Lead paper presented at the 11th International Congress of the World Federation of Occupational Therapists, London (1994, April), and in modified form at the 1st Asia-Pacific Occupational Therapy Congress, Kuala Lumpur (1995, September)

Judy Ranka is a Lecturer in the School of Occupational Therapy, The University of Sydney

Christine Chapparo is a Senior Lecturer in the School of Occupational Therapy, The University of Sydney

PUBLISHED ABSTRACT:

The four year Bachelor of Applied Science degree in occupational therapy [BAppSc(OT)], at The University of Sydney, Australia graduates up to 150 students annually. This curriculum evolved over ten years from one based on a medical model emphasising diagnosis and disease to one founded on the philosophy, assumptions and principles of occupational therapy. This model expands on current concepts of occupational performance and is represented by an interactive structure of seven primary constructs: occupational roles, performance areas, performance components, performance environment, core elements of body/mind/spirit, space and time. By integrating the seven construct categories with principles of curriculum design the authors demonstrate that occupational performance can be employed as an educational model for professional preparation. This represents the first educational model generated from within the profession which is based on a view of occupational therapy practice and has been successfully implemented. One pivotal innovation of this curriculum model is to discard the notion of ‘student’ therapist and focus on professional preparation required to assume the occupational role of ‘therapist’. Learning experiences are designed to actively facilitate professional roles required for practice including those of practitioner, inquirer, teacher/learner, advocate and manager. This paper describes a theoretical base for this curriculum and outlines how the six construct categories form a structure for undergraduate education in occupational therapy.

PAPER PRESENTED:

Introduction:

Throughout world, people, organisations and professions are struggling to find their place. In this, occupational therapy is no exception (Jenkins, 1993). Various pressures associated with political and economic reform are impacting on all facets of occupational therapy, including the provision of direct services to clients (Ostrow & Joe, 1983), funding for research to test and refine our knowledge base (Dawkins, 1987; Yerxa, 1983) and the position of occupational therapy education within institutions of higher learning (Dawkins, 1987). These pressures challenge occupational therapy educators to define 1) what occupational therapy is; 2) what occupational therapy education programs are; 3) why our educational programs look the way they do; and 4) what outcomes we expect from educational programs. How do we answer these questions?

Historically, occupational therapy educational programs have evolved out of an apprenticeship-training model (Anderson & Bell, 1988; Coleman, 1992a,b,c; Hopkins, 1988) which is characteristic of most medical programs. This apprenticeship model influenced occupational therapy curriculum designers to construct programs which prepare students to work in broad areas of practice (physical disabilities, psychiatry, paediatrics), or with specific ‘diagnostic’ groups (‘CVA’, acute anxiety disorders, dementia, learning disabilities), or in different contexts (acute care, community, schools). However, the scope of occupational therapy practice has undergone continual expansion since its inception (Reed, 1993; Yerxa, 1992) and new contexts for practice and classifications of diseases and disorders make it impossible for occupational therapy curricula to address all possibilities. What should we include?

More recently, pressures from colleges and universities challenge occupational therapy educators to make educational programs more ‘academic’ (Yerxa & Sharrott, 1986), that is, more theoretical and research oriented with less emphasis on practical skills and labour intensive modes of ‘teaching’. Course contact hours are being reduced, tutorial structures are under threat and large lectures or ‘independent learning’ modes encouraged. This places even more pressure on curriculum developers to make decisions about what objectives can be achieved and what ‘content’ should be included. How do we decide?

The profession demands our programs be theoretically sound yet retain their capacity to prepare students with the ‘tools’ for practice and research in a culturally diverse world. The profession also expects that educational programs instil in students a sense of professional identity in order to ‘counter’ groups who suggest they can provide ‘occupational therapy’. How do we accomplish this?

PURPOSE:

This focus of this paper is on describing how one occupational therapy program (The University of Sydney, Australia) has attempted to answer these questions. An undergraduate occupational therapy program has rejected the legacy of the ‘apprenticeship’ era in occupational therapy education and designed a course structure to be congruent with a model of occupational therapy, an evolving Australian version of ‘Occupational Performance’ (Chapparo & Ranka, 1992). Although other programs have moved in similar directions using different models (Dalhousie University, University of South Australia; Thomas Jefferson University), what appears unique about this program is its application of occupational performance principles to the education of students; that is, we address the ‘occupational need’ of students and prepare them for the ‘occupational role’ of occupational therapists. This represents an initial step in the development of a theoretical rationale for the preparation of occupational therapists which has been created from a model of occupational therapy practice rather than models of education.

A description of the altered course structure and a discussion of how the application of occupational performance constructs to the preparation of occupational therapy students for the role of ‘occupational therapist’ follows:

BACKGROUND:

The four year Bachelor of Applied Science course in occupational therapy at The University of Sydney graduates up to 150 students annually. We also have a comprehensive graduate program with coursework and research options. Our curriculum evolved from an undergraduate program based on a medical model of diagnosis and disease to one founded on the philosophy, assumptions and principles of occupational therapy as reflected in the model of occupational performance (Chapparo & Ranka, 1992). The transition to this new structure has been an evolutionary process which commenced in 1984 as a result of curriculum review (School of Occupational Therapy, 1986). Through a process of ongoing review and formal curriculum evaluation conducted in 1991, the initial model of occupational performance as well as its use as a theoretical foundation for occupational therapy education was refined to the point presented here.

MODEL OF OCCUPATIONAL PERFORMANCE:

The conceptual framework used to design the course is an Australian version of Occupational Performance (Chapparo & Ranka, 1992) currently being developed. This model of Occupational Performance builds on and extends similar developments in the United States (American Occupational Therapy Association, Inc., 1973) and Canada (Canadian Occupational Therapy Association, 1991).

The Australian version is represented by an interactive structure of eight primary constructs, including: occupational performance, occupational role, occupational area, components of performance, core elements, environment, space and time (Fig.1). The interaction within and between these constructs explains the nature of occupational therapy and occupational therapy’s view of people and the world. Occupational performance identifies the domain of concern of occupational therapy as being the performance of human occupations. We acknowledge that humans have an occupational existence and aim to address their occupational need (Chapparo & Ranka, 1992)

Figure 1: A model of Occupational Performance (Adapted from Chapparo & Ranka, 1992).

This model maintains that a person’s engagement in human occupations is organised by the occupational roles they assume either by choice or out of need and expectation. Occupational roles may have a social dimension but are primarily configurations of activity from one or all of the major occupational areas. The nature of occupational therapy practice is shaped by first identifying the occupational roles clients possess, desire, require and are within their capacity. The primary goal of therapy is for those who receive occupational therapy services to be able to identify, choose and perform needed or desired occupational roles within their capacity to the satisfaction of themselves or significant others (Ranka & Chapparo, 1993).

OCCUPATIONAL PERFORMANCE AS A FOUNDATION FOR CURRICULUM STRUCTURE

The application of this model to curriculum structure resulted in a re-configuration of subject content away from diagnosis and disease to a structure based on occupational performance constructs. First, subjects were re-organised and re-named as indicated below (Table 1).

Occupational Therapy
Sensory Motor Processes
Psychosocial Processes
Lifestyle & Lifespan Development
Interdisciplinary Studies

Selected Studies
Special Investigation
Clinical Education
Biological Sciences
Behavioural Sciences

Occupational Therapy Theory & Process

Occupational Role Development
Human Occupations
Components of Occupational Performance
Evaluation of Occupational Therapy Programs
Occupational Therapy Fieldwork
Biological Sciences
Behavioural Sciences

Table 1: Comparison between subjects in the 1980 BAppSc(OT) course and the current course (Note: each subject consists of several units which cross multiple years of the course.).

This required curriculum developers to arrange content in a way that would support the relationships proposed by the model and it’s generic view of occupational therapy. For example, teaching and learning activities which occur support the links purported by the model and the stated goals of occupational therapy.

Case study assignments require students to integrate subject content from several subjects to construct a total picture of a client in order to determine the focus of occupational therapy. For example, one case assignment may require students to consider issues associated with ‘occupational role development’, ‘human occupations’ and ‘components of occupational performance’ in designing specific intervention whereas, another case study may address theoretical issues (Occupational Therapy Theory and Process) associated with tests of cognition or personality inventories (Components of Occupational Performance) and their significance to client function (Human Occupations).

Application of theory to practice is always congruent with the view of occupational therapy described in the Model (Chapparo & Ranka, 1992). In this way students learn a process of thinking about occupational therapy and to synthesise knowledge, skills, attitudes and values from several areas of the course. This does create some difficulties, especially, when we are asked to demonstrate where students learn about, ‘occupational therapy in stroke rehabilitation’ or ‘occupational therapy in adolescent psychiatry’–the whole course prepares them for practice in these areas.

Additional information concerning structural aspects of the course will not be described in this paper.

OCCUPATIONAL PERFORMANCE AS A FOUNDATION FOR THE OCCUPATIONAL ROLE DEVELOPMENT OF STUDENTS

With subsequent development of occupational performance as a model for practice, it became apparent that the way the model views people and their occupational performance could be used as the theoretical basis for course design in occupational therapy in terms of supporting student occupational performance and their occupational role development as occupational therapists. The remainder of this paper describes this dimension of the educational model.

Construct 1: Occupational Performance

Occupational performance is the ability to perceive, desire, recall, plan and perform activities and tasks for the purpose of self-maintenance, productivity or school, play or leisure and rest to the satisfaction of one’s self, significant others or society (Chapparo & Ranka, 1992). An occupational need exists when occupational performance is compromised (Ranka & Chapparo, 1993). Educational practice is aimed at addressing the occupational needs of students and the profession through enhancing students occupational performance.

Occupational performance results from interactions that occur within and between two environments: an internal environment and an external environment. The internal environment consists of those aspects of performance which occur within a person. The external environment considers the broader context in which occupations are performed. The need for occupational performance can arise from the internal environment (a personal or collective goal) or the external environment (a need for shelter, financial security). Each of these environments influence each other Chapparo, & Ranka, 1992). The internal and the external environment are considered relative to the preparation of students.

Construct 2: Occupational Roles

Occupational roles are patterns of occupational behaviour which consist of configurations of occupational activities and tasks from a number of occupational areas (Chapparo & Ranka, 1992). In this model, the occupational role of ‘occupational therapist’ is identified and represents the central focus of the model (Fig 2).

Figure 2: Occupational Role of ‘Occupational Therapist’

We assume that students have chosen the ‘occupational role’ of occupational therapist and our curriculum attempts to engage them in developing this role. We expect that at the end of our course students will be able to identify, choose and perform in the ‘role’ of occupational therapist to the degree expected of someone at entry level, and to the satisfaction of themselves, their clients, their employers and the profession.

In reality, not all students have made this choice on commencement of the course. This mirrors occupational therapy practice–often a major task of therapists is assisting clients in making decisions about needed or desired roles. Similar processes are put in place for new students to assist them in making role choices (occupational therapy versus another profession) and role transitions (eg., from high school student to university student, from daughter/son living at home to flatmate). This includes using the model to clarify what an occupational therapist is, describing what is required of someone commencing the development of this role (what the course is like) and what commencement of this role will not do (assure entry into a physiotherapy course). For example, Year Coordinators and ‘mentors’ assist in providing role transition support through regular group representative meetings, social events and facilitation of ‘peer networks’.

The assumption that students are commencing development of the occupational role of ‘occupational therapist’ suggests they should be viewed as new members of the profession. The label of ‘student’ is discarded and notions of students as ‘colleagues’ or ‘participants’ adopted. This change in our personal view of students prompts an attitude shift which is fundamental to this educational model. It immediately acknowledges that as ‘colleagues’, students are also ‘peers’. Educational practices used become more collaborative, adult-like and ‘mentor’ oriented, rather that purely directive and pedagogical. This shift is analogous to similar trends in the profession concerning the use of the word, ‘patient’ and an emphasis on ‘client-centred’ practice (Townsend, Brintnell & Staisey, 1991).

We anticipate that this view will also address some problems associated with role transition from student to therapist. For example, historically, graduation has marked the point of role change from student to therapist and the associated entry into the profession. This model acknowledges that ‘graduation’ is an important career stage in that a ‘license’ to practice is one step closer but graduation is not a demarcation point for entry into the profession: students are already colleagues.

Elimination of this demarcation point between student and therapist also means that the barrier between therapist and student is eliminated. This reinforces a desired aim of the curriculum, and the profession: that occupational therapists will engage in learning as a lifelong aim and participate in continuing professional education courses or re-enrol in higher degrees.

Construct 3: Occupational Areas

Occupational role performance requires that occupational therapists are able to perform a range of activities and tasks which arise from major occupational areas outlined in the model of Occupational Performance (Fig. 1) (Chapparo & Ranka, 1992). At a broad level, this educational model acknowledges that self-maintenance, leisure/play, and rest are important dimensions of occupational role development; however, the primary occupational area being developed by the curriculum is that of productivity and school occupations. Five ‘productivity/school’ categories of activities and tasks are identified: practitioner, teacher/learner, advocate, inquirer and manager (Fig. 3).

Figure 3: Occupational Performance Areas

This categorisation is used to help make decisions concerning what activities and tasks to include and what teaching/learning methods will be used. It ensures that consideration is given to the occupational areas which contribute to the role of an occupational therapist, and that the level of performance expectations are identified for each area (eg. level of managerial skill expected of a new graduate vs level of practitioner skill expected of a graduate certificate student; or level of inquiry skill expected of a new graduate vs level of inquiry skill expected of a doctoral candidate). It also contains structured experiences which facilitate student recognition of how activities and tasks which address one occupational area can be translated into other occupational areas. This occurs through self-classification ‘exercises’ in which students determine the occupational areas being addressed by various curriculum activities and tasks.

Construct 3: Components of Performance

The activities and tasks performed by occupational therapists in each of the occupational areas require blends of human component abilities. The curriculum attempts to develop participant component abilities to support activity and task performance in biomechanical, sensory motor, cognitive, intrapersonal and interpersonal areas (Fig.4).

Figure 4: Components of Performance

This aspect of the model encourages educators to consider the scope of human component function that is required during occupational activity and task performance. For example, consideration is given to interpersonal (interpersonal component) factors involved during the application of physical handling techniques (biomechanical component), or the ability to read sensory cues arising from one’s own body (sensory-motor component) during public speaking exercises and apply visualisation techniques (intrapersonal component) to relax; or appropriate use of questioning (interpersonal component) to identify (cognitive component) client occupational role needs.

It also encourages educators to consider that the component contributions to performance will change according to the occupational areas being addressed. For example, the activities and tasks of a practitioner require a different blend of component function to those of a manager. The component emphasis placed on an activity or task is determined by the area being addressed and the level of occupational role performance being developed (eg. ‘novice’, ‘skilled’). This aspect of the curriculum demonstrates a need for a range of teaching and learning strategies including small group tutorials.

Construct 4: Core Elements

The fundamental element of occupational performance is the ‘body-mind-spirit’ unit. In this model, core elements are the course objectives which express knowledge, skills, attitudes and values to be gained (Fig. 5).

Course objectives are stated to reflect the aim of developing the occupational role of students, and objectives for each educational activity or task presented are congruent with this aim. The balance of knowledge, skills, attitudes or values to be addressed in any one task vary according to the area being addressed and the emphasis placed on component function during that particular task. For example, one ‘practitioner/advocate’ task may address ‘skill’ development in ‘interpersonal’ interactions, whereas another task may focus on an exploration of ‘attitudes’ and ‘values’ concerning the use of upper limb orthotic systems (biomechanical component). The model provides a guide to ensure that objectives are comprehensive in terms of knowledge, skills, attitudes and values and that they are focused on occupational performance.

Figure 5: Core elements

The model also encourages educators to consider that all participants in the course bring with them a range of knowledge, skills, attitudes and values which have been created by their own unique life experiences and personal endowment. This ‘prior learning’ contributes to shaping each participant’s component abilities. For example, some participants will excel at learning to use their body (biomechanical skill emphasis) while others will excel at creating new ideas (cognitive knowledge emphasis) or relating to others (intrapersonal skill emphasis). This pattern is reflected throughout other levels of the model; for example, prior learning may influence one participant to enjoy ‘managerial’ activities and tasks while others may prefer ‘inquirer’ activities and tasks. Educational practice in this model thrives on this diversity. It acknowledges that all participants are resources in the process of occupational role development and attempts to utilise the unique contribution of each one.

Construct 5: Environment

The environment is a physical-sensory-socio-cultural phenomenon which provides a context for performance (Chapparo & Ranka, 1992). In this educational model, consideration is given to the scope of occupational therapy practice environments participants are being prepared for, as well as, the environmental constraints and opportunities for learning which exist on the immediate campus and in the community (Fig. 6).

Figure 6: External Environment

Curriculum activities and tasks require students to explore sociocultural implications for practice including such things as factors affectingintercultural interaction, as well as what a ‘practice’ environment might consist of. Alternately, environmental factors place constraints on the type of educational experiences which can be provided and are considered in curriculum planning. For example, this curriculum has 550+ enrolled students in the BAppSc(OT) course for the four-year duration of the program–the constraints and opportunities abound. Curriculum practice must consider that there are ten first year tutorial groups and, very soon, four Schools of Occupational Therapy attempting to secure fieldwork sites in the Sydney metropolitan area: we are ‘environmentally’ challenged.

Constructs 7 & 8: Time and Space

The notions of time and space suggest that people have a past and a future and that occupational performance has both temporal and spatial dimensions (Fig. 7). These two constructs encourage educators to consider the ‘timing’ and ‘spatial’ complexity of curriculum activities and tasks. They reinforce a developmental approach to the design of curriculum activities and tasks and remind educators that participants may not perceive themselves as ‘ready’ (time) for the complexity of tasks (space) they are expected to participate in. This dimension to the model ensures that opportunities for choice exist in the curriculum, including choice in goals, choice in style of participation and choice in assessment methods. These constructs also ensure that consideration is given to the amount of time participants spend on various activities and tasks.

The complete educational model

The use of the complete model (Appendix 1) allows an evaluation of the total curriculum in terms of how well it prepares students for what will be expected of them. It can be used to map the curriculum in terms of content focus and level of competence addressed relative to the occupational areas of concern to occupational therapists at an undergraduate and graduate level.

Using this foundation, occupational therapy educators can make choices from a range of educational models and approaches (for example, problem-based learning, self-directed learning, experiential learning, lifelong learning, didactic instruction, computer-aided instruction) but are able to apply them within the context of a common view of occupational therapy. Finally, it provides an educational and professional rationale for curriculum choices made concerning what and how we teach.

Figure 7: Time and Space

SUMMARY

A model for the professional preparation of occupational therapists has been described in this paper. This model represents an attempt to uncouple educational programs from their original medical foundation in favour of an occupational therapy one. Through the use of occupational performance as an educational model for the professional preparation of occupational therapists, students learn about occupational therapy in a manner which is congruent with our professional philosophy, values and assumptions. This marks the emergence of an educational theory on which decisions can be made about occupational therapy curricula which is unique to our profession. From this perspective, graduates gain not only a theoretical understanding of occupational therapy, they are prepared for the occupational activities and tasks required of an occupational therapist now and in the future, that is, the activities and tasks of practitioners, inquirers, teachers/learners, inquirers, advocates and managers.This ensures their employability.

REFERENCES:

American Occupational Therapy Association, Inc. (1973). The roles and functions of occupational therapy personnel. Rockville, MD: Author

Anderson, B., & Bell, J. (1988). Occupational therapy: Its place in Australia’s history. NSWAOT: Sydney.

Canadian Occupational Therapy Association (1991). Guidelines for client-centered practice in occupational therapy. (Available from CAOT, 110 Eglinton Ave., West, 3rd floor, Toronto, Ontario, Canada M4R 1A3).

Chapparo, C., & Ranka, J. (1992). Occupational performance model (draft manuscript). (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW Australia, 2141)

Coleman, W. (1992a). Maintaining autonomy: the struggle between occupational therapy and physical medicine. American Journal of Occupational Therapy, 46(1), 63-71.

Coleman, W. (1992b). Looking back–Evolving educational practices in occupational therapy: the War Emergency Courses, 1936-1954, 44(11), 1028-1036.

Coleman, W. (1992c). Looking back–the curriculum directors: influencing occupational theapy education, 1948-1964, 44(3), 244-246.

Dawkins, J.S. (1987). Higher education: a policy discussion paper. Canberra: Australian Government Publishing Service.

Hopkins, H.L. (1988). An historical perspective on occupational therapy. In H.L. Hopkins and H.D. Smith (Eds), Willard and Spackman’s occupational therapy (7th ed.) (pp. 16-37). Philadelphia: JB Lippincott

Jenkins, M. (1993). So we think we are unique…. British Journal of Occupational Therapy, 56(1), 1

Ostrow, P., & Joe, B.E. (1983). Negotiating the environment: Ahieving quality care in a time of flux. American Journal of Occupaitonal Therapy, 36(12), 779-781

Ranka, J., & Chapparo, C. (1993, September). Occupational performance: A practice model for occupational therapy. Paper presented at the 6th State Conference of OT Australia AAOT-NSW, Mudgee, NSW.

Reed, K.R. (1993). the beginnings of occupational therapy. In H.L. Hopkins, & H.D. Smith (Eds.) Willard and Spackman’s occupational therapy (8th ed.) (pp. 26-43). Philadelphia: J.B. Lippincott

School of Occupational Therapy (1986). Stage IV review, Bachelor of Applied Science (Occupational Therapy) course. (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW Australia, 2141)

Townsend, E., Brintnell, S., & Staisey, N. (1991). Developing guidelines for client-centered occupational therapy practice. Canadian Journal of Occupational Therapy, 57(2), 69-76.

Yerxa, E. R. (1983). Research priorities. American Journal of Occupational Therapy, 37(10), 699.

Yerxa, E.R. (1992). Some implications of occupational therapy’s history for its epistemology, values and relation to medicine. American Journal of Occupational Therapy, 46(1), 79-83.

Yerxa, E.R., & Sharott, G. (1986). Liberal arts: the foundation for occupational therapy education. American Journal of Occupational Therapy, 40(3), 153-159.

Judy Ranka is a Lecturer in the School of Occupational Therapy, The University of Sydney. At the time of writing this essay she was also a part-time graduate student in an MA (Hon) program in the School of Education at Macquarie University

INTRODUCTION:

Education has been defined as the organised, systematic effort to foster learning, to establish the conditions for learning and to provide the activities through which learning can occur (Smith, 1983, p.37). The success of this process is dependent on how well the learning experiences offered match the needs and capabilities of the learners (Knowles, 1984; Zais, 1976). Effective teaching and learning, therefore, is dependent on educational experiences which are ‘individualised’ to learners (Smith, 1983; Knowles, 1973).

Recent, radical changes in knowledge and understanding in numerous fields of inquiry suggest there is a growing rejection of explanations of the world which view entities as independent of their environment or other entities; of adhering to linear, cause-effect predictions of change and of accepting that there can be one universal explanation of events (Bateson, 1979; von Bertalanffy, 1926/1971; Bronffenbrenner, 1979; Gardner, 1985; Giroux, 1990; Goodall, 1986; Prigogine, 1980; Sameroff, 1982). This represents a widespread paradigm shift which opposes linear, Newtonian and reductionist viewpoints (Doll, 1989). Individuals, collective groups, organisations, organs, cells, mathematical structures and chemical compounds, to name a few, reveal incredible uniqueness and unpredictability.

This paradigm shift also confronts traditional and generally applied curriculum designs and frameworks. Doll (1989) suggests that most practice in this area remains based on linear concepts of predicted change described by Tyler (1949, 1979) in which teaching experiences are structured and sequenced in the form of a syllabus and presentation of material is generally in didactic form. The intent of the curriculum is ‘cummulative’, that is, learners gradually acquire (accumulate) pre-determined and specified knowledge. Doll (1989) proposes an alternative view of education which is aligned with the changing views of knowledge and understanding taking place elsewhere. The intent of this alternative curriculum is ‘transformative’ (Doll, 1989). This view emphasises contingency and ambivilance rather than structure (Carter, 1993), and aims to bring about transformation in learners (Giroux, 1988) rather than accumulation. It considers the interdependence which exists between learner, teacher, curriculum practice and curriculum environment and thrives on unexpected challenge and change. ‘Individualised’ education in a transformative curriculum views learners (single learners or collective groups of learners) as entities which have unique educational needs, and stresses an environment where there is mutual respect and trust between all participants (Kitwood, 1990).

Although a return to holistic paradigms is evident in occupational therapy practice (Kielhofner, 1985; Reed, 1984; Townsend, Brintnell & Staisey, 1990), little reference is made in occupational therapy literature to the application of models of occupational therapy to curriculum structure.

Reilly (1958, 1969) encouraged occupational therapy educators to adopt ‘occupation’ as the focus of professional education. Others have suggested a structure for how this could occur (American Occupational Therapy Association, Inc., 1974), and recommended a theoretical basis for the arrangement of curriculum activities (Rogers, 1983). Most occupational therapy literature, however, is concerned with aspects of curriculum practice. For example, authors have described the application of various teaching and learning principles in occupational therapy educational programs, including: self-directed learning (Hollis, 1991; Ranka, Twible & Pitkeathly, 1991) and problem-based learning (Jacobs & Lyons, 1992). Others discuss issues related to curriculum implementation and change (Jantzen, 1977; Leonardelli & Gratz, 1986; Mularski, Nystrom & Grant, 1989; Neistadt, 1987; Pelland, 1987; Rogers, 1980a,b).

Recently, Schemm, Corcoran, Kolodner and Schaaf (1993) provide an example of curriculum modelling which has occupation as its core and systems theory (von Bertalanffy, 1968) as its theoretical foundation. No reference is made to any model of occupational therapy practice as an organising framework for curriculum decisions as originally proposed by the American Occupational Therapy Association, Inc. (1974). The value of a curriculum model which is based on a model of occupational therapy practice lies in its potential to direct educational practice and research in a manner which is congruent with occupational therapy philosophy.

PURPOSE.

The purpose of this essay is to present an initial conceptalisation of a curriculum model which reflects the paradigm shift described earlier. It is founded on principles which arise out of postmodernism, and incorporates aspects of the framework, principles and operations described in the models and frameworks of occupational performance (American Occupational Therapy Association, Inc., 1974; Chapparo & Ranka, 1992). The curriculum model presented is in the formative stage of model development described by Krefting (1985) and others (Creek, 1990; Mosey, 1986; Reed, 1984). A theoretical base is identified, constructs are named and defined and their interactions are explained relative to a ‘curriculum’. Further work is required to refine the constructs and delineate their implications for educational practice.

POST-MODERN PERSPECTIVES:

Postmodern, it has been suggested, “represents a critical reappraisal of modern modes of thought, religious belief and moral conviction” (Waters, 1985, p.113). This reappraisal is advancing holistic and interactionist themes. Specifically, Waters (1986) suggests there is a deepening suspicion of rigid dichotomies between objective reality and subjective experience, fact and imagination, secular and sacred, public and private. Prigogine and Stengers (1984, p.xxvii) summarise by noting that we are, “developing a new dialogue with nature [wherein] our vision of nature is undergoing a radical change toward the multiple, the temporal and the complex”. Conversely, there is a shift away from the universal, stable and simple as asserted by early scholars and proponents of reductionist modes of thinking.

The foundations of what is referred to as ‘postmodern’ may be partially found in the systems work of von Bertalannfy (1926/1971), the developmental biology work of Piaget (1971) and the philosophy of Whitehead (1929). A synthesis of these ideas with developments in the fields of non-linear mathematics and physical chaos appears in the work of Prigogine (1980) and Prigogine and Stengers (1984), and is added to by their work in the field of non-equilibrium thermodynamics.

Prigogine (cited by Doll, 1989, p.244) received the 1977 Nobel Prize for his work on dissipative, or far-from-equilibrium thermodynamic structures. A far-from-equilibrium structure is one which is in the process of ‘becoming’. These structures are in developmental and emergent states. They are unstable and dissipative and are in formative and often chaotic states of far-from-equilibrium becoming (Prigogine, 1980).Stable structures are inert, mechanical structures which occasionally get out of balance (disequilibrium) and then settle back into a state of equilibrium.

While both types of structures exist in the world, Prigogine (1980) believes that far-from-equilibrium structures are more common. He further suggests that dissipative (far-from-equilibrium) structures are not variations of equilibrium situations. A state of equilibrium is analogous to stagnation. An example which illustrates this point is provided by Prigogine and Stengers (1984, p. 148). They refer to a basin of water with hot and cold running taps. If the taps are turned off, the basin of water will gradually resume a state of equilibrium, or loss of energy. Consequently, stagnation, or death by entropy occurs. If, however, the water is boiled or frozen, reaching the relevant temperature produces a sudden transformation of molecules (steam, ice). The change is a quantum leap. To accomplish this, Prigogine and Stengers (1984) assert that communication among molecules must occur, that is, they must communicate to reorganise. The system, therefore, acts as a whole and self-organises. Prigogine and Sengers (1984) describe this process as order arising out of chaos.

Postmodern views in education generally reflect this notion of order arising out of chaos (Berlin, 1992; Hlynka, 1991; McCracken, 1989). This idea of self-organisation and that of far-from-equilibrium structures described by (Prigogine, 1980; and Prigogine & Stengers, 1984) provide the foundations of the curriculum framework proposed here. Doll (1989) summarises three tenets of post-modern thought which emerge from the work described above and outlines the implications of these for the curriculum. These include ideas about open systems, complex structures and transformative change.

Curriculum as an open system:

Systems may be described as interactive units which may be ‘closed’ or ‘open’. Closed systems are analagous to machines. They have inputs and the machine functions as the vehicle for using the input to produce something which becomes the output. Information about the output is returned to the machine as feedback via a feedback loop. This ‘informs’ the machine about whether it should continue to function or cease operating. The machine continues to function until all the inputs cease or feedback indicates a broken part.

Doll (1989) suggests that the traditional, linear curriculum perspectives widely used are closed systems. They have pre-determined ends in the form of objectives, lesson plans which are congruent with those objectives and assessments which are designed to measure accomplishment of the pre-determined objectives. Closure is the satisfaction of the objectives. Alternatively, open systems continually change. Inputs can arise from a number of different sources and this makes change unpredictable. Open systems view reorganisation as fostering growth and transformation, and therefore seek triggers to re-organise.

A post-modern curriculum structure is one which has this capacity to reorganise. It encourages transformation to happen from within rather than by pre-determined methods. It recognises that people, equipment and the environment are an inherent part of the larger curriculum ‘system’.

Curriculum as a complex structure:

Newtonian and reductionist perspectives view existence in terms of linear trajectories, order, uniformity, harmony and simple paths. Postmodern views recognise that reality is complex and web-like with multiple interacting forces (Prigogine & Stengers, 1984; p. xxvii). Knower and known are interactively entwined and multiple interactions are occurring between elements in most situations. Consequently, predictions about how the system will respond to a given change anywhere in the system are difficult to make. This complexity also enables these dissipative structure to reorganise themselves on a higher plane rather than suffer entropy. Complex structures therefore have a history and an unpredictable and more complex future.

A postmodern curriculum structure is also complex with multiple interacting elements. The boundaries between curriculum areas are, in many instances, artificial as are boundaries between teachers and learners and experts and novices. Predictions about change are hard to make (Doll, 1989).

Curriculum as a vehicle for transformative change:

Transformation means that what once was, is now something else. Incremental change is planned, predictable and leads to stagnation (Doll, 1989). Errors made in an incremental or traditional curriculum structure are viewed as ‘wrong’ and corrected. For example, student errors on assignments are viewed as failed learning and students are made to repeat work. Transformation sees errors as necessary perturbations for growth and quantum leaps to occur. This suggests that student errors may encourage quantum leaps in curriculum tasks presented or teaching/learning strategies used.

A postmodern curriculum structure supports the process of transformation or growth; it does not contain and protect a body of knowledge (Doll, 1989). Teachers and learners are viewed as a major stimuli for transformation. They are both encouraged to combine supportive with challenging behaviour to promote a higher reorganisation of knowledge and curriculum practice.

While it is recognised that postmodern views do not hold all the answers for curriculum design (Doll, 1989; Giroux, 1988; McCracken, 1989), educators are challenged to study contemporary developments elsewhere. Many other fields of inquiry have models which pay attention to disequilibrium, internal structures, pathways of development and transformative reorganisation (Doll, 1989). Educators are advised to examine the best practice occurring outside the field of education and develop curriculum models which are multifaceted matrices. Educators are also challenged by these developments to reconsider what it means to be a ‘teacher’ (Bain, 1991).

INITIAL CONCEPTUALISATIONS OF A POST-MODERN CURRICULUM MODEL

The model of Occupational Performance (Chapparo & Ranka, 1992) presents a framework which organises occupational therapy practice around a common general theme, ‘occupational role performance’. It is a complex and interactive structure which identifies an internal environment (within a person) and an external environment (outside a person). It contains several levels of constructs with multiple interactions occurring at each level and in both environments. It recognises that the system is never passive, activity is always occurring somewhere. Any activity anywhere in the system prompts a response, there is no reductionist hierarchy. The response which occurs is felt throughout the system and may be adaptive or maladaptive. A maladaptive response exists when the system no longer accomplishes its aim; in the case of Occupational Performance, ‘Occupational Role Performance’ has been compromised (Chapparo & Ranka, 1992).

The framework of the Occupational Performance model (Chapparo & Ranka, 1992), as well as the principles and operations of the model provide a vehicle for constructing a model of a ‘postmodern’ curriculum. The remainder of this paper will focus on describing this structure, defining the major constructs and providing examples of their interactions as they relate to a curriculum .

Definition of a Postmodern Curriculum

The major construct around which this model is conceptualised is ‘postmodern’. As described earlier, this term has not been defined. It is a perspective which rejects rigid cause-effect relationships of reductionism, and dichotomies between the objective and subjective, fact and imagined, knower and known (Aronowitz & Giroux, 1991; Doll, 1989; McCracken, 1989; Prigogine & Stengers, 1984; Waters, 1986). It aims for transformation to occur within students; that is, they engage in ‘deep’ learning (Biggs, 1987) and reorganise their knowledge, skills, attitudes and values on a higher level in the process of becoming an occupational therapist.

Proposed Curriculum Framework

Structurally, this curriculum is viewed as an interactive, open and ‘living’ system in which there is interaction occurring within and between two immediate environments relative to a particular curriculum: the internal environment and the external environment. The internal environment is composed of the structures, conditions and influences that are found within a curriculum. These form an aggregate of educational activities and tasks. Constructs which are contained in the internal environment are: Educational Role, Curriculum Areas, Objectives of Curriculum Tasks and Resources. The lines indicate that interaction occurs between all levels of the internal environment (Fig. 1)

Figure 1: Internal Environment of the Curriculum

The external environment is composed of structures, conditions and influences that surround educational activities and tasks. The external environment may be equated with curriculum context. The interaction which occurs between all constructs within the system form an ongoing dialogue within and between the two environments. This dialogue occurs within the context of space and time (Fig. 2).

Figure 2: Relationship between the internal environment, external environment, space and time.

All constructs within the system are interdependent; therefore, change which occurs in any one construct will have an impact on all other constructs.

CONSTRUCTS OF THE INTERNAL ENVIRONMENT

The internal environment of the curriculum in this model is composed of interactive levels. As stated earlier, these are Educational Role, Curriculum Areas, Objectives of Curriculum Tasks and Resources (See Fig. 1).

Construct 1: Educational Role

The educational role of the curriculum is determined by a number of factors including professional demand and standard, socio-political forces influencing education, history and tradition. ‘Role’ may be equated with purpose, goal or mission. ‘Role’ is used in this model because it imparts a notion of ‘character’ thus giving the curriculum ‘life’. Accomplishment of educational roles influences and is dependent on the interaction occurring between all other constructs in the model (Fig. 3).

School of Occupational Therapy

Faculty of Health Sciences

The University of Sydney

P.O. Box 140

LIDCOMBE, N.S.W., 2141

Occupational health and occupational rehabilitation are areas of clinical practice which many occupational therapists have entered over the last 5 to 10 years in Australia (Innes, 1988). Internationally, particularly in North America, this is a similar trend.

When considered within the Occupational Performance Model (Chapparo & Ranka, 1992), it is logical for the profession to be involved in this area of practice. Occupational therapists are concerned with individuals achieving self-identified occupational roles to their level of satisfaction within their own context and environment. Productivity, self-maintenance, leisure and rest are viewed as the major occupational task areas in which an individual engages. Productivity is also identified by most people as a major life role. It is reasonable, therefore, for occupational therapists to be actively engaged in the rehabilitation of injured or ill people, enabling them to return to their major life roles in productivity. This emphasis on the return to a positive productivity role is the essence of occupational rehabilitation.

Within industrial and corporate organisations, as with individuals, there are many factors which contribute to their overall performance. In many cases the performance of an organisation is seen in terms of productivity or profitability. For managers and employers the aim is to improve an organisation’s performance through improvements in both productivity and profitability.

One of the factors which can have a detrimental effect on this performance is less than optimal employee or worker performance as a result of work-related injuries and disease, along with sub-optimal working conditions. An increasing awareness of this situation has resulted in a greater emphasis on occupational rehabilitation, and also occupational health and safety.

Occupational health can, therefore, be viewed as the proactive step of occupational rehabilitation, where potential problems and hazards are identified within a workplace. These problems are them remediated before the individual workers are affected, and their performance of their productivity roles compromised. Occupational therapy involvement in occupational health, therefore, attempts to maximise individuals’ satisfaction in their productivity roles within an optimal environment through the identification and remediation of potential problems.

This paper presents an adaptation of the Occupational Performance Model (Chapparo & Ranka, 1992) and Hunt’s (1972) Model of Organisations, as a framework for occupational therapy practice in the area of occupational health and safety. This framework is consistent with the profession’s view of individuals and applies this to organisations.

Hunt (1972) sees the performance of an organisation as being the result of the interplay between four main factors which exist within an external environment. These variables arepeople or the individual variable (those individuals within an organisation), technical or hardware (which includes aspects such as equipment, physical layout, and space),formalstructure (the rules and regulations within a company), and informal structure (encompassing the informal channels of communication, informal hierarchies of control and power) (Figure 1).

In a similar way occupational therapists perceive an individual’s occupational performance in terms of his or her occupationalrole, which is fulfilled by engagement inperformance areas (self maintenance, productivity, leisure and sleep/rest). The ability to carry out activities from these performance areas is the result of the interplay betweenperformance components (biomechanical, sensory-

motor, cognitive, interpersonal and intrapersonal). All components are necessary in varying degrees in order to carry out any occupationaltask and all interact with each other. This performance is seen within the context of an individual’s environment (physical, social, and cultural) (Figure 2).

If we are to then compare these two models, one focussed on organisation and the other on the individual, some analogies can be drawn. Whilst Hunt (1972) only considers variables operating within an environmental context, aspects such as an organisation’s mission statement and the various departments which comprise an organisation will also be considered. It is felt that, without due consideration to these aspects of an organisation, it is not possible to see the intimate links which occur throughout the system.

The occupational role of an organisation could be defined by it mission statement (Figure 3). It is the mission statement which guides an organisation’s overall focus and function, defining it’s purpose and being used to set future goals. In the same way, an individual’s occupational role defines the purpose for being and performing a wide range of activities which make up the successful performance of that role.

The performance areas of self-maintenance, productivity , leisure and rest, can be equated with the various departments within an organisation, such as Human Resources, Administration, and Production/Service Provision, which interact to enable the organisation’s mission and goals to be achieved (Figure 3). Each department performs a specific function, such as marketing the goods/services to customers. Performed in isolation, the department would be operating in a vacuum with no ultimate purpose of goal. Similarly, an individual performing occupational tasks, such as dressing or driving a car, without an ultimate purpose (e.g. satisfactorily carrying out the role of a worker), is functioning in a vacuum.

The component areas which enable successful performance of occupational tasks are equated with the four organisational variables presented by Hunt (1972) (Figure 3):

Biomechanical & Sensory-motor= Technical/Hardware

Cognitive =Formal Structure

Interpersonal = Informal Structure

Intrapersonal= People/Individual

The following describes the organisational variables (Hunt, 1992) and compares them with the component areas of the Occupational Performance Model (Chapparo & Ranka, 1992).

Hardware/TechnicalSystem: The technical and physical system includes such things as equipment, machinery, furniture, layout of offices, the buildings, the physical arrangement of employees, lighting and air conditioning.

With the individual, this aspect may be equated with the biomechanical and sensory-motor component areas.

Biomechanical - level, quality &/or degree of joint motion, muscle strength and tone, endurance, functional use of limbs and body, and gross and fine motor skills (Pedretti & Pasquinelli, 1990; Reed & Sanderson, 1983)

Sensory-motor - level, quality &/or degree of “body scheme, posture, body integration, reflex and sensory functions, visual perception & sensory-motor integration” (Pedretti & Pasquinelli, 1990).

The physical features of an organisation, therefore, are equated with the physical abilities/attributes of an individual.

FormalStructure: Within any organisation there is the need to co-ordinate and control activities between people within that organisation. There tends to be within any organisation the development of structures, hierarchies and controls. In large organisations there are more controls, rules, regulations.

This formal control and structure within an organisation is similar to the cognitive component within an individual.

Cognitive - level, quality and/or degree of comprehension, written and verbal communication, concentration, problem solving, time management, conceptualisation, integration of learning, judgement and time-place-person orientation (Pedretti & Pasquinelli, 1990; Reed & Sanderson, 1983).

The cognitive component, therefore, structures and organises. It is aware of and creates hierarchies, and rules to deal with the world.

InformalStructure: Hunt described this as a “complex network of relationships among different members who are attracted to one another for non-formal reasons. Work, similar interests, friendship, education, age and sex are only some of the reasons for the formation of such interpersonal relationships… Attitudes about friendship, about social and leisure activities and about common problems produce a much looser structure of informal, interpersonal ties which are based on face-to-

face communications” (Hunt, 1972, p.14). The office “grapevine” is part of this informal structure and especially important.

The interaction and communication at this informal level results in interpersonal relationships within an organisation, which is similar to the interpersonal component of an individual’s occupational performance.

Interpersonal - level, quality &/or degree of dyadic (relationships to peers, subordinates and authority figures; demonstrating trust, respect and engaging and sustaining interdependent relationships; communicating feelings) and group interaction (abilities in performing tasks in the presence of others; sharing tasks with others; cooperating and competing with others; fulfilling a variety of group membership roles; exercising leadership skills; perceiving and responding to the needs of group members) skills (Reed & Sanderson, 1983).

The similarity between the informal structure and the interpersonal component is relatively self-evident in terms of the focus on relationships between people.

IndividualVariable/People: The individual variable of people is an integral part of all organisations. Without them organisations would simply not exist. We must therefore recognise that all other variables are dependent on this one. It is also necessary to also recognise that each individual has a multitude of needs. It may include characteristics of individuals (psychological and physical factors, health behaviours, attitudes, beliefs, sociodemographic factors) (Sloan & Gruman, 1988).

Within each individual this is the unique personality that each of us possesses which makes us different. This is reflected in the intrapersonal component.

Intrapersonal - level, quality and/or degree of self-identity, self-concept, coping behaviours, defence mechanisms, emotional states and feelings (Pedretti & Pasquinelli, 1990; Reed & Sanderson, 1983).

ExternalPressures/Environment: Organisations and individuals do not exist in a vacuum. They are part of a larger social system. Society and the structures within it also have an effect on performance. For example, the laws governing Occupational Health and Safety and Workers’ Compensation may influence the type of policies, programs and approaches to health many organisations adopt, or economic pressures may influence the speed of production. Individuals in turn are influenced by their physical, social and cultural environments, which may include some of these environmental factors affecting organisations.

Perhaps the clearest way of explaining these models is through the use of an example:

Company X had an unacceptably high level of work-related back pain and overuse injuries. The company introduced a lifting and handling education program to deal with the back injury problem and new ergonomically designed furniture for the overuse injury problem. Unfortunately, although there was some initial improvement, there was no apparent sustained, long-

term benefit. The question asked by management was “What went wrong?”

Unfortunately this scenario has an all too familiar ring to it. Nothing may have gone wrong, but perhaps Company X did not consider ALL the factors which contribute to the overall performance of an organisation, and their interaction and interplay.

The components or variables which affect performance in the individual or the organisation are interdependent and interact with one another. A change in any one component may produce changes in another. For example, educating an individual about correct body mechanics and fitness [cognitive] may result in a decrease in pain levels and improvement in posture [sensory-motor], an increase in range of motion and endurance [biomechanical], an improvement in self-esteem and coping behaviours [intrapersonal] and a resultant improvement in personal relationships within the family [interpersonal]. This may be hoped for, but we are aware that this outcome is more the exception than the rule.

The converse is probably a more realistic situation, where treating only one aspect of an individual will not necessarily result in overall improvement in performance. For this reason most occupational therapy interventions are necessarily multi-

faceted.

The occupational therapist may provide education [cognitive] regarding correct body mechanics and fitness, develop a work conditioning program to increase strength and endurance [biomechanical], incorporate the use of biofeedback and relaxation training for pain management [sensory-motor] and to instil a sense of personal control for the individual [intrapersonal], AND involve the family in the treatment to reinforce positive health behaviours at home [interpersonal]. Perhaps this scenario sounds more familiar?

It is highly unlikely that only one performance component would be addressed without consideration also being given to these other factors.

It is necessary to consider all performance component areas and how these aspects inter-relate. This is not a new concept to most, however, it is important to take into account all aspects of the individual to ensure that the all aspects are considered. What may be new or different is to apply this concept to organisations in the area of occupational health.

By considering organisations in a similar way in which we view individuals, it is possible to become aware of the interplay between variables. It is vital to understand this interplay and inter-relationship if an effective overall intervention program is to be developed. It is not possible to focus on any one variable without recognising the effect that change may have on other variables, or the influence that other factors may have on a single component.

Going back to Company X, sustained improvement may have occurred if consideration had been given to a comprehensive program encompassing all variables. Some examples of other variables which may have been considered by Company X are:

FormalStructure:

*A policy stipulating the maximum weight of packaged products produced in this factory is less than 15 kgs. Where this is not possible, mechanical lifting equipment will be provided.

*A policy which acknowledges that employees who return to work following a prolonged absence (more than 4 weeks) will be permitted to upgrade to their pre-leave level of performance over a period of x day/weeks.

InformalStructure:

*Discussion of health and safety issues with staff representatives, selected by their peers, not only managers, supervisors and union representatives [formal].

*Identification of informal power brokers and attitudes to problems or proposed changes.

Technical/Hardware:

*Provision of equipment and an environment which promotes health and safety – e.g. lifting devices, benches at appropriate heights, adequate lighting, noise reduction, etc. These tend to be aspects which are readily identified and focussed on as the only areas requiring change or intervention.

IndividualVariable:

*Determining the level of knowledge and skill individuals possess; level of language skills (including literacy in spoken and written english and/or other languages); level of training and education required by individual employees.

A criticism of this approach is that it is not possible to make all these changes – access to all necessary avenues of influence may be limited. By the same token, this criticism could also be levelled at consideration of all performance components within the individual. Occupational therapists recognise that there may be aspects within some of our clients where little, if any influence may occur, but this does not negate the fact that this aspect is taken into consideration when planning a treatment program or intervention strategy. Similarly, it may not be possible to implement an occupational rehabilitation or occupational health and safety program within an organisation which encompasses ALL the variables in the detail outlined, however, it should not stop the therapist questioning these areas and determining how they may impact on the overall intervention.

Hunt’s (1972) model of an organisation’s performance has been compared with the Occupational Performance Model (Chapparo & Ranka, 1992) and adaptation made to provide a framework for practice for occupational therapy in the area of occupational health and safety. If the variables which affect an organisation’s performance are considered in the same way in which an individual’s performance is perceived, it is possible to use this framework for practice in both occupational rehabilitation [productivity for individuals] and occupational health [prevention of injuries within organisations]. By doing so, occupational therapists will be able to provide a high quality, comprehensive service within an organisation which is acceptable to management and which reflects the basic premises and tenets of the profession.

References:

Chapparo, C. & Ranka, J. (1992).The model of occupationalperformance. [Handout available from the School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Lidcombe, N.S.W., 2141, Australia.]

Hunt, J.W. (1972).The restless organisation. Sydney: John Wiley & Sons.

Innes, E. (1988). Occupational therapy: Still at work.AustralianOccupational Therapy Journal, 35(4), 173-180.

Pedretti, L.W. & Pasquinelli, S. (1990). A frame of reference for occupational therapy in physical dysfunction. In L.W. Pedretti & B. Zoltan (Eds.), Occupational therapy: Practice skills forphysical dysfunction (3rd ed.) (pp.1-

17). St Louis: C.V. Mosby.

Reed, K.L. & Sanderson, S.R. (1983).Concepts of occupationaltherapy (2nd ed.). Baltimore: Williams & Wilkins.

Sloan, R.P. & Gruman, J.G. (1988). Participation in workplace health promotion programs: The contribution of health and organisational factors. Health Education Quarterly, 15(3), 269-288.

Jill Hummell, Diana Barnett and Sharon Doyle

Based on a performance indicators document produced by Westmead Hospital, November, 1994 and a paper presented at the 6th State Conference of OT Australia AAOT-NSW, Mudgee, NSW (1993, October)

JillHummell, BA,MADipOT, is a lecturer in the School of OccupationalTherapy, The University of Sydney. At the time of writing theoriginal paper and document, she was Deputy Manager, OccupationalTherapy Department, Westmead Hospital, Westmead, NSW.

DianaBarnett BAppSc(OT) is a therapist at The New Children’s Hospital,Westmead, NSW. At the time of writing the original paper anddocument, Diana was an occupational therapy Student Unit Supervisorat Westmead Hospital, Westmead, NSW.

SharonDoyle BAppSc(OT) is a therapist at The New Children’s Hospital,Westmead, NSW. At the time of writing the original document, Sharonwas an occupational therapist at Westmead Hospital, Westmead, NSW.

INTRODUCTION

It is essential for occupational therapy to be effective and efficient and optimize the use of scarce resources. A strategy which can be used within an overal plan to evaluate services, promote accountability and quality mangement is the use of process and outcome measures. These measures can be viewed as one method of collecting and analyzing quantifiable effects of occupational therapy intervention with the aim of using the data to maintain a continuous cycle of quality improvement. In addition, the process and outcome measures can form the basis from which empirical research can be developed and implemented.

Although evaluation has long been one aspect of the occupational therapy process (Hagedorn, 1992; Hopkins & Tiffany, 1978), in the current economic climate, it is critical that evaluation is based on quantifiable measures. The Australian Council of Health Care Standards (ACHS, 1992; 1995) maintains that a range of quality activities which address both processes and results must be utilized to evaluate and improve patient/client care.

Recent occupational therapy literature, including Austin and Clark (1993), Barnett and Hummell (1994), Hammell (1994), Noyce (1993) and Rogers and Holm (1994), has raised many issues relevant to measuring outcomes of occupational therapy services. In addition, these authors have identified strategies which can be used to measure the effects of intervention.

PURPOSEOF THIS PAPER

This paper outlines the evolution of process and outcome measures originally developed in the Paediatric Area of the Occupational Therapy Department at Westmead Hospital as well as our later revisions. Examples of the process and outcome measures used are provided. Information about documenting these measures, benefits encountered and future plans are included in addition to recommendations for occupational therapists who which to develop measures for their service.

The method of developing, implementing and evaluating process and outcome measures

described in this paper is one of a range of methods. Each occupational therapy service needs to determine the method/s and measures which are most meaningful to that service.

We anticipate that we will continue to evaluate and modify the information contained in this paper. Process and outcome measures consistent with other aspects of occupational therapy services need to be regularly evaluated and improved.

We have chosen to document process and outcome measures using a positive framework (Muhlenhaupt, 1991). An example of a positive outcome measure is “increased skill in self care activities”. Primary reasons for using a positive framework include:

*Relative to process measures there is consistency with the procedures involved in the occupational therapy process of assessment, goal setting, intervention and evaluation.

*Relative to outcome measures, there is consistency with individual and programme goals of direct intervention.

DEFINITIONS

The terms ‘process measures’ and ‘outcome measures’ have been used to identify the two different types of measures we believe are most relevant to occupational therapy direct intervention services. Both are measures “used to review performance” (Noyce, 1993.p.1).

Aprocess measure is a documented measure of an activity, for example,an assessment, which is in engaged in with/for a client (Noyce, 1993).

Barnett and Hummell (1994) suggest that process measures are developed after identifying the optimal procedures in the occupational therapy process of assessment, goal setting, intervention and evaluation of direct intervention with each client caseload/subgroup.

Anoutcome measure is a documented measure of the results ofintervention, for example client progress, as a direct or indirectresult of intervention provided (ACHS, 1995; Noyce, 1993)

Outcome measures are “a means of assessing the impact of intervention” (Hammell, 1995.p.46). They need to be sensitive (Hammell, 1994; Velozo, 1994), objective (Rogers & Holm 1994), meaningful (Atkins & Clark, 1993; Barnett & Hummell, 1994; Noyce, 1993) and reliable (Hammell, 1994). In addition, they need to provide information about the unique contribution of occupational therapy services to individual clients and client groups (Barnett & Hummell, 1994; Hammell, 1994; Velozo, 1994).

We recommend that process and outcome measures are developed for specific client caseloads/subgroups and services. Some measures may be useful across client caseloads and services and others may not. The examples we provide in this paper may be meaningful or may require partial or complete revision to obtain data appropriate to other settings.

Generating process and outcome measures is followed by data collection, collation and analysis. The results of the analysis and ensuing recommendations for changes, if these are required to improve the service, are documented. These changes are implemented and the cycle continues (Austin & Clark, 1993; Barnett & Hummell, 1994).

EVOLUTIONOF PROCESS AND OUTCOME MEASURES

The original process and outcome measures were developed for the client caseload for children with perceptual motor difficulties and their families (Barnett & Hummell, 1994). The primary reason for this was that the client management protocols for this population were being reviewed. Focussing on a single client caseload assisted in making the task achievable.

Two tools were employed to assist in developing these measures. First, existing occupational performance models were used to construct a framework for developing performance indicators (Chapparo & Ranka, 1993; Pedretti & Pasquinelli, 1990). Occupational performance was used because it offered the greatest scope for describing the focus of occupational therapy practice for children with perceptual motor difficulties at the time.

Second, principles of flow charting (McConnell, 1989) were used to facilitate our understanding of the optimal procedures followed in the occupational therapy process of assessment, goal setting, intervention and evaluation of direct intervention. The process measures developed were based on the outcome of the flow charting.

After successfully trialling the assessment and process measures, additional ones were developed for children with perceptual motor difficulties. Simultaneously, measures were developed for other client caseloads. Developing and trialling these later process and outcome measures was achieved much more efficiently than the original ones for a range of reasons including:

*practice

*many of the original measures were directly applicable to other client caseloads, or required minor modifications

Some were inappropriate and new ones were developed specific to the new client caseload. For example, children who had conditions/disorders which resulted in occupational therapy which targetted maintenance of skills with or without aids or equipment, outcome measures were modified to reflect this.

PROCESSPERFORMANCE INDICATORS

The procedures that constitute occupational therapy managment for children with perceptual motor difficulties from the receipt of referral to discharge are illustrated by the flow chart in Appendix 1 (Barnett & Hummell, 1994.pp 16-18). Charting the procedures allowed us to identify the essential and optional processes at each stage of occupational therapy intervention (for example, referral, gather data). The essential processes became ourprocess measures and are outlined as follows (Barnett & Hummell, 1994):

Assessment

*Initial interview is completed

*Relevant non-standardised assessments are completed

*Relevant standardised assessments are

completed

*Assessment findings are discussed with parents and child at the appointment following assessment or via telephone within two weeks of assessment, as negotiated with parents and children.

Aimsand Goal Setting

*Treatment aims/broad goals are determined collaboratively between the child, family members and therapist (including other team members when appropriate).

DocumentingGoals

*Goals are documented in the therapy file.

ReportWriting – Outpatients

*Initial report is written by the sixth appointment

*Letter/report is sent to referring doctor and parents.

*Initial report and/or review report/discharge report is written and sent to appropriate personnel with parent/guardian’s permission.

Documentation- Outpatients

*Relevant information is documented into therapy file immediately after each client contact.

Evaluation

*The child’s progress is formally evaluated at a time determined with the client and family, when the goals are set.

OUTCOMEMEASURES

The initial outcome measures were determined through group discussion about the primary presenting problems of children with perceptual motor difficulties and therefore the primary aims/goals of occupational therapy intervention (Barnett & Hummell, 1994). Later, outcomes

measures were developed for children from a range of other client caseloads. All outcome measures were developed which:

*retainedand promoted the individualised nature of occupational therapyintervention

*capturedthe essence of occupational therapy involvement with children andtheir families

These two characteristics were achieved by documenting individual goals and consequently outcome measures using the Occupational Performance Model (Australia) (Chapparo & Ranka, 1993). Consistent with this occupational performance model, the outcome measures were documented relative to those occupational roles, occupational performance areas and occupational performance components. that were most frequently identified as occupational therapy treatment goals with children from each specific client caseload. Examples are detailed below.

1.OccupationalRoles

*Satisfaction with occupational roles – self maintainer and/or player and/or school or pre-school student – relative to the current physical, cultural and social environments, as determined collaboratively with the child and family.

* Increased independence with occupational role performance

2.OccupationalPerformance Area Tasks

Productivity

*improved handwriting

A number of more detailed performance indicators were drafted in the occupational performance area of productivity for handwriting. These included:

ProductivityOutcome Measure

Improvedhandwriting

Examples of more specific outcome measures for handwriting tasks and subtasks

Increasedspeed of writing

Increasedquality of writing

-spacing

-size

-neatness

-formationof letters

Increasedquantity of writing

Increasedconsistency of writing

Increasedendurance when writing

Improvedposture when writing

Improvedgrip when writing

Play

*increased engagement in age appropriate play

SelfMaintenance

*increased skill in self care sub tasks, tasks and routines

A number of more detailed outcome measures were developed for these areas. For example, in the occupational performance area of self maintenance, detailed outcome measures were structured as follows.

SelfMaintenance Outcome Measure

Increasedskill in self maintenance subtasks, tasks and routines

Examples of more specific outcome measures within this performance area include:

Mealtime Routines

Increasedskill with utensils

Increasedskill with pouring a drink

Improvedsocial behaviour at mealtimes

Dressing Routines

Increasedskill with dressing

Increasingskill with undressing

Increasedskill with fastenings

Increasedskill with buttons

Increasedskill with shoelaces

Personal Hygiene Routines

Increasedskill with bathing

Increasedskill with cleaning teeth

Increasedskill with combing hair

Increasedskill with drying self

Increasedskill with washing self

The outcome measures listed here are not considered inclusive of all occupational therapy intervention aims/broad goals for children. They are examples which demonstrate the varying levels of specificity of outcome measures that can be developed.

Sleep/Rest

* Increasedbalance betweensleep/rest and activity routines

3.OccupationalPerformance Components

The following are examples of outcome measures relevant to each performance component.

Sensorymotor

*Improvedmotor control appropriate to occupational tasks, subtasks androutines

Biomechanical

*Increasedrange of motion required to perform occupational subtasks, tasks androutines

Cognitive

* Increasedsustained attention to an occupational task, subtask and routine

Interpersonal

*Improvedpeer interaction during occupational tasks, subtasks and routines

Intrapersonal

*Increasedperseverence when participating in occupational tasks, subtasks, androutines

4.ExternalEnvironment

The following are examples of outcome measures developed relevant to external environments.

PhysicalEnvironment

* Increasedaccessability to home/leisure/school environments

SocioculturalEnvironment

*Increasedability of carers to safely and effective care for their child’soccupational needs

*Parentscan identify positive qualities/skills in their child’s occupationalperformance

SensoryEnvironment

* Parentsconfidently handle and position their child for occupationalperformance tasks, subtasks and routines

*Parentprovide developmentally appropriate toys for their child’s leisureneeds

Consistent with the individualised nature of occupational therapy intervention with children who have perceptual motor difficulties, individual goals are initially developed collboratively with the child and his/her family prior to intervention and after assessment, as outlined in the flow process chart in Appendix 1. The content of short and long term goals are documented in a manner that is consistent with major constructs in the Occupational Performance Model (Australia), 1993.

Whether or not the goals are achieved is the measureable aspect of the outcome performance indicator.

DATACOLLECTION FORMAT

Data is collected for each child who received intervention and for the relevant caseload.

Data collection forms are used to document the extent to which process measures have been completed, and outcome measures achieved. One form is used to document process and outcome measures for each child, and another form, to collate information for each client caseload.

IndividualChild Data

The process and outcome measures for each child are documented onto the goal sheet in Figure 1 (Barnett & Hummell, 1994). On this sheet, the completion of process measures is indicated by a date in the relevant space. A blank space indicates non completion. The abbreviations on the top right hand side of this form are explained in the accompanying key (See Figure 1).

The achievement of outcome measures is indicated using a 1 – 4 rating scale and placing the relevant number in the ‘outcome measure’ column. Figure 1 provides an example of this documentation. It must be remembered that these goals are set with the child and parents and are considered high priorities by them at the time. The information obtained from each child is subsequently collated onto the caseload process and outcome measure forms.

Figure1: Goal Sheet and Key to Abbreviations

CaseloadData

The data collected for each client caseload is collated onto the caseload process and outcome measure forms prior to data analysis (Barnett & Hummell, 1994). Relevant comments are also transferred onto this form. The figures below provide examples of caseload process (Figure 2) and outcome measures (Figure 3) forms.

Figure2: Process Measures Form

(Adapted from form developed at

Westmead Hospital, September, 1994)

TimeFrame

A time frame for the collection and analysis of data needs to be determined relevant to each client caseload. For example, if initial contracts for therapy are approximately three to four months for children with perceptual motor

Figure3: Outcome Measures

Form(Adapted from form developed at Westmead Hospital, September, 1994) difficulties, process and outcome measures are collated and analyzed approximately every four months. Time frames for collation and analysis for process and outcome measures may vary for different caseloads.

DATAANALYSIS

Calculationof Percentages

Once the data has been collated for each client caseload onto the appropriate form, percentages are calculated (See Figures 2 and 3).

To calculate percentages for each process and outcome measure the following method is suggested (Barnett & Hummell, 1994):

Process Measures Numerator =The number of children for each completed process measure. Denominator =The number of children in the relevant caseload who attended occupational therapy.

Outcome Measures Numerator=All children who achieved their documented goal for the relevant outcome measure.

Denominator=All children who had a documented goal for the relevant outcome measure.

Analysis

The collated data, with the percentages of children who achieved their stated goals in relevant occupational roles, occupational performance area and occupational performance components, in addition to meaningul comments, is analysed (See Figure 4). Given that one child

Figure4: Outcome measure data analysis may have a number of goals documented in one performance role, area, or component category the collated data is no longer relevant to the number of children who have achieved these outcomes, but to programme outcomes.

Any comments noted on the child’s individual goal sheet (See Figure 1), are important for data analysis. For example, a child may not have achieved his/her stated goals, but a major event in the child’s life may have occurred which explained this outcome. Data is similarly analyzed for process measures.

As a group, all occupational therapists involved with the relevant caseload are given an opportunity to discuss the results of the documented process and outcome measures for the caseload. For each process measure, the percentage completed are discussed. For each outcome measure, the percentage of goals achieved or not achieved are discussed. Issues relevant for discussion with each client caseload when reviewing the data have been found to include:

*In terms of percentages, what are the outcomes of occupational therapy intervention programmes.

*Are occupational therapy intervention programmes more effective in achieving some goals/skills than others?

*For those goals/skills for which intervention is less effective, are different intervention strategies required or is there another service/profession to which referrals should be made?

*Are the documented goals appropriate, do they represent the current priorities; are they too difficult; too easy?

*Are the documented procedures (process measures) being followed? If not, do they need to be changed?

The following categories may be useful when analysing the data (QRB), 1989).

Client issues

These include the perceived level of motivation, and/or health, for example the child was ill during the period of intervention.

Therapist issues

These include the quality of the therapeutic relationship and the therapists expertise in intervention and goal setting.

Organisational issues

These include the available resources, for example, space and equipment to carry out intervention.

REVIEW

It is important to regularly review the process and outcome measures. When reviewing them, issues to consider can be summarised by the following questions.

Dothe process and outcome measures provide meaningful data?

Arethey the most appropriate measures to use?

Dothey achieve their stated purpose?

Dothey require modification or elimination?

In addition, it is important to regularly review the data collection format and data analysis process.

FUTUREPLANS

Future plans for process and outcome measures include the following:

*determining and developing additional specific outcome measures

*reviewing the frequency of data collection

*investigating the computerization of documentation and data collection

*integrating the measures with statistics collected

*reviewing relevant literature on an ongoing basis

*engaging in outcome research studies

BENEFITS

The benefits encountered by the occupational therapists involved in the development of these process and outcome measures have both direct and indirect. They have included the following (Barnett & Hummell, 1994):

*improved skills in goal setting and clinical reasoning

*clarification of the goals of occupational therapy intervention at both an individual and programme level

*discussions and clarification of the appropriate focus and priorities of occupational therapy intervention, evaluation and procedures

*philosophical and clinical discussions about occupational therapy including sharing information and networking within and between departments

*provided data on the effectiveness of direct occupational therapy intervention and a formal review of client mangement protocols and outcomes at a programme level

*improved skills in the development of data collection forms and data analysis

*increased confidence with clarification of the occupational therapy role, and data demonstrating the effectiveness of intervention

RECOMMENDATIONS

The following recommendations are made for people who wish to develop, implement and evaluate process and outcome measures in their services (Barnett & Hummell, 1994)

1) Review client management protocols

2) Link the development of process performance indicators with existing protocols

3) Use group discussion as a means of developing, analysing and reviewing measures

4) Develop a small number, 2 – 3, outcome measures which are meaningful and reflect the priority of the service. These may be caseload specific or across all caseloads.

5) Develop forms for recording process and outcome measures.

6) Trial the forms and analyse the data collected

7) Implement recommended changes

8) Review/evaluate forms used and the value of the measures developed

9) Develop additional process and outcome measures and continue the process outlined.

SUMMARY

This paper has outlined the evolution of process and outcome measures for children which were initially developed at Westmead Hospital, and our later revisions. Data collection and data analysis procedures have been discussed. The need to regularly review the measures developed and the data collection format was stressed. Future plans and the benefits of engaging in this process of developing performance indicators along with recommendations are provided for those interested in developing process and outcome measures for their service.

CONCLUSION

It is hoped that we have provided a strategy for the development, implementation and evaluation of process and outcome measures for occupational therapists. As stated earlier, this is one method of developing process and outcome

measures. Measures need to be relevant to the caseload of clients seen and the existing protocols within the service delivery system.

It is helpful to use a practice model to assist in the generation and revision of process and outcome measures. The Occupational Performance Model (Australia) (1993) contains the necessary scope to do this. The constructs within this model, particularly occupational roles, occupational performance areas and occupational performance components reflect the scope and diversity of occupational therapy intervention that occupational therapists offer to children with a range of presenting problems, and their families.

ACKNOWLEDGEMENTS

The authors acknowledge the paediatric occupational therapists from Westmead Hospital and The New Children’s Hospital (formerly Royal Alexandra Hospital for Children) who assisted in the development of the process and outcome measures. We acknowledge the encouragement provided by Sue Robinson for the original project.

References

Austin, C., & Clark, C.R. (1993) Measures of outcome: For whom? BritishJournal of Occupational Therapy, 56(1), 21-24

Barnett, D. & Hummell, J. (1994) Performance indicators for

occupationaltherapists working with children who have perceptual motordifficulties, and their families. (Available from the Occupational Therapy Department, Westmead Hospital, Westmead, NSW) November.

Chapparo, C., & Ranka, J. (1993, October) Occupational

performance:a practice model for occupational therapy. Paper presented at the OTAustralia AAOT-NSW 6th State Conference, Mudgee, NSW

Characteristics of clinical indicators (1989) Quality Review

Bulletin,November, 330-339

Caddow, P. (1986) Questions on quality. Nursing Times, July 16, 42-43

Hagedorn, R. (1992) Occupational therapy, foundations and

practice. London:Churchill Livingstone.

Hammell, K.R.W. (1994) Establishing objectives in occupational therapy practice. Part 2. British Journal of Occupational Therapy, 57(2) p 45-48

Hopkins, H.L. & Tiffany, E.G. (1978)Occupational therapy – a

problem solving process. In H.L. Hopkins and H.D. Smith (Eds.). Willardand Spackman’s Occupational Therapy (5th Ed.). Philadelphia: J.B. Lippincott

Lehmann, R. (1989) Forum on clinical indicator development; a discussion on the use and development of indicators. Quality Review Bulletin,July, 223-227

McConnell, J. (1989) The seven tools of TQC. (3rd Ed.). Delware Group: Dee Why, NSW

Muhlenhaupt, M. (1991) Components of the program planning

process. In W. Dunn (Ed.). Paediatric occupational therapy: Facilitatingeffective service provision (pp. 124-136), New Jersey: Slack Inc.

Noyce, J.A. (1993 April) Performance indicators – A summary for occupational therapists.Newsletter of the NSWAOT, Edition 307, 14-16

NSW Association of Occupational Therapists Performance

Indicators Working Party. (1993, October). Performance indicators foroccupational therapists – draft 2. (Available from OTAustralia AAOT-NSW, PO Box 142, Ryde, NSW, 2112)

Pedretti, L & Pasquinelli, S. (1990) A frame of reference for

occupational therapy in physical dysfunction. In L. Pedretti, and B Zoltan, (Eds.). Occupational therapy: Practice skills for physicaldysfunction (3rd ed.) (pp. 1-16). St. Louis: C.V. Mosby.

Rogers, J.C., & Holm, M.B. (1994) Accepting the challenge of

outcome research: Examining the effectiveness of occupational therapy practice. American Journal of Occupational Therapy, 48(10), 871-876

Schnieden, H. (1988) Management and performance indicators – is a backlash possible?Hospital and Health Services Review, February, 28-29

The Australian Council on Healthcare Standards (1995)Charter forchange: The framework. Sydney, ACHS.

The Australian Council on Healthcare Standards (1991) Clinicalindicators: a user’s manual – hospital wide medical indicators. Sydney: ACHS

Thomas, J.W. (1990) The issue is not the useability of claims data but the quality of the indicators.Quality Review Bulletin, December. 422-423

Velozo, C.A. (1994) Should occupational therapists choose a single functional outcome measure? American Journal of Occupational Therapy, 48(10) 946-947

APPENDIX

Paper presented as, “Application of a model of occupational therapy practice in a rehabilitation setting” at the 18th Federal and Inaugural Pacific Rim Conference of OT Australia, Hobart, Tasmania (1995, July).

SandraColyer is currently employed as the NSW Home Healthcare Consultant,Faulding Home Healthcare, Pty Ltd. At the time of writing this papershe was the Director of Occupational Therapy Services at the RoyalRehabilitation Centre Sydney.

PUBLISHEDABSTRACT:

This paper outlines the application of a Model of O.T. Practice in a rehabilitation setting. The royal Rehabilitation Centre Sydney is a large rehabilitation centre in Sydney that has several specialised units including spinal, neurological, brain injury and orthopaedics. As a response to organisational changes in the management structure at the centre and changes in Government policy in relation to the delivery and accountability of health care service, the Occupational Therapy Service decided to adopt a Model of O.T. practice. The aim of this was to assist in uniting the Occupational Therapy staff through this changing time and to help define the Occupational Therapy Service for the future. This paper, therefore, outlines the practical implementation of a Model in a rehabilitation setting and its impact on the attitudes of both the Occupational Therapy staff and centre staff towards Occupational Therapy practice. This paper looks at the benefits of having one Model as a guide to which language and report writing are based.As we move to the future and the needs to be more accountable it is important that the Occupational Therapy profession has a more united front with a special confidence in what we can offer. This paper may hold some of the answers to this.

PAPERPRESENTED:

PURPOSE

The aim of this paper is to describe how the model of Occupational Performance (Chapparo, & Ranka, 1992) was used to unite services in a large occupational therapy department which has a devolved unit structure and diverse areas of practice.

BACKGROUND

The Royal Rehabilitation Centre Sydney provides services to clients requiring rehabilitation. It is predominantly funded by the State Government but has a number of other sources of government and private funding. The Centre consists of several specialised units which include Brain Injury, Spinal Cord Injury, Orthopaedics, Neurology, Aged Care and Residential Care.

The structure of the Centre has recently moved towards business units and a matrix system where staff are responsible and accountable to both a Unit Manager and Service Director, or professional head. The aim of the unit structure is to provide specialised customer-focused services to specific groups of clients within a defined budget. These changes have come about in response to the ‘shrinking’ health care dollar and, therefore, the need to rationalise client services.

I commenced my position as Director of Occupational Therapy Services at the Centre 20 months ago when the new matrix management structure was being implemented. The occupational therapy staff consist of 18 occupational therapists and 12 support staff including diversional therapists, recreational staff and occupational therapy assistants. All these staff are allocated to the specialised units and there is little opportunity for rotation.

Soon after my appointment, all professional groups at the Centre were being asked to define the service they were providing and to predict the future direction of services in light of this changing climate. As a manager, I assessed that this time of change was difficult for staff of both the Occupational Therapy Service and the Centre.

I saw two significant factors which were impacting on both occupational therapy service provision and development of the Service. These were 1) the structural changes occurring throughout the Centre, and 2) the apparent diversity of training and skills within the occupational therapy staff. I decided my main role as a new manager was to assist the occupational therapy staff through this change, and that this could occur by two primary means:

First,there needed to be mechanisms put in place that would unite theservice and assist staff in maintaining professional cohesion.

I believed that establishing professional cohesion would ensure a support network that appeared to be threatened by the unit structure. This was also important because, apart from the new unit structure, I observed difficulties in communication between the occupational therapy staff.

We assume as occupational therapists that our language is the same. Experience indicates that when occupational therapists communicated, they actually alienated each other by using unfamiliar language and interpreting the same language in different ways. For example, try asking the person next to you what ADL or Activities of Daily Living means. I am sure it varies from your definition! This could be due to a variety of factors such as those experienced at the Centre. The occupational therapists I work with are from various educational backgrounds which have shaped their individual language. For example, some have degrees, others have diplomas; some trained in Australia, others overseas; some trained recently and others years ago; some trained in programs which are structured around a specific theoretical model and others had a more general training; some have backgrounds in acute care, some rehabilitation and others community, etc. The support staff are also an integral part of the Occupational Therapy service and their backgrounds are even more varied. Overall, this diversity in backgrounds significantly impacted on communication styles and led to misunderstandings amongst the occupational therapy staff, which in turn impacted on interaction with other health professionals. The physical separation created by the unit structure compounded the situation.

Second,staff needed to be given ownership of the present and any futurechanges.

I was concerned that staff felt in control of the process and that changes taking place in the Centre and the Department were not imposed on them. To achieve unity, they needed to be involved in shaping the change.

The major question I was faced with was, “What mechanisms would enable us to achieve unity as an occupational therapy service?” I believed this required a clear and common sense of identity. Occupational therapy however has had a long history of difficulty defining its role. Occupational therapists know instinctively what their role is but how effectively is this role communicated to others? If the profession has difficulty explaining itself now, how is it going to educate others about where it wants to be in the future? How were we to explain where we wanted to be as a Service in the future?

USINGTHE MODEL OF OCCUPATIONAL PERFORMANCE TO ESTABLISH DEPARTMENTAL UNITY

One solution to developing a sense of unity and identity and to providing structure to occupational therapy services is to find a

common language. The model of Occupational Performance (Chapparo, & Ranka, 1992) appeared to have a language and structure that could be easily adapted to meet our needs.

Barriersto implementation

The process of deciding how to utilise the model had several barriers that needed consideration

First, the impact of educational training of occupational therapy staff as previously outlined.

Second, the impact of diversity of personalities and learning styles; for example, it seemed that those who prefer structure embraced the model with fewer reservations.

Third, the differing perceptions of service provision; for example, some occupational therapists viewed the service provided to spinal clients as being very different to the service given to aged care clients. Some staff had conceptual difficulties in regarding these as fundamentally similar.

Fourth, there were expectations of occupational therapy practice held by other health professionals which impacted on the process; for example, some staff in other departments had expectations of what occupational therapy service delivery should be based on historical practises within the Centre.

Implementation:

The occupational therapists could see a need for unity and some structure, and were willing to challenge themselves and their work habits. They eventually reached consensus that the model of Occupational Performance (Chapparo, & Ranka, 1992) is both adaptable and comprehensive and could be used to explain occupational therapy practice in each of the specialised services. It also was congruent with the views of different therapists and their different styles of practice.

The time frame for the introduction of the Model was approximately 12 months although it is recognised that this will be an ongoing process

as new staff enter the Service and continual changes occur within the health care area. At the time of this presentation we are nearing the end of this 12 month period.

BENEFITSOF USING OCCUPATIONAL PERFORMANCE:

The Service has recently seen the benefits of utilising the Model as evident in the following examples:

Definingthe Service

First, the Model provided a clinical framework in which occupational therapists defined their services. These definitions all focused on addressing the occupational need of clients and enhancing occupational performance. The Model provided a structure that was easily conceptualised and, consequently, clearly illustrated the existing Occupational Therapy Service. With this knowledge the occupational therapy staff were able to identify both a rationale for existing services and could easily identify future changes in service delivery. For example, previously, occupational therapists working in Neurology focused specific intervention sessions on component operations such as biomechanical components and cognitive components. However, now there is a need for us to look more clearly at how component- focused interventions (eg., neurodevelopmental therapy) contribute to or enhance a client’s ability to function in their own environment (occupational role performance).

From a manager’s perspective the constructs and structure of the Model provided a framework from which policies and procedures for occupational therapy services in each of the Units in the Centre could be established and still reflect a common view of what occupational therapy is (eg. addresses clients occupational needs). From these we were also able to develop an outline for standards of clinical performance.

StrategicPlanning:

As a result of being clearer about our present role, we were able to devise a strategic plan which clearly identifies future directions of the Service. In order to achieve the marketing goal in our strategic plan, we recently utilised the Model to identify photographs that depicted the roles of occupational therapy within the Centre. This process only took half an hour because we didn’t have to spend time discussing what the focus of service is in the various Units.

ReportWriting:

Report writing has always been a difficult area for occupational therapists to reach consensus on what headings should be included and what should be documented under these headings. Previously, staff had adapted old formats to suit their service area according to how they had conceptualised the occupational therapy role. This was time consuming, lacked accuracy and was inconsistent in content across the Occupational Therapy Service.

Currently, the Occupational Therapy Service is using the Model to develop a series of report writing formats which cover the performance areas identified in the model (Occupational Roles, Occupational Areas, Components of Occupational Performance, Core Elements, Environment, Space & Time) and therefore report writing is becoming standardised over all Units.

Otherareas:

Other areas in which the Model has been utilised are reporting at case conferences, student education and formats for case presentations and job descriptions. I am happy to discuss these at the end of this paper.

SUMMARY:

In conclusion, the general consensus from staff is that although the Model doesn’t convey any new information, it provides a framework for their practice. From a management perspective it has provided consistency and standards to occupational therapy work practices throughout the Centre. At a time when outcome measures are increasingly important it is anticipated that the Model will be invaluable for this purpose.

Utilising the Model has without a doubt given the Occupational Therapy Service a sense of unity and the staff are now more confident in the services they are providing — primarily because they can articulate the rationale for their actions. This has been an important process for our service, and I believe has a message for our profession worldwide. Can we articulate a consistent message locally and internationally about what we do as occupational therapists and why?

Acknowledgments:

The Occupational Therapy Service Staff at Royal Rehabilitation Centre Sydney

Judy Ranka, Lecturer, School of Occupational Therapy, The University of Sydney

REFERENCES

Chapparo, C., & Ranka, J. (1992).Occupational performance, Draftmanuscript. (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW, Australia 2141)

Christine Chapparo, Judy Ranka

This paper is adapted from Chapter 9: Research Development. In C.Chapparo and J. Ranka, The PRPP Research Training Manual: ContinuingProfessional Education Edition 2.0, (1996)

ChristineChapparo, MA,DipOT,OTR,FAOTA is a senior lecturer in the School ofOccupational Therapy, Faculty of Health Sciences, The University of Sydney.

JudyRanka, BSc, MA, OTR, is a lecturer in the School of OccupationalTherapy, Faculty of Health Sciences, The University of Sydney.

DESCRIPTION

The Perceive: Recall: Plan and Perform System (PRPP) is a process-oriented, criterion referenced assessment that employs task analysis methods to determine problems with cognitive information processing component function during routine, task or subtask performance. The PRPP System is for use with adults and children who have difficulty performing daily or episodic tasks. It is suitable for adults and children of either sex and from any cultural background. The time taken to administer the PRPP System varies with the severity of information processing difficulty and the complexity of tasks assessed. The assessment of one person on four or five tasks can be completed in most cases in one to two hours by a tester familiar with the PRPP System and the client.

The PRPP System is:

*appropriate for adults and children regardless of disabling condition, sex or cultural background

*used by a responsible occupational therapist who knows the client well and who is knowledgable about the effects of information processing disorder on occupational performance

*administered to individual adults or children as they are performing routines or task in an individual or group context

*used in multiple settings where the child or adult performs daily routines and tasks (home, hospital, school, work)

*used to assess routines, tasks and sub tasks that are deemed important by the client or significant others to the client’s occupational role performance

*a comprehensive task analysis of four areas of information processing required for task performance: perception, recall, response planning and performance.

The purpose of this paper is to outline the stages of research that have been carried out to develop the instrument to its present form.

DOMAINOF CONCERN

The PRPP System is viewed as a tool that can be used by occupational therapists to describe the impact of cognitive component impairment on client performance of occupational roles, routines and tasks (Chapparo & Ranka, 1996), and specifically, information processing. Cognition, has been defined as ‘the individual’s capacity to acquire and use information to adapt to environmental demands’ (Lidz-Schneider, 1987). Occupational therapy focuses on improving occupational performance by integrating component functions. Cognition is conceived as one of the parameters of the profession’s ‘domain of concern’ (Mosey, 1986). Therefore, many occupational therapy conceptual models recognise the importance of cognition to occupational behaviour (Clark, Parham, Carlson, Frank, Jackson, Pierce, Wolfe & Zemke, 1991;

Depoy & Burke, 1992; Nelson, 1988). Similarly, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996), recognises cognition as a major component of occupational performance. The structure of this model suggests a relationship between cognition and occupational performance in everyday functions. Not only is cognition represented in the model as one component of function, it is reflected in the overall definition of occupational performance: “Occupational performance is the ability to perceive, desire, recall, plan and carry out roles ….. for the purpose of self maintenance, productivity, leisure and rest in response to demands of the internal and external environment” (Chapparo & Ranka, 1996.p.4). The PRPP System of Task Analysis was developed out of the expressed need of occupational therapists for an instrument that enabled them to more fully examine the relationship between cognitive information processing and occupational performance.

NEEDFOR THE INSTRUMENT

Development of the PRPP System began in 1985 in response to problems that occupational therapy clinicians identified with current methods of assessing cognitive problems in clients with brain injury. Problems centred around four main issues:

*Formal tests of cognition that were available to occupational therapists did not describe real world performance of clients (Tupper & Cicerone, 1988).

*Those tests that were perceived as being ecologically valid were viewed as having limited application for use in the broad practice area of brain injury (Tupper & Cicerone, 1988). Limitations were described in both the number and type of test items and the types of clients that could be tested.

*Therapists felt that the formal test results did little to contribute to planning intervention.

*Most of the formal tests lacked a sound theory base.

Therapists identified a need for a system of assessing cognitive deficits that:

*employed a standard format of administration

*was flexible enough to be used with a wide variety of clients at all levels of function and from different cultural backgrounds

*focussed on the domain of concern of occupational therapy, namely, the impact of cognitive deficits on the performance of client occupational roles and tasks

*was economical in its use of time

*could give guidance for occupational therapy intervention

The PRPP System of task analysis is being developed to meet these needs. Four major phases in development of the PRPP System have been completed to date.

INSTRUMENTDEVELOPMENT

The process of instrument development is a lengthy one that requires continued revision and review. If the final product is to be of use to occupational therapy, it must be reliable, valid and fulfil its main purpose: to enhance the quality of clinical decision making (Opacich, 1991). Benson and Clark (1982) outlined a step by step process through which new occupational therapy instruments can be planned, developed and validated. Four phases are involved in their process of instrument development: planning, construction, quantitative evaluation and validation.

The planning stage described by Benson and Clark (1982), begins with the formulation of statement of purpose of the intended instrument, including a specification of the domain of concern and constructs which are to be measured. The intended target group is also clearly specified. Once the purpose of the instrument is stated, a review of the literature surrounding the area of concern is performed. This aids in formulating the operational definitions of the constructs to be measured. Operational definitions are viewed as being critical to any instrument and must be established at this stage so that the underlying constructs can be linked to the empirical world being observed. When clear operational definitions of observable quantifiable behaviours

exist, the instrument can be constructed and examined for reliability and validity. The following outline of instrument development for the PRPP System of Task Analysis shows that the initial planning stage of development has been completed. It has an identified purpose. An underlying conceptual model has been developed (Phase 2 of the research), and all the constructs within the model have been defined (Phase 3). The relevance of the conceptual model to adults and children with brain impairment has been established (Phase 2, 3 and 4), and its relevance to other client populations is currently under study. Preliminary reliability and validity studies have been completed (Phases 1, 2, 3, 4) and a numerical scoring system is undergoing review.

PHASEONE: (Chapparo and Ranka, 1987 – 1990)

Research Outcome: Development of STAGE 1 analysis of the PRPP System.

25 male (15) and female (10) adults between the ages of 18 and 64 who did not have brain impairment were videotaped performing eating, dressing and meal preparation tasks. Their performances were analysed using a routine behavioural task analysis whereby the task performance was broken down into major motor steps (Brown, 1987). The task steps were then analysed to determine how similar the performance steps were among the 25 adults and to give the researchers some idea about the extent to which individual differences in performance of routine tasks were likely to be viewed as errors in performance. Although there were individual differences in the sequence of some tasks (e.g. sandwich making), there were no identifiable errors.

Test-retest consistency achieved for this analysis on each task among 6 testers ranged above 92%.

20 clients with brain injury who were residing in one of four brain injury units in Sydney were then videotaped performing the same types of tasks. Clients had varying levels of physical and cognitive ability from severe physical limitations and residual post traumatic amnesia to independent in mobility and oriented to time and place. All clients were identified by their occupational therapists as having some difficulty with cognitive processes that interfered with optimum performance of occupational tasks.

The videotaped performances were analysed

using the same task analysis format described above. Errors were catalogued and subjected to content analysis. Four main error types were identified from the analysis.

*Errors of omission (steps omitted)

*Errors of repetition (steps were unnecessarily repeated)

*Errors of accuracy (steps were inappropriate or wrong, leading to inability to accurately perform the task)

*Errors of timing (the total time taken to complete the task was too long, or too rushed)

Interrater agreement and intrarater consistency in error identification of this part of the analysis was above 90%.

This initial task analysis forms STAGE 1 of the present two stage PRPP System of analysis (Figure 1).

Figure1: THE PRPP SYSTEM SCORING SHEET

ClientName:

Date:

TaskAnalysed:

_______________________________________

____STAGE1 ANALYSIS_______________

______________________________________

STEPSERRORTYPES

AC O RT

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

NOTEERROR TYPES:

Accuracy(AC)

Omission(O)

Repetition(R)

Timing(T)

PERCENTAGEOF ERROR FREE PERFORMANCE:_______________________

EXPECTEDPERCENTAGE OF ERROR

FREEPERFORMANCE:_________________

PHASE2: (Chapparo and Ranka, 1991-1993)

Research Outcome:

a.A system of classifying cognitive errors in performance of occupational tasks. (STAGE 2 ANALYSIS)

b.Identification of a theoretical base for the assessment model, based on information processing theory.

Developmentof stage 2 analysis

Although the Stage 1 analysis allowed therapists to identify breakdown in performance of tasks, and to identify the types of errors causing the breakdown in performance, more information was needed to determine the possible reason for errors from a cognitive perspective.

45 adults with brain impairment were videotaped performing dressing, eating, grooming and meal preparation tasks within their hospital environments. Stage 1 analyses were completed, identifying errors in performance relative to omission, repetition, accuracy and timing.

After lists of errors were made, microanalyses were performed on each error. Over 4000 errors were catalogued for analysis. Categorisation of error types relative to the cognitive processes associated with the error fell into four broad error types:

* Errorsof perception

Difficulties with attending to the task and perceiving all of its elements

Figure2: The Expanded Skill Cycle

(Romiszowski, 1984.p.124)

* Errorsof recall

Difficulties classifying objects and body parts, remembering how to use them and fitting objects into a functional context

* Errorsof planning

Difficulties in planning what to do and how to do tasks, problem solving before and during task performance

*Errorsof performance

Difficulty initiating task performance, knowing when to stop or continue performance to its completion

Theoreticalbase

A literature review of the body of knowledge of perception and cognition as it related to brain injury revealed one model of information processing that was congruent with the categorisation of error types. Romiszowski (1984), an instructional psychologist, had developed a model of cognitive requirements for skilled performance of work tasks, which he called the Skill Wheel. He proposed that difficulties in work performance (for example typing) could be explained relative to problems

in perceiving, recalling, planning or performing aspects of the task. He further categorised these skill areas into a further 12 subcategories (See Figure 2). Using Romiszowski’s Skill Cycle Model, a further content analysis was completed on each of the four broad error categories to determine if a similar breakdown of error type was possible relative to the performance of the 45 clients with brain impairment.

Fig 2.

Client errors were able to be divided into twelve distinct subcategories that were similar but not identical to Romiszowski’s subcategories emerged from this analysis: three in each of the four error types as (See Figure 3).

RELIABILITYAND VALIDITY

To determine the effectiveness and comprehensiveness of the model to identify cognitive errors in task performance, 5 therapists who were considered experienced in the management of adults with brain injury were asked to review 10 of the research tapes. After training to identify behaviours as defined by subcategory constructs, therapists identified errors made by the clients using the total error classification system.

Figure3: The PRPP System (1993)

Quadrantsand Subcategories

There was above 85% agreement on placement of errors.All errors were able to be described using one or more of the model subcategories.

The therapists were then asked to rate the system of error identification relative to their satisfaction with its ability to identify and describe cognitive errors in task performance. On a scale of 1 to 10, therapists rated their satisfaction at or above 8.

Romiszowski’s (1984) original model was modified to accommodate the descriptions of errors seen in the performance of 45 adults with brain injury as follows.

PHASE3: (Chapparo, Ranka and Osbourne, 1994-1995)

Outcome:

a.Further validity studies of the content of the assessment system.

b.A further refinement of error classification by development of ‘descriptors’ (a standard error definition system) for each subcategory of the PRPP System.

To further enhance the descriptive ability of the PRPP System, the following research was carried out.

VALIDITYSTUDY

A further 25 adults and adolescents with brain impairment were videotaped performing eating, drinking, meal preparation and dressing tasks. Stage 1 task analysis was completed to identify errors. Errors were listed and interpreted using the Stage 2 analysis model of the Perceive, Recall, Plan and Perform quadrants, and 12 subcategories (Figure 3). In this second sample, all errors made in performance were again able to be described by using the model, thereby lending support for the validity of the constructs used in the model to describe cognitive performance errors (Osbourne, 1995).

DEVELOPMENTOF DESCRIPTORS

2001 errors were identified in this latest sample of task performances. Transcriptions of the videotaped errors were analysed to determine the key descriptive words used to describe errors made in each of the subcategories.

The list of key words were studied and a final choice of single or paired words, termed ‘descriptors’, that best described subcategory errors were chosen according to five criteria:

*they were ‘doing’ words (See Figure 4)

*they described a cognitive event

*they were observable

*they were everyday words, rather than medical or jargon words

*each word was judged to best reflect the error type

Each descriptor was then operationally defined from three perspectives. First, the Macquarie Dictionary (1990) and Thesaurus (1987) were used to define the essential meaning of each word. Second, the original videotaped performances of adults without brain impairment were used to develop a definition of the descriptor word relative to usual behaviour one would expect to observe during performance of any task. Third, the videotapes of adults and adolescents with brain impairment were used to describe examples of behaviours that would be deemed descriptor errors (See Chapparo & Ranka, 1995; Osbourne, 1995 for detailed definitions). The descriptors were then placed in the appropriate position in the assessment model and the model developed in Phase 2 of instrument was extended (See Figure 4).

Use of the descriptors was trialled on 60 therapists who work with adults with brain impairment, children with neuromotor disorders, children with learning disorders and adults who required work based training or placement.

Therapists were trained in the use of the PRPP System over a three day period and asked to watch videotaped performances of adults and children doing everyday tasks ranging from eating and dressing to motor proficiency tests and work site job trials. Therapists were asked to give feedback about

a)the degree to which the PRPP System, specifically descriptor use,

was able to identify errors in performance, and

b)the clarity of definitions of each subcategory and descriptor.

38 final year occupational therapy students were also trained in the use of the PRPP System and the descriptors over a four week period. They were then requested to watch two videotapes of one adult with brain impairment and one child with cerebral palsy as they completed hygiene and dressing tasks. Interrater agreement among the 38 students on error identification of each individual descriptor ranged from 95% to 100%. This indicated that:

Figure4:The PRPP System

Quadrants,Subcategories and

Descriptors(Chapparo, Ranka

and Osbourne, 1995)

a)with training in the definitions and concepts underlying the PRPP System, therapists can achieve acceptable agreement regarding the observations that are made about client error in performance and,

b)with training in specific methods of observation, therapists with little clinical experience are able to make pertinent observations about information processing errors that interfere with performance of occupational tasks.

Fig.4

As a result of feedback about the instrument from both therapists and students, the following modifications were made to the 1995 PRPP System Model. Subcategories in the Recall and Plan Quadrants were renamed to better ‘fit’ the nature of errors seen in those aspects of information processing and several descriptor changes were made.

The current training model of the PRPP System is illustrated in Figure 5.

Figure5: The PRPP System Model

(Chapparo & Ranka, 1996)

PHASE4: (Chapparo & Ranka, 1995 – 1996)

The present stage of development is in progress. The objective is to test the effectiveness of the PRPP System of task analysis in identifying information processing deficits in other client populations. Target client populations in this phase of research include children with neuromotor disorders and learning disorders and adults who are ready for work placement. These two client groups were targeted specifically because:

a) occupational therapists who

intervene with these clients are required to assess various types of functional performance in everyday contexts, and

b) there is no alternative assessment procedure available to determine the impact of information processing difficulty on occupational task performance in these clients.

FUTUREDIRECTIONS

Currently, therapists, who have received training are using the PRPP System of Task Analysis as

a formal task analysis method to identify and describe the impact of cognitive information processing deficits on everyday performance. Reports indicate that the tool has met its original purposes in that it can:

Consistently, enable therapists to identify cognitive deficits that interfere with occupational performance (Osbourne, 1995);

Be used to analyse performance of clients at any level of function (Chapparo & Ranka, 1991, 1992);

Give direct guidance to intervention (Fry & O’Brien, 1997).

Its future use with additional client populations will be determined through additional research.

SUMMARY

Occupational therapy assessment and management of clients with cognitive deficits is in transition in Australia. Traditional practices of assessment involving norm referenced measures are giving way to new forms of analysing occupational performance. The PRPP System of Task Analysis was developed to meet contemporary needs of therapists to determine the impact of cognitive information processing deficits on everyday occupational performance in real world conditions.

The theoretical model underlying the assessment is based on information processing theory and occupational performance. It assumes that knowing how to generate occupational behaviour at any level is based on a process of a person being able to construct a model of reality that is based on need, choice and interaction with the environment. These individually constructed models occur for each occupational task that is performed and are stored internally as networks of related constructs or schemata of occupational performance. It is these schemata that occupational therapists need to be able to evaluate in depth in order to plan intervention.

The PRPP System involves a two stage process. First, client task performance is analysed to determine where errors occur in terms of type and sequence. Second, the identified errors are categorised as to whether they are errors of perception, errors of recall, errors of planning or errors of control. To assist the therapist,

observations are guided by use of a series of ‘descriptors’, or defined information processing behaviours that are used to identify strengths and weaknesses in task performance. These descriptors are used by the therapist to target processing behaviours that the client needs to learn to successfully complete chosen or needed occupational tasks and routines.

The test, although in its infancy is viewed as a potentially valuable tool for therapists who manage adults and children who have problems with occupational performance due to poor information processing.

REFERENCES

Benson, J., & Clark, F. (1982) A guide for instrument development and validation. American Journal of Occupational Therapy. 36(12) 789-800

Chapparo, C. & Ranka, J. (1996) The Perceive, Recall, Plan and PerformSystem of Task Analysis. OT Australia, AAOT-NSW, Continuing Education Workshop, Sydney, NSW. February.

Chapparo, C., & Ranka, J. (1992) Development of an informationprocessing task analysis to identify errors in self-maintenanceperformance of brain injured clients. (Final research report, Category B: Internal). (Available from School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, East St. Lidcombe. NSW. 2141)

Clark, F.A., Parham, D., Carlson, M.E., Frank, G., Jackson, J.,

Pierce, D. Wolfe, R.J., & Zemke, R. (1991) Occupational science: Academic innovation in the service of occupational therapy’s future. AmericanJournal of Occupational Therapy, 45, 300-310

DePoy, E. & Burke, J.P. (1992) Viewing cognition through the lens of the model of human occupation. In N.Katz (ed.). Cognitiverehabilitation: Models for intervention in occupational therapy, pp.240-257

Fry, K., & O’Brien, L. (1997) Using the Perceive, Recall, Plan and Perform Model to assess cognitive deficits in a client with traumatic brain impairment.OT Australia, ‘Making a Difference’, 19thNational Conference.Perth, Western Australia. May.

Lidz-Schneider, C. (1987) Dynamis assessment. An international approach toevaluation learning potential.. New York: Guilford Press

MacquarieEncyclopedic Dictionary (1990) Autralia: The

Macquarie library.

MacquarieThesaurus (1987) Australia: The Macquarie Library.

Mosey, A.C. (1986). Psychosocial components of occupational t

therapy.New York: Raven Press

Nelson, D. (1988). Occupation: form and performance. American Journal ofOccupational Therapy, 42, 633-641

Opacich, K. (1991) Assessment and informed decision making. In C. Christiansen & C. Bauma (Eds.). Occupational therapy:overcoming human performance deficits. (pp.355-372) USA:Slack.

Romiszowski, A. (1984) Designing instructional systems. London: Hogan Page

Tupper, D.E., & Cicerone, K.D. (1988) The neuropsychology of everydaytasks:Assessment and basic competencies. Kluwer Academic Publishers.

PRPPSystem Research Dissemination

Workshops:Papers: Publications

1996

Ranka, J. (Speaker). (1996).Introduction to The PRPP System ofassessing information processing deficits. (Cassette Recording). Sydney, NSW: OT Australia AAOT-NSW

Ranka, J., & Chapparo, C. (1996, October). The Perceive, Recall,Plan & Perform System of Task Analysis. Two day CPE course. Sponsored by Riverina Rural Health Training Unit. Wagga Wagga, New South Wales

Chapparo, C., & Ranka, J. (1996, June). The Perceive, Recall, Plan &Perform System of Task Analysis. Three day CPE course. Sponsored by AAOT-Vic., Melbourne, Victoria

Ranka, J. and Chapparo, C. (1996, May) The Perceive, Recall,

Plan& Perform System of Task Analysis. Two day CPE course. Sponsored by Far North Coast Region of AAOT-Q. Cairns, Queensland

Chapparo, C. and Ranka, J. (1996, April) The Perceive, Recall,

PlanPerform System of Task Analysis. Three day CPE course. Sponsored by Occupational Therapy Paediatric and Adult Group of AAOT-SA & The University of South Australia. Adelaide

Chapparo, C., & Ranka, J. (1996, February).The Perceive,

Recall,Plan & Perform System of Task Analysis. AAOT-NSW, Sydney

1995

Ranka, J. and Chapparo, C. (1995, September). Identification of

informationprocessing deficits in adults with brain injury: The PRPP System. Paper presented at the 1st Asia-Pacific Occupational Therapy Congress. Kuala Lumpur. Malaysia.

Ranka J. & Chapparo, C. (1995, March). Functional assessment -Technology or technique: Assessing information processing deficitsthrough observations of function: The PRPP System. Paper presented at the 12th World Congress of the International Federation of Physical Medicine and Rehabilitation. Sydney, Australia

1994

Chapparo, C., & Ranka, J. (1994, September).Assessing

informationprocessing impairment in adults with brain impairment: The PRPPSystem. Invited key note paper. Neurorehabilitation Seminar. Hong Kong Brain Foundation. Hong Kong

Ranka, J. & Chapparo, C. (1994, September). Cognitive

rehabilitationtraining course. Hong Kong Occupational Therapy Association and the Hong Kong Hospital Authority. Hong Kong

Chapparo, C., & Ranka, J. (1994, May).Identification of cognitivedeficits in task performance of adults and children: Alternativeassessment strategies. Far North Queensland Group Occupational Therapists, Cairns, QLD. Australia.

Chapparo, C. & Ranka, J. (1994, April). Identification of

informationprocessing deficits in adults with neurological impairmant: A taskanalytic approach. World Federation of Occupational Therapists. London, England

1993

Chapparo, C., & Ranka, J. (1993, September) Identification of

informationprocessing deficits through the use of the Perceive, Recall, Plan andPerform System (PRPP). Invited pre-conference workshop presented at The 6th State Conference of AAOT-NSW, Mudgee, NSW.

Ranka, J., & Chapparo, C. (1993, May)Identification of

informationprocessing deficits through the use of the Perceive, Recall, Plan andPerform System (PRPP). AAOT 17th Federal Conference, Darwin.

1992

Chapparo, C. & Ranka, J. (1992, September). Motor planning,

motorlearning and occupational performance. AAOT-Vic. Neurology Special Interest Group. Melbourne, Victoria

Chapparo, C., & Ranka, J. (1992, September)Motor planning,

motorlearning and occupational performance: New ideas for analysis andtreatment. Two day CPE course sponsored by AAOT-Tas., Launceston, Tasmania

Chapparo, C. & Ranka, J. (1992, September). Motor planning, motor learning and occupational performance: Assessment & intervention. Queensland Occupational Therapy Association. Brisbane, Queensland

Chapparo, C., & Ranka, J. (1992, June). Task analysis and occupationalperformance. G.F.Strong Rehabilitation Hospital, Vancouver. Canada.

Chapparo, C., & Ranka, J. (1992, June). Motor planning, motor learning and occupational performance. Sponsored by Educational Resources, Inc. Boston, MA

1990

Chapparo, C., & Ranka, J. (1990, November). Task analysis: New Focus forthe 90′s. Paper presented at The World Congress of Occupational Therapists. Melbourne, Victoria

Ranka, J., & Chapparo, C. (1990, October). Using task analysis to identify problems and structure treatment for brain damaged adults. Two day CPE course sponsored by AAOT-NSW, Sydney, New South Wales

1989

Chapparo, C. & Ranka, J. (1989, January) Occupational

performance: the development of adaptive skills in brain damaged adults. Four day CPE course sponsored by Northwestern University Research & Training Centre – The Rehabilitation Institute of Chicago. Chicago, Illinois.

1987

Chapparo, C. & Ranka, J. (1987, January). Identification of motor planning disorders in brain damaged adults: Strategies for intervention. Four day CPE course sponsored by Northwestern University Research & Training Centre – The Rehabilitation Institute of Chicago, Chicago, Illinois.

PRPPResearch: Training Manuals

Training Manual Undergraduate (UG) Edition 3.0 (1996) (Semester 2, COP3)

Training Manual Undergraduate (UG) Edition 1.0 (1996) (Semester 1, COP1A)

Training Manual Continuing Professional Education (CPE) Edition 2.0 (1996) (May)

Training Manual Edition 1.0 (1996) (April)

Training Manual Prototypes (1992-1995)

Contintinuing Professional Education Course Notes (1987-1993)

Jodie Nicholls, BAppSc(OT),GradCertAppSc(OT) in Neurology, is an occupational therapist at the Brain Injury Unit at Westmead Hospital, Westmead, NSW.

Christine Chapparo, MA,DipOT,OTR,FAOTA, is a senior lecturer at the School of Occupational Therapy, The University of Sydney, NSW, and a clinical consultant to the Brain Injury Unit, Westmead Hospital

PURPOSE

This paper outlines an approach to intervention of one of the more difficult levels of cognitive recovery in head injury: the client who is progressing through the stage of extreme agitation. The paper contains an outline of the following.

DESCRIPTION OF AGITATED BEHAVIOUR OCCURRING AFTER BRAIN IMPAIRMENT

The classification of agitation is derived from the Rancho Los Amigos Stages in Cognitive Recovery Scale (Hagen, 1981; Ylvisaker, 1985). This behavioural scale describes reorganisation of cognition relative to eight levels from Level 1 (vegetative state) to Level VIII (approaching normal function). Agitation is a critical feature of Levels IV and V. At these levels, the scale clearly defines the behaviours demonstrated by clients in the following way.

IMPACT OF AGITATION ON OCCUPATIONAL PERFORMANCE

The impact of agitation on a client’s occupational role performance is devastating. The inability to attend to any task, coupled with the confusion about events, people, places and objects, causes the clients to become totally dependent on others for all aspects of life. It is also clear from observation that the agitated behaviour limits the client’s social interactive roles due to the ‘out of proportion’ response to external stimulation. Clients at Level IV or V can be both verbally and physically aggressive and are often unable to differentiate between medical staff and relatives. This leads to limited social interaction, isolation from significant other persons in the client’s life and development of further disordered role behaviour over time. The behaviours that accompany agitation are viewed as one of the greatest barriers to engagement in chosen or needed occupational and social roles. Agitation, when severe, can result in danger to the client, family and staff and can result in reduction or cessation of intervention.

While the Rancho Los Amigos Scale (Hagen, 1981) clearly defines the difficulties and goal expectations of this level of recovery, there is little or no guidance from the literature regarding the actual therapy approach that is most successful. Staff at the Brain Injury Unit, at The Westmead Hospital began to apply principles of systematic instruction to restore client performance of occupational tasks and roles. The need to examine more specific methods to instruct these clients arose when the Unit began to admit increasing numbers of clients with agitated behaviour. It was clear that staff from all professional groups were at a loss as to the best way to manage these clients who were often physically abusive. Occupational therapy became one of the primary forms of therapy at this point in their recovery.

SYSTEMATIC INSTRUCTION PRINCIPLES AND APPLICATION TO CLIENTS WITH AGITATION

Systematic instruction, when used as an intervention method in occupational therapy, is a model of teaching occupational tasks that is drawn from the body of knowledge of cognitive behaviour theory. Several assumptions underlie this approach and form the major principles of its application to this client group (Donelly, 1994; NSW Dept. of Education, 1980; Snell, 1987).

PHILOSOPHICAL ASSUMPTIONS THAT UNDERLIE SYSTEMATIC INSTRUCTION FOR PEOPLE WITH AGITATION IN AN OCCUPATIONAL PERFORMANCE CONTEXT

According to the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996), people are active participants in creating their own occupational being. Occupational therapists assist the client and family to develop aspects of occupational role performance that are chosen or needed by the client and/or their social environment. It is the view of the authors that any instruction given to modify behaviour will be given relative to the client and family need. It is therefore not acceptable to modify agitated behaviour merely because it is behaviour that is viewed as inconvenient to the staff, or unusual.

INVOLVEMENT OF STAFF AND FAMILY IN OCCUPATIONAL PERFORMANCE GOALS

Agitation and its associated behaviours is usually perceived as an impediment to intervention by all staff who interact with clients. Clients who are at Level IV or V (Hagen, 1981) are cognitively dependent, requiring therapy, nursing and family input for all occupational tasks and routines. Daily routines become a battleground that is characterised by physical and verbal abuse. Often, the agitation at this stage of recovery is interpreted by family and staff as being personally directed at them. Before any instructional program is implemented, understanding of the following parameters of agitation are necessary. There must be frank recognition that:

PHASES OF SYSTEMATIC INSTRUCTION

There are four phases to a systematic instruction programme that supports performance of occupational routines and tasks:

Phase One

Involves defining the target behaviour and specifying the desired outcome. For example, in the case that is discussed in this paper, the target behaviour was initially eating with a spoon and the desired outcome was independence in this task.

Phase Two

This phase involves evaluating the client within various contexts to determine how behaviours change in relation to different environments. For example, the client in this case study was socially appropriate and more responsive to requests given to her by male members of staff.

Careful assessment of the client’s agitated behaviours is required before any instruction is implemented. Descriptions of the nature of agitation should include the circumstances in which agitated behaviours occurred over a number of days. From the perspective of occupational performance, it is important to record the following:

Phase Three

Involves making decisions about the environment in which the therapy will take place and selecting positive reinforcers based on information gained in phase two. For example, in the case outlined in this paper, a decision was made that the client would be treated by herself, in a non-distracting environment. The reinforcer was determined by her most frequent request when she was in therapy.

Positive consequences must be meaningful. This refers to the consequence being perceived as truly desirable to the person, not the therapist. Consequences are effective if they are obvious and follow the behaviour to be taught immediately. This establishes a strong learning link between the task behaviour that is desired and the positive consequences of the performance.

Phase Four

This phase involved instructing the client in the task to be learned by breaking down the task into achievable steps During the instruction, reinforcement schedules are maintained and the number of steps of the task are gradually increased. For example, in the client case discussed in this paper, eating was the determined task with the ability to increase the number of spoonfuls eaten within a therapy session.

The remainder of this paper describes how these phases were applied to intervention for a client who is at Level Five – showing agitated, confused and inappropriate behaviour.

ANNA

Anna was a 33 year old woman who was involved in a motor vehicle accident in February. The accident occurred in the USA while she was attending her mother’s funeral. She sustained injuries which caused a right frontal subarachnoid and subdural haematoma. In September, following the accident, Anna was transferred to Westmead Brain Injury Unit to commence active rehabilitation. She had remained in a comatose state until one month before this transfer, with all prior medical expectations that she would die as a result of the injuries sustained. Anna was married with two young children.

Occupational Performance Assessment

When seen by the occupational therapist, Anna had marked agitation, making implementation of nursing and therapy programmes impossible. Her agitation was so extreme that she was unable to consistently recognise family members, including her own two and four year old children.

Anna was incapable of attending to any task presented. Her conversation was abusive and at times, sexually provocative to staff members. She demonstrated consistent confusion for events, places and people, with a total inability to recall her mother’s death.

Anna was dependent in all areas of self maintenance, of particular concern was eating and mobility. Anna’s abusive, agitated behaviour dramatically increased any time therapists or nursing staff attempted to engage her in these routines. She was therefore fed by means of a gastrostomy tube, although assessment revealed that there was no biomechanical reason for her inability to swallow.

INTERVENTION TO REDUCE AGITATION AND ENHANCE OCCUPATIONAL PERFORMANCE

Phase One

The Occupational Performance Model (Australia) is used in this context as a ‘top-down’ model. Occupational need of any client is determined relative to occupational roles that are needed or chosen by the client or significant others in the social environment. In Anna’s case, it was necessary for survival that she assume more responsibility for her own occupational role as a self maintainer by eating. Her family needed her to assume aspects of her expected role as a family member, as they expected Anna to live back at home with them in the future. Anna’s own personal choice was to engage in full time rest. A balance of these role expectations, derived from both personal and collective aspects of Anna’s life was needed.

The immediate goals, therefore centered on her eating, grooming, showering and dressing. Due to the complexity of showering and dressing, it was decided to concentrate on eating for the following reasons. First, it was necessary for health reasons that Anna start eating and drinking. Second, it is a simple, continuous task that occurs many times throughout the day, thereby offering natural repetition and practice opportunities. Third, it provided her family with an opportunity to be involved in her intervention in the role of family members sharing a meal.

Phase two

The decision was made to treat Anna in a non-distractible environment, with only one person making behavioural requests. This decision was made relative to her high levels of distractibility and severely limited attention.

Phase three

A meaningful reinforcement system was created using a positive reinforcer that was truly desired by Anna. She made continuous requests throughout the day to lie down and rest. This became her reinforcer. It was behaviourally appropriate, supported her need to rest, as well as being able to be immediately implemented.

Phase four

This phase involved the actual instruction during therapy. Anna was positioned in a comfortable sitting position at mealtime and requested to take a mouthful of food. The request was kept simple, directive and repeated until the mouthful was eaten. When the food was swallowed, Anna was then able to lie down for a short period. When the request to eat was given and Anna continued with her agitated and abusive behaviours, she was asked to repeat the request (to eat one spoonful) plus the consequence (lying down) to eat back to the therapist (‘if I eat, then I can lie down’). This vocalisation of her intended action assisted her performance dramatically. Getting Anna to repeat the instruction provided her with the opportunity to learn to problem solve and to learn 1) to direct her own actions, and 2) to learn the consequences of her actions (‘If I do ……, then this will happen’). This laid down the foundation for problem solving strategies during more complicated self maintenance tasks and routines. The vocalising of actions indicated that her attention had been captured and the requests had been processed.

PROGRESS

In the first therapy session, utilising this approach, Anna spent the majority of the time verbally abusing the therapist. She did eventually consume one mouthful of food in 60 minutes. This was, however, the first time in two months that Anna followed a direct request and participated in an occupational task. It was viewed by the therapist and her family as a major achievement. With the continuation of this approach, Anna improved her eating routine performance rapidly to independent eating within three weeks. The time between the request to eat being given and her actual eating performance decreased and Anna was eventually able to consume one whole meal in a therapy session and later with her family.

As Anna’s ability to eat increased, the amount of agitated behaviour dramatically decreased. This occurred in response to her limited attentional ability being focussed on one functional task.

Once independent eating had been achieved, the goal of independence in drinking and grooming routines were quickly established. The same techniques and reinforcement system was used.

The challenge at this stage of therapy was to increase her performance in occupational tasks and routines without the need for an artificial reinforcer. This was achieved by gradually increasing the number of steps required to be performance before the reinforcer was given.

Finally, when mastery was evident in the tasks learned, the task itself and her control over it became the driving force for completion.

With independence in grooming achieved, therapy goals centered on showering and dressing. Due to the complexity of these tasks, a structure or routine was created to assist her learning. Anna was directed to undress, wash and redress in a very structured and specific sequence. This sequence remained consistent throughout her stay within the unit. As she began to learn her showering routine, Anna would spontaneously vocalise her intended actions, keeping herself on track. This created a functional self prompting mechanism.

Discharge

On discharge from Westmead Brain Injury Unit, Anna was able to:

Apart from these gains in mastery of occupational performance tasks and routines, her agitated behaviour had decreased dramatically, and was only exhibited in times of physical stress and pain. Even during this events, little physical aggression occurred and there was use of socially acceptable language. Anna recognised her family members more consistently and began engaging in appropriate social interaction with them. She also began to inconsistently recall events, including her mother’s death, though her time frame remained confused.

PERSONAL AND CONTEXTUAL CONSIDERATIONS

A number of personal and contextual considerations became apparent and were important to the success with which Anna’s agitation was managed by therapists.

Contextual

While there are a small number of brain injury units designed specifically to manage clients with agitated and aggressive behaviour, this was not the case at Westmead. As with the majority of Brain Injury Units, staff at Westmead are expected to manage clients who have a broad range of problems to varying severity. In this context, difficulties posed by clients with agitation are enhanced. It is important that team and family members understand the nature of agitation and learn to identify and predict succeeding stages of recovery. The Rancho Los Amigos Cognitive Stages of Recovery (Hagen, 1981) are useful for this purpose.

Personal

For therapists, frank recognition of the personal difficulties involved in managing clients with extreme agitation is imperative. The following are guidelines to cope with these difficulties over time.

SUMMARY

Principles of systematic instruction, when applied within the context of meaningful occupational performance to clients with severe agitation following traumatic brain injury, work to improve performance of occupational tasks and establish functional roles.

Through a case example of one client, this paper presented step by step guidelines illustrating how principles of systematic instruction can be applied within an occupational therapy context to manage extreme agitation and facilitate useful occupational task and role performance. Using this approach, therapists find that:

REFERENCES

Donelly, M. (1994). Systematic instruction: Study guide. Graduate Certificate in Applied Science (Occupational Therapy in Neurology) Available from School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW. Australia.

Hagen, L. (1981). Language disorders secondary to closed head injury: Diagnosis and treatment. Topics in Language Disorders. 1, 73-87

New South Wales Department of Education (1980). Strategies for teaching students with severe intellectual disability. Sydney: NSW Department of Education.

Snell, M (1987). Systematic instruction of persons with severe disability. (3rd ed.). Columbus: Merrill

Ylvisaker, M. (Ed.). (1985). Head injury rehabilitation: Children and adults. London: Taylor & Francis

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

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)

Major client difficulties related to time may therefore be observed by the therapist as:

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.

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:

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:

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:

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.

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.

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:

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:

Initially a watch was purchased and David read the time as a response to this question.

Initially he was unable to give this information.

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

This paper is a copy of an article published in the Journal of Occupational Science: Australia, Vol. 2, No 3. (pp. 88-99), 1996. Reprinted with permission of the authors.

Anne Hillman BAppSc(OT) is a lecturer in the School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney.

Christine ChapparoMA,DipOT,OTR, FAOTA, is a senior lecturer in the School of Occupational Therapy, The University of Sydney.

INTRODUCTION

This paper is an introduction to research which investigates the occupational role performance of men who have had a stroke and are living at home. It contains a discussion of the nature of life roles and of their occupational roles in particular. The conceptual framework for this research is a person centred occupational performance model. The rationale for using this approach is given and the data collection methods are briefly described. Preliminary findings are presented, together with a case history to illustrate these findings.

OCCUPATIONAL ROLE

Life roles can be described as social, cultural and occupational roles. These divisions are not intended to be absolute, however, and involve considerable overlap, such that social cultural roles also have an occupational or doing element to them, while occupational roles can be seen to have social and cultural elements.

One model of occupational performance, developed by Chapparo and Ranka (Chapparo & Ranka, 1993, October), describes occupational roles as patterns of behaviour composed of self maintenance, work, leisure and rest activities. Occupational role performance refers to the way these activities are carried out. Occupational roles are established through need and/or choice and are modified with age, ability, experience, circumstance and time (Chapparo & Ranka, 1994). It follows that occupational roles are one means by which daily activities are determined and organised.

It has long been assumed that occupational role performance has a direct influence on lifestyle and health issues (Barris, Kielhofner & Watts, 1988). More recent research has demonstrated such links (Bränholm & Ful-Meyer, 1992). Elliott & Barris, (1987) have established a relationship between the number of roles performed, the degree of meaningfulness of such roles and overall life satisfaction. Although the depletion of occupational roles that occurs following the onset of major disability may be assumed to lead to a corresponding decrease in overall lifestyle or role performance satisfaction, nobody has investigated this specifically in relation to people who have had a stroke. Indeed, very little is known about the specific occupational roles of the elderly, or about the way elderly people who have had a stroke organise their daily activities following resettlement at home.

The saying that reality is only what individuals perceive of the world around them can be applied to people’s perspectives of their roles in life. People’s perceptions about their roles are coloured by their own life experiences and beliefs and attitudes. In describing role performance, health professionals often make assumptions about the meaning and balance that is ascribed by clients to their own life roles (Kielhofner, 1995; Oakley, Kielhofner, Barris & Reichler, 1986). For example, the initial focus of many rehabilitation programs is on the development of specific self care skills determined by the institution. These are seen as underpinning general performance at the role level (Culler, 1993; Levine & Brayley, 1991) as well as enabling the continued performance of self maintenance roles such as personal carer and home maker (Foster, 1992; Hill, 1993). The researchers believe this process often reflects the meaning and importance that the health care team attributes to a self maintainer role rather than the meaning and priorities of the client (Chiou & Burnett, 1985). In order to reduce the bias that these assumptions may introduce, this study adopted a person centred interview approach whereby the participants were invited to identify their own roles, give reasons for performance that relate to occupation, and talk about meaning in terms of value and satisfaction.

Although role assessment instruments have been developed for adults and the elderly, they have limitations in the scope and type of information they provide. Principally, they either rely upon interpretation of information by the investigator to determine role performance, like The Occupational Performance History Interview (Kielhofner & Henry, 1988), or, like The Role Checklist (Oakley, 1981), provide the person with a list of assumed roles and ask them to indicate participation and value. Satisfaction with performance is not always considered. Assessments like The Role Change Assessment (Jackoway, Rogers & Snow, 1987) also reflect an assumption that everyone views a named role in the same way. For instance, that everyone would see the role of household cook as self maintenance. The researchers adopt Chapparo & Ranka’s (1994) view that a given role can be given a different meaning by different people. For example, the role of cook may be self maintenance to one person, productivity to another, and leisure to a third. Indeed, the same person may view such a role in different ways in different circumstances. For example, preparing Sunday breakfast may be seen as a family activity, while cooking the regular evening meal could be seen as work.

Heard (1977) developed a model of role acquisition which illustrated how internal and external expectations affected roles that were acquired. As a conceptual basis for this study, the researchers have proposed an extension of Heard’s model to highlight the place of perceived external and internal expectations on role choice, role performance and role satisfaction (see table 1).

This model shows that reasons for role performance are individually determined and depend upon the person’s own perceptions of what is expected of them by others, what they expect of themselves and what resources are available to them for achieving performance. Based on this model, it is clear that there is a need to investigate people’s own perceptions of their performance at the role level, rather than make decisions based on indirect information given. Role assessments such as The Occupational Performance History Interview, while based on the self-reporting of interviewees as their primary source of information (Kielhofner & Henry, 1988; Moorhead, 1969), do not ask them questions about their own perceptions of their performance at the role level. Instead, questions are asked about past and present behaviour and from this the interviewer interprets and rates that person’s role performance.

This study represents a starting point for a line of research that investigates self perceived occupational role performance following stroke. It describes what occupational roles are carried out post stroke, the nature of that role performance, and what satisfaction is derived as a result. If there is an overall depletion in role performance satisfaction, as distinct from the number of roles performed or the nature of role performance, then this will have an impact on the nature of health and community service provision for people who have had a stroke.

The purpose of this study, therefore, is to gather information about the self-perceived occupational role performance of elderly men who have had a stroke and are living at home. The study was restricted to men, as it was felt that the issues they face following a major life event such as a stroke differ in many ways to those faced by women.

Research design

Qualitative research methodology was employed utilising in depth interviewing. This was done for two reasons. First, it permitted explanation of questions and further probing of responses, thus facilitating a greater depth and quality of information than could be obtained by other means. Second, from the participant’s point of view, it allowed the interviewer to understand the meanings attributed to particular role performance.

Participants

18 participants so far have been interviewed. Selection criteria included the following. Participants were men over 60 years of age who had had a stroke requiring admission to hospital, and who were discharged home three to six months prior to interview. They were not engaged in paid work and lived in the Sydney metropolitan area. People were excluded from the sample if they were female, were under 60 years of age, still worked in a paid capacity, lived in an institution, had a serious handicap resulting from a chronic condition unrelated to their stroke, were discharged from hospital less than three months or more than six months ago at the time of the interview, spent less than two weeks in hospital, did not receive rehabilitation while in hospital, had more than one stroke, or required an interpreter while in hospital.

The occupational therapy departments of a number of major teaching hospitals and rehabilitation units in the Sydney metropolitan area were used in order to obtain the participant sample. Ethics committee requirements did not permit the researchers to actively engage in the selection process or in inviting potential participants to take part. Occupational therapists who agreed to assist with this study selected potential participants from their own case load or by obtaining nominations from other therapists, according to the criteria set down by the researchers. These people were then contacted by the therapist who nominated them. The researchers provided therapists with material to distribute to potential participants. This consisted of a letter containing information about the study and inviting participation. If people indicated they were interested in participating, permission was obtained by the therapist to forward their contact details to the researchers. Where people were still attending an occupational therapy outpatient program another therapist in the department who had not worked with them made the contact in the same way.

Data Collection Procedures

Of the eighteen interviews conducted so far, seven were carried out by one of the researchers of this study and eleven by people trained by that researcher. Interviewers were trained in the following way: a series of tutorials culminated in a one day workshop which included audio and videotaping of practice interviews. Following this workshop, interviewers were required to submit an audio tape of an interview, using the procedures they had been taught, with someone of their acquaintance who was over 60 years of age. This tape was evaluated by the researcher and feedback was given. If the tape was unsatisfactory, interviewers were required to do another interview and submit a second tape. No-one proceeded with interviewing for the study until they had submitted a satisfactory tape.

Participants were contacted by the researchers and an appointment was made. Interviews were held in the participants’ own homes. In most cases there was no third party present. The length of interview varied from 45 minutes to 2 1/2 hours and ended when the participant tired or saturation of information occurred. Permission was obtained to tape the interview and a tape machine and microphone were placed in full view but in a non-intrusive way on any convenient surface nearby. Participants commented more than once that they had forgotten they were being taped.

The interview process had six parts:

1) Explanation of purpose of interview.

2) Recording demographic information.

3) Gathering information about role performance.

4) Participant identification and confirmation of roles.

5) Sorting roles under performance area and sociocultural headings.

6) Participant rating of roles.

The technique of ethnographic semantics (Spradley, 1979) was used to discover the way participants categorised their own immediate roles, role performance and role needs. This involved asking questions of three orders: descriptive, structural and contrast. The form of these questions changed with the understanding of the participant. The whole process commenced with a “grand tour” question such as: “Can you tell me about your roles now?” The purpose of this question was to find out what meaning the participant ascribed to the general term of role. The strong emphasis on open ended questions in this part of the interview ensured that the comments of participants were spontaneous and self-generated.

Descriptive questions yielded information about what the daily roles, functions and activities actually were for the participants. An example of a common stimulus question was “how do you spend your time?”. Further probes consisted of questions such as: “do you do anything with other people?”, “what sort of things do you do with your children?” and “what sort of things do you do around the house?” These types of questions yielded a list of tasks and activities that were later consolidated to form role patterns.

Structural questions in the form of role sorting enabled the researchers to determine how participants ascribed these role patterns into major role categories. This occurred in two stages. First, during the interview, the interviewer listed what (s)he perceived the participant’s roles to be. At the end of the interview the participant was asked to either confirm the role titles or suggest changes. The interviewer then privately sorted these roles under the major headings of productivity, self maintenance, leisure and sociocultural roles. The second stage of role sorting followed. Role titles were written by the interviewer on stickers. These were handed to the participant one by one and they were invited to sort the roles by placing each one under the heading that best described the reason for its performance. Participants were asked why they placed roles where they did and were usually able to give clear reasons for their decision.

During this second stage, a role sorting board was employed to help participants decide which role heading best described particular patterns of activity. The board was made of cardboard with a whiteboard surface and measured 610 mm x 440 mm. It carried simple definitions of each of these major role headings in large bold print for easy reading, often with clarification from the interviewer. The definitions were as follows:

Productivity: work, giving a service, doing something that can be used by others.

Self Maintenance: what you need to do to get by and get on with the rest of your life.

Leisure: fun, enjoyment.

Social Cultural: relationships, being with others, beliefs and values.

Other (no definition given).

Contrast questions were used to help participants identify what they would like to do that they were not able to do and to describe their perceptions of the frequency, value and satisfaction of role performance. Frequency was discussed in terms of how often the participant did things in that role. Value was considered as relative to the importance they ascribed to it. They were asked to consider satisfaction in terms of how they felt about their own performance in the role. Examples of contrast questions were: “if you could spend your day doing anything you wanted, what would you do?”, and “what is it that stops you doing this?”. Contrast questions of this type were used to assist participants to focus on immediate role performance needs rather than role performance prior to their stroke. Contrast questions led ultimately to participants being able to rate their role performance.

When rating their role performance, participants were asked to rate, as a single unit, the roles in each of the categories for frequency of performance, value of role, and satisfaction with performance. They were shown a five point scale represented on a large piece of card measuring 360 mm x 240 mm and asked to rate by pointing. Each scale had polar descriptions, with 1 as the lowest rating and 5 as the highest. For example, the value scale read:

“I consider this role to be:

In summary, the interview yielded both quantitative and qualitative data to describe aspects of self perceived roles. Information gathered related specifically to the participants’ own perceptions of their current role performance in the areas of productivity, self maintenance and leisure, as well as their sociocultural role performance. Perceived frequency of performance; perceived role value and degree of satisfaction with role performance were discussed and evaluated for each of these areas.

Data Analysis

Seven sets of data have been analysed at this stage of the study and form the basis of the findings reported in this paper.

Truthfulness of Data

Several checking measures were used to determine trustworthiness of the data collected. First, member checking was employed by ensuring that judgements on role identification and role categorisation were made by the participant rather than the interviewer.

This process establishes credibility of the data whereby the truth value is determined by how well the researcher is able to represent the participant’s experiences rather than the defined a priori of the researcher (Sandelowski, 1986). Second, comparisons were made between the qualitative information obtained in the interview section and the quantitative ratings made by the participants at the end of the interview. This process allowed the researchers to determine the consistency of the data and to track where variability in the data occurred. Third, another researcher reviewed a number of transcripts and role ratings made by the interviewers. Comparisons were made between the findings of the first researcher and the findings of the second (Minichiello, Aroni, Timewell & Alexander, 1990). Following this, additional questions relative to the style of questioning used in interviews and interpretation of the data were proposed. This process assured a certain freedom from bias in interpretation of the data that came from the natural biases, motivations and perspectives of the researchers themselves (Guba, 1981). This resulted in constant modification and refinement of the interview technique.

Data analysis procedures

All taped recordings of interviews were converted to written transcripts (Miles & Huberman, 1984). After each transcription was complete, the notes were edited by researchers for accuracy. The data set from each interview was read and researchers identified the possible scope of the data. Topics and themes that occurred and re-occurred were identified and assigned preliminary codes that subsequently became the initial content label discussed under ‘preliminary findings’ in this paper.

The level of detail of coding was multi-sentence ‘chunks’ rather than word or sentence coding (Miles & Huberman, 1984). Multiple copies of the transcribed and reduced data were made and passages of text were coded using descriptive terms according to the thematic interpretation made by the researcher as outlined below. Specifically, texts were examined for information relating to roles that had been identified by that participant. The text was then further examined for statements of frequency, value and satisfaction relating to performance of each of the roles identified. The entire data set of seven participants was double coded (Miles & Huberman, 1984) to determine the internal consistency of the researcher’s interpretation of the text. For this reason, the preliminary findings presented below will focus on interpretations of these seven participants.

Preliminary Findings

The preliminary findings are presented according to the themes that emerged. As each theme is discussed, narratives will be included to demonstrate similar and contrasting thematic perspectives as identified by the researchers.

These are preliminary findings. They will be discussed relative to the following four aspects of the analysis:
1) statements that relate to specific role performance,
2) commonly occurring roles that were identified,
3) findings related to role sorting, and
4) findings related to role rating.

Role Statements

As described previously, the interview commenced with a “grand tour” role question. Participant responses to this question were often revealing, in that they summed up the nature of that person’s focus or outlook on life.

Participant 16 was asked “can you tell me what your roles are now?

He responded:

“My main idea is to get out of the wheelchair and able to walk, that’sthe main thing I want to do. That’s why I will do whatever therapy they’ve got for me to do. They can tell you what you’ve got todo. They can’t make you do it. You’ve got to do it yourself”.

A great deal of his conversation and responses revolved around this theme. He explained at length how he managed his wheelchair, how he transferred and many other issues. Managing the after effects of his stroke was a major role for him, which he discussed with a passion.

Next, Participant 2:

Interviewer:”How do you see yourself? I mean we all have a lot of different roles in life…”

(Pause – Bursts into tears) “/…/ I got six kids … /…/ andfourteen grandchildren. /…/ So I’m just Grandpop to them.”

This gentleman was quite labile. His sociocultural roles were of particular importance to him and he discussed at length his relationships – good and bad – with those around him. Again, there was passion in his responses on this theme that was absent when discussing other areas of his life.

Participant 15 was different:

He was asked:”What are the roles that you have in life?”

“ Well,I’m just looking forward to the time when it foldsup, and somebody else has got to look after the problem then. /…/It doesn’t worry me. /…/ I’ve got a limited time I know, and Ijust keep on going.”

It subsequently became clear that this person had no particular focus to his life. His roles were identified, but there were none that appeared to be of particular significance to him, and there was no passion in his responses.

Commonlyoccurring roles

Role names were given by the interviewer and the participant on the basis of what seemed to best describe the role. The roles most frequently identified by participants were as shown in table 2:

Table2: Roles most commonly identified by the seven participants.

Role Sorting

Comparing Interviewer Sorting With Participant Sorting

The interviewer made sorting errors in every case and averaged 2.5 errors per interview.

Examination of Participant Role Sorting

Under the heading of productivity, four people identified a total of seven roles, while three could identify no productivity roles. All seven participants placed roles under each of the other headings. A total of eleven roles were placed under self maintenance, sixteen under leisure and twenty-four under social cultural.

There was an idiosyncratic placement of some commonly occurring roles (see table 3). For example, the role of father was placed by three people under the social cultural heading, giving it the meaning of being something the person did because of his beliefs and values and/or his relationships with others. This placement corresponds with the general view of father as primarily a social role. However, three people placed the role of father under another heading. Participant 18 placed father under leisure, saying:

“They’re my children and all that caper. Tremendous good looking children as well/…/It’s a lifetime’s pleasure really”.

Participant 17 placed the role under the productivity heading, explaining that he saw his role as a father in terms of ensuring his children were financially secure. He said:

“But we’ve got eight children. Right? /…/ What are you going to do/…/ to fix them up, without it distressing the others? Ah, itgives you something to think about.”

Participant 15 placed the role of father under self maintenance. He lived with his daughter, and seemed to be saying that, although his children cared for him, he did not reciprocate by doing anything for them. Their relationship with him seemed to focus on checking on his ability to care for himself successfully.

“I seem to have more of a relationship with them than I have with them. Do you understand?

Interviewer:”No, say that again.”

“Well,they’re always … seeking to see how I am … and I haven’t bothered about them!

Interviewer:”Oh I see what you mean. So you think the relationship’s a bit one way?

“Well,it is…Because after all, they’ve got their own relationships Participant 16, although a father, preferred to includethe role under the larger heading of family member.

Table 3 also groups together roles that appeared to go together, such as father and grandfather, and day care attender and health maintainer. The nature of some of these roles will now be explained.

Day Care Attender: In every case the person received therapy as part of a larger program.

Person with a Disability: The person carried out a remedial program at home and disability directed much of his attention and time.

Time Passer: Passive leisure, for example, television, radio, reading, talking books and street watching. This role was characterised by the statement that it “passes the time”.

These variations in sorting and placement would seem to indicate that the same role has different meanings to different people, supporting the contention that meaning cannot be arbitrarily ascribed to roles by others.

Other roles that were identified followed more closely the pattern that might expected, although there were still some surprises such as Home Maintainer and Pet Owner (see table 4).

Role Rating

The Ratings Sheet

Participants were asked to rate on three different five point scales for frequency of role performance, how much they valued the role, and how satisfied they were with their performance of that role.

Two participants completed role sorting, but did not rate their roles, leaving a total of five participants who undertook role rating.

Internal consistency between interview and ratings

Using a subjective comparison of the ratings with statements made by the participants in the text, it was estimated that approximately 75% consistency was achieved.

Preliminary consideration of role ratings for the seven participants analysed so far indicate certain themes. A total of fifty-four ratings were made overall, for frequency, value and satisfaction in the four areas of productivity, self maintenance, leisure and social cultural. When all the ratings are viewed together, the majority of participants rated at the top end of the five point scale. 63% rated five for any given rating, 18.5% rated 4, 16.5% rated 3 and 2% rated 2. No participant rated one, the lower end of the scale, for any rating.

Overall performance area ratings for the five participants were totalled using a weighted score. A rating of 5 was given five points, a rating of four was given four points and so on. This meant that if all five participants rated five for a given rating, the maximum possible score was 25. If no-one had rated it at all, the lowest possible score was 0. All five participants who completed ratings identified roles in the performance areas of self maintenance, leisure, and social cultural. Only three identified roles in the productivity area. For this reason the productivity ratings were further adjusted so that ratings for each area could be compared on the same level of five respondents.

From figures 1 to 4, it can be seen that social cultural roles and self maintenance roles were performed most frequently, with leisure roles being performed least. Social cultural roles were valued most highly, with productivity roles being valued least. Finally, social cultural roles produced the highest rating for satisfaction with performance, with productivity roles being valued the least. It must be emphasised that these results represent preliminary analysis only on a small number of participants. Data will be presented in a more meaningful way when the study has been completed.

CASE EXAMPLE – Participant 16

Findings are illustrated by the following case example:

Table 5 shows role distribution for participant 16. The role of Stroke Manager (person with a disability), ascribed as a self maintenance role, was one that took up most of this man’s time and was very involving for him.

The stroke had changed his life and had become the focus for him. A great deal of what he had to say related to how he was now dealing with his disabilities:

“The wife gives me therapy twice a day. Iget it once a week over at the day care centre. What I learn there, I’ve been able to tell the wife. We try to carry that out as further therapy. Because Ilook at this way – what you learn on Wednesdays, if you don’t get anymore done till the following Wednesday, you go backwards./…/So you’ve got to have it continuous./…/ That’s what we do./…/I go inon Wednesday and have full therapy, for walking. I walk with an aidbut can’t walk without. Because I can’t stand alone. Then I come home and tell the wife what’s been doing. Then we put the actual therapy into practice./…/ We got two hours a day doing it. First thing of a morning. Then afternoon, say about two o’clock. Then just before going to bed at night.”

This is an expression of the nature and frequency of role performance.

It is interesting to note that he had no personal carer role. It seems that for this man, Personal Carer was subsumed by Person With a Disability and had become part of that larger role.

He had successfully achieved the transition from active to passive participant in a number of roles, despite the fact that he is a man who, from the interview, seemed to need active involvement. For example, in his role as a Hydroponic Gardener, he sat

in his wheelchair at the top of the back step and directed his wife. This was his expression of satisfaction with this role:

He was asked: “The way that you carry out that role now, – do you get some satisfaction out of that?”

“Oh yes, knowing that it is going to be still done. /…/ I’ve got it in my computer, which is the brain box. /…/ And what’s got to be done is there and can be done. Somebody carries it out with the instructions, and that’s done satisfactorily so I don’t worry about it now.”

This man’s family seemed happy to participate in his roles on this basis.

Role ratings for participant 16 are shown in table 6. He rated five for satisfaction with all areas of role performance, and the researchers judged that there was agreement between this rating and what he said in the interview. However, this is what he said in relation to the role of Person With a Disability:

“Because when you get a stroke, well you are in it. And, as I say, it’s a nightmare and … you can’t get out. It’s like … going through atunnel and you can see the light at the end of it and you’re clawingand clamouring to get to it, but you can’t”.

When discussing his performance as a Person With a Disability, he said:

“Well,if you carry that out together it’s not so bad. But you feel …left alone at times. You wonder what it’s all about … whether it’sworth it or not because sometimes you can see you’ve progressed andother times you don’t have progress. /…/You don’t seem to cotton onto it. That’s how the … stroke leaves you. You don’t comprehendalways what you’ve got to do. /…/Just one of these silly damnthings. It’s aggravating and frustrating. You see things you wantto do and you can’t. When I was in hospital, with the therapy theywere giving me -it was all right. Then they asked me about what sortof therapy I thought would be the best and I told them home therapy,being in your own home. Here in your own surroundings, you do whatyou want to do.”

When asked to rate satisfaction with his performance he said:

“Oh yes, I’m contented. Everything’s moving along the way I want. I am satisfied all the time with what I am trying to do and the things that have been done for me. I work very hard.”

From this it appears that he was satisfied with his performance in this role, but derived no pleasure from it, and performed it through need rather than choice.

Discussion and Implications for Further Research

Preliminary analysis has revealed a number of interesting points:

When a general question about role performance is asked, such as “tell me how you see your roles now”, the response can sometimes reveal the overall focus of that person’s life. For instance, participant 16 responded to this question by saying he wanted to get out of his wheelchair and overcome the effects of his stroke. Participant 2 spoke of his relationships with those around him. Participant 17 spoke at length about his advocacy activities. In each case, the response to this initial question revealed a theme that was returned to many times throughout the rest of the interview, indicating that it was of primary importance to that person. For others, such as participants 15 and 18, responses to this role question were general and diffuse and no such theme was revealed. Further questioning also failed to reveal any particular focus and these men appeared to participate in a more passive way in what was going on around them.

Results so far seem to show that it is not possible for one person to accurately to ascribe meaning to the roles of another. For example, comparison of the two stages of role sorting in this study demonstrated that the interviewer made errors in every case, despite feeling confident, from what had been said in the interview, of how the participant would view that role.

It appears that a role sorting process can enable the principle meaning ascribed to particular roles to become clearer to both the interviewer and the participant. Role sorting required the participant to choose the main reason they performed the role in terms of the headings of productivity, self maintenance, leisure, and social cultural. While they were all able to make this choice, some did indicate that there was more than one reason for performance. For instance, participant 18 placed his advocacy role under productivity, but discussed how it also gave him great pleasure and could therefore have been viewed as leisure. Sorting allowed the discussion and clarification of the meaning roles had for individuals.

Most of the people interviewed, when asked to rate their roles, rated them positively for frequency, value and satisfaction with performance. For example, not one person rated 1 (the lowest rating) on the five point scale for any role. When the ratings for all participants for all ratings (frequency value and satisfaction) were looked at together, 63% of the responses were at 5 (the highest rating). There could be a number of reasons for this. For example, from a cultural perspective, Australian men in this age group expect and are expected by their peers to confront life events and be stoic about them (Job, 1994). This could lead to more positive ratings. Also, giving a low rating for frequency, value or satisfaction could be viewed by the participant as too self-revealing or too challenging to their own perceptions of how they are performing overall in their life roles. Again, older people are sometimes reluctant to reveal too much in case there are consequences in terms of loss of control and the imposition by others of restrictions to their autonomy (Russell, 1981). Finally, the selection method for participants meant that participants were selected and invited to participate by the occupational therapist who had worked with them during their rehabilitation. It is possible that therapists may have selected people whom they considered had a positive outlook and could give a good account of themselves. The ratings may accurately portray people who were actively participating in valued roles to a level that they found satisfying overall. The researchers estimated that there was approximately 75% agreement between the ratings and the content of the interview transcripts, indicating consistency in responses.

This study is not yet finished and further investigation of satisfaction with role performance is planned.

Summary

In summary, this paper has presented preliminary findings of research into the occupational role performance of elderly males who have had a stroke. The conceptual framework for this research is a person centred occupational performance model. The rationale for using this approach was given and data collection and analysis methods described. A case history was presented by way of illustration, and results were given and discussed.

With the established link between occupational role performance, meaningfulness of roles and positive health and well being, it is important that we do not ignore this aspect of occupation. It is hoped that further research into role performance that is person centred will enable us to develop a better understanding of the meaning ascribed to role performance by individuals.

ACKNOWLEDGEMENTS

The authors acknowledge the contributions of the participants and their families to this study, as well as the School of Occupational Therapy, The University of Sydney for partially resourcing the study.

References

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In practice, the majority of occupational therapists concern themselves with activities of daily living and productivity-related issues (Graham, 1990; Gregory, Fairgrieve, Anderson & Hammond, 1992; Powell, 1994). Occupational performance is often viewed in limited terms of self-maintenance and productivity. Additionally, therapists place emphasis on: a) the biomechanical, sensory motor and cognitive components of performance; and b) the physical environment. Less emphasis is placed on: a) leisure and rest aspects of performance; b) the interpersonal and intrapersonal components of performance; c) the social, sensory and cultural environments; and d) the body/mind/spirit core elements of human existance, all of which, at least theoretically, influence a person’s occupational performance (Chapparo & Ranka, 1993). These restricted views of occupational performance do not mirror the profession’s holistic theoretical and philosophical foundations (See for example, Meyer, 1922).

This paper explores an area often neglected by occupational therapists, friendship and social interaction, from the perspective of four children who have fragile X syndrome. In schools, no single profession has addressed the social needs of children, especially those with disabilities (Damon & Phelps, 1989). This is a significant omission considering that, both quantitatively and qualitatively, children with disabilities have few, if any, friendships with children without disabilities (Alper & Ryndak, 1992; Kishi & Meyer, 1994; Sabornie, 1985; Zetlin & Murtaugh, 1988). Perhaps this situation could be rectified by school-based occupational therapists actively working to identify and support children’s social needs.

In doing so, occupational therapy could implement a broader service with the adoption of practices that focus on social needs across a variety of practice settings. As Bonder (1993, p. 211) stated, ?for occupational therapy to provide a holistic view of meaningful activity, we must understand the relationship between physical, psychological, and social variables.? At present however, the nature of the relationship between social variables and occupational performance in children (particularly those with disabilities) is unknown and needs to be investigated. This paper begins to explicate this relationship through examination of the occcupational nature of social experiences of four children with fragile X syndrome as explained by constructs contained in the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996).

THE STUDY

The data for this examination is obtained from an ethnographic study (Baker, 1996) that explored the social experiences of four children with fragile X syndrome, a genetic disorder causing a range of physical, intellectual and behavioural disabilities (Reiss & Freund, 1990). The four children attended four different schools, with two attending regular schools. They all lived within family units of differing configurations, but consisting of at least one parent. Single in-depth interviews were conducted with each child’s parents, teachers and two occupational therapists, as well as three half-day participant observation sessions at each child’s school, making a total of ten interviews and twelve observation sessions. The empirical data yielded detailed case studies of each child’s social experiences. Grounded theory method (Strauss & Corbin, 1990) was used to analyse interview transcripts and observational fieldnotes.

Social experiences were composed of two dimensions – social interaction and friendship – and of the interrelationship between them. The dimension of social interaction was indicated when children who were not friends played together. This dimension was characterised by: a) reliance on social skills and a social medium, b) minimal emotional content, c) non-restrictive involvement of children, d) spontaneity, and e) the fostering of a sense of belonging. The dimension of friendship was uniquely characterised by: a) free will and selection; b) mutual satisfaction of social needs; c) disobedience of authority; d) similar ability, interests and personality; e) an emotional bond; and f) an inherent mystery that was more than the sum of the parts identified here. The dimensions of social interaction and friendship were also interrelated when friends participated in social interaction as an overt display of their friendship.

The study supported previous research by finding that the four children’s social experiences were lacking when compared to children without disabilities, particularly out-of-school activity and involvement with children without disabilities. However, in contrast with previous research, each child still valued and enjoyed a diverse range of friendships and social interactions. The study identified numerous personal and environmental factors contributing to the quality of each child’s social experiences which are summarised progressively throughout this paper.

The following sections are devoted to exploring the children’s social experiences from an occupational performance perspective relative to the eight primary constructs of the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996): space, time, external environment, components of occupational performance, occupational performance roles, occupational performance areas and finally occupational performance.

SPACE

All the social experiences of these children occurred within the infinite boundaries of their internal and external domains. Body structures necessary for social interaction were housed in each child’s body – their internal space. Of greater significance to social experiences was the area surrounding the child - external space - in which all friendships and social interactions took place. The corporeal area around a social experience - physical space (Chapparo & Ranka, 1996) – was not a great influence. Nevertheless, it ultimately determined the type of social interaction possible within its physical boundaries. Of greater influence was the child’s perception of this corporeal area - felt space (Chapparo & Ranka, 1996). The children typically had negative perceptions of felt space when an area was unfamiliar, small, cluttered, loud or populated with other children. Similarly, positive views of felt space usually occurred where environments were familiar, spacious, more ordered, not overly loud and with fewer children. However, not all children adhered to this pattern. One child had entertaining social experiences in a positive felt space that was small, enclosed by oddly shaped buildings and with many teachers about. In fact, his neighbourhood was deemed by him to be a negative felt space (probably because of a detrimental social history with neighbourhood children), despite it being larger, quieter and unpopulated when compared to his school. Generally, the children avoided negative felt spaces, subsequently reducing opportunities for social experiences. Positive felt spaces, on the other hand, were usually preferred and contributed to the creation of opportunities for social experiences.

TIME

The children’s social experiences were influenced by time - physical time (Chapparo & Ranka, 1996) – and restricted to certain times throughout the day. Some biological rhythms (eg, sleep), determined by physical time, restricted opportunities for social experiences in the twenty-four hour day. Opportunities to engage in social experiences were further restricted by the child’s, and the immediate sociocultural context’s, interpretations and manipulations of physical time - felt time (Chapparo & Ranka, 1996). This resulted in the greatest opportunities for social experiences being at school. Even there however, felt time imposed restrictions. Children only attended school five days a week and did not attend at all during school holidays. The school ?day? itself was also subdivided by felt time, beginning just before nine o’clock in the morning and finishing just after three o’clock in the afternoon. Still further, social opportunities at school were decreased during educational periods and increased during recess and lunch periods. These leisure periods ran no more than ninety minutes each day and time still had to be allocated to eating in these periods.

Social experiences were influenced by space and time in both physical and felt senses, as defined by Chapparo & Ranka (1996). These findings correspond to the postulations made in the Occupational Performance Model (Australia) regarding the impact of space and time on occupational performance. Social experiences, as observed in these children, are partly explained by notions of space and time that are central constructs of occupational performance.

EXTERNAL ENVIRONMENT

Social Environment

Each child’s relationships (if any) with other children - social environment - were particularly important with regard to social experiences. There are several layers to the social environment, of which the most exterior is society. Society is discussed in the section on Cultural Environment in this paper, since it was the mechanism through which societal beliefs and ideals were transmitted from person to person that affected social experiences. Of more relevance to the social environment was the presence of other children and the child’s family and school, as part of the neighbourhood/community layer of the social environment.

Other children existed within the children’s social environment, some of whom were friends and others who were not. Two social situations involving the presence of other children mitigated against engagement in social experiences in these children: a limited number (quantity) and restricted range (variability of personal attributes) of other children present. Generally, a social environment with few children and/or a low degree of variability between children decreased opportunities for social experiences, and vice-versa. However, this trend was not always observed. The children’s preferences for particular children was an important factor, in that each child chose with whom they interacted or became friends. This choice depended upon the number and range of children present, where a larger number and range increased the chances of meeting their personal preferences, and vice-versa. For example, many social experiences of children attending segregated schools (for only children with disabilities) were limited by an inadequate number and range of other children. In contrast, the potential for social experiences at regular schools (for children with and without disabilities) was enhanced by a larger number and range of other children.

The family was a nucleus for social experiences – a crucial foundation upon which social opportunities were provided and removed. Sound familial relationships allowed the child to venture from the family unit and explore their social environment. Informants gave examples of tense or estranged family relations that removed this exploratory foundation. As one teacher said, “if there is a problem happening at home it does surface, often, in the playground.” Informants went on to describe how, subsequently, social experiences were damaged by the child getting “into fights or … not playing with anyone … just standing out as being different.” The influence of parents on social experiences was particularly significant considering that the children were largely dependent on their parents for out-of-school social experiences. Parents used a variety of techniques to facilitate social experiences. Indirectly, parents provided advocacy, increased exposure to social environments, and overcame barriers to community integration. Directly, parents facilitated social experiences with encouragement, social engineering, education, social identity development, and activity arrangement. However, parents occasionally interrupted social experiences with disciplinary action and separation of friends. Parents sometimes prioritised other occupational performance tasks and routines that rendered their child’s social needs to a secondary concern.

School was an incredibly dense social environment that greatly affected social experiences. School staff created and removed opportunities for social experiences. There were instances where executive staff decisions (that were sometimes economically derived) disrupted close friendships. Attitudes of school principals partly determined the behaviour of staff and students and dramatically impacted upon social experiences, both positively and negatively. Autocratic teaching or therapy styles, emphasising strict discipline and one-on-one teaching, quelled social behaviour. Egalitarian styles, emphasising fair and flexible discipline and groupwork, supported social behaviour. Many teachers and therapists created social opportunities using some of the following facilitation strategies. On some occasions, formal facilitation strategies were adopted that included direct instruction, social engineering, social skills training, buddy systems, education and peer tutoring. On other occasions teachers preferred to use informal facilitation ? an active, sensitive and cooperative process relying on natural social processes with minimal professional interference.

The existence of school policy that guided professional conduct had a tremendous impact on social experiences. Several professionals stated that they were “bound” by general school policies, even though they knew it to be detrimental to friendships and social interactions. Policies regarding socially appropriate (especially age-appropriate) behaviour lead teachers to restrict certain social interaction and punish children for behaving inappropriately on the basis that, as one teacher said, “it is for their own good.” Policies relating to the standard transition from primary to secondary school disrupted some children’s social experiences. One parent stated that “the concept of going to a new school is so frightening for him because it is a new social situation.” Policy regarding the enrolment of children into schools and classes determined with whom the child could interact. Policies outlining the integration of children with disabilities into regular schools had differing effects on social experiences. On the one hand they supported social experiences with their socially oriented purpose. Many professionals commented that “a lot of (integration) is done purely … to increase social interaction.” Enrolment policies determined the number and range of other children with whom the children could interact or make friends. On the other hand, some integration policies were criticised because they “singled out” children with disabilities and subsequently impaired their social experiences. Such stigmatising integration policies pertained to special education programs, academic curriculums, and the procedures for integration into regular schools.

Cultural Environment

Social experiences were influenced by Australian culture, or “society,” and the beliefs and practices therein: the cultural environment (Chapparo & Ranka, 1996). The effect was twofold. First, certain people within society believed and practiced a reluctance to accept children with disabilities. Second, this reluctance meant that some children with disabilities perceived children without disabilities as intimidating and were therefore reluctant to approach them. However, at one of the children’s schools these societal beliefs and their negative effect on social experiences were rarely observed. This school’s belief system contrasted that of ?society? in that it was based on principles of equality and acceptance. Subsequently, the child at this school had many enjoyable social experiences.

Ethos was defined as the underlying and distinctive climate or spirit of a group. Two significant factors in determining the school’s ethos were student-teacher relationships and discipline. There were two types of ethos observed across the four schools: an ethos of clemency and one of tyranny. An ethos of clemency was observed to be conducive to social experiences. Student-teacher relationships were characterised by: empathic emotional regard, propensity to care, mutual respect, frequent displays of affection, discipline that considered social experiences, and infrequent misbehaviour by children. The style of discipline comprised: minimal aggression and greater assertion (sharp and clear tone of voice, low volume, minimal physical manipulation), egalitarian treatment of children, rationality, explanation of the wrong committed and an indication of how to correct it. An ethos of tyranny was observed to be deleterious to social experiences. Student-teacher relationships were characterised by: apathetic emotional regard, lack of concern and respect, frequent displays of hostility, discipline that did not consider social experiences, and periodic misbehaviour by children. The style of discipline comprised: aggression, authoritarian treatment of children, irrationality, and minimal explanation of the wrong committed and how to correct it.