Uniting practice and theory in an occupational framework. 1998 Eleanor Clarke Slagle Lecture

Holistic and biomedical concepts of health: a study of health notions among Swedish occupational therapists and a suggestion for developing an instrument for comparative studies

The objectives of this study were to inquire into notions of health among a group of 439 Swedish occupational therapists and to test a model derived from a qualitative study by Björklund & Svensson with a representative sample of occupational therapists in Sweden. The data were collected through a questionnaire and were analyzed using descriptive statistics, cluster analysis, and confirmatory factor analysis. The means and ranking of the health notions showed that Swedish occupational therapists most frequently hold holistic notions of health, and to a lesser extent biostatistical ones. Most Swedish occupational therapists indicate that being clearly conscious of one's health notions is important both to themselves and to their profession. The test of the model provides a step towards developing an instrument for measuring notions of health that clearly distinguishes between holistic and biomedical ones and that could possibly be used for comparative studies.

OCCUPATIONAL GAPS IN EVERYDAY LIFE 1–4 YEARS AFTER ACQUIRED BRAIN INJURY

OBJECTIVE

To explore adaptation, by examining the occupational gaps occurring between what individuals want to do and what they actually do in terms of their everyday activities before and after brain injury. In addition, the relationships between occupational gaps and impairment/activity limitations and the time lapse since the brain injury were explored.

DESIGN

A cross-sectional study.

SUBJECTS

A total of 187 persons, affected by traumatic brain injury or subarachnoid haemorrhage 1-4 years previously.

METHODS

A postal questionnaire encompassing questions concerning gaps in the performance of activities in everyday life before and after the brain injury and perceived impairment/activity limitations.

RESULTS

The numbers of occupational gaps increased after the injury, with the number of gaps having increased from 46% to 71%. The number of occupational gaps was significantly related to executive impairment/activity limitations, and motor impairment/activity limitations and other somatic impairments, such as headache, also had an impact. The time lapse since the brain injury had no significant effect on the number of occupational gaps.

CONCLUSION

The results suggests that there is a need for adaptation in everyday activities, even several years after a brain injury, which indicates that follow-up and access to individualized rehabilitation interventions in the long-term are required.

Reliability and validity of the Canadian Occupational Performance Measure for clients with psychiatric disorders in Taiwan

The purpose of the study was to examine the reliability and validity of the Canadian Occupational Performance Measure (COPM) in Taiwanese clients with psychiatric disorders. The COPM was translated into Mandarin and tested on 141 Taiwanese clients. The average age of the clients was 35.6 years; 94% were diagnosed with schizophrenia. The results of the study showed that the test retest reliability of the COPM was r = 0.842. The COPM identified occupational performance problems that included self-care (37%), productivity (25%), and leisure occupations (20%). Fifty percent of the therapists were receptive in adapting the client-centred approach and applying the COPM in their clinical practice. It was concluded that the COPM can be applied reliably to Taiwanese clients. Furthermore, the COPM was valuable in identifying information related to occupational performance that could not be identified elsewhere. Since 50% of the therapists felt reluctant about the appropriateness of the client-centred approach in their culture, it was important to examine the gap between clients' judgements and actual performance, as well as to evaluate the feasibility of the client-centred concept in clinical practice. Finally, the concept of the client-centred approach needs to be disseminated and communicated to the occupational therapy profession in order that the COPM can be adequately applied in mental health practice.

Effects of a hand training programme in five patients with myotonic dystrophy type 1

The aim of this study was to evaluate hand function and self-rated occupational performance before and after specific hand training in five participants with myotonic dystrophy (MD) type 1. MD is the commonest of the muscular dystrophies with adult onset and is associated with muscle weakness, wasting and myotonia. Compensatory techniques and strategies are mostly offered as the only intervention therapy. In the present study, the participants were their own controls using pre- and post-test measures. Each participant was tested at intervals a total of nine times before and nine times after hand training. A hand-held myometer (Microfet2), Grippit, Purdue Pegboard and self-rated myotonia were used as outcome measures. Occupational performance was assessed pre- and post-test using the Canadian Occupational Performance Measurement (COPM) in which the participants rated their own performance and satisfaction in five self-chosen occupational performance areas. The participants performed hand training for a total of three months, three times per week using a specific resistance training programme including Theraputty, a silicone-based putty. Hand function was significantly increased and a positive change in self-rated occupational performance was noted after the training period. This study indicates that hand training has a positive effect on hand function, i.e. motor function and occupational performance. The present results need to be replicated in a controlled study including a larger number of patients and over a longer period of time.

Cognitive training in home environment

PRIMARY OBJECTIVE

To examine the efficacy of cognitive rehabilitation in the patient's home or vocational environment.

RESEARCH DESIGN

Pre-post-follow-up design.

METHODS AND PROCEDURES

Ten outpatients with acquired attention and memory problems received cognitive training three times weekly, for 3 weeks. They received individual attention training with Attention Process Training, training for generalization for everyday activities and education in compensatory strategies for self-selected cognitive problems. Treatment effects were evaluated with neuropsychological and occupational therapy instruments before and after the training and after 3 months on impairment, activity and participation levels.

MAIN OUTCOMES AND RESULTS

The results indicated a positive effect on some measures on impairment level, but no differences on activity or participation levels at follow-up.

CONCLUSIONS

The study indicates that home-based cognitive training improves some attentional and memory functions and facilitates learning of strategies. Future controlled studies are needed to confirm the results and analyse the efficacy of different aspects of home-based training.

Reflecting on practice: are home visits prior to discharge worthwhile in geriatric inpatient care? Clients' and occupational therapists' perceptions

The discharge process of elderly clients from inpatient hospital care to their homes has lately received extensive attention but there is a lack of knowledge about the clients' problems as experienced in the home environment and their perceptions of corresponding home interventions prior to discharge. The aim of this clinical study therefore was to illuminate from both clients' and therapists' perspectives, common practice occupational therapy interventions at predischarge home visits in geriatric inpatient care. Home visits were carried out together with 23 clients before discharge during which their problems and the occupational therapy interventions at home were documented. After discharge, a follow-up home visit was carried out and the apprehensions of both parts regarding the interventions undertaken at the previous home visit were documented. In addition, a group interview was held with the nine therapists engaged in the study. The results exhibited a strong focus on physical disability, environmental issues and assistive devices. The clients were in general satisfied with the home visit interventions but their perceptions and responses to problems also differed from those of the therapists. When there was dissatisfaction, it resulted from serious delay in delivery of home modifications or devices, which posed a risk to their safety at home. For multiple reasons, both pre- and postdischarge home visits were found to be very important for the clients' safety.

Attitudes towards rehabilitation needs and support from assistive technology and the social environment among elderly people with disability

This study aimed to survey the attitudes of elderly people with disabilities who were living at home regarding their support from assistive technology and the social environment. These attitudes were compared with their identified needs by an occupational therapist and in relation to perception of social engagement, loneliness and overall contentment with life. From a sample of 102 participants who were interviewed using a standardized procedure, 53 persons were included in the study. The results indicated that attitudes among elderly people towards social and occupational engagement and change have a greater influence on their rehabilitation status than their disability as indicated by their health condition and limitations in activities of daily living and instrumental activities of daily living. The elderly people who accepted rehabilitation were more able, and were better equipped and better supported with assistive technology, than those who declined rehabilitation. Rehabilitation needs that the occupational therapists recognized were not always shared by the disabled elderly people, for several reasons; one reason of particular importance was the elderly person's attitude towards change and social engagement. However, the small sample size limits the generalization of the findings to the population of elderly people with disabilities. An ethnographic research design that allows for repeated interviews and observations of elderly people with disabilities for a prolonged period of time in their ordinary everyday lives may present an avenue for future research and lead to a deeper understanding of the issues.

Facilitating professional identify in occupational therapy students

The purpose of this study was to explore how a graduate course in occupational therapy theory can help prepare students to develop a professional identity. Thirty students participated in the study. The course included content on the history of occupational therapy, models of practice and the social, philosophical, political and economic factors that impact on occupational therapy. The students were divided into groups of four or five where they discussed issues assigned by the instructor. An electronic blackboard was used to share the discussion with the class. Surveys of the students' opinions were used to collect data on what the students viewed as the strengths and weaknesses of the course. The students felt that the class discussions were the strongest part of the course. They felt that the course improved their critical thinking and problem solving significantly. It was concluded from the results that the course facilitated their professional identity through the connection made between theory and practice. There is a recognized need to explore the issue of developing a professional identity in occupational therapy students through courses integrating philosophical topics and clinical practice. Specifically, it is recommended that further research be carried out in educational settings with larger samples, using comparison groups and other methodologies to evaluate the issue of facilitating professional identity in occupational therapy students.

The meaning of life experiences: application of a meta-model to rehabilitation sciences and services

A motivational, developmental meta-model of the meaning of everyday life experiences is presented. The model proposes that there are 3 fundamental ways in which people establish meaning across the life span: the paths of belonging (relationships), doing (meaningful engagement in activities), and understanding oneself and the world. The principles of the model include intertwined, fundamental meanings of human experience; the indeterminacy of cause and effect; individual differences in preferences for ways of attaining meaning; the importance of commitments in life; and life-long adaptation and changes in meaning. The model provides an organizing framework that clarifies the assumptions of various disciplinary frames of reference with respect to establishing meaning in everyday life. Implications of the model are discussed for the rehabilitation sciences and rehabilitation service delivery.

Validity of a performance assessment of activities of daily living for people with developmental disabilities

BACKGROUND

Since clients with different types of developmental disabilities often experience difficulties in activities of daily living (ADL), it is critical that assessments of ADL are evaluated in order to ensure that one can make valid judgements based on the results of the appraisal. The purpose of the present study was to evaluate the validity of a specific performance assessment instrument, the Assessment of Motor and Process Skills (AMPS), when used by occupational therapists with clients with developmental disabilities. Unlike global ADL assessments, the AMPS is used not only to evaluate the level of ADL dependence, but also to estimate the quality of each specific action performed when a person is performing ADL tasks.

METHODS

Data were gathered from 1724 participants with different developmental disabilities, including intellectual disability (ID), cerebral palsy and spina bifida. Many-Facet Rasch (MFR) analysis was used to examine person-response validity, and task and item scale validity.

RESULTS

Goodness-of-fit statistics showed that the tasks and items had acceptable scale validity. The participants had acceptable person-response validity on the ADL motor scale, but had slightly lower than expected levels of person-response validity on the ADL process scale. The results indicate that clients with more severe forms of ID may have a higher proportion of different performance profiles in ADL than is expected by the MFR model of the AMPS. Since the proportion of participants who did not meet the criteria was only 3% lower than expected and in accordance with other studies, the difference may not be clinically meaningful. Otherwise, the results indicated that the AMPS is a valid tool when used with clients with developmental disabilities.

CONCLUSIONS

Further research is needed to evaluate the use of the AMPS in clinical assessment and intervention planning for this group of clients.

Therapeutic strategies used by occupational therapists in self-care training: a qualitative study

Self-care training is one of the most frequently used interventions in rehabilitation. However, there is a need for clear descriptions of what occupational therapists do during self-care training with clients. The aim of this qualitative study was to describe what characterizes the therapeutic strategies used by occupational therapists during self-care training. Twelve occupational therapists working with clients who had had a stroke (n = 6) or spinal cord injury (n = 6) were interviewed and asked to tell a therapeutic story focusing on the self-care training process of one client. Data were transcribed and analysed using the Empirical, Phenomenological, Psychological (EPP) method, a qualitative method that aims to describe the essence, structure and character of the studied phenomenon (that is, therapeutic strategies). The characteristics of eight intervention strategies, used by all participants during self-care training, were identified. Findings showed that the occupational therapists' strategies focused primarily on how to create a relationship built on trust with their clients, how to find the right way to motivate clients, how to support the setting of goals, and how to provide enabling occupational experience and adjust training to the needs of the client, rather than focusing on teaching clients how to use technical and compensatory strategies. The general aim for using the strategies was to support the clients in taking control of their lives again. One conclusion from this study is that occupational therapists could, through understanding the individual's unique situation, vary their strategies and adapt themselves, like a chameleon, to meeting clients' experiences and needs during self-care training. However, the therapeutic outcome of using these strategies needs to be verified in future studies focusing on clients' experiences from self-care training.

Occupation reconsidered

The current article delineates the need for the profession of occupational therapy to maintain relevance and be responsive to current trends. As part of such responsivity, this article proposes a reconsideration of the concept of occupation as an 'adaptive response' to the current societal need for clarification regarding occupational therapy. Reconsideration of what is meant by occupation for general use is discussed and illustrated by the ambiguous use of the term occupation as both a means and an end. Although occupational therapists are comfortable with such ambiguous use because of their apparent ease with complexity, use of the term in an ambiguous manner makes it harder for society to understand what is meant by occupation. Related to this, an annotation of literature on the definitions of occupation is presented in summary form. Furthermore, the political need to reconsider the term occupation is argued in light of the revision of International Classification of Functioning, Disability and Health (ICF), which includes the use of the word activity. Finally, this article proposes that occupation should be considered as the process of doing with meaning, and that activity should be the outcome. Such reconsideration renders us consistent with ICF and paves the way to reduce ambiguity in the use of the term occupation with the general public.

On occupational performance

Occupational therapists use many complex and dynamic techniques and approaches in their interventions. The notion of occupational performance is emerging within our profession as one such approach that is unique to occupational therapy and that has great promise for our clients. The thesis of this article is that for occupational performance to be therapeutic, it must meet certain necessary conditions. In this article the author offers a definition of occupational performance, explores the three conditions of occupational performance, and explores the application of occupational performance in therapy.

The meaning and form of occupational therapy as experienced by women with psychoses. A phenomenological study

The meaning and form of occupational therapy as experienced by women with psychoses: a phenomenological study The aim of this study was to illuminate the experiences of occupational therapy interventions in individuals with psychoses. Repeated tape-recorded narrative interviews were conducted with six women participating in occupational therapy immediately after an intervention. The subsequent analyses followed a phenomenological approach. Key constituents integrated in two structures, are the main findings. The meaning of occupational therapy as expressed in the key constituents relief, self-knowledge, belief in the future, capability, resistance and satisfaction formed one structure. The form of occupational therapy as expressed in the key constituents time, environment, guidance, voluntariness and collaboration represented the other structure. These findings confirm and give empirical support to beliefs and assumptions expressed in occupational therapy literature. The results form a conceptual base for developing an evaluative assessment instrument for individuals with psychoses participating in occupational therapy.

Psychiatric occupational therapists' verbal interaction with their clients

This study reports from a survey investigating psychiatric occupational therapists' (n=292) use of verbal interaction on a regular basis with their clients. Among predefined areas of verbal interaction, routine occupations, self-image and ego-strengthening interventions were among the most frequently given alternatives. Verbal interaction with clients was more common among occupational therapists in outpatient care than among those in inpatient care. Verbal interaction with clients was also more common among occupational therapists with advanced education in psychodynamically oriented psychotherapy. The respondents' use of theoretical frames of reference was related to the focus of their verbal interaction with clients. Interventions to reach certain goals emerged as the most common category of verbal interactions. It was concluded that verbal interaction with clients is essential to the occupational therapy process. Future research needs to investigate the interplay between verbal and non-verbal components of interaction in occupational therapy and how patients benefit from these elements.

Annotated bibliography of chaos for occupational therapy

Given the level of complexity at which the practice of occupational therapy operates, chaos may be the key to fresh insight into the nature of occupation. This article, through an innovative scholarly format-the annotation-presents essential concepts of chaos theory which are relevant for occupational therapy. A rationale for the importance of chaos theory and complexity science is presented and the limited extent to which chaos theory has been addressed in the occupational therapy literature is identified. Occupational therapy links to chaos and complexity are delineated and explained based upon a review of fourteen articles appearing in peer reviewed journals over a five year period (1993-1998), which are presented in three categories: (a) interdisciplinary applications, (b) mental health and creativity applications, and (c) educational and research applications. Conclusions about the relevance of chaos theory to occupational therapy are presented in the last section of the paper.