STAGE ONE (1989-1990):

The purpose of Stage One was to identify literature support for using occupational performance to explain occupational therapy practice.

Methods:

A review of occupational therapy literature covering a twenty-year period from 1970 to 1990 was conducted using electronic and CD-ROM databases, published indexes and online search techniques. During subsequent stages of development this review expanded to 1995.

Findings:

The term, occupational performance, was classified according to how it was used in the literature. Four classifications emerged: use of occupational performance as a generic frame of reference for national practice including definitions of the term, use of occupational performance as a generic frame of reference for undergraduate occupational therapy curricula, use of occupational performance terminology by occupational therapy theorists to explain practice, and use of occupational performance to develop assessment tools.

1.	Use of occupational performance as a generic frame of reference for national practice.

Descriptions of occupational performance have appeared in occupational therapy literature in the United States and Canada since 1973. The pivotal conceptualisation of occupational performance seems to have been generated by a series of American Occupational Therapy Association, Inc. (AOTA, Inc.) task forces and committees charged with developing policy statements about generic domains of concern for the profession (AOTA, Inc., 1974, 1973). Concurrently, the Canadian Association of Occupational Therapists (CAOT) developed a similarly conceptualised notion of occupational performance to address growing concerns inside and outside the profession for assuring quality of services (Townsend, Brintnell, & Staisey, 1990). The following description of the evolution of occupational performance is based on the sequence and the way that discussions on occupational performance appeared in the literature from 1970 to 1991.

In 1973, the AOTA, Inc. presented the profession with a unifying concept of occupational therapy. This publication described occupational performance as a unifying, generic frame of reference and defined it as the individual’s ability to accomplish the tasks required by his or her role and related to his or her developmental stage. Occupational performance included self care, work and play/leisure time performance (AOTA, Inc., 1973). Subsequent AOTA, Inc. publications have reaffirmed that, “the generic foundation or frame of reference (of occupational therapy) is to be found in the concept of occupational performance” (AOTA, Inc., 1974, p.8).

Performance areas consisted of self?care, work and play/leisure activities and reflected the core concept of occupational therapy: purposeful activity. Skills carried out in these performance areas were purported to be influenced by what was the called the life space of a person. This referred to a cultural, social and physical environment. Performance components were described as behavioural patterns based on learning, and developmental stages and were seen to be the foundation attributes for occupational performance. These included sensory integrative functioning, motor functioning, social functioning, psychological functioning and cognitive functioning.

In 1979 and 1989, the AOTA, Inc. published documents which sought to create a consistent occupational therapy terminology based on this occupational performance framework. Terminology created by the occupational performance frame of reference has been adopted by AOTA, Inc. for use in the United States for purposes of documentation, charge systems, education, program development, marketing and research (AOTA, Inc. 1989, p.808). Thus the concept of occupational performance in the United States was developed from a series of committees from the AOTA, Inc. who used professional conceptualisations of practice to create a generic frame of reference for practice (Pedretti, & Pasquinelli, 1990, p.3).

Beginning in 1979, a task force of the Canadian Association of Occupational Therapy (CAOT) outlined a generic conceptual framework of function as an overriding guideline within which therapists could use specific frames of reference appropriate to their clients, work settings and modes of practice. The resulting generic model of occupational performance, “depicts a performance view of health” (Townsend, et al., 1990, p.70). It is an adaptation from the work of Reed and Sanderson (1980) and similar to the 1986 curriculum model described earlier (See Fig. 2).

Central to the Canadian notion of occupational performance was affirmation about the worth of a person as an active participant in his/her own therapeutic relationship. Using occupational performance, the traditional holistic view of people conceptualised by Meyer in 1922/1977 was reinforced. There was acknowledgment that occupation takes place within a developmental perspective and emphasis on the central belief in the therapeutic use of purposeful activity (Townsend, et al., 1990, p.70).

Similar to the American model, three areas of occupational performance were described: self care, productivity and leisure. However in the Canadian model, play was grouped with productivity rather than leisure. This model recognised only four performance components: mental, physical, sociocultural and spiritual. Townsend, et al. (1990, p.71) highlighted the recognition that integration and execution of all occupational performance components and areas is defined and shaped by a person’s social, physical and cultural environment. As they stated, “in achieving occupational performance, each individual both influences and is influenced by his or her environment” (Townsend, et al.,1990, p.71).

Using this model, the CAOT developed a new outcome measure for occupational therapy, The Canadian Occupational Performance Outcome Measure (Law, Baptiste, McColl, Opzoomer, Polatajko, & Pollock, 1990). This is described as an individualised measure designed for use in evaluating occupational performance in clients receiving occupational therapy intervention. The development, validation and use of this measure are purported to contribute to providing a standard comprehensive method of individualised assessment for occupational therapy across Canada (Law, et al., 1990).

2.	Use of occupational performance as a generic frame of reference for undergraduate occupational therapy education.

In 1974, the AOTA, Inc. suggested that occupational therapy educators use their notions of occupational performance as a curriculum guide. The frame of reference was described schematically in terms of a two level model comprised of performance areas and performance components (AOTA, Inc., 1974, p.12) However no subsequent reference to its use as a curriculum model was found in the literature.

3.	Use of occupational performance terminology by individual occupational therapy theorists to explain occupational therapy practice.

During the 1980′s, individual theorists employed the occupational performance frame of reference to describe the content and process of occupational therapy in different areas of practice. Each of these individuals have further refined and explained different aspects of occupational performance, or alternatively, have used occupational performance nomenclature to describe related models. Reed and Sanderson (1983, p.17), for example, used an interactive model similar to the one proposed by AOTA, Inc. to describe the relationships between a person’s occupations. Although they do not identify this interactive model as occupational performance, it is composed of the same configuration of constructs. Reed’s (1984, p.496) subsequent work in developing a model of Adaptation Through Occupation uses the same categorisations but different terminology.

Mosey (1981) referred to occupational performance as the domain of concern for occupational therapy. She described areas of human existence which were of most concern to occupational therapy as consisting of, “performance components within the context of age, occupational performance and the individual’s environment”. In applying the frame of reference to practice in mental health, Mosey (1980) suggested that a person’s overall quality of occupational performance depends in part on the balance established among the component performance, the environment and occupational performance.

Mosey’s view is echoed in the work of Nelson (1984, p.130) who developed a circular interactive model of occupational performance in which the three performance areas are connected, reflecting their interdependence. Housed within conceptual boundaries made by self-care activity, work activity and play, he placed six component abilities in a complex interconnected configuration. This was adapted and used as a working model to demonstrate interaction between constructs within the model (Fig. 3).

He further described some of the mutual cause and effect relationships between the six component abilities as follows:

“motor output generates sensory feedback and sensation is a guide to motor response. Perception builds on sensation and cognition builds on perception. Interpersonal abilities depend on one’s thought processes. Emotion colours and motivates one’s sensations, perceptions, thoughts and interpersonal relations” (Nelson, 1984, pp.45?46).

 

Figure 3: Occupational Performance Framework, 1988 (Adapted from Nelson, 1984, p.130).

The outer boundaries of the model are purported by Nelson to form the outer boundaries of the whole person since participation in occupational performance areas, “serves as a bridge between the inner reality of the individual and the external environment” (Nelson, 1984, p.38). This assertion reflects earlier work by Fidler, and Fidler (1978, p.305).

In more recent work, Nelson (1988, p.633) has constructed a schema wherein occupation is defined as the relationship between an occupational form and occupational performance. Contextual elements of occupation are termed, “the form” of occupation, whereas occupational performance consists of, “the doing” of occupation. In applying this schema, Nelson suggested that occupations have meaning only to the extent that people who are performing them interpret their forms. Therefore an occupational form can have a social or cultural meaning, an idiosyncratic meaning or little meaning at all. Putting this into a temporal context, Nelson (1988, p.637) suggested that, “the meaning” of occupation is largely retrospective while, “the purpose” of occupation is largely prospective.

Pedretti, and Pasquinelli (1990) interpreted the practice context of physical disabilities within the occupational performance frame of reference. They demonstrated how occupational therapists can employ an occupation focused model as an alternative to a medical model within the context of rehabilitation and acute care service delivery models. They described the occupational therapist’s domain of concern as focussing on the client becoming as independent as possible in performance skills, and to resuming previously held occupational roles or to assuming new and satisfying occupational roles. Their interpretation of occupational performance extended beyond this structural model to include a conceptualisation of occupational therapy intervention as a loose step?by?step progression which takes the client through a logical progression from dependence in performance skills to resumption of life roles (Pedretti & Pasquinelli, 1990).

Llorens (1982) identified the need for a client care record that had a strong scientific base and could be used to monitor quality care and accountability of occupational therapy services. Through research, she produced The Sequential Client Care Record (SCCR) which documents the occupational therapy process using the occupational performance constructs ‘areas of occupational performance’ and ‘occupational performance components’. Based on structures developed by AOTA, Inc. (1974), Dunn (1988) and others (Dunn & McGourty, 1989) employed a matrix which allowed therapists to systematically identify deficit and strength areas of performance, and to select appropriate activities to address these areas in occupational therapy intervention. By employing this grid, occupational therapists are able to determine how abilities and limitations in performance components can affect functional outcomes in the performance areas.

4.	Using occupational performance to develop assessment tools.

Using occupational performance as a guiding frame of reference, Arnadottir (1990) developed an assessment tool, The Arnadottir OT?ADL Neurobehavioral Evaluation, which was designed to detect dysfunction in self care performance areas (The Functional Independence Scale) and in specifically defined performance components (Neurobehavioral Scale). The assessment reveals information about self-care performance skills and neurobehavioural component dysfunction thereby proposing possible links between neurobehavioural function and occupational performance.

Although many other occupational therapy assessments examined performance, this was the only one that specifically identified the use of an occupational performance theoretical structure to guide the development of constructs. Subsequent to 1990, other assessment formats have been developed using occupational performance constructs, for example, the Assessment of Motor and Process Skills (AMPS) (Fisher, 1990) and The Perceive, Recall, Plan and Perform Systems (The PRPP System) (Chapparo & Ranka, 1991a).

In summary, the major constructs associated with occupational performance that were derived from the literature during this stage of model building included occupational performance, occupational performance areas, components of occupational performance and an emerging notion of occupational and life roles.

Outcome:

Using information derived from the literature review, the circular occupational performance model described earlier (Fig. 2) was revised and resulted in a two-level model that was similar to the AOTA, Inc. curriculum guide. This structure was based on three primary constructs: occupational performance, occupational performance areas (self-maintenance, leisure, productivity) and components of occupational performance (biomechanical, sensory motor, cognitive, psychosocial and creative).