Occupational Performance Measures: Â Review Based on the Guidelines for the Client-centred Practice of Occupational Therapy

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C J O T — V o 1 . 57 — N o. 2

Occupational Performance M easures:Â Review Based on the Guidelines

for the C lient-centred Practice ofOccupational Therapy

Nancy Pollock, Sue Baptiste, Mary Law,

Mary Ann McColl, Anne Opzoomer, Helene Polatajko

Key Words:• Assessment process,

occupational therapy

• Outcome and process

assessment

Nancy Pollock, M.Sc., O.T. (C) is Re-

search Clinician, Occupational Therapy,

Chedoke-McMaster Hospitals, 1 20 0 MainStreet West, Hamilton, Ontario, L8N 3Z5

Sue Baptiste, M.H.Sc., O.T. (C) is Direc-

tor, Occupational Therapy, Chedoke-

McMaster Hospitals.

Mary Law, M.Sc., O.T. (C) is Assistant

Professor, Departments of Medicine and

Clinical Epidemiology and Biostatistics,

McMaster University and Research

Manager, Occupational Therapy, Che

M a s t

Mary Ann McColl, M.H.Sc., O.T. (C) is

Assistant Professor, Department of Reha-

bilitation M edicine , University of Toronto

and Director of Research, Lyndhurst

Hospital, Toronto.

Anne O pzoomer, M .Sc., O.T. (C) is Assis-

tant Professor, Occupational Therapy

Program, University of Ottawa.

Helene Polatajko, Ph.D., O.T. (C) is As-

sociate Professor, Departments of Occu-

pational Therapy and Education, Univer-

sity of Western Ontario.

ABSTRACT

In 1987, Health and Welfare Canada

and the Canadian Association of

Occupational Therapists Task Force

recommended that work go forward to

develop an outcome measure for

occupational therapy which reflects the

Occupational Performance Model. The

first step in this process was to review

critically those outcome measures

which assess occupational performance

and that are currently available in theliterature.

This paper will present the review

process, describe in more detail eight

assessments that fulfilled many of the

review criteria, discuss the limitations

of these measures using the "Guidelines

for the Client-centred Practice of

Occupational Therapy as the

framework, and make recommendations

for the development of a new outcome

measure for use in occupational

therapy.

The Canadian Occupational Therapy Foun-

dation was pleased to provide a research grant

to assist the authors with their work.

In 1983, Health and Welfare Canadaand the Canadian Association of Occupa-

tional Therapists Task Force published

the "Guidelines for Client-Centred Prac-

tice of Occupational Therapy" (Depart-

ment of National Health and Welfare &

Canadian Association of Occupational

Therapists, 1983) describing a conceptual

framework for the practice of occupa-

tional therapy in Canada. This frame-

work, the Occupational Performance

Model "...views an individual's occupa-

tional performance as having three areas:self-care, productivity and leisure, predi-

cated on the interaction of the individual's

mental, physical, sociocultural and spiri-

tual performance components" (p. 8).

In 1987, the Task Force out l ined the im-

portance of outcome measures in advanc-

ing our profession. Well developed as-

sessments can assist in demonstrating the

effectiveness of our programs, improving

the quality of patient care, and clarifying

our role (Department of National Health

and Welfare & Canadian Association ofOccupational Therapists, 1987). The Task

Force used the Occupational Perform-

ance Model as a basis to investigate avail-

able outcome measures in occupational

therapy. The task force se t out a number of

criteria which the outcome measure(s)

should meet. Specifically the measure

s h o u ld :

a) be based on the occupational per-

formance model.

b) focus on performance in self-care,

productivity and leisure as the pri-

mary outcome.

CANADIAN

OCCUPATIONAL

THERAPY

FOUNDATION

April/avril 1990 7



c) consider performance components

(physical, mental, sociocultural and

spiritual) as secondary outcomes,

measured only for their contribu-

tion to occupational performance.

d ) consider the client's environment,

developmental stage, life roles and

motivation.

e) be sensitive to clinical change rele-

vant to occupational therapy goals

including development, restoration

and maintenance of function, and

prevention of disability.

0 not be diagnosis specific.

g) be modular for use in whole or in

part.

h ) incorporate measurement proper-

t ies of reliability, respon siveness and

validity.

i) be usable in terms of format, ad-

ministration, time, ease of scoring

and client acceptability.

be scorable.j)

CJOT — Vo1.57 — No. 2

Name of Instrument:

Author:

Description/Intent:Self-Care:es no

Productivity:es no

Leisure:es no

Environment:es no

Roles:es no

Importance to client:es no

Assesses ability

or performance:

Purpose:

Developmental Stage:Target Population:

Culture:

Setting:

Informant:

Structured:

Method:

Scale:

Score Types A vailable:

The National Health Research and De-velopment Program of Health and Wel-

Source:

If yes, how?

If yes, how?

If yes, how?

fare Canada and the Canadian Occupa-

tional Therapy Foundation subsequently

funded a project to continue this process

and develop an outcome measure for oc-

cupational therapy.

The first stage of this research project

was to update the review done by the T ask

Force of current measures of occupational

performance to determine if a suitable

measure or measures existed. This paper

will describe the review process, high-

light some of the occupational perform-

ance measures currently available and

assess their correspondence with the

Occupational Performance Model.

Review Process

The first step in the review process was

to generate a list of assessments covering

all developmental levels and client types

currently available to occupational thera-

pists. Literature searches and input from

therapists and academic faculty were used

to develop this initial list. These instru-ments were reviewed by the Task Force

and the research group, and the areas(s) of

occupational performance assessed and/

or the performance components assessed

were indicated. The assessments that

measured only performance components

(physical, mental, sociocultural or spiri-

tual) were excluded from the rest of the

review process. A total of 136 assess-

ments were identified and 82 of those

were excluded as they assessed only per-

formance components.

The second step in the process was to

design evaluation criteria to be used in

reviewing the remaining 54 measures.

Based on the criteria set out in the Task

Force report, a form for evaluation was

developed (Table 1). A database was

designed from this evaluation form and

the information entered for subsequent

analysis.

Of the 54 instruments reviewed, 13

were not accessible through the literature

because they are unpublished or "home

grown" assessments, therefore only 41

could be evaluated. Of these, eight met

mo st of the review criteria and were closely

aligned with the Occupational Perform-

ance Model. Several of these measures

have not been standardized or formally

tes ted , but were inc luded because the focus

of this review was on content and philoso-

phy, no t on psychom etr ic propert ies . Table

2 summarizes the results of the review.

The Sickness Impact Pro fi le

The Sickness Impact Profile (SIP)

(Gilson et al., 1975) is an interviewer

administered global measure of health

status. It is concerned with the impact that

sickness has on everyday activities and

behaviours. The measure consists of 235

statements grouped into 14 categories that

describe a situation (eg., I am going outless to visit people). The client checks

only those items that she feels describe

her behaviour. Scoring is based on a

weighting system developed through in-

terval scaling procedures (Bergner, Bob-

bitt, Carter & Gilson, 1981). A percentage

score can be calculated for the entire SIP

as well as for each category.

The SIP is an individualized measure

within which the client checks only those

items that apply to her situation, although

those ra t ings a re judged externa l ly througha weighting system, not based on the

Table 1

O.T. Outcome Study E valuation Form

Discriminativeredictivevaluative

Child

dolescence

dult

ater Years

Selfherapistther

yes no

Self-Reportbservation

Nominalrdinalnterval

April/avril 19908



CJOT — Vo1.57 — No. 2

Table 2

Summary of the Review Measures

Performance Areas

Assessed

Considerations Developmental

Stage

SC = self-care R = roles C child

P productivity I importance Y youth

L leisure to client MY = mature years

E = environment A adult

Measure

1. Occupational Pe rformance History Interview SC , P,L R, I, E Y,A,MY

(Kielhofner & Henry, 1988)

2. Functional Status Questionnaire SC, P, L A

(Jette et al., 1986)

3. Sickness Imp act Profile SC, P, L R A, MY

(Gilson et al., 1986)4. Reintegration to Normal Living Index SC, P, L R, I, E A, MY

(Wood-Da uphinee et al., 1988)

5. Satisfaction w ith Performance

Scaled Questionnaire P, L I Y, A

(Yerxa et al., 1988)

6. National Institutes of Health Activity Record SC, P, L I A, MY

(NIH, 1985)

7. MACT AR Patient Preference

Disability Questionnaire SC, P, L I A

(Tugwell et al., 1987)

8. Activity Pattern Ind icators SC , P,L E Y, A, MY

(Diller et al., 1983 )

client 's own situation. Occupational per-

formance is con sidered, but in a general

fashion along with many other health status

indicators . The outcom es measured arenot based specif ic to o ccupational ther-

apy.

Activity Pattern Indicators

Reh abilitation Indicators (Diller et al.,1983) are a series of three functional as-

sessment instruments. Th e S kill Indica-tors measure what a cl ient "can do". The

Status Indicators and the Activity PatternIndicators measure what the client "does

do". T he three instrum ents can be usedseparately or together. The Activity Pat-

tern Indicators (AP I) are mo st closelyaligned to the Occupational Performance

mo del. The AP I is a highly detailed log of

daily activities. The client docum ents the

frequency and duration o f her involve-ment in social, recreational, household,

childcare, rehabilitation, business, educa-

tional and perso nal care activities for the

previous week. The API also records the

location, level of assistance required, and

the level of social interaction involved in

the a ctivity.

The A PI covers a broad spec trum o factivities and provides a detailed descrip-

tion of an individual's daily patterns,

however the level of detail makes it im-practical for clinical use. It does not give

any indication of the activities most af-fected by the client's disability or those

that are most impo rtant to the client. The

information wou ld have limited value inestablishing treatment priorities or in m oni-

toring change in the individual.

The Activity Record

The National Institutes of H ealth Activ-

i ty R ecord (AC TRE ) (Kielhofner , 1985,p.472) is a daily activity log kept by the

client.

Activities for each 1/2 hour periodduring the day are recorded and a series of

questions asked about each activity. The

cl ient is asked to rate , on a fou r-pointscale, pain and fatigue while doing thatactivity, her competence, the perceived

difficulty of the a ctivity, meaningfulness,

and enjoyment in doing the activity. Ac-

tivities can be classified as leisure, self-care, transpo rtation etc., and the balanceof activities in the client's daily routineare examined. As the scores are not cumu-

lative over the entire test, there is no total

score.

The ACTRE provides a comprehensive

look at ho w the client is spending her time

and also her performance level and senseof sa t i sfact ion wi th her perform ance.Although the individual records provide

useful information to the client and thera-

pist, the lack of a total score limits theuseof the ACT RE as an outcome m easure.

April/avril 1990 9



CJOT — Vo1.57 — No. 2

Th e Functional Status

Questionnaire

The Functional Status Questionnaire

(FSQ) (Jette et al., 1986) is a self-admini-

stered scale which looks at physical, psy-

chological and social or role functions. Aseries of questions determine levels of

function in activities of daily living, work,

social activities and the client's own view

of his health status. The scoring system is

computerized and provides a profile for

each client highlighting "warning zones"

based on his score. These warning zones

were developed by a consensus panel of

experts and indicate areas of possible

concern.

The FSQ considers work and social

functions, in addition to daily living ac-tivities and so provides a comprehensive

assessment. It is also based on what the

client is actually doing, providing a real-

istic functional picture. Unfortunately, the

warning zones have been determined for

all clients and thus the measure is not

individualized. It does not consider the

import ance of these activities, roles or

functions to the individual client within

his own environment.

The MAC TAR Pat ientPreference Disability

Questionnaire

The MACTAR Patient Preference Dis-

ability Questionnaire (Tu gwell et al ., 1987)

is designed specifically for clients with

arthritis. The client is asked if her arthritis

limits her ability to accomplish activities,

and then to priorize which of these activi-

ties she would most want to perform with-

out pain or discomfort. This information

is used in the reassessment to monitor

change. In the reassessment, the client is

asked if there has been any change in her

ability to do the activities that she had

previously listed.

The MACTAR allows the client to set

her own priorities and reflects her own

interests, roles and environment. In this

way the authors hope that the MACTAR

will be more sensitive to small, but impor-

tant changes that occur. At present the

scale does not use a weighting system so

that the activity identified as the highest

priority carries the same weight in the

score as the lower priority items. This

may limit the scale's responsiveness to

change.

The O ccupational Performance

History Interview

The Occupational Performance History

Interview (OPHI) (Kielhofner & Henry,

1988) is a structured interview designed

to gain information about a client's work,

p la y a n d s e l f- c a re p e r f o rma n c e . T h e O PH I

is based on the Occupational Role History

(Florey & Michelman,1982; Moorehead,

1969). The OPHI consists of 39 questions

covering past and present behaviours in

the following content areas: organization

of daily life routines; life roles; interests,values and goals; perception of ability and

responsibility; and environmental influ-

ences. Each content area is rated by the

therapist on a five-point scale ranging

from totally adaptive to totally maladap-

tive.

Although the OPHI considers the

client's life roles and his environment, the

therapist is required to make a judgement

about the client's level of function, so the

measure is not truly client-centred. The

rating scale requires considerable thera-pist judgement in converting interview

data to scores and this leads to difficulties

with reliability. Keilhofner and Henry

(1988) report low levels of reliability

between raters.

The Reintegration to Normal

Living Index

Another assessment of global function

status is the Reintegration to Normal

Living Index (RNL) (Wood-Dauphinee,

Op zoomer, W il liams , Marchand & Spi tzer ,

1988). The RNL was designed primarily

to evaluate change in individuals or groups.

Clients rate 11 statements on a visual

analog sca le with the ancho r phrases "does

not describe my situation" and "fully

describes my situation". Through a con-

tent validation process, the authors deter-

mined that indoor, distant and community

mobility, self-care, daily activity, recrea-

tional and social activities, coping skills,

family roles, personal relationships, and

presentation of self to others were most

closely related to reintegration to normal

living. The statements in the RNL reflect

those domains.

The RNL is very much a client-centred

assessment, measuring client perceptions

of her individual situation. It addresses all

areas of occupational performance, roles

and ro le expectations, as well as the client 's

sense of satisfaction. This measure comes

closest to meeting the criteria outlined by

the Task Force. It is limited because it is

global and so, does not lead to the devel-

opment of specific occupational therapy

goals, and it may not be applicable to all

client groups. The focus is on clients who

have recently had an incapacitating ill-

ness or trauma, so it may not be as useful

for those with congenital or chronic con-

ditions. As well, the RNL assumes a level

of insight in the client which would not be

present in young children, those with

dementia and some mental health clients.

The Satisfaction with

Performance Scaled

Questionnaire

Yerxa, Bu rn ett-Beaulieu, Stocking and

Azen (1988) developed the Satisfaction

with Performance Scaled Questionnaire(SPSQ). This assessment is based on the

client's perception of her level of satisfac-

tion with her performance in home man-

agement and social/community problem

solving. Twenty-four home management

tasks (eg., disposing of garbage) and 22

social/community tasks (eg., going on an

inte rv iew) are rated by the client on a five-

point scale. The ratings indicate the per-

centage of time in the past six months that

the client has been satisfied with her per-

formance of the specified activities.

The S PSQ is another example of a c l ien t -

centred measure and places most of its

emphasis on client satisfaction. It is not,

however individualized to reflect the

client's roles or environment. The fixed

list of activities may not be important to

individual clients. As well, the items are

equally weighted in the total score, but

seem to be at very different levels of

complexity, eg., find and use social activi-

ties vs. clean vegetables. Given this ine-

quality, the total satisfaction score may be

misleading.

80 pril/avril 1990



C J O T — V o 1 .5 7 — No. 2

S U M M A R Y

This review shows that the majority of

assessments available to measure out-com es in occupa t ional therapy are s t i ll

directed at perform ance com ponents . Of

those that measure actual occup at ional

performance, the majori ty are self-careassessments and very few consider roles

and/or the client 's environment.

The eight assessments reviewed in more

detail provide examples of client-centred

measures, content areas reflective of the

Occupat iona l Performance Model and a

variety of scoring and scal ing method s.

Each o f the assessmen ts , however , has

shortcom ings that prevent them from ful-

fi ll ing al l of the cri teria for an occ upa-

t ional therapy outcome measure.

There remains a need in occupat ionaltherapy for a val id and rel iable o utcome

measure that assesses the total sphere of

occupat ional perfo rman ce fo r the indi -

vidual client and within her environment.

For this reason, a new measure, the Cana-

dian Occupational Performance Measure

(Law et al., 1990) has been designed,

incorporat ing many of the posi t ive fea-

tures of the assessments reviewed and

based on the client-centred practice of

occupational therapy.

REFERENCES

Bergner, M., Bobbitt, R. A., Carter, W. B.,

& Gilson, B. S. (1981). The Sickness

Impact Profile: Development and final

revision of a health status measure. Medi-

cal Care, 19, 787-805.

Department of National Health and Welfare

and Canadian Association of Occupa-

tional Therapists. (1983). Guidelines for

the client-centred practice of occupa-

tional therapy (H39-33/1983E). Ottawa,ON: Department of National Health and

Welfare.

Department of National Health and Welfare

and Canadian Association of Occupa-

tional Therapists. (1987). Toward outcome

measures in occupational therapy (H39-

114/1987E). Ottawa, ON: Department of

National Health and Welfare.

Diller, L., Fordyce, W., Jacobs, D., Brown,

M., Gordon, W., Simmens, S., Orazem, J.,

& Barrett, L. (1983). Final report,

Rehabilitation Indicators Project. NIHR,

U. S. Department of Education, Grant

G008003039.

Gilson, B. S., Gilson, J. S., Bergner, M.

Bobbitt, R. A., Kressel, S., Pollard, W. E.,

& Vesselagô, M. (1975). The Sickness

Impact Profile: Development of an out-

come measure of health care. American

Journal of Public Health, 65, 1304-1310.

Florey, L. L., & Michelman, S. M. (1982).

Occupational role history: A screening

tool for psychiatric occupational therapy.

American Journal of Occupational

Therapy, 36, 301-308.

Jette, A. M., Davies, A. R., Cleary, P. D.,

Calkins, D. R., Rubinstein, L. V., Fink,

A., Kosecoff, J., Young, R. T., Brook, R.

H., & Delbanco, T. L. (1986). The Func-

tional Status Questionnaire: Reliability

and validity when used in primary care.

Journal of General Internai Medicine, 1,

1 43 - 1 49 .

Kielhofner, G. (Ed.). (1985). A model of

human occupation: Applications of a

conceptual approach to occupational

therapy. Baltimore: Williams & Wilkins.

Kielhofner, G., & Henry, A. D. (1988).

Development and investigation of the

occupational performance history inter-

view. American Journal of Occupational

Therapy, 42, 489-498.

Law, M., Baptiste, B., McColl, M.A.,

Opzoomer, A., Polatajko, H., & Pollock,

N. (1990). The Canadian Occupational

Performance Measure: An outcome meas-

urement protocol for occupational

therapy. Canadian Journal of Occupa-

tional Therapy, 57, 82-87.Moorehead, L. C. (1969). The occupational

history. American Journal of Occupa-

tional Therapy, 23, 329-334.

Reed, K. & Sanderson, S.R. (1980).

Concepts in Occupational Therapy. Balti-

more: Williams and Wilkins.

Tugwell, P., Bombardier, C., Buchanan, W.

W., Goldsmith, C. H., Grace, E., &

Hanna, B. (1987). The MACTAR Patient

Preference Disability Questionnaire: An

individualized functional priority ap-

proach for assessing improvement in

physical disability in clinical trials inrheumatoid arthritis. Journal of Rheuma-

tology, 14, 446-451.

Wood-Dauphinee, S. L., Opzoomer, A.,

Williams, J. I., Marchand, B., & Spitzer,

W. O. (1988). Assessment of global func-

tion: he Reintegration to Normal Living

Index. Archives of Physical Medicine and

Rehabilitation, 69, 583-590.

Yerxa, E. J., Burnett-Beaulieu, S., Stocking,

S., & Azen, S. P. (1988). Development of

the Satisfaction with Performance Scaled

Questionnaire. American Journal of

Occupational Therapy, 42, 215-221

ACKNOWLEDGEMENTS

Th e authors wish to acknowledge the

following individuals who have provided

valuable advice and assistance during the

d ev e lo p m en t o f the Canadian Occupa-tional Performance Measure: Sharon

Brintnell, Thelma Gill, Sue Laughlin,Micheline Marrazani, Barbara Quinn,

Nancy Staisey, Serge Ta i l lon, E l izabeth

To wnsend, and Elizabeth Yerxa.

This research was funded by grants

f rom The Nat iona l H eal th R esearch and

Development Program of Health and

Welfare Canada and The Canadian Occu-

pat ional Therapy Foundat ion. Mary Law

holds a C areer Scient is t Award from the

Ontario Ministry of Health.

Résumé

En 1987, un groupe de travail formé par

Santé et Bien-être social Canada et par

l'ACE recommandait d'aller de l'avant

pour - mettre au point une mesure des résu l-

tats en ergothérapie compatible avec le

modèle axé sur la capacité fonctionnelle.

La première étape de ce processus a été de

faire une revue critique des instruments

de mesure des résultats qui évaluent la

capacité fonctionnelle et dont fait état la

littérature actuelle.

Cette étude présente le processus de

révision, décrit en détail huit évaluations

qui répondent à plusieurs des critères de

révision et discute des limites de ces in-

struments de mesure dans le cadre les

Lignes directrices relatives à la pratique

de l' ergothérapie axée sur le client; enfin,

elle fait des recommandations pour

l'élaboration d'un nouvel instrument de

mesure des résultats en ergothérapie.

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Occupational Performance Measures: Â Review Based on the Guidelines for the Client-centred Practice of Occupational Therapy