STAGE TWO (1990-1991):

Purpose:

The purpose of Stage Two was 1) to determine whether the constructs as outlined in the two level model were relevant to occupational therapy practice in Australia, and 2) to discover whether there were other dimensions to occupational therapy practice that were not explained by the model.

Methods:

A major area of practice, occupational therapy intervention for adults and children with neurological impairment, was chosen for examination of the existing constructs because 1) it is a practice area involving the use of many models of intervention thereby presenting an opportunity to test for the inclusiveness of occupational performance, and, 2) it is an area of practice that encompasses acute and chronic, hospital and community aspects of occupational therapy intervention.

Five two-day continuing professional education courses were conducted over a twelve month period during 1990-1991 in the Sydney area, titled, “Occupational performance: Acquisition of adaptive skills in adults and children with brain damage” (Chapparo & Ranka, 1990, 1991b,c,d,e). Each of the six workshops examined a specific aspect of occupational therapy intervention for adults and children with neurological impairment; such as, the use of task analysis to identify problems, neurodevelopmental therapy in occupational therapy, proprioceptive neuromuscular facilitation in occupational therapy, upper limb orthotics, and cognitive disorders and occupational therapy intervention.

In each of the courses the three major constructs in the model (occupational performance, areas of occupational performance, components of occupational performance) were outlined and defined. Intervention as determined by the particular workshop topic was taught and finally, by means of case-based problem solving, therapists were asked to integrate concepts of occupational performance with the course topics. Detailed notation was made of therapists’ descriptions of the observed and perceived problems of client performance of functional tasks from videotaped examples; therapists’ descriptions of their own hospital and community-based intervention scenarios; goals; therapists’ rationales for intervention and program evaluation. Finally, therapists were encouraged to talk about the applicability of occupational performance constructs relative to their own work settings.

Findings

1.	Therapists readily identified with the existing constructs and terminology of the model: occupational performance, occupational performance areas and components of occupational performance.
2.	Three major occupational performance areas addressed were self-maintenance occupations, work/school occupations and leisure/play occupations. Therapists who treated children linked play with leisure and school with work. Therapists talked about the nature of occupations in terms of activities (constellations of tasks) or tasks (specific).
3.	The components of occupational performance that therapists routinely considered important in practice were biomechanical, sensory-motor, cognitive and psychosocial. There was strong rejection of the notion of ‘creativity’ as a separate component. Creativity was perceived as a multifaceted phenomenon involving all component functions.
4.	Most therapists employed many different theoretical and practical approaches to guide intervention that had been developed for use outside the profession (for example, Motor Relearning Program, Neuro-developmental Therapy, Biomechanical Approach). Descriptions of their interventions were characterised by switching from one approach to another depending on the perceived client problem and their own personal comfort with the intervention. In these instances they used occupational performance constructs to focus multiple interventions within the domain of occupational therapy and to achieve a cohesive approach to complex problems usually seen in one client.
5.	Over the course of 12 months therapists consistently used theoretical links between the occupational performance constructs within their work contexts to set occupation-centred treatment goals (for example, they related sensory-motor goals or cognitive goals to functional outcomes).
6.	Others reported instances where use of the model brought cohesion within large departments where occupational therapy services were provided in a variety of areas of practice.
7.	Using case scenarios, it became apparent through therapists’ story telling of their practice that two additional factors featured prominently in their reasoning. One was an environmental factor that had physical, cultural and social dimensions. The second factor was concerned with the totality, satisfaction and value of the occupational existence for their clients that went further than occupational areas or components, and seemed similar to theoretical notions of occupational roles.

Outcome:

The constructs, occupational performance areas (self-maintenance, work/school and leisure/play), and components of occupational performance (biomechanical, sensory motor, cognitive, psychosocial) were confirmed to be major constructs used in occupational therapy practice in both hospital and community settings. Two additional constructs, environment and occupational performance roles, were identified to be important to dimensions of practice which focus on human occupations, and were incorporated into a third revision of the model of Occupational Performance.

Literature support for adding the environmental construct to the revised model was found in the work of multiple authors (see for example, Barris, 1982; Clark, Parham, Carlson, Frank, Jackson, Pierce, Wolfe, & Zemke, 1991; Colvin & Korn, 1984; Howe & Briggs, 1982; Keilhofner & Burke, 1980; King, 1978; Law, 1991; Llorens, 1970, 1984; West, 1986). Support for the construct, occupational performance role, in actual practice was more tenuous. While there has been increasing emphasis in the literature that the goals of the profession focus on valued occupational roles of clients, discussion of how this construct is used in practice is almost wholly theoretical (Christiansen, 1991; Jackoway, Rogers & Snow, 1987; Keilhofner, Harlan, Bauer, Maurer, 1986; Matsutsuyu, 1971; Moorhead, 1969; Oakely, Keilhofner, Barris, & Reichler, 1986; Vause-Earland, 1991; Versluys, 1980). Christiansen (1991, p.28), for example, conceptualises a widely accepted theoretical concept of an occupational performance hierarchy which ranges from activities to roles. Roles, he specifically defines as sets of activities which have some recognisable purpose and, which are distinctive positions in society that carry specific expectations for behaviour.