OCT 1141H : Assessment in Occupational Therapy

September 21: Law, M. (2000). Identifying occupational performance issues. In V. Fearing & J. Clarke (2001). Individuals in context: A practical guide to client-centred practice. (Chapter 3). Thorofare, N.J.: Slack.

 First step of Occupational Performance Process Model (OPPM) = identifying occupational performance issues (OPI’s)

Listening to the Client’s Story

(refer to Table 3-1, p. 32 for illustration of Different Approaches for Initial Assessment Process)

  • Therapists generally agree that identification of OPI’s is very impt in the initial stages of OT intervention  but less agreement about skills required to do this and the most appropriate methods to use  an effective process to identify OPIs requires considerable skill to ensure that rapport is built and that the therapist truly listens to the client’s story

How do I hear the person’s story?

(refer to p. 33 for examples of questions to think about when hearing a person’s story)

  • Most important act therapist can do is listen and hear client’s story
  • Client is the expert of their lives; they have knowledge about occupations that are important to them and those with which they are having difficulty  on other hand, OTs know how to identify factors affecting occupational performance and ways to help client resolve these issues
  • Be careful avoid professional jargon  distances client and discourages open talk
  • Use open-ended interview questions
  • Monitor person’s reactions during interview to ensure person understands what is being discussed and is feeling comfortable

What skills do I need as a Therapist?

  • Client-centered practice  emphasizes equality, sharing, partnership  shift from traditional way of practice
  • OTs more frequently providing services to non-health care groups and organizations these clients have more power and freedom to make choices that fit their lives/situations
  • The therapeutic process involves a sharing of control and power
  • Therapist must be comfortable in engaging in discussion about meaning of occupation and ways in which OT can help in resolving OPIs
  • Clients need support to become confident in developing such a partnership with an OT
  • Skills of interaction, negotiation, facilitation of problem-solving are necessary for successful client-centered encounter

Why is the client the expert?

  • Recognizing client’s expertise in defining issues for therapy intervention:
  • Increases his/her motivation to engage in therapy process
  • Promotes skills for living

How do I learn about a person’s Occupational History?

  • The interview must focus on performance of occupations, not on the components of occupation (ie. on how the hand-injury affects everyday occupations in self-care, work, leisure; rather than ROM and strength issues with the injury).

Why is it important to prioritize OPIs?

  • Only the client and family can identify the most impt OPIs for them  after that, OT works together with client to assess why occupation performance difficulties are occurring and to intervene to increase performance.

Identification of OPIs – A Screening process?

  • Screening involves identification and prioritization of OPIs
  • When using theoretical approach centered on persons doing occupations within their environment, this focuses on whether person/group is having difficulty in performing occupations of their choice  necessary and efficient way to ensure OT services are provided to those who require them
  • The following questions can be used by OTs to guide their practice in order to ensure that screening for OPIs is evidence-based and does more good than harm:
  1. have any studies been completed comparing occupational performance and health outcomes for persons who participated in an occupational identification and goal setting process?
  2. is the OPI of sufficient importance to be identified and receive intervention?
  3. is a screening done consistently and with everyone seeking occupational therapy services?
  4. if the screening identifies OPIs, is further assessment and intervention available?
  5. if OPIs are identified, can your program offer intervention that is known to be effective?

Why identify OPIs?

  • Highlights importance of taking time to get to know clients and ensuring that OT services are required in each situation  given health care restraints, services should be provided to those for whom intervention can make a difference.
  • Implementation of client-centered practice  time is one of most significant barriers
  • One of great advantages of occupational performance identification process is that it saves time  majority of clients or families able identify OPIs; only those clients who identify OPIs that need intervention are seen for further assessment and this saves time

Methods to Identify OPIs

  • Both qualitative and quantitative assessment methods have been identified as appropriate for use by OTs to screen for OPIs
  • Qualitative: informal interviews most often used method
  • interviews can be effective but only if done in way that provides structure and guidance to client in identifying OPIs
  • some examples of more structured approaches include: metaphor, narrative methods, life histories
  • this approach most appropriate to use with persons who are able to clearly articulate the meaning of occupation in their daily lives
  • For more guided or structured approaches to identification of OPIs, following measures are suggested:
  • COPM (Canadian Occupational Performance Measure): focuses on gathering narrative info from clients about occupations they perform that cause them difficulty  administered using semi-structured interview conducted by therapist together with client  scoring of COPM using 1-10 scale considers importance to client of occupational performance areas and client’s current performance and satisfaction with that performance
  • OPHI-II (Occupational Performance History Interview) : focuses on areas of organization of daily routines, life roles, interests, values and goals, perceptions of ability and responsibility, and environmental influences designed for use with adolescents, adults, elderly
  • OSA (Occupational Self Assessment): self-report assessment completed by client in which client rates how well they function on each item, and then rate importance area of functioning or environmental influence for each item  but b/c OSA includes a set list of items may be limited in ability to provide individualized info about client

When is the best time to identify OPIs?

  • Best if done as an initial assessment:
  • learning about client’s issues from his/her perspective right from the beginning shows client that process will be a working partnership
  • also helps therapist focus further assessment and intervention on components contributing to OPIs rather than just a general assessment approach

How do I identify OPIs for groups and organizations?

  • Impt to know whether perspective you receive is that of group or only a few individuals
  • Can interview persons individually and summarize results
  • If organization is the client, can do this process with a person or persons representing the organization

What if I do not have time to screen for OPIs?

  • Perception that time required to engage client in identification of OPIs and to hear client’s story is more than most OTs have available
  • But identification of individualized and prioritized OPIs assessment of performance leads to a streamlined occupational therapy assessment and intervention process(ie. ensures only assessing and intervening on relevant issues)

What if the person cannot or does not identify any OPIs?

  • If this happens, important to know whether due to lack of understanding of the process or b/c there are no issues for which OT intervention is required  sometimes client may not identify OPIs but issues are apparent to therapist; important to consider whether these differences in opinion reflect differences in values or issues of the client’s competency

How do I identify OPIs in practice situations that are short lived?

  • In such situations the methods that have been described to identify OPIs can be used but must be done in a more focused manner (ie. center the interview on OPIs that affect person immediately)

What if a person does not identify something that I believe is important or I don’t agree with what he or she has identified?

  • Impt to discover if these differences are based on different perceptions of person’s occupations, differences in values, or if person unable identify these things b/c lack of insight or cognitive impairment  but never make assumptions about person’s level of insight
  • If issue that therapist identified is issue of safety or risk, it is responsibility of therapist as professional to discuss that issue with the client and/or caregivers and to take steps to ensure issues is addressed

Does this identification process work with people from all cultures?

  • Must remember concepts underlying a client-centered practice were developed largely in North America b/c of this implicit assumptions built into these models that are reflective of culture
  • Identification of OPIs should be able to accommodate differences in values
  • Choice of which assessment tool to use in identification of OPIs may also be affected by culture ie. numerical rating scales – the idea of using numbers to rate items may be foreign in many cultures