Occupational Therapy Process PDF

SERIES 2: THE OCCUPATIONAL THERAPY PROCESS Week 4: Instruction by Jonathan Legarte OTD, OTR/L, CSRS, CAPS  OVERVIEW OF OT PROCESS & OUTCOMES  LEARNING OBJECTIVES After reading this chapter, you will be able to: Explain the components of the...

SERIES 2: THE OCCUPATIONAL THERAPY PROCESS Week 4: Instruction by Jonathan Legarte OTD, OTR/L, CSRS, CAPS  OVERVIEW OF OT PROCESS & OUTCOMES  LEARNING OBJECTIVES After reading this chapter, you will be able to: Explain the components of the OT process. Examine how evidence from research and practice is integrated in the OT process. Analyze the professional reasoning typically associated with components of the OT process. Apply the OT process to a client cases.  OCCUPATIONAL THERAPY AS A PROCESS Occupation is the central focus of OT services. OT services incorporate the therapeutic use of occupation to promote client’s engagement and performance of their preferred daily activities. The use of occupation as: An end goal A means to achieve OT’s unique contribution to health services THE OCCUPATIONAL THERAPY PROCESS MAP  COMPONENTS OF THE OT PROCESS The starting point of the OT process is evaluation, followed by intervention and reevaluation. Outcomes are inherent in the process and serve as goals to guide the therapy process. Evidence provides background that supports OT process.  EVALUATION OT decision: “Who is my client and does my client need OT services?” Evaluation includes: Occupational profile Analysis of occupational performance Targeted outcomes  OCCUPATIONAL PROFILE The occupational profile provides a The OT practitioner collects and summary of client’s history, resources, organizes subjective data on client’s and performance. occupational: Focus on understanding and describing History client’s perception of his or her own Contexts occupational performance. Goals  ANALYSIS OF OCCUPATIONAL PERFORMANCE The analysis of occupational performance The OT practitioner has client perform is collection, organization, and synthesis selected activities important to the of objective data on client’s occupational client’s occupations using valid and performance. reliable assessment tools. The ideal analysis of performance situation reflects client’s real-life situation. May need to simulate client context  TARGETED OUTCOMES After occupational profile and analysis of The OT and client: occupational performance are completed, Create short-term and long-term goals final task of evaluation is to define targeted outcomes. Determine procedures to measure progress toward goals Targeted outcomes based on client’s occupational performance problems that OT interventions are likely to improve.  EVIDENCE FOCUS DURING EVALUATION Considerations include: Theories most relevant for client and clinical setting Available research regarding reliability and validity of appropriate assessment tools Preferences of client Therapist experience  INTERVENTION The primary question or therapy decision OT practitioner has to make during intervention is “What OT interventions can best help my client?” Intervention includes: Intervention plan Intervention implementation  INTERVENTION PLAN The intervention plan determines Determine range of interventions selection of specific OT activities to appropriate to: address client’s targeted outcomes. Address client’s occupational performance The intervention plan is developed in problems collaboration with client. Select those with potential to improve performance and match client’s occupational profile  INTERVENTION IMPLEMENTATION The intervention implementation puts The OT practitioner: plan into action. Observes and examines client’s Involves carrying out interventions and performance while engaging in monitoring client’s response interventions Adjusts as needed to achieve targeted outcomes  EVIDENCE FOCUS DURING INTERVENTION Considerations include: The relationship between selected intervention and theories relevant for client and clinical setting Available research about benefits of selected interventions Experiences and competence of the OT practitioner to provide interventions effectively Preferences of the client  REEVALUATION OT practitioner’s decision during reevaluation is “How has OT affected my client’s performance?” Reevaluation includes: Reanalysis of occupational performance Review of targeted outcomes Identification of action  REANALYSIS OF OCCUPATIONAL PERFORMANCE The reanalysis of occupational Imperative: Use same measures during performance includes systematically reevaluation as used in evaluation. measuring and recollecting of data. The OT practitioner compares data obtained from original evaluation with reevaluation findings.  REVIEW OF TARGETED OUTCOMES The review of targeted outcomes determines whether OT interventions achieved intended targeted outcomes through goal attainment. The OT practitioner determines changes in client’s occupational performance relevant to measurable goals established during evaluation.  IDENTIFY ACTION Based on reanalysis of occupational performance and review of targeted outcomes, the OT practitioner: Determines to continue therapy Refers client to another service or specialty Discontinues services  EVIDENCE FOCUS DURING REEVALUATION Considerations include: Available research regarding reevaluation for specific type of client and assessment tools administered at evaluation Combining evaluation and intervention research APPLYING THE OCCUPATION THERAPY PROCESS  APPLICATION The OT process: Is a cycle which may repeat Requires regular attention to both evaluation and intervention Try it out on a case in the text, online, or in your fieldwork! ANALYZING OCCUPATIONS & ACTIVITY  LEARNING OBJECTIVES After reading this chapter, you will be able to: Describe approaches to analyzing occupations and activities in occupational therapy. Compare activity analysis and occupational analysis. Discover how occupational performance is the result of skilled transactions between the person and the performance context. Explain the concept of occupational orchestration. Analyze occupations in order to understand factors that promote or limit performance and participation Analyze activity in general and as experienced by an individual.  TWO PERSPECTIVES ON ANALYSIS ACTIVITY OCCUPATION The general idea about the things The personal activities that individuals individuals do and the way they typically choose or need to engage in and the do them in a given culture ways in which each individual actually experiences them Decontextualized approach, because it is an abstract idea of what the practitioner The specific details of the client’s thinks typically occurs. It is not what any occupations within a specific context one particular person actually experiences.  OCCUPATIONAL ORCHESTRATION Practitioners also analyze how clients orchestrate their occupations across a day, week, and longer periods of time. Occupational orchestration reflects the capacity of individuals to: Enact their occupations on a daily basis to meet their own needs and the expectations of the many environments May include attention to: Habits and routines and The interface of these with the needs and expectations of others Orchestration (musical term) implies: A rhythmic, harmonious composition of daily life Has habitual or routine components Also responsive to changes in demands from day to day  EXAMPLES OF ACTIVITY ANALYSIS VERSUS OCCUPATIONAL ANALYSIS ACTIVITY ANALYSIS OCCUPATIONAL ANALYSIS Making soup Making your own soup in your own kitchen Putting a toddler to sleep Putting your own toddler to sleep at home Cleaning the floor Cleaning your kitchen floor Walking a dog Walking your large and small dogs in your neighborhood Dancing Dancing with your husband at your daughter’s wedding  ENVIRONMENTAL CONTEXTS ARENAS SETTINGS Describes the places in which activities Describes those aspects of the arena to occur which the person attends Abstract conceptualization Actual experience The general idea of where activities occur Setting is where the occupational activity is specifically performed. Example: Local market where a mother Example: Grocery store goes down the “baby aisle” to get supplies for her infant daughter  ROLES VERSUS OCCUPATIONAL ROLES Roles (sociological concept) Occupational roles (OT concept) Normative models shaped by the culture-social OT focuses on occupational roles. position (mother, worker, daughter, etc.) How an individual or group interpret the expectations to How individuals see themselves and the multiple fit their own values and beliefs aspects of a person’s life How the role is personally experienced an enacted Role critiques Roles may overlap. May not accurately reflect experiences of people in society CONTINUUM OF TERMS  ANALYSIS FORMAT—ACTIVITY AND OCCUPATION (TABLE 25-3) Activity analysis: a way of thinking about Analysis typically includes attention to: Description of activity an activity as it is typically done in a given Tools, materials, and equipment culture Space demands Occupational analysis: a way of analyzing Social demands how a specific individual engages in an Sequence, timing, patterns activity within a specific context Required skills Required body structures/functions Safety hazards Adaptability to promote participation Grading  ANALYSIS OF OCCUPATIONAL ORCHESTRATION Analysis of how an individual or groups engage in their rounds of occupational participation (refer to Table 25-3) Occupations Meaning Purpose Level of skill and efficiency Routines Organization of routines Adaptability to promote participation Needs  ANALYSIS OF PERSONAL FACTORS, SKILLS, AND CONTEXTS When assessing individual performance, will typically involve attention to: Personal factors—strengths and impairments (see Chapter 28) Performance skills—strengths and difficulties (see Chapter 26) Performance context (see Chapters 28 and 33)  FINAL POINTS Use of these analyses requires practitioners to understand the following: The general properties and demands of activities as they are customarily performed in given arenas and cultures The specific occupational activities as the individual performs them How to select activities that are occupationally relevant to clients How to use occupations and activities as therapy How to support individuals to engage in occupational roles and participate in society PERFORMANCE SKILLS Performance Analysis  LEARNING OBJECTIVES After reading this chapter, you will be able to: Describe the difference between (1) performance skills and (2) body functions. Implement an analysis of performance skills (performance analysis) and document a person’s baseline quality of occupational performance. Describe how the results of a performance analysis are used to collaboratively establish client-centered goals.  CLARIFYING CONCEPTS Performance analysis Task analysis Activity analysis What we observe the Analysis of factors Analysis of the task in a person doing—describing that influence quality general sense—thinking quality of performance, of task abstractly about what specifically motor, process, performance— doing the tasks requires and social interaction skills thinking about person in terms of person factors, body factors, body functions, functions, task demands, environmental environmental characteristics, and characteristics, and sociocultural sociocultural influences influences  OBSERVATION Two students come to the front of the room and bounce a small ball back and forth to one another (five passes of the ball) using one hand. What did we observe?  PERFORMANCE ANALYSIS: MOTOR SKILLS Bouncing a Ball Walked to the front of the room without effort Carried the ball to one side of the room without effort Bent and reached to catch the ball without stiffness Turned the ball in hand to bounce it back with dexterity Used two body parts (two hands or chest) to catch Used force that was adequate to bounce the ball across the room The statements above reflect analysis of the quality of performance of motor skills.  PERFORMANCE ANALYSIS: PROCESS SKILLS Bouncing a Ball Searched/located and gathered the ball effectively from instructor Used the ball as a ball Handled the ball with care so it did not drop Initiated bouncing the ball without a delay The statements above reflect analysis of the quality of performance of process skills.  PERFORMANCE ANALYSIS: SOCIAL INTERACTION SKILLS Bouncing a Ball Gestured (e.g., nodded and pointed) that he or she was ready for the ball Turned toward and then looked at the other person Replied to messages with relevant comments related to playing ball Timed responses such that he or she did not interrupt the social partner The statements above reflect analysis of the quality of performance of social interaction skills.  PERFORMANCE ANALYSIS Analyzing quality of skills—observable actions The universal performance skills provide a structure to guide analysis. Motor skills Process skills Social interaction skills SKILLS—OBSERVABLE ACTIONS  TASK ANALYSIS Interpreting reasons for any problems in performance: Person factors and body functions Task demands Environmental characteristics Sociocultural influences  TASK ANALYSIS FOR BOUNCING A BALL Ball was flat or too bouncy. Ball was too small. Not a big enough space to play ball Many people watching Expectation of good performance in a class  ACTIVITY ANALYSIS FOR BOUNCING A BALL Environment Person factors Open space Internalized routine for playing ball Another person with whom to bounce ball Body functions Task demands Shoulder and elbow movements (flexion, extension) Ball (required object) Motor planning Catch and then bounce ball (steps and sequence of steps) Vision Visual perception Emotional regulation  PURPOSE OF EACH TYPE OF ANALYSIS Performance analysis Task analysis Activity analysis To describe the quality of To consider possible To analyze requirements a person’s performance causes of problems in of a task during a task performing a task Purpose: Purpose: Purpose: To document baseline To consider To consider the task of occupational interventions to for possible use in performance address underlying intervention and To establish goals problems options for modification of the task  PUTTING PERFORMANCE ANALYSIS IN CONTEXT OF PRACTICE Gather information from client What is important for client to do? What is challenging for client? What would client like to address in OT? We then: Observe the client perform tasks that are important, challenging, and desired Analyze the performance of observed task(s) and document our analysis Write goals with the client, based on the observed performance of a task that is important, challenging, and desired  PERFORMANCE ANALYSIS Focus on the quality of performance for each observable action (each link in the chain seen earlier) Motor skills Process skills Social interaction skills Rate the quality of each action using standardized assessment tools or nonstandardized ratings of: No problem Mild problem Moderate problem Marked problem  MOTOR SKILLS Describe the quality of motor performance. Physical effort and/or clumsiness As the person: Moves self and objects in environment during the task Holds and manipulates task objects There are 16 universal motor skills defined in Table 26-1.  PROCESS SKILLS Describe the quality of process skills. Efficiency As the person: Organizes time Organizes space and objects Adapts performance as needed to prevent problems from occurring or reoccurring There are 20 universal process skills defined in Table 26-1.  MOTOR AND PROCESS SKILLS Problems in either type of skill can lead to: Safety concerns Need for assistance When might this information be useful?  SOCIAL INTERACTION SKILLS Describe the quality of social interaction skills to: Share information Gather information Problem-solve or make decisions Collaborate Acquire goods or services Converse socially When do people use social interaction skills?  PERFORMANCE SKILL PROBLEMS Consider the universal performance skills. Do you ever: Fumble your pencil or other object? Have a potato or apple slip from your grip when you are peeling it? Delay to support and object so that it almost falls? Pause before starting the next step? Pause while you are doing an action? Look away from your task? Of course so, we all do! Good observations will capture these errors.  DETERMINING IF PROBLEMS IN PERFORMANCE SKILLS ARE SIGNIFICANT We need to consider the overall quality of a task performance and how the performance skills contribute to the overall quality. Risk of injury Need for assistance Timely completion of task Quality of end product  GOOD OBSERVATIONS Allows occupational therapists to accurately: Analyze and describe performance Identify problems in performance skills that contribute to overall decreased task performance Document baseline performance  STEPS OF PERFORMANCE ANALYSIS Step 1. Observe performance. Step 2. Rate performance. Step 3. List effective and ineffective skills. Step 4. Cluster skills and write summary statements.  IMPLEMENTING A PERFORMANCE ANALYSIS Step 1: Observe Performance Maurice—preparing a glass of orange juice Re-read the observation description of Maurice pouring a glass of orange juice in the case study presented at the beginning of Chapter 26.  IMPLEMENTING A PERFORMANCE ANALYSIS Step 2: Rate Performance Rate the quality of Maurice’s performance of this task using the universal performance skills in Table 26-1. The rating of Maurice’s task performance when putting on his socks and shoes, presented in Table 26-3, will provide a model.  MAURICE’S QUALITY OF ADL TASK PERFORMANCE—PREPARING A GLASS OF JUICE ADL motor Behavior observed Rating skills Stabilizes Walks  STEP 3. LIST EFFECTIVE AND INEFFECTIVE SKILLS. EFFECTIVE SKILLS INEFFECTIVE SKILLS  STEP 4. CLUSTER SKILLS AND WRITE SUMMARY STATEMENTS. Step 4: Cluster Skills & Write Summary Statements Your comments …  BENEFITS OF PERFORMANCE ANALYSIS Focuses on tasks that client wants to do better Focuses on analyzing the quality of doing—not underlying body function Uses language that is clear, objective, and understandable by the client and others Leads to writing goals that are client-centered and based on occupation Keeps occupational therapists focused on occupation!  ACTIVITIES OF DAILY LIVING & INSTRUMENTAL ACTIVITIES OF DAILY LIVING  LEARNING OBJECTIVES After reading this chapter, you will be able to: Describe the purposes of an occupational therapy activities of daily living (ADL) and instrumental activities of daily living (IADL) evaluation. Given a case, identify client and contextual factors that would influence the evaluation plan. Develop client-centered goals that will drive the intervention process.  LEARNING OBJECTIVES—(CONT.) Describe contextual considerations that influence goal development. Explain the most common approaches to ADL and IADL intervention. Describe the role of client and caregiver education in intervention of ADL and IADL impairments. Grade intervention activities to progress clients toward increased participation in ADL and IADL.  DEFINITION OF ADL AND IADL Activities of daily living (ADL) Activities that are oriented toward taking care of one’s own body1 Instrumental activities of daily living (IADL) Activities that support daily life within home and community environments.1 They are often complex in nature than ADL. 1Definitions verbatim from the Occupational Therapy Practice Framework: Domain and Process (3rd ed) (AOTA, 2014).  EVALUATION OF ADL AND IADL Evaluation: the process of gathering and interpreting data to plan intervention. Includes: Developing an evaluation plan Implementing the data collection Interpreting the data Documenting the evaluation results Assessment: the specific method used to collect data One component of the evaluation process Standardized assessment methods are known as assessment tools or instruments.  EVALUATION PLANNING: SELECTING THE APPROPRIATE ADL AND IADL ASSESSMENTS Step 1: Identify the purpose of the ADL/IADL evaluation. Step 2: Have clients identify their needs, interests, and perceived difficulties with ADL/IADL. Step 3: Further explore clients’ relevant activities so that the activities are operationally defined. Consider level of independence, safety, and adequacy parameters (defined by the client or societal standards).  EVALUATION PLANNING: SELECTING THE APPROPRIATE ADL AND IADL ASSESSMENTS—(CONT.) Step 4: Estimate the client factors that affect ADL/IADL and the assessment process. Step 5: Identify contextual features that affect the assessment process itself, including: Physical and social context Safety Client’s past experience with a task Time constraints Therapists’ training/experience Available resources and reimbursement  EVALUATION PLANNING: SELECTING THE APPROPRIATE ADL AND IADL ASSESSMENTS—(CONT.) Step 6: Consider features of assessment tools. Tasks included in the assessment Standardized versus nonstandardized Descriptive versus quantitative data Reported versus observed performance Step 7: Integrate the information from Steps 1 to 6 to select the optimal ADL/IADL assessment tools.  I M P L E M E N T I N G T H E E VA L UAT I O N : G AT H E R I N G DATA , C R I T I C A L O B S E RVAT I O N , A N D H Y P OT H E S I S G E N E R AT I O N Gathering data and critical observation Thoughtful selection of assessments is important. Hypothesis generation Clinical reasoning—a kind of internal dialogue—is used to interpret assessment data. Used to identify and focus the therapists’ understanding of the clients’ assets and problems  ESTABLISHING CLIENTS’ GOALS: BRIDGE BETWEEN EVALUATION & INTERVENTION Establishing client goals—an important step—enables transition from evaluation to intervention. Synthesizing evaluation results into a meaningful, individualized intervention plan. A complex cognitive task Selecting effective intervention activities is easier when OT has attainable and measurable goals.  IDENTIFYING APPROPRIATE GOAL BEHAVIORS Performance parameters used to establish goals for intervention that target appropriate client behaviors: Value Level of difficulty Safety Fatigue and/or dyspnea  IDENTIFYING APPROPRIATE DEGREE OF PERFORMANCE FOR GOALS Intervention goals must include a measurable outcome. How well or at what level will the identified behavior will be done? The performance parameter most commonly focused on in OT is independence in activity performance. Safety is also important to consider when setting goals. Safety is a quality of the person-task-environment transaction—cannot be observed or treated in isolation from independence  IDENTIFYING APPROPRIATE DEGREE OF PERFORMANCE FOR GOALS Adequacy or quality of the targeted goal behavior can be reflected in the goal. Consider: Pain during or following activity Fatigue or dyspnea during or following activity Time needed to complete the task (duration) Societal standards Client satisfaction with the outcome Aberrant task behaviors  ADDITIONAL CONSIDERATIONS FOR SETTING REALISTIC CLIENT GOALS Additional factors can affect goal achievement and must be considered: Prognosis for client’s impairments Client’s past experience with the task Client’s capacity for learning and openness to alternative methods Projected follow-through with program outside of treatment Time available for intervention Resources and the expected discharge context  INTERVENTIONS FOR ADL AND IADL DEFICITS Planning and implementing intervention Selecting an intervention approach: Modify Establish/restore Integrated approaches Education of the client or caregiver: Fit instructional methods to client or caregiver needs.  INTERVENTIONS FOR ADL AND IADL DEFICITS Grading the intervention program: Start with easier tasks and progress to harder tasks. Increase the complexity within a task. Vary the performance environment of a task. Therapist-facilitated to client-facilitated problem solving  INTERVENTION REVIEW Reevaluation of ADL and IADL performance is needed to determine if the: Intervention is resulting in improvement Intervention should be continued or changed Maximal benefit from OT has been achieved