Sharon Reyolds BAppSc(OT),is an occupational therapist in the Transitional Living Unit, Westmead Hospital, Westmead, NSW.
Christine Chapparo MA,DipOT,OTR,FAOTA, is a senior lecturer in the School of Occupational Therapy, University of Sydney, Lidcombe, and a clinical consultant at Westmead Hospital, NSW.
INTRODUCTION
Throughout all human experience; through every aspect of the world and universe we inhabit, runs time. Time tells us when to get up, when it is time to go to school or to work, time to get food, or to eat it, time to go to sleep. Setting out on a journey, we check timetables to plan; we correlate time and distance to find our way.
Time governs not only our activities, but our very being (Peat, 1994). We exist by grace of thousands of intricately synchonized rhythms. Our pulse keeps time; the electrical waves in our brains time their rhythms to sleep or wakefulness. Our biological times link our interior processes to the regular rhythms of the outside world. Time gives continuity and pattern to life – and it also brings disruption.
Disruption to the regular temporal order of daily living is most keenly seen in clients who have had traumatic brain injury.
PURPOSE
| The purpose of this paper is to: | |
| a. | Discuss time relative to occupational performance |
| b. | Describe the types of disruptions to time that are commonly seen in clients with brain injury |
| c. | Present case examples to illustrate these disruptions and the various intervention methods that can be used to reorder the temporal rythmn to daily life. |
Clinicians working with clients who have traumatic brain injury, tend to focus of the performance of ‘occupations’ or purposeful activity without considering the importance of timing. Once independence in performance of a task is achieved, health professionals often fail to recognise that a distortion in the perception of timing of events can be just as disabling as not being able to complete the steps of the task or the routine itself.
TIME AND OCCUPATIONAL PERFORMANCE
Time is defined several ways. In the Model of Occupational Performance (Australia), (Chapparo & Ranka, 1996), time is defined relative to physical time, the temporal ordering of events and felt time, the person’s individual understanding of the meaning of time. Physical and felt time contribute to occupational performance at any level.
Immediate time has representation at the component level, where various biomechanical, sensory motor and cognitive operations occurring in the here and now contribute to task performance. Immediate timing of interactions between people contributes to appropriateness of specific instances of social interaction. At the level of core elements, time is essential to muscle contraction, neuronal transmission and a spiritual feeling of the ‘right’ time. At the occupational performance areas, immediate timing of subtasks is essential to forming sequential routines. At the occupational role performance level, immediate timing of events serves to link people to social and environmental circumstances, thereby establishing a feeling of being in the ‘right place’ at the ‘right time’.
Broad notions of linear time are derivatives of western society, and establish boundaries for how people in those societies ‘spend time’ throughout the day, week or year. Beyond the broad developmental concepts of time relating birth to death, linear time can be viewed more abstractly as simply the ‘unfolding of time’ and therefore is important to sequencing of occupations, particularly routines and tasks that occur over time and in concert with others in the environment of all people (Peat, 1994).
Cyclical time heralds feelings of ‘knowing’ when events should happen, and occurs with repetition of occupations to the point where they become habitual, thereby grounding us in ‘place’ (Chapparo, & Ranka, 1996).
The external environment has its own time, that is composed of physical elements as well as the timing of external events to which individual notions of time must be matched. This aspect of time is essential for satisfactory occupational role performance.
In occupational therapy, many clients with traumatic brain injury spend much of their time learning how to complete their activities of daily living. Once they are deemed ‘independent’ in the form of a task, they are moved onto the next one. The goal of the client, the family and the team has been achieved – or has it? An ability to complete the task in a reasonable length of time, and at a time of day or week that is acceptable within their environment, influences the ultimate success of achieving independence and the return to purposeful occupational roles in the home and community.
An additional phase of retraining occupational task and role function is emerging at Westmead Brain Injury Unit, where disruptions to time are commonly seen in the following four broad areas. These four areas parallel levels of expected occupational performance functions within the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996)
| 1. | Fluency, or speed of task completion |
| 2. | Chunking time, or the ability to place events in succession or routine time |
| 3. | Linking personal timing of events with environmental time, or meeting the time demands from the person’s environment |
| 4. | Planning or purposefully filling time, or establishing self initiated role performance. |
Major client difficulties related to time may therefore be observed by the therapist as:
| * | slowness in completing individual tasks |
| * | difficulty in establishing consistent timed routines and sequences of activity throughout an extended time period such as a week |
| * | difficulty completing activities and tasks at and within a time that is identified as appropriate within the client’s social environment |
| * | disruptions to timing of tasks that inhibit development of chosen or needed occupational roles. |
One intervention method that can be employed for these timing problems is based on principles of systematic instruction (Donelly, 1994; Snell, 1987). Consideration of the following steps ensures that performance as well as timing will be addressed by occupational therapists who wish to improve both the form and the timing of client performance.
| 1. | Identify the client’s chosen or needed occupational roles (for example, the role of self maintainer) |
| 2. | Select the tasks that will be required to fulfil this role and which are important to the client. (For example, being able to complete the morning routine including showering, dressing, preparing breakfast, tasking medication). |
| 3. | Complete a detailed assessment of these tasks (task analysis) |
| 4. | Establish performance goals with the client and significant others/ carers |
| 5. | Instruct to achieve mastery of the task |
| 6. | Instruct to achieve timing of the task |
ASSESSMENT OF TIMING
An effective and objective method of assessing the client’s ability to carry our a task or routine is to complete a task analysis. Task analysis involves breaking down the task into observable steps or components (Snell, 1987).Based on a specific behavioural task analysis system developed through the University of Sydney and Westmead Hospital, five error types were identified which inhibited clients’ independent completion of tasks and routines. These errors included:
| 1. | Inaccurate sequencing of the task |
| 2. | Missing a task step completely |
| 3. | Not stopping the task step |
| 4. | Too slow or too quick in task performance to the extent that quality and independence is affected |
| 5. | Task steps that were inappropriate |
Focussing on errors of timing, a step of a task may be considered as incorrect if a client completes the step or the task, or the routine too quickly or too slowly. Consideration needs to be given to the timing scheme or context of the task. For example, assessment of client’s ability to time the entire task, knowledge of the time of day or week when the task is carried out and the ability to link personal knowledge of time and performance of timed events with timing expectations that form part of the client’s external environment.
Errors of timing result in:
| * | The task being completed by the staff, family or carers due to staff, family or client frustration at the time taken. |
| * | A perception by others that the client is unable to complete the task. |
| * | Decreasing client motivation to achieve independence and resulting reduction in self esteem |
| * | Persistence in physical assistance from staff and family throughout a day to keep the client ‘on time’, even though the client has achieved mastery of the steps of the task. This ultimately influences discharge decisions regarding destination and care requirement. |
STEPS TO IMPROVE TIMING OF TASK AND ROUTINE PERFORMANCE
Several steps are important prerequisites to improving timing of occupational performance. Most important, fo improved timing at any level of performance, clients must achieve mastery of a step, task or routine before issues of timing can be addressed. Therapy therefore addresses:
| 1. | Errors of accuracy of performance by practicing the form of the task. This may be done through massed practice initially (practicing particular steps that are difficult). |
| 2. | Practicing the entire task or routine for accurate performance (all the steps are correct). |
| 3. | Finally, once, mastery is achieved, the timing of performance can be addressed. |
The following case studies are presented to illustrate how intervention for three different types of timing problems was structured. Each case study focuses on a different aspect of disruption of the perception of felt time that is commonly seen in clients who have brain injury. Each case study also reflects the impact of the timing disturbance on individual occupational role performance.
ANDREA: FLUENCY IN TASK PERFORMANCE
Andrea is 21 years of age. She was a passenger in a motor vehicle accident which resulted in severe closed head injury with multiple orthopaedic injuries.
She remained in post traumatic amnesia (PTA) for six months post injury, suggesting chronic amnesia. Her reduced ability in completing daily activities stemmed from cognitive and physical difficulties.
Following neuropsychological assessments, it was reported that she had specific difficulty with verbal and visual memory, sequencing, and complex cognitive functions such as problem solving and information processing.
Physically, Andrea presented with heterotopic ossification in both upper limb resulting in reduced range, weakness and pain. Although her mobility was limited initially to an electric wheelchair, on discharge she walked with the assistance of walking sticks.
Prior to her accident, Andrea lived with her mother and worked as a receptionist at a Medical Centre. Her leisure time was spent with her boyfriend and friends. Her mother assumed responsibility for most of the household duties. Prior occupational roles that were considered important to Andrea included those of self maintainer, worker, friend and daughter. Andrea sought to resume satisfying occupational performance in these roles. Her physical and cognitive difficulties, however, led to a dependence on staff at the Brain Injury Unit, and her family for basic self care tasks.
Assessment
Negotiation with Andrea resulted in goals being set for independence in self maintenance routines of showering, dressing and grooming.
Task analysis demonstrated that Andrea was dependent in all three tasks due to poor sequencing of steps and difficulty completing some aspects due to physical limitations. She was extremely slow in her performance, taking an average of two hours to complete showering, dressing and grooming. Task analysis assisted in identifying and isolating the particular steps in which she lacked mastery.
Achieving Mastery
Steps in task performance that lacked mastery were modified to suit her physical needs, or removed from the task sequence and mass practiced until mastery was obtained.
One example of this was putting on tights. Andrea was trained in a step by step routine for putting on tights in sitting. She had chosen this item of clothing as one that was important to her previously. This task in the routine of dressing was mass practised in separate sessions until Andrea could apply her tights without physical assistance or prompting in the procedure. Once the tasks in all the identified routines were mastered, they were placed back into the whole routine.
Achieving Timing
Despite mastery, timing continued to be an issue. Andrea was slow in her performance which was unacceptable in a busy ward situation and in the family home routine. It was addressed using the following strategies.
| 1. | A negotiated time: An initial acceptable time frame to complete showering, drying, dressing, and grooming was negotiated with Andrea, taking into account her physical limitations. | ||||||
| 2. | Routines were broken into parts: This negotiated time frame of 50 minutes was divided between three tasks:
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| 3. | Time prompts were established: Checking a clock was ineffective for Andrea due to her cognitive difficulties, as well as her fear of being left alone. The therapist became her prompt for time. | ||||||
| 4. | Fading of prompts: Initially the therapist was present during performance of all tasks, giving verbal prompts about the time left for completion every 5 minutes.Verbal prompts consisted of “5 minutes is up – how long do you have left to finish?”. This prompt system developed Andrea’s internal time clock.
Prompts were reduced to one verbal prompt every 10 minutes, and finally to one verbal prompt at the beginning of each of the three tasks. |
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| 5. | Staff and family were educated about the task sequencing prompts and the time expectations. |
Following this training, Andrea completed her task in the allocated time without the prompt of the therapist. This was then generalised to her home environment through weekend leave and training of the family.
Discharge
Andrea was discharged from the unit independent in these routines and continued to complete the tasks in her home environment without the assistance of her family and carers, thus meeting her personal goal.
RORY: LINKING PERSONAL TIME TO EXTERNAL TIME
Rory is a 22 year old man who was followed up with a Community Programme, after his discharge from the Brain Injury Rehabilitation Unit and the Transitional Living Unit. This programme focussed specifically on Rory returning to his chosen roles of self maintainer, player and family member.
Rory resided with his parents and sister on a property isolated from public transport. As he could no longer drive, he relied on family and friends to provide transport. A cabcharge was provided by his insurance company to reduce his dependence on others and to encourage pursuit of his desired roles.
Due to a period of depression and anxiety on his return home, Rory was unable to order and use the cabs, becoming extremely anxious when ordering a cab or waiting for one to arrive. Slowness, inability to problem solve and difficulty recalling information were major difficulties when calling taxi companies. His reduced speed in completing this task within the time frame expected by the cab company despatchers , and his anxiety resulted in his family completing the task for him or providing transport. He expressed increasing frustration at this.
Assessment
A task analysis was completed on this task. It was identified that he had difficulty planning and organising the task, recalling information and verbally expressing information on the telephone. He was extremely slow in the task taking 30 minutes and requiring maximal prompting to prepare for and order a cab.
Achieving mastery
The task was divided into steps, and strategies were developed to reduce prompting required from the therapist. Each step was mass practiced.
| 1. | Preparation: Rory was prompted to prepare the information required for the phone call to the taxi company. This included making an appointment time to come to the Transitional Living Unit the following week and recording this in his diary. He was required to write down information for the phone call, using a checklist which was placed in the front of his diary, including name, address of destination, address of ‘pick up’, the time to be collected, the day and date of appointment. |
| 2. | Making the phone call: Rory practiced making the phone call using the written prompts. |
| 3. | Checking the information: A reminder was written in his diary advising him to call the taxi company and confirm a booking a day before his appointment, thereby reducing his anxiety. |
Achieving timing
Once mastery of these steps was achieved with practice, verbal feedback was given about the time taken to complete each component of the task. Care was taken to ensure mastery was achieved before timing was addressed to avoid increasing his anxiety. Rory agreed that he needed to improve his timing.
Reinforcement in terms of praise and feedback was given initially after each step and then after the whole task. Natural positive reinforcement was achieved with the success of each trip he organised to the Transitional Living Unit.
The training was completed once a week for two months. Rory reached a point where he no longer needed to attend the Transitional Living Unit for training in the task. He was ordering a cab with minimal prompting and in a time frame which was functional. He had reduced the time taken to do the task to 15 minutes and his confidence improved.
Ordering a cab was then generalised to his home environment by educating his family on the strategies he used and by Rory using the cab to attend a variety of appointments.
Outcome
Rory had achieved his goal of ordering a cab and getting to appointments independently. This contributed to his desired independent roles of self maintainer and player.
DAVID: CHUNKING TIMESPANS
Clients who have had severe traumatic brain injury, especially those who are diagnosed as ‘chronic amnesics’ often have a poor concept of timespan in a day, week or year. They don’t seek out time information. These clients are often disoriented to the day, date and time. They rarely initiate completing routine activities, they complete activities repetitively or complete tasks at inappropriate times of the day. Use of traditional strategies such as diaries and timetables are rarely effective.
This results in a high degree of dependence in recalling and carrying out even the most basic events during a day within the home or community. Prompting is required to get up, to eat, to take medication, to shower and dress, to complete basic chores and to fill in spare time.
David became a resident of the Transitional Living Unit for an assessment of his daily living skills in a less structured environment. He had been a client of the Brain Injury Unit for nine months at which time the neuropsychologist reported that he remained in PTA. David mobilised independently, however had restricted movement of both arms resulting in an inability to reach his face and head. Occupational therapy at the Brain Injury Unit had therefore focussed on retraining of self care tasks, utilising modified equipment to achieve mastery of these tasks.
His ability to complete simple routines was poor and he required maximum prompting for his daily routine. Within the Transitional Living Unit, this became excessively demanding on the staff’s time.
A basic daily routine plan was developed with David. The routine was written out and placed on his mirror in his bedroom. This was to provide visual feedback and also to assess his ability to use visual aids to memory.
The routine consisted on a negotiated time to:
| * | get out of bed |
| * | have a shower |
| * | dress and shave |
| * | have breakfast |
| * | take medications |
| * | have lunch |
| * | have dinner |
It also included two house duties to be completed after dinner which were watering the garden and locking the house before bedtime. Tasks were “chunked”, or placed in specific successive patterns to aid recall.
It was found that David did not initiate using the written routine as a prompt to recall tasks, therefore it was used only as a visual reinforcement to verbal prompts given by staff.
Combinations of verbal and visual timing prompts included:
| “what is the time David?” |
Initially a watch was purchased and David read the time as a response to this question.
| “what do you usually do at this time?” |
Initially he was unable to give this information.
| “maybe we should check your routine” |
David quickly learned where his routine was kept.
The prompting continued for each daily routine until staff began to report that David was starting to initiate the routines and was completing them in correct order. Once this was achieved, the visual routine prompts were removed from his mirror.
This strategy allowed David to resume his role as a self maintainer within a specific environment and reduced the time demand and level of care required of the staff. Staff were able to engage in more non-routine tasks with him such as shopping, or leisure outings.
The strategies used were extended to the use of a calendar to develop a concept of time in a week. Regular routines and appointments were scheduled weekly with him. These included going to the occupational therapy workshop, twice per week, attending physiotherapy exercise class, an outing one afternoon per week, one shopping day, house meeting time, and routine meetings with the occupational therapist. As with his routine schedule, David required visual and verbal prompts to refer to his calendar. Similar prompts were used to establish a weekly routine as those used to establish a daily routine.
It took about 6 months for David to consistently develop daily and weekly routines. Ultimately, he developed notions of both linear and cyclical time by developing and maintaing consistent routines and habits that grounded him in time and place. His ability to ‘chunk’ time in terms of daily and weekly routines contributed to his ability to participate in family routines in his role as a family member.
SUMMARY
This paper illustrates the important place that time plays in the performance of everyday occupations and in establishing functional and satisfying occupational roles.
Three types of timing difficulties were examined through three case studies. First, establishing fluency, or timing of tasks. Second, linking personal timing of performance to external timeframes. Third, chunking time to establish extended daily and weekly routines and habits.
The cases demonstrated how occupational therapists need to consider both mastery and timing of occupations to assist clients achieve needed and desired occupational role performance.
ACKNOWLEDGMENTS
The authors acknowledge the assistance given by Jodie Nicholls, occupational therapist, in the Brain Injury Unit, Westmead Hospital in the preparation of this paper.
REFERENCES
Chapparo, C., & Ranka, J. (1996) The Occupational Performance Model (Australia). Draft manuscript. (Available from The School of Occupational Therapy, The University of Sydney, Lidcombe, NSW 2141) May.
Donelly, M. (1994) Systematic instruction: Study guide. Graduate Certificate in Applied Science (Occupational Therapy in Neurology). (Available from the School of Occupational Therapy, The University of Sydney, Lidcombe, NSW, 2141)
Peat, D. (1994) Blackfoot physics: A journey into the native american universe. London: Fourth Estate