect current prac-
tice ideas. Questions drawing on the
Guidelines are now part of the national
certification examination. Therefore,
student occupational therapists in all pro-
grams have had some exposure to the
Guidelines. CAOT ensures continuing
exposure to the Guidelines both in official
documents and as a way of organizing
April/avril 1990
professional materials and activities. One
example is that CAOT requires writers of
national position papers to describe areas
of practice with reference to the Guide-
lines. The Guidelines are also infiltrating
provincial documents and promotional
materials.
A third criterion for evaluating impact
is the Guideline's usefulness for clinical
practice. Task Force members have all
heard testimony that the Guidelines are
now a standard item on bookshelves! Of
those responding to the outcome survey,
87% reported being aware of and 78%
reported having read the 1983 and 1986
Guidelines. However, most rated their
"knowledge of the Guidelines" (p.38) as
moderate (3 on a scale of 1 to 5). "Fewer
reported using them to a moderate or great
extent, and a smaller number reported
using the model of occupational perform-
ance outline in the Guidelines" (p.38).
Members have heard glowing reports of
therapists structuring quality assurance
programs around the Guidelines, or of
administrators finding in the Guidelines a
clarity of purpose from which to interpret
the diversity they observe in occupational
therapy. On the other hand, Task Force
members have also heard that the Guide-
lines are difficult to apply to specific
situations, particularly if therapists do not
work face-to-face with individual clients.
Clinicians have reported that the concept
of integrated occupational performance is
unclear and difficult to implement in set-
tings where the goals are less global. Many
occupational therapists are faced with
policies and procedures which support
attention only to performance components
such as muscle strength or self-esteem.
Other therapists face workloads of splint-
ing and provision of adaptive equipment
with little time to determine the place of
such technology in overall occupational
performance. By 1986, use of Guidelines
or the model of occupational performance
was only moderate. It takes time for new
ideas to influence everyday practice.
Therefore, studies are needed to formally
evaluate the current impact of the Guide-
lines before updating can proceed.
What Lies Ahead?
The Chairperson of four Task Forces,
Thelma Gill, summarized the history and
CJOT — Vo1.57 — No. 2
development of the Guidelines and the
COPM at the September, 1989 OT Atlan-
tic Conference in Prince Edward Island.
She highlighted the succession of Task
Force activities by declaring "Where do
they find the strength to go on?" Those
within CAOT hope that the energy will go
on. On October 1, 1989, CAOT created a
new national committee, the Client-
Centred Practice Committee, to oversee
and coordinate this energy. The Commit-
tee will extend the work of the Task Forces,
particularly in formulating a mechanism
for updating the Guidelines.
Updating the Guidelines is particularly
urgent. Since 1980, when the ideas for the
generic conceptual framework of occupa-
tional performance were first formulated,
occupational therapy understanding of and
ability to articulate client-centred occu-
pational therapy practice has rapidly
developed. As well, client-centred occu-
pational therapy practice and health serv-
ices are visibly changing. How might
therapists interpret the Guidelines for use
in a broadening range of institutional and
community practices? For instance, client-
centred occupational therapy practice it-
self requires clarification. Are therapists
in client-centred practice when they work
with clients through intermediaries, such
as homemakers, attendants, employers,
recreationists and others? Does client-
centred practice include therapists who
work with clients to develop self-help
programs, to advocate for social change
on behalf of disability groups, or to edu-
cate employers about the potential of
people with disabilities? Furthermore,
how can the Guidelines speak to the inter-
national concern for health promotion
documented in Achieving Health for All:
A Framework for Health Promotion
(DNHW, 1986) and Mental Health for
Canadians: Striking a Balance (DNHW,
1988)? What constraints as well as possi-
bilities exist for implementing practice
according to the Guidelines within every-
day work situations? How can therapists
resolve the contradictions produced be-
tween their medical orientation to illness
and dysfunction and a conceptual frame-
work of healthy occupational perform-
ance? What constraints and possibilities
exist for therapists, who are largely young,
middle class females, to work collabora-
tively with disabled people whose
75
CJOT — Vo1.57 — No. 2
struggles against poverty and discrimina-
tion therapists have rarely experienced?
What constraints and possibilities do
occupational therapists face in facilitat-
ing occupational performance in settings
where accountability is based on numbers
of people seen or restorative-oriented
change (rather than maintenance or pre-
vention)? The updated Guidelines may
not answer these and other questions, but
an updating process needs to take them
into account.
In the Guidelines, occupational thera-
pists have a tool for speaking about and
focusing action in their work. The Cana-
dian Association of Occupational Thera-
pists, the Department of National Health
and Welfare, and the Canadian Occupa-
tional Therapy Foundation have all con-
tributed to the development of these Guide-
lines. National and provincial organiza-
tions and educational programs have made
them part of practice. It is left to us to use
them as a philosophical statement, aguide
for implementing practice, and a base
from which to develop our theoretical and
practical future
REFERENCES
Department of National Health and Welfare.
(1986). Achieving health for all: A
framework for health promotion (H-39-
102/ 1986E). Ottawa, ON: Department of
National Health and Welfare.
Department of National Health and Welfare.
(1988). Mental health for Canadians:
Striking a balance (H-39-128/1988E).
Ottawa, ON: Department of National
Health and Welfare.
Department of National Health and Welfare
and Canadian Association of Occupa-
tional Therapists. (1983). Guidelines for
the client-centred practice of occnpa-
tiomal 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. (1986). Intervention
guidelines for the client-centred practice
of occupational therapy (H39-100/
1986E). Ottawa, ON: Department of
National Health and Welfare.
76 View publication stats
Department of National Health and Welfare
and Canadian Association of Occupa-
tional Therapists. (1987). Toward outcome
measures in occupational therapy (H39-
1 14/1987E). Ottawa, ON: Department of
National Health and Welfare.
Donabedian, A. (1966). Evaluating the
quality of medical care. Milbank Memo-
rial fund Quarterly, 44, 166-206.
ACKNOWLEDGEMENT
The article ends with a tribute to those
who have worked, some for over ten years,
to produce the Guidelines. The highest
recognition goes to Eve Kassirer who
guided our work on Volumes I, II and III
within the Department of National Health
and Welfare, and to Thelma Gill who
chaired the Task Forces, on behalf of the
Canadian Association of Occupational
Therapists, from beginning to end. After
the death of Eve Kassirer, we were fortu-
nate to gain a strong supporter in the new
Department representative, Serge Taillon.
He was a member of the Task Force for the
COPM and is currently coordinating the
Working Group on Occupational Therapy
Mental Health Services. Thank you to all
Task Force members.
Task Force, Volume I:
Eve Kassirer, Thelma Gill, Sharon
Brintnell, Susan Laughlin, Micheline
Marazzani, Barbara Quinn, Seanne Wilk-
ins, Elizabeth Townsend, Simon Ramesar
(Canadian Psychiatric Association), David
Skelton (Gerontologist), David Syming-
ton (corresponding member, Canadian
Medical Association)
Task Force, Volume II:
Eve Kassirer, Thelma Gill, Sharon
Brintnell, Anne Larson, Susan Laughlin,
Micheline Marazzani, Barbara Quinn,
Seanne Wilkins, Elizabeth Townsend,
Simon Ramesar (Canadian Psychiatric
Association), Joseph Marotta (Neurolo-
gist, Faculty of Medicine, University of
Toronto)
Task Force, Volume III:
Eve Kassirer, Thelma Gill, Sharon
Brintnell, Micheline Marazzani, Mary Ann
McColl, Anne Opzoomer, Elizabeth
Townsend, Nancy Staisey (occupational
therapist and researcher
Résumé
Les Lignes directrices relatives à la pra-
tique de l'ergothérapie axée sur le client,
sont un guide de portée générale issu d' un
consensus national. Elles ont été élaborées
pour faire le point sur les préoccupations
croissantes à l'intérieur et à l'extérieur
de la profession concernant la qualité des
services de santé. De 1979 à 1987, des
groupes de travail successifs, mis sur pied
par Santé et Bien-être social Canada et
par l'Association canadienne des er-
gothérapeutes, ont publié trois volumes
de lignes directrices. La base théorique
de l'ergothérapie constitue l'essence du
Volume 1; il porte donc sur le fonctionne-
ment occupationnel tenant compte de
l'environnement physique, culturel et
social du client. Ce premier volume décrit
aussi les étapes de la pratique de
l'ergothérapie axée sur le client de même
que l'évaluation et la planification du
programme de traitement. Le Volume 11
courre les question, les concepts et les
éléments fondamentaux de l' intervention
de même que les lignes spécifiques de
cette intervention, du congé, du suivi et de
l' évaluation des programmes de soins. Le
Volume 111 traite de la mesure des résul-
tats en ergothérapie suivant l'aspect priv-
ilégié par l'ergothérapie: la capacité
fonctionnelle. Les auteurs, membres des
divers groupes de travail, donnent une
vue générale du développement de ces
lignes directrices et de leurs espoirs les
concernant. L'usage et l'influence de ces
lignes directrices n'a pas encore été bien
étudié. Toutefois, des projets voient le
jour et l'ACE est à former en nouveau
comité qui proposera ur processus de
mise à jour de ces trois volumes.
April/avril 1990