STAGE THREE (1991-1992):

Purpose:

The purpose of the third stage of model development was 1) to further explore use of occupational performance terms in acute care environments where short-term stay made traditional forms of occupational therapy intervention impossible, 2) to determine whether occupational performance could be used in an area of practice that was characterised by strong adherence to a particular theoretical and practice model (eg. sensory integration) and, 3) to determine what philosophical base therapists using occupational performance held in their everyday practice.

Methods:

Information collected during Stage Three of the model building process came from three sources. First, further continuing professional education courses were held during 1992 in the practice area of neurology in Victoria (Chapparo & Ranka, 1992a) and Tasmania (Chapparo & Ranka, 1992b). These courses mirrored the content of the courses conducted in Stage Two. The constructs occupational performance, occupational performance roles, occupational performance areas, components of occupational performance and environment were described. Intervention scenarios using videotapes of clients acted as the stimuli to facilitate therapists to use the constructs for treatment planning, and in describing their own intervention styles and work settings. Responses of therapists working in acute care environments were particularly noted.

Second, two continuing professional education courses in the practice area of sensory integration were held in NSW (Chapparo & Hummell, 1992a) and South Australia (Chapparo & Hummell, 1992b) where the occupational performance constructs were incorporated into the constructs inherent in sensory integration theory and practice. Case studies were used as the stimulus for getting therapists to describe their treatment planning and the rationales for their actions during these courses. Descriptions generated by therapists included what they perceived as problems that required occupational therapy intervention in children with sensory integrative disorders, perceptions of the nature of order and disorder in childhood occupations, and perceptions of what constituted occupational therapy for children.

Third, through a continuing professional education course that specifically sought to explore the process of developing a personal frame of reference for practice (Chapparo & Ranka, 1991f), therapists were encouraged to describe important elements of their own personal beliefs, values and principles underlying their practice relative to occupation and occupational performance. Descriptions generated by therapists incorporated what they believed about human potential, health, occupations, and occupational therapy.

Findings:

1.	Therapists working in acute care facilities were required to consider human occupations at a level that was fundamental to the previously identified component level. This was particularly evident in intensive care units, acute neurosurgical units and trauma units where more fundamental aspects of physical, mental and spiritual elements were perceived as core elements of human function to be considered along with other occupational performance constructs (Nicholls, 1993, Ryan & Nicholls, 1993).
2.	These findings were also reflected in occupational therapy practice with clients who were terminally ill. Spiritual aspects of existence were emphasised and occupational role behaviour was focused on affirmation of life roles and preparation for death.
3.	Therapists in acute care settings described intervention as primarily assessment, placement and discharge planning. Social and physical aspects of the environment construct featured heavily in consideration of client occupational performance.
4.	Direct intervention at the level of occupational performance areas and occupational performance roles did not feature prominently in descriptions of acute care practice. However, all therapists described a process of reasoning in acute care that required them to develop predictive visions about client performance at these levels. These predictive visions of client role performance were used to determine discharge plans and actions relative to specific discharge environments.
5.	Therapists working with children and using a sensory integrative approach to treatment placed sensory integration within the broader constructs of occupational performance.
6.	Therapists reported that placing sensory integrative constructs within the broader framework of occupational performance altered intervention in two ways. First, consideration of occupational performance constructs broadened the scope of their intervention from the child’s performance at school to other dimensions of daily living such as play, and to other component areas such as interpersonal and intrapersonal dimensions of the child’s occupational being. Second, therapists employed the occupational performance structure as a vehicle for linking sensory integrative modes of intervention with others that were applicable to the same groups of children, such as skills training and more psychodynamic forms of intervention.
7.	Beliefs and assumptions that therapists viewed as influencing the way they used occupational performance constructs fell into four dimensions. First, they articulated a series of beliefs that related to human potential for occupational performance. Included in this dimension was the prevalent belief that people have an occupational being that is individually and actively created, and is influenced by both internal and external factors. This occupational being is expressed through occupational performance and ultimately defined in one’s occupational roles. Fundamental to this was the belief that people have the right to determine their own occupational being.The second dimension concerned beliefs about the nature of occupations. Human occupations were viewed by therapists in these workshops as highly idiosyncratic behaviours that fell into three patterns. First, patterns of doing that were described as tasks, sub-tasks, activity patterns or roles. Second, patterns of thinking that involved planning, reminiscing and imagining and could either be incorporated into patterns of doing or exist by themselves. Third, patterns of being that were characterised by notions of self-actualisation and inner visions of becoming. Occupations were categorised by people relative to the meaning they ascribe to them. The configuration of occupations changes with chronological/developmental age, life stage and life circumstances. Development, performance and maintenance of occupations are influenced by internal and external factors. There is a balance of occupations that is highly individual and is related to well being in body, mind and spirit. The third area related to what therapists viewed as health. Relative to occupational performance, health was viewed as satisfaction with the ability to develop and perform occupations and maintain occupational roles. Engagement in occupations was believed to support health and well being. Non-health was viewed as dissatisfaction with performance of occupations and could result from internal or external factors. The fourth dimension related to therapists’ beliefs and assumptions about occupational therapy. Performance of occupations was viewed as involving an adaptation process. Adaptation was believed to be an active process of doing and/or thinking and/or being that depended on goal-direction. The role of the occupational therapist was to facilitate the adaptation process by engaging the person in the development, performance and maintenance of chosen occupations. Occupational therapy was viewed as a collaborative process between the therapist, client and significant others. The primary tools of the occupational therapist were engagement in purposeful occupations. Use of intervention methods out of the context of the individual’s occupational performance was not considered to be occupational therapy.

Outcome:

The existing occupational performance model was further revised to include a construct named ‘core elements’. This included notions of an integrated body/mind/spirit element of human existence that is expressed in all other constructs as the `doing-knowing-being’ dimensions of occupational performance. The environmental construct was further refined to specifically include physical/social/cultural dimensions.