Evaluating ADL measures from an occupational therapy

Transcription

Evaluating ADL measures from an occupational therapy perspective
Sheryl Klein
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Ingrid Barlow
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Vivien Hollis
Key words
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Activities of daily living
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Outcome measures
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Action research
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Nominal group technique
Mots clés
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Activités de la vie quotidienne
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Mesures des résultats
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Recherche-action
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Technique du groupe nominal
Abstract
Background. Measures reflecting occupational therapy's conceptualization of occupational performance support the profession's
contribution to evidence-based practice and fiscal accountability. Purpose. This study compared measures of performance-based
activities of daily living (ADL) with principles of occupational therapy practice and intended outcomes. Methods. Using an action
research study design, occupational therapists and researchers (N=13) systematically clarified the clinical problem, identified
occupational therapy principles inherent to the assessment of daily living activity via nominal group technique; defined the key
principles as constructs; and reframed these constructs as a questionnaire against which 18 published standardized ADL measures
were evaluated. Findings. Participants identified six measures as most congruent with principles of occupational therapy practice:
ADL Profile, Assessment of Motor and Process Skills, Functional Performance Measure, Rivermead ADL Assessment, Edmans ADL
Index, and Melville-Nelson Self-Care Assessment. Implications. Findings guide occupational therapists' search and use of
performance-based ADL measures that demonstrate the profession’s distinct health care contribution.
Résumé
Description. Les mesures témoignant de la conceptualisation du rendement occupationnel en ergothérapie appuient l’apport
de la profession face à la pratique fondée sur les faits scientifiques et la responsabilité financière. But. Cette étude visait à
comparer des mesures du rendement à la réalisation des activités de la vie quotidienne (AVQ) aux principes de la pratique de
l’ergothérapie et aux résultats escomptés. Méthodologie. À partir d’un plan expérimental basé sur la recherche-action, des
ergothérapeutes et des chercheurs (N=13) ont systématiquement clarifié le problème clinique et déterminé les principes
ergothérapiques inhérents à l’évaluation des activités de la vie quotidienne par l’intermédiaire de la technique du groupe
nominal. IIs ont ensuite défini les principes clés comme des construits, puis ils ont reformulé ces construits sous forme de
questionnaire à partir duquel 18 mesures standardisées des AVQ ont été évaluées. Résultats. Les participants ont identifié six
mesures comme étant les plus congruentes avec les principes de la pratique de l’ergothérapie : le ADL Profile, l’Assessment of
Motor and Process Skills, la Functional Performance Measure, la Rivermead ADL Assessment, l’Edmans ADL Index et le MelvilleNelson Self-Care Assessment. Conséquences. Les résultats orientent la recherche de l’ergothérapeute et favorisent l’utilisation
des mesures basées sur le rendement aux AVQ qui démontrent l’apport distinct de la profession dans les soins de santé.
iscal accountability (Dobrzykowski & Lieberman, 2000)
and evidence-based practice (Dunn, 2005; Law & Baum,
1998; Tickle-Degnen, 1999) are driving forces that
necessitate the documentation of intervention efficacy in health
care. Occupational therapists advocate the use of assessment
procedures and intervention-efficacy outcomes that reflect the
profession’s conceptualization of occupational functioning
(Backman, 2005; Department of National Health and Welfare &
Canadian Association of Occupational Therapy, 1987; Law,
Baum, & Dunn, 2005). Gillette (1991) wrote: “The basic
concepts of a profession should be reflected through the tests
and measurements used in its practice. For occupational
therapy, this means functional assessments of performance
based on tests that measure change in occupational
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performance” (p. 565). Performance-based measures, which
comprise the aims and accepted principles of occupational
therapy intervention, enable practitioners to demonstrate the
profession's unique contribution to health care.
Based on occupational therapy principles, activities of
daily living (ADL) have historically been a key component of
practice (Christiansen, 1991b; Townsend et al., 1997), but the
number of studies that document occupational therapy
efficacy outcomes is limited (Letts & Bosch, 2005). One
possible reason is that occupational therapy efficacy-study
outcomes may be compromised if the ADL measures used do
not adequately capture the objectives of occupational therapy
assessment and intervention as guided by the profession's
values, beliefs, and principles.
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Changes within the health care system have created an
emphasis on the functional status of individuals and resulted
in a variety of professionals’ (e.g., physical therapists, nurses,
neuropsychologists) publishing ADL outcome research.
Frequently ADL outcomes are based on generic scales of
functional independence, such as the Functional Independence Measure (Gutman, 1998; Heinemann, 2000). The use
of generic scales allows comparisons of outcomes across
diagnostic categories and health care providers but limits the
recording of discipline-specific input.
Law (1993) reminded us that ethical and philosophical
principles and perspectives are reflected in the construction of
measures. The values, beliefs, and principles on which a
measure is developed may not be explicitly stated, but they are
frequently embedded within the measure's conceptual basis,
item inclusion, standardization, and scale design. For example,
a measure is not congruent with the occupational therapy
values of choice and client-centredness if the measure design
does not recognize the independence of a client who uses a
technical aid or hires a personal care assistant.
This study used a collaborative practitioner-researcher
action research study design to examine published,
standardized performance-based ADL measures developed for
adult/geriatric populations and then draw conclusions about
which best matched occupational therapy practice principles.
Methods
The key motivator for this study was the dissonance between
occupational therapists' need to demonstrate efficacy and
their feelings about the lack of adequate performance-based
ADL measures. Occupational therapists employed in a large
tertiary-care rehabilitation hospital expressed concern that
the ADL measures they used in their day-to-day practice did
not always identify factors that they deemed important from
their clients' and their own professional perspective. Nor did
they adequately capture the outcomes that occupational
therapists emphasize during their intervention. Action
research was the chosen research strategy because it enabled
therapists, who identified the problem, to participate in a
process that systematically addressed their concerns and
resulted in change (Wallis, 1998/99). When using action
research, researchers and practitioners collaborate to
examine and consider the problem, then plan for and effect
change as they progress through a cyclical process toward
resolution (Denscombe, 1998; Stringer, 1999).
The Regional Ethics Review Board approved the study.
Occupational therapist participants provided informed
consent in keeping with approved ethical practice standards.
Participants
Ten occupational therapists from one tertiary-care rehabilitation hospital, who voiced the initial concern regarding the
clinical issue, and three researchers collaborated in this
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action research process. The therapists had a diversity of
clinical experience with adult/geriatric clients diagnosed with
a physical dysfunction, an average of 10.6 (SD=5.3) years of
experience as occupational therapists, and an average of 9.3
(SD=5.4) years of experience in adult/geriatric rehabilitation.
Two researchers held clinical research positions within the
hospital, and one university researcher had extensive
experience using qualitative methodology.
Study design
The study comprised three phases, each following the action
research process of looking, thinking, and acting (Stringer,
1999).
Phase 1. Problem identification
Existing ADL measure reviews (e.g., Christiansen, 1991b;
Law, 2002b; Law & Letts, 1989; McDowell & Newell, 1996;
Unsworth, 1993) were examined. The reviews included
information on the measure's purpose, psychometric
properties, and clinical utility. Despite literature stressing the
need for outcome measures to reflect professional practice
(Backman, 2005; Corr & Siddons, 2005), the published
reviews had limited information on the ADL measures as
they related to occupational therapy practice. Participants
posited that the concept of ADL, as used in the design of
measures, was not always compatible with the constructs
important for occupational therapy process and outcome.
This led to the second phase, when participants identified
constructs that were fundamental for occupational therapy.
Phase 2. Construct identification and the
development of a rating scale to evaluate
performance-based ADL measures
Participants chose the Canadian Model of Occupational
Performance (CMOP) practice model as a basis for agreeing
on the critical criteria of principles of occupational therapy
practice. The CMOP was developed as an occupational
therapy practice guideline (Townsend et al., 1997) and
endorsed by the Canadian Association of Occupational
Therapists. An author of the book Enabling Occupation: An
Occupational Therapy Perspective (Townsend et al.) provided
a participant training session to ensure uniform understanding of the practice model, including the values, beliefs,
and principles that underpin occupational therapy practice.
A second training session helped participants
understand the nominal group technique (NGT), used
during construct identification. NGT is a group consensus
method (Fink, Kosecoff, Chassin, & Brook, 1984) described
in the occupational therapy literature (Steward, 2001) that
provides a balance between individual item generation and
group discussion to prioritize items.
To facilitate understanding of the concept of “construct,”
participants examined the construct of cognition and
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reviewed a cognitive assessment used by occupational
therapists with the CMOP practice model.
Participants met to identify and agree on the important
constructs of occupational therapy practice, using NGT. The
10 therapists divided into three subgroups and brainstormed
the constructs they believed to be inherent in the CMOP that
related to the definition and measurement of ADL. The
group reconvened, and each therapist identified one
construct from his or her small-group brainstorming list and
discussed the construct's importance as it pertained to ADL
and the intention and practice of occupational therapy. This
process continued until the list of constructs was exhausted.
Gaps were identified and additional constructs were added
(See Figure 1: Step One).
When all constructs were identified, participants
individually ranked 8 of the 16 constructs. Researchers
collated the rankings and presented the results to the group,
including the mean rank (See Figure 1: Step Two).
FIGURE 1
Flow chart depicting construct identification process
Step One. All identified constructs.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Client-centredness
Control
Uniqueness of how task can be completed
Pre-existing role definitions, new role, cultural definitions
Meaningful activity
Functional ability within client's typical environment
Resources, cultural role, social support, education
Client ability to learn and accept (aware of deficits and
resources);
Holistic perspective
Pre-morbid status
Client's level of risk taking
Depth (qualitative) aspects of assessment
Dynamic interaction between person/environment/task
Financial ability to access resources
General level of communication
Client ability to solve problems
uniqueness of individual (motivation, spirituality)
Step Two. List of constructs ranked
through nominal group technique.
1.
2.
3.
4.
5.
6.
7.
8.
Holistic perspective
Client-centredness
Dynamic interaction
Functional ability
Resources
Meaningful activity
Uniqueness
Control
(Mean = 7.2)
= 6.7
= 6.2
= 4.2
= 3.8
= 3.8
= 3.4
= 2.8
Step Three. Final list of defined constructs.
1. Holistic
A view of persons as whole beings integrated in mind, body, and spirit (incorporates the whole picture of the client:
roles, gender, culture, resources, performance components, the physical environment, social supports, spiritual beliefs, and
values). Holism was viewed as a construct that must be considered within all aspects of the client's life and thus
incorporated within all other constructs.
2. Client-Centred
Respect for clients (values and beliefs systems), involve clients in decision making and recognize the client's experience
and knowledge. Reflects a collaborative approach wherein relevant goals and optimal outcomes can be mutually agreed
upon.
3. Dynamic Interaction
Recognition of the dynamic relationship between the person, environment, and task.
4. Uniqueness of Individual
The inherent attributes of the person, including affect and physical, cognitive, and spiritual aspects (what does the person
bring to the task of ADL or success with the ADL task)
5. Uniqueness of Performance
The process is meaningful only in that it is acceptable to the client and meets safety standards. Emphasizes recognition
of the client's definition of task success as either a process towards achievement or the product of achievement (while
recognizing the need to ensure safety standards
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During the ensuing discussion, participants determined
that some constructs overlapped or subsumed others. The list
was consolidated into five constructs: (1) holism; (2) clientcentred practice; (3) dynamic interaction; (4) uniqueness of
the individual; and (5) uniqueness of performance, and
defined by participants in occupational therapy terms (See
Figure 1: Step Three).
This list was developed into a series of questions (See
Figure 2) and formatted into the ADL Construct Rating
Review Form (See Figure 3), for use when evaluating ADL
measures for congruence with occupational therapy practice.
The format of the rating review form approximated the
process outlined in the Dynamic Performance Analysis
framework (Polatajko, Mandich, & Martini, 2000).
To ensure that the original constructs were captured in
the rating form, the two clinical researchers compared it with
the original nominal group constructs. Two therapists rated
an ADL measure to pilot the use of the rating form for its
utility. The clinical researchers made subsequent modifications to clarify wording.
Phase 3. The process of rating ADL measures for
those that best fit with principles of occupational
therapy
A second literature search was conducted using CINAHL,
MEDLINE, OT Source, and books of previously reviewed
FIGURE 2
Initial construct question development
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1. Holism
1.1 Embedded within constructs 2-5.
2. Client-Centred
2.1 Does the measure identify what the client values?
2.2 Does the measure identify tasks important to the client and success as defined by the client
rather than by a standardized process?
2.3 Does the measure allow the client to use alternate methods or processes to accomplish the task
and thereby address role expectations, cultural values, time restraints, etc.?
2.4 Does the measure reflect a collaborative approach (e.g. allow the client to identify more
important components, etc.)?
2.5 Does the measure enable the client to prioritize what he or she wishes to work on and achieve?
2.6 Does the measure allow for making informed decisions about taking risks?
2.7 Does the test only have a total score or can it be done in components valued by the client?
3. Dynamic Interaction
3.1 Does the measure recognize or acknowledge interaction between person/environment/task?
3.2 Does the measure recognize successful task completion if the task or task process is modified
(e.g., use of a sock aid or reacher)?
3.3 Does the test identify the physical environment in which the client will need to use his or her
skills and allow consideration of the environment in determining task success (e.g., bathroom
accessibility, distractions, clutter, independence across a variety of environments, etc.)?
3.4 Does the measure identify the social support, including the institutional support environment
(e.g., client's financial resources to cover equipment costs, family support, caregiver support,
culture, homecare support, health care system, etc.)?
3.5 Does the measure identify how culture affects the way the ADL task is completed (e.g., use of a
bowl or chop sticks, how the culture values independent occupational performance)?
4. Uniqueness of the Individual
4.1 Does the measure recognize the client's motivation to learn new ways to be independent?
4.2 Does the measure recognize client's willingness to persist with the task to complete it?
4.3 Does the measure recognize the client's awareness of strengths, challenges, and ability to
prioritize tasks, (e.g., decide what the client wants to invest his or her energy in doing)?
4.4 Does the measure recognize/assess the client's implicit knowledge of task demands
(e.g., process steps, knowledge of hip precautions, balance limitations, etc.)?
4.5 Does the measure recognize the client's ability to solve problems or offer some solutions to
develop independence in ADL tasks?
4.6 Does the measure identify or allow observation of underlying performance components
(e.g., sensation, motor control, perception)?
4.7 Does the measure allow for qualitative observation?
4.8 Does the measure identify the client’s role expectations of self and others (e.g., how acceptable
it is to get assistance from another family member)?
5. Uniqueness of Performance
5.1 Does the measure allow the client to use alternate methods or processes to accomplish the task,
and in doing so address role expectations, cultural values, time restraints, and so on?
5.2 Does the measure recognize successful completion of the task if the task is modified for the
client to achieve success (e.g., task success vs. “doing it correctly”)?
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FIGURE 3
ADL construct rating review form
ADL Construct Rating Review Form
This form is intended to be used for reviewing established ADL measures for constructs identified as important for the assessment of ADL in occupational therapy practice. Please keep in mind the following:
• Each question has some examples that were raised to help illustrate this construct. This is not meant to be exhaustive, just to help recall the
construct.
• Many of these measures will not have the construct you are looking for outlined clearly in the supporting documentation (that would be too easy!).
You will need to examine the measure, the way it has the tester examine ADL, and how the tester scores it to see if that particular construct is
“implied” or “inherent” by the way it is structured. For example, the measure may not overtly state that they consider the environment, but it may
have a place on the score sheet to describe the test environment. For this reason, we are asking you to comment on what drew you to that
conclusion about that particular question. This will be very important for our review.
Score measure based on the following scale:
(0) Construct not present
(1) Some elements of construct present
(2) Construct present
Construct
1.
1.1
1.2
1.3
2.
2.1
2.2
2.3
Comments:
Construct
Is the measure client-centred?
question(s):
Does the measure allow the tester to identify tasks important to the client?
• 2.1
0 1
• E.g., does the test have a total score or can it be done in components valued by the client?
• E.g., is the measure comprised of a scoring format that allows the client to priorize tasks where he or she wants to • 2.4
• 2.5
invest his or her energy?
• E.g., does the measure acknowledge role expectations of self and others (gender, culture, age, how acceptable it is • 2.7
to get assistance from other family members, how the culture values independent occupational performance)?
• 4.1
0 1
Does the measure identify if the client is motivated to learn new ways to be independent?
• 4.2
0 1
Does the measure identify when the client is willing to persist with the task to complete it?
Does the client have a general knowledge of task demands?
Does the measure identify the client’s knowledge of the task demands?
• E.g., does he or she know the steps of the task?
Does the measure recognize the client's awareness of strengths, challenges, and ability to prioritize tasks, (e.g.,
decide what he or she wants to invest their energy in doing)?
Does the measure allow for making informed decisions about taking risks?
• E.g., the client is aware that going down to the bottom of the tub may increase the risk of a fall, but that is the way
he or she wants to do it.
3.
Is the client’s performance competent?
3.1 Is task competence identified/defined* by the client?
3.1.1 Does the measure allow for the task success to be defined by the client?
• E.g., the client has identified getting clean while bathing as a task that requires submersion in a tub bath, not showering.
3.1.2 Does the measure allow for different ways or processes for completing the task?
• E.g., task success vs. doing it“correctly”
• E.g., Task process is only important if the client has identified that as a concern—such as speed of dressing.
• E.g., allows for how the culture affects the way an ADL task is done ( China bowl for eating, rather than with plate,
knife, fork).
3.2 Where is the performance breaking down?
3.2.1 Does the measure recognize or acknowledge interaction between the person, environment, and task?
3.2.2 Does the measure allow for qualitative observation?
3.3 Does the client have the ability (performance components)?
3.3.1 Does the measure identify or allow observation of underlying performance components (e.g., sensation, motor
control, and perception)?
Are the demands/supports of the task appropriate for the person’s ability and environmental situation
(i.e., task modification)?
3.4.1 Does the measure recognize/identify modifications needed for success?
• E.g., does the measure identify issues related to time restraints – dressing for work/school vs. less pressured time
restrictions?
• E.g., a client is unable to dress independently due to limited ROM, but would be able to if long-handled aids were
available, or a different dressing technique.
2
2
2
• 4.4
0 1
2
• 4.3
0 1
2
• 2.6
0 1
2
• 2.2
0 1
2
• 2.3
• 3.2
0 1
2
• 3.1
• 4.7
0 1
0 1
2
2
• 4.5
• 4.6
0 1
2
• 5.1
• 5.2
0 1
2
• 3.3
0 1
2
3.4
3.5 Are the demands/supports of the environment appropriate for the person’s ability and task difficulty?
3.5.1 Does the measure identify the "assessment" environment and the demands of the“discharge”or“typical”
environment?
Continued on next page
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Continued from previous page
Construct
Comments:
Construct
• E.g., hospital vs. home
question(s):
• E.g., when role requires changing environments for task
3.5.2 Does the measure acknowledge the social support environment?
• 3.4
0 1
•
E.g., does it identify who lives with the client and how much they are able to assist?
• 4.8
•
E.g., does it identify the client’s role expectations of self and others related to how acceptable it is to get assistance
from another family member?
3.5.3 Does the measure identify whether financial resources/supports are available?
•
E.g., does the client have the ability to pay for equipment or environmental modification that may be needed to be • 3.5
0 1
independent?
Total Score
2
2
_____/ 60
Note. To improve reader understanding of the development of the ADL Construct Rating Review Form, the construct question number from Figure 1 matching the question
on the ADL Construct Rating Review Form was inserted into the comment section of the ADL Construct Rating Review Form.
measures to identify ADL measures meeting the following
criteria: (1) based on standardized performance as observed by
a therapist; (2) published in peer-reviewed literature; (3)
developed for use with an adult/geriatric population with a
physical dysfunction. Information pertaining to the ADL
measures’ purpose, theoretical foundation, item content,
reliability, validity, responsiveness, clinical utility, and scoring
was compiled (Polgar, 1998). The primary purpose of the
measure selected was to assess personal/basic ADL function,
although several measures examined some instrumental ADL.
Of the 93 measures identified through the literature
review, 18 met the inclusion criteria, had publications that
described item content, and had at least minimal information
describing the measure's reliability and validity. One clinical
researcher and 1 of the 10 therapists reviewed each measure.
The ADL construct rating review form used a three-point
Likert scale consisting of construct not present (0); some
elements of construct present (1); and construct present (2).
To establish inter-rater reliability for measure ratings,
Pearson product moment correlations were calculated as r =
0.83, with r >0.75 reported as good for research purposes
(Portney & Watkins, 1993).
The results of the measure reviews were collated. A cluster
of six measures with the highest ratings was identified as being
most congruent with the process and outcomes specific to
occupational therapy professional practice. A final participant
focus group was held to discuss this cluster of measures and to
examine the measures' clinical utility, reliability, and validity.
Following this focus group, therapists explored use of these
measures within their clinical specialties. To date, one therapist
has obtained training to enable implementation of one measure
with clients with brain injuries.
Findings
Of the 18 measures reviewed, 6 measures received high
ratings by reviewers for their “fit” with the values, beliefs, and
principles that underpin occupational therapy practice (See
Figure 4).
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These measures were ADL Profile, Assessment of Motor
and Process Skills, Functional Performance Measure,
Rivermead ADL Assessment, Edmans ADL Index, and
Melville-Nelson Self-Care Assessment (See Table 1). The
appendix describes the selected measures, including the
theoretical foundation, description, and psychometric
properties.
The six measures were chosen as the focus of
deliberation. Although some provided a more holistic
perspective, none considered the client's financial and social
environment.
The ADL Profile (Dutil, Bottari, Vanier, & Gaudreault,
2005; Dutil, Forget, Vanier, & Gaudreault, 1990) was
developed to assess clients with head injuries. Construct
reviewers found the ADL Profile met most construct criteria.
It was unique in incorporating task initiation as an
assessment criterion.
The Assessment of Motor and Process Skills (AMPS)
(Fisher, 2001a; 2001b) was developed as an occupational
performance assessment of ADL motor and process skills.
Construct reviewers reported that the AMPS met most
constructs important to occupational therapists. The finding
that the AMPS was the only measure that fully met the clientcentredness criterion was noteworthy. The underlying
premise of the AMPS is the influence of personal meaningfulness of the task on the individual’s performance; the client
is asked to identify valued tasks and the manner in which the
task is to be completed. Concerns regarding clinical utility
were expressed. Our study and others (Donnelly & Carswell,
2002) felt that the rater calibration training costs might be
prohibitive for many facilities. While the AMPS received high
ratings for its fit with occupational therapy practice, its
acceptance by other professionals within multidisciplinary
teams was questioned.
The Functional Performance Measure (FPM) (Carswell,
Carson, Walop, & Zgola, 1992; Carswell, Dulberg, Carson, &
Zgola, 1995) met most of the identified criteria but was not
reported as client centred. Given that its purpose is to assess
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FIGURE 4
ADL measure ratings
Rating Values (range= 0 - 60)
ADL function for a client population diagnosed with
Alzheimer's disease, this finding is not anomalous.
The Rivermead ADL Assessment (Lincoln & Edmans,
1990; Whiting & Lincoln, 1980) was developed for use with
brain injury and cerebral vascular accidents (CVAs). The
Rivermead ADL Assessment had a standardized procedure
requiring task completion in a specified manner. When the
task process is rigidly specified, modifications to the task or
the environment that result in successful task completion
may not be acknowledged. The measure was evaluated as
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clinically useful because of its ease of use, its scoring method,
and the inclusion of a comment section for qualitative
observations. Limitations included lack of client-centredness
and failure to examine the dynamic interaction between the
client, the task, and the environment.
Edmans ADL Index (Edmans & Webster, 1997) was
developed to assess ADL performance of clients with a CVA
for their potential to live independently at home. Although
Edmans ADL Index has a standardized specified procedure
for task completion, a comment section enabled individual
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TABLE 1
Fit of measures with constructs representing occupational therapy practice principles
ADL Constructs
ADL
measure
Holism
Client-centred
practice
Dynamic interaction
Uniqueness of
performance
The ADL
Profile
Score enables
Did not
meet criteria item
relevancy for
client.
Acknowledges dynamic interaction
between the client, task, and
physical environ-ment.Does not
consider the financial or social
environment.
Enables assessment of
physical, affective and
cognitive performance
components.
Client determination of
task process unless
client safety is a factor.
Assessment
of Motor
and Process
Skills
Met all criteria
Did not
meet criteria for clientcentredness.
Acknowledges dynamic interaction
between the client, task, and physical
environment. Does not consider the
financial or social environment.
Enables assessment of
physical, affective, and
cognitive performance
components.
Client determination of
task process unless
client safety is a factor.
Assessment of the dynamic interaction
between the person, the task, and the
physical environment is embedded.
within the measure's standardized
procedure.
Incorporates assessment
of the client's performance components into
the item content and/
or the standardized
procedure of the
measure.
Incorporates assessment of the uniqueness of the performance,
into the item content
and/or the standardized
procedure of the
measure.
Not
Did not
Functional
Performance meet criteria applicable.
Measure
Rivermead
ADL
Did not meet
Did not
meet criteria criteria.
Enables observation of
Some aspects of the dynamic
interaction between the person, the performance
task, and the physical environment components.
are embedded; e.g., use of aids
Score reflects Some aspects of the interaction
Edmans ADL Did not
between the person, the task, and
meet criteria relevancy of
Index
item for client. the physical environment are
embedded; e.g., use of aids.
MelvilleNelson SelfCare
Assessment
Score reflects Standardized procedure allows
Did not
inference of some aspects client /task
meet criteria relevancy of
item for client. /environment interaction. Considers
environmental supports based on the
assistance required for task
completion.
Standardized procedure
enables client to have
some determination
of task completion
process.
Comment section
enables consideration of
performance
components.
limits modifications to
task completion
process.
Therapists are
able to observe
underlying performance
components.
limits modifications to
task completion
process.
recording of client attributes and the uniqueness of the
client's performance. The measure did not address the
interaction of client, task, and environment.
The Melville-Nelson Self-Care Assessment (SCA)
(Nelson et al., 2002) is based on the Conceptual Framework
for Therapeutic Occupation (Nelson, 1996) and meets
regulatory requirements for skilled nursing facilities and subacute rehabilitation. As with other measures reviewed, the SCA
had the potential to be client-centred because of the scoring
procedure. The measure differs from many other measures in
that it identifies environmental supports based on the degree
of assistance the client requires for task completion.
for occupational therapists to be aware of a measure’s foundational constructs and congruency with the focus of their
professional practice. The action research process made it
possible to identify constructs and subsequently to discuss
their importance within the context of client assessment.
Although the five identified constructs are tacitly accepted as
established professional principles, discussion reinforced the
need for practicing occupational therapists to consider them
when reflecting on a measure's use and practice foci.
Discussion
In reviewing implicit and inherent attributes of the measures,
it was evident that several issues established a measure's
congruency with occupational therapy practice. These issues
pertained to the measure's construction and conceptual basis.
ADL measures are often developed from differing conceptual
Study findings provide information for the practicing
occupational therapist faced with clinical decisions regarding
use of specific measures. This research also shows the need
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Uniqueness
of individual
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Overview: Measures and
construct congruence
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bases and include differing content items (Law, 1993;
Unsworth, 1993). The ADL Profile and the AMPS, for
example, were developed from recognized models of occupational performance whereas the theoretical base of others (e.g.,
the Barthel Index, the Klein-Bell Activities of Daily Living
Scale) was not as well defined reflecting client progress as a
checklist of ADL performance tasks. Item content, derived
from the conceptual base or purpose of the measure,
frequently accounted for the presence or absence of important
occupational therapy constructs. Moreover, differing
standardization procedures and modes of measurement
determined a measure’s fit with occupational therapy practice.
Holism
Although occupational therapists place immense importance
on the construct of holism (Christiansen, 1991a), no measure
was reported as being all inclusive. None of the measures
fully captured the essence and importance that occupational
therapists place on the integration of clients’ roles, culture,
resources, spiritual beliefs, and values.
Client-centredness
The AMPS was the only truly client-centred measure
allowing clients to choose the tasks they value and the
process of task completion. Others enabled therapists to
recognize client values and goals within the scoring system.
For example, Edmans ADL Index and the ADL Profile
instruct therapists to mark items as not applicable if the client
did not historically perform or plan to complete a task. A
scoring system that gives both therapist and client discretion
in choosing items gives a more accurate picture of a client’s
functioning within his or her environment. Personal
meaningfulness of occupations is a crucial concept in clientcentredness that needs further consideration in the revision
and development of performance-assessment tools.
Dynamic interaction
Measures such as the ADL Profile, the AMPS, and the
Functional Performance Measure recognize the interaction
between the client, the environment, and the task. Others
(e.g., Edmans ADL Index) do not explicitly address this
interaction, but the scoring system allows therapists to make
inferences as the client’s score is dependent upon the degree
to which the client requires physical assistance or assistance
in organizing the environment for task completion. Letts et
al. (1994) stressed the need to both observe what the client
brings to the task during the assessment and consider how
the task or the environment may be modified to enable
successful task completion. Law (2002a) challenged
therapists to consider how the environment, including the
social and institutional environment, contributes to an
individual's ability to participate in self-chosen occupations.
Many reviewed measures developed by occupational
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therapists place emphasis on the dynamic person-taskenvironment triad that is so essential to achieving occupational performance competence.
None of the reviewed measures considered the client’s
financial status or social supports that might assist with ADL.
This finding concurred with Pollock et al. (1990), who
reported that few measures took the social environment into
account. Law (1993) states:
The goal in occupational therapy programs to improve
functional performance in ADL and IADL is more than
simply self-independence. Rather, the goal can be selfreliance and the ability to perform or direct the
performance of those activities that the client needs to
do (p. 235).
Clients may not be physically independent in ADL task
completion but may choose to be autonomous by accessing the
assistance of a family member, employed support personnel, or
technical assistance. Recognition and sensitivity to the situational
and life circumstances of people is crucial to appreciating
opportunities and restrictions (Watson & Fourie, 1994).
It is important to observe and understand a client’s
function in context (Baum & Law, 1997). The lack of complete
contextual grounding that comes from assessing all environmental supports means that some ADL measures may give an
erroneous overall picture and direct attention to tasks that have
little relevance to clients’ personal circumstances. The person’s
physical and social environment, his or her abilities (to feel,
think, and do), and the task demands of participation are
important factors in dynamic interaction. Measures scoring
highest enabled occupational therapists to approach the
assessment with this dynamic interaction in mind.
Uniqueness of the individual
All higher ranking measures discussed enabled therapists to
record the uniqueness of the client (e.g., attributes such as
motor performance, ability to plan and organize the steps of
a task, motivation, self-awareness, etc.).
Uniqueness of performance
There is dissonance between the need for measure reliability,
which is strengthened by standardized task performance, and
the need for ecological validity, which recognizes task
modification that occurs in real life situations. The less
restrictive measures were regarded as more suitable to
occupational therapy practice because they allow therapists
to evaluate uniqueness of performance within the dynamic
person-environment-occupation interaction. None of the six
measures devalued the independence of function using a
technical aid. The assessment of function and subsequent
development of clients’ self-sufficiency should recognize the
use of all available supports.
Law (1993) expressed concern that measures may not
reflect differences in cultural or gender-based norms. We
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noted that item content had the potential to reflect cultural
and gender-based differences, capture differing approaches
to task completion, and incorporate personal choices. For
example, a client may use chopsticks rather than a knife and
fork or take a sponge bath instead of bathing in a bathtub.
Differences in item construction allowed or prohibited
therapists’ considering the uniqueness of an individual’s
performance. Wording of items should not record gender,
cultural, or personal choice differences as inability.
Measures such as the FIM (Uniform Data System for
Medical Rehabilitation, 1993) and the Modified Barthel
Index (Shah, Vanclay, & Cooper, 1989) examined
intervention efficacy for managing rehabilitation programs
for clients with a variety of physical dysfunctions, such as
CVAs, traumatic brain injury, spinal cord injury, or frail
elderly (e.g., Bode, Heinemann, Semik, & Mallinson, 2004;
Jette, Warren, & Wirtalla, 2005; Johnston & Wood, 2000;
Slade, Tennant, & Chamberlain, 2002). Outcomes addressed
therapy intensity, therapy focus, and length of stay.
Discipline-specific researchers have found it necessary to
supplement these standardized measure outcomes with
additional information: an audit of client selected goals
(Welch & Forster, 2003); discipline-specific instruments
(Baldelli, Boiardi, Ferrari, Bianchi, & Hunscott Bianchi, 2004;
Heinemann & Hamilton, 2000); and qualitative research
methodology (Unsworth & Cunningham, 2002). Program
management outcomes may not demonstrate that client
function improvement is attributable to occupational therapy
input but rather to the participation of the multidisciplinary
team (Unsworth & Cunningham). Furthermore, program
management measures tend to identify a standardized level
of function that is important in determining the of level of
care required whereas occupational therapists seek measures
that show client functioning within the context of the client’s
physical and social environment. Occupational therapists'
use of assessment and outcome measures that are congruent
with their profession-specific values, beliefs, and principles
show the profession's unique contribution.
The research findings presented support the dissatisfaction that some occupational therapists expressed with
existing outcome measures. Many measures are used because
health care systems demand accountability and evidencebased practice but do not allow for consideration of values
inherent to the occupational therapy profession (Price, 2005).
To lessen this discord between health care system needs and
professional responsibility, consideration should be given to
the updating of existing measures to incorporate some of the
features described or to the development of a professionspecific addendum to more general measures.
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Study limitations
The therapists critiquing measures were employed in the same
hospital. Issues that these therapists identified may be specific to
their regional health care system or to a tertiary rehabilitation
setting and may not be generalizable to other locations. However,
support from the literature suggests otherwise.
Participants in this study used the CMOP as the practice
model from which they identified constructs congruent with
occupational therapy principles. The use of other models
may have produced different results.
Inter-rater reliability of the measure rating scores was
acceptable, but some inconsistency between items scores was
observed. The use of multiple raters in the rating process was
a limitation that may have affected scoring consistency. Given
this limitation, we have chosen to focus on outcomes for a
cluster of measures rather than discussing rankings of
specific measures.
Conclusion
Occupational therapists provide a unique perspective within the
delivery of health care but continue to face the challenge of
demonstrating their intervention efficacy and their unique
professional contribution in complementing the work of other
rehabilitation practitioners. Only when therapists use outcome
measures that recognize occupational therapy assessment and
intervention goals will the profession have evidence of its
essential contribution in the provision of quality rehabilitation
services that truly meet each client’s needs.
Key messages
• To best support their unique contribution to health
care, occupational therapists need measures that are
not only psychometrically sound but that are
congruent with the values, beliefs, principles, and
intent of occupational therapy practice.
• Six measures that were found to be most consistent
with occupational therapy practice principles are
identified and discussed.
Acknowledgements
The authors would like to acknowledge the contribution of the
therapists who shared their knowledge of occupational therapy
practice; Sharon Brintnell for providing her expertise with the
Canadian Model of Occupational Performance; and Lorna
Reimer, the Manager of the Occupational Therapy Service at
the Glenrose Rehabilitation Hospital, for her ongoing support
of clinical research. The authors would also like to acknowledge
the Canadian Occupational Therapy Foundation, which
provided the research funding for this project.
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/icidh
Authors
Sheryl Klein, MSc, OT(C) is Staff Occupational Therapist, Clinical
Researcher, Glenrose Rehabilitation Hospital, 10230-111
Avenue, Edmonton, Alberta, Canada T5G 0B7. Telephone:
(780) 735-7999 (ext. 15239), Fax: (780) 735-6022, E-mail:
[email protected]
Ingrid Barlow, MSc, OT(C) is a Staff Occupational Therapist,
Clinical Researcher, Glenrose Rehabilitation Hospital, 10230111 Ave., Edmonton, Alberta, Canada T5G 0B7.
Vivien Hollis, PhD, OT(C), is Professor and Chair, Department of
Occupational Therapy, Faculty of Rehabilitation Medicine,
2 - 64 Corbett Hall, Edmonton, Alberta, Canada T6G 2G4.
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APPENDIX
Description of top rated measures
Measure name
and authors
Theoretical model(s)
employed
ADL Profile
(Dutil, Bottari, Vanier,
& Gaudreault, 2005;
Dutil, Forget, Vanier,
& Gaudreault, 1990)
Recently published
in English, but French
version reviewed in
the study.
Description/Population
Psychometric properties
Reed’s conceptual model of
occupational performance
(Reed, 1984); underlying
performance components
based on Luria’s model of
functional organization of
the brain (Luria, 1973)
ADL assessment for clients with head injuries. A
3-point ordinal scoring system used with options
for scoring items as “not appropriate.” Although it
contains instrumental activities of daily-living skills
used in home and community environments, the
personal care dimension is specific to personal ADL.
The measure follows a hierarchy that includes the
dimension assessed (e.g., personal care), the activity
within a dimension (e.g., dressing), and the task
(e.g., donning outside clothing). Tasks are then
analyzed for underlying components.
At the time of the
review a study
published in French,
reported inter-rater
reliability as fair or
substantial (Rousseau,
Dutil, & Lambert,
1994); no validity
studies were
published.
Assessment of
Motor and Process
Skills (AMPS)
(Fisher, 2001a;
2001b)
Model of human occupation
(Kielhofner, 1995); consistent
with the World Health
Organization model of body
function and structure,
activities, and participation
(WHO, 1999).
Occupational performance assessment used to assess
motor and process skills. These skills are defined as
the actions used when the client sequences the ADL
task action, including selection and use of
appropriate tools, or adapts performance when
encountering problems. Includes performance
components as part of the procedure of the measure.
Scoring follows a 4-point ordinal rating scale that
rates occupational performance as competent,
questionable, ineffective, or markedly deficient.
Rasch analysis and computer-based scoring used to
allow item difficulty and rater severity in scoring to
be factored into the outcome score.
Extensive studies
support the psychometric properties of
the AMPS (e.g., Doble,
Fisk, Lewis, &
Rockwood, 1999;
Fisher, Liu, Velozo, &
Pan, 1992; Josephsson,
Backman, Borell,
Nygard, & Bernspang,
1995).
Functional
Performance
Measure (FPM)
(Carswell, Carson,
Walop, & Zgola,
1992)
Theoretical model
of functional performance
developed by authors
provided framework for the
development of the FPM.
ADL function assessment in clients with Alzheimer’s
disease. Enables therapists to address subcomponent skills fundament-al to function and the
environmental fact-ors that impact performance.
Scored with visual analogue that ranges from fully
agree to fully disagree.
Basic reliability and
validity studies
reported (Carswell,
Dulberg, Carson, &
Zgola, 1995).
Rivermead ADL
Assessment
(Whiting & Lincoln,
1980)
None identified.
ADL assessment for clients with hemiplegia. Authors
describe its use with clients diagnosed with brain
injury and cerebral vascular accidents (CVAs). Items
included were compiled by therapists for content
validity and ordered hierarchically through Guttman
scaling (Whiting & Lincoln, 1980).
Item scaling validated;
reliability acceptable
(Lincoln & Edmans,
1990; Whiting &
Lincoln, 1980).
Edmans ADL Index
(Edmans & Webster,
1997)
None identified.
ADL performance of clients who have had a CVA for
their potential to live independently at home.
Basic reliability and validity
acceptable (Edmans &
Webster, 1997).
Melville-Nelson
Self-Care
Assessment (SCA)
(Nelson et al., 2002)
Occupational therapy model of
practice is consistent with the
conceptual framework for
therapeutic occupation developed by Nelson (1996) and
designed to meet requirements
for evidence– based practice,
and the regulatory and administrative practice conditions for
sub-acute rehabilitation within
the United States.
Uses objective criteria based on identified sociocultural methods of doing tasks to differentiate the
client’s ability to perform occupations (e.g., bed
mobility, transfers, dressing, eating, toileting,
personal hy-giene, bathing). A support score rates
clients for the degree of assistance they require
from another individual.
Inter-rater reliability,
concurrent and
predictive validity, and
test responsiveness is
acceptable
(Nelson et al., 2002).
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Evaluating ADL measures from an occupational therapy

Transcription

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