Occupational Therapy Practice Framework: Domain and Process PDF

GUIDELINES Occupational Therapy Practice Framework: Domain and Process Fourth Edition...

GUIDELINES Occupational Therapy Practice Framework: Domain and Process Fourth Edition Contents Preface Preface.....................................................................1 The fourth edition of the Occupational Therapy Practice Framework: Domain Definitions..........................................................1 and Process (hereinafter referred to as the OTPF–4), is an official document of Evolution of This Document..............................2 Vision for This Work..........................................4 the American Occupational Therapy Association (AOTA). Intended for Introduction..............................................................4 occupational therapy practitioners and students, other health care Occupation and Occupational Science...........4 OTPF Organization.......................................4 professionals, educators, researchers, payers, policymakers, and consumers, Cornerstones of Occupational Therapy the OTPF–4 presents a summary of interrelated constructs that describe Practice......................................................6 Domain.....................................................................6 occupational therapy practice. Occupations.......................................................7 Contexts............................................................9 Performance Patterns.....................................12 Definitions Performance Skills..........................................13 Within the OTPF–4, occupational therapy is defined as the therapeutic use of Client Factors..................................................15 Process..................................................................17 everyday life occupations with persons, groups, or populations (i.e., the client) Overview of the Occupational Therapy for the purpose of enhancing or enabling participation. Occupational therapy Process....................................................17 Evaluation........................................................21 practitioners use their knowledge of the transactional relationship among the Intervention......................................................24 client, the client’s engagement in valuable occupations, and the context to Outcomes........................................................26 Conclusion.............................................................28 design occupation-based intervention plans. Occupational therapy services Tables....................................................................29 are provided for habilitation, rehabilitation, and promotion of health and References.............................................................68 Table 1. Examples of Clients: Persons, Groups, wellness for clients with disability- and non–disability-related needs. These and Populations............................................ 29 services include acquisition and preservation of occupational identity for Table 2. Occupations......................................30 Table 3. Examples of Occupations for Persons, clients who have or are at risk for developing an illness, injury, disease, Groups, and Populations..............................35 disorder, condition, impairment, disability, activity limitation, or participation Table 4. Context: Environmental Factors.......36 restriction (AOTA, 2011; see the glossary in Appendix A for additional Table 5. Context: Personal Factors................40 Table 6. Performance Patterns.......................41 definitions). Table 7. Performance Skills for Persons.......43 When the term occupational therapy practitioners is used in this Table 8. Performance Skills for Groups.........50 Table 9. Client Factors....................................51 document, it refers to both occupational therapists and occupational therapy Table 10. Occupational Therapy Process for assistants (AOTA, 2015b). Occupational therapists are responsible for all Persons, Groups, and Populations.............55 Table 11. Occupation and Activity aspects of occupational therapy service delivery and are accountable for the Demands......................................................57 safety and effectiveness of the occupational therapy service delivery process. AOTA OFFICIAL DOCUMENT 1 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p1 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES Table 12. Types of Occupational Therapy Occupational therapy assistants deliver occupational therapy services under Interventions................................................59 Table 13. Approaches to Intervention............63 the supervision of and in partnership with an occupational therapist (AOTA, Table 14. Outcomes........................................65 2020a). Exhibit 1. Aspects of the Occupational Therapy Domain...........................................................7 The clients of occupational therapy are typically classified as persons Exhibit 2. Operationalizing the Occupational (including those involved in care of a client), groups (collections of individuals Therapy Process.........................................16 Figure 1. Occupational Therapy Domain and having shared characteristics or a common or shared purpose; e.g., family Process..........................................................5 members, workers, students, people with similar interests or occupational Authors............................................................72 Acknowledgments...........................................73 challenges), and populations (aggregates of people with common attributes Appendix A. Glossary.....................................74 such as contexts, characteristics, or concerns, including health risks; Scaffa Index................................................................85 & Reitz, 2014). People may also consider themselves as part of a community, such as the Deaf community or the disability community; a community is a collection of populations that is changeable and diverse and includes various people, groups, networks, and organizations (Scaffa, 2019; World Federation of Occupational Therapists [WFOT], 2019). It is important to consider the community or communities with which a client identifies throughout the occupational therapy process. Whether the client is a person, group, or population, information about the client’s wants, needs, strengths, contexts, limitations, and occupational risks is gathered, synthesized, and framed from an occupational perspective. Throughout the OTPF–4, the term client is used broadly to refer to persons, groups, and Copyright © 2020 by the American Occupational Therapy Association. populations unless otherwise specified. In the OTPF–4, “group” as a client is distinct Citation: American Occupational Therapy from “group” as an intervention approach. For examples of clients, see Table 1 (all Association. (2020). Occupational therapy tables are placed together at the end of this document). The glossary in Appendix practice framework: Domain and process (4th ed.). American Journal of Occupational A provides definitions of other terms used in this document. Therapy, 74(Suppl. 2), 7412410010. https://doi. org/10.5014/ajot.2020.74S2001 Evolution of This Document ISBN: 978-1-56900-488-3 The Occupational Therapy Practice Framework was originally developed to For permissions inquiries, visit https://www. copyright.com. articulate occupational therapy’s distinct perspective and contribution to promoting the health and participation of persons, groups, and populations through engagement in occupation. The first edition of the OTPF emerged from an examination of documents related to the Occupational Therapy Product Output Reporting System and Uniform Terminology for Reporting Occupational Therapy Services (AOTA, 1979). Originally a document that responded to a federal requirement to develop a uniform reporting system, this text gradually shifted to describing and outlining the domains of concern of occupational therapy. The second edition of Uniform Terminology for Occupational Therapy (AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and published in 1989. The document focused on delineating and defining only the occupational performance areas and occupational performance components that are addressed in occupational therapy direct services. The third and final edition of Uniform Terminology for Occupational Therapy (UT–III; AOTA, 1994) was adopted by the RA in 1994 and was “expanded to reflect current practice and to incorporate contextual aspects of performance” (p. 1047). Each revision 2 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p2 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES reflected changes in practice and provided consistent n The terms occupation and activity are more clearly terminology for use by the profession. defined. In fall 1998, the AOTA Commission on Practice (COP) n For occupations, the definition of sexual activity as an embarked on the journey that culminated in the activity of daily living is revised, health management is Occupational Therapy Practice Framework: Domain added as a general occupation category, and intimate and Process (AOTA, 2002a). At that time, AOTA also partner is added in the social participation category published The Guide to Occupational Therapy Practice (see Table 2). (Moyers, 1999), which outlined contemporary practice n The contexts and environments aspect of the for the profession. Using this document and the feedback occupational therapy domain is changed to context on received during the review process for the UT–III, the COP the basis of the World Health Organization (WHO; 2008) proceeded to develop a document that more fully taxonomy from the International Classification of articulated occupational therapy. Functioning, Disability and Health (ICF) in an effort The OTPF is an ever-evolving document. As an to adopt standard, well-accepted definitions (see official AOTA document, it is reviewed on a 5-year Table 4). cycle for usefulness and the potential need for further n For the client factors category of body functions, refinements or changes. During the review period, the COP gender identity is now included under “experience of collects feedback from AOTA members, scholars, authors, self and time,” the definition of psychosocial is practitioners, AOTA volunteer leadership and staff, and expanded to match the ICF description, and other stakeholders. The revision process ensures that the interoception is added under sensory functions. OTPF maintains its integrity while responding to internal and n For types of intervention, “preparatory methods and external influences that should be reflected in emerging tasks” has been changed to “interventions to support concepts and advances in occupational therapy. occupations” (see Table 12). The OTPF was first revised and approved by the RA in n For outcomes, transitions and discontinuation are 2008. Changes to the document included refinement of the discussed as conclusions to occupational therapy writing and the addition of emerging concepts and changes services, and patient-reported outcomes are in occupational therapy. The rationale for specific changes addressed (see Table 14). can be found in Table 11 of the OTPF–2 (AOTA, 2008, n Five new tables are added to expand on and clarify pp. 665–667). concepts: In 2012, the process of review and revision of the + Table 1. Examples of Clients: Persons, Groups, OTPF was initiated again, and several changes were and Populations made. The rationale for specific changes can be found + Table 3. Examples of Occupations for Persons, Groups, and Populations on page S2 of the OTPF–3 (AOTA, 2014). + Table 7. Performance Skills for Persons (includes In 2018, the process to revise the OTPF began again. examples of effective and ineffective After member review and feedback, several modifications performance skills) were made and are reflected in this document: + Table 8. Performance Skills for Groups n The focus on group and population clients is (includes examples of the impact of ineffective increased, and examples are provided for both. individual performance skills on group n Cornerstones of occupational therapy practice are collective outcome) identified and described as foundational to the + Table 10. Occupational Therapy Process for success of occupational therapy practitioners. Persons, Groups, and Populations. n Occupational science is more explicitly described n Throughout, the use of OTPF rather than Framework and defined. acknowledges the current requirements for a unique AOTA OFFICIAL DOCUMENT 3 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p3 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES identifier to maximize digital discoverability and to students, communication with the public and promote brevity in social media communications. It policymakers, and provision of language that can shape also reflects the longstanding use of the acronym in and be shaped by research. academic teaching and clinical practice. n Figure 1 has been revised to provide a simplified Occupation and Occupational Science visual depiction of the domain and process of Embedded in this document is the occupational therapy occupational therapy. profession’s core belief in the positive relationship between occupation and health and its view of people as Vision for This Work occupational beings. Occupational therapy practice Although this edition of the OTPF represents the latest in emphasizes the occupational nature of humans and the the profession’s efforts to clearly articulate the importance of occupational identity (Unruh, 2004) to occupational therapy domain and process, it builds on a healthful, productive, and satisfying living. As Hooper and set of values that the profession has held since its Wood (2019) stated, founding in 1917. The original vision had at its center a profound belief in the value of therapeutic occupations as A core philosophical assumption of the profession, therefore, is that by virtue of our biological endowment, people of all ages and abilities a way to remediate illness and maintain health (Slagle, require occupation to grow and thrive; in pursuing occupation, humans 1924). The founders emphasized the importance of express the totality of their being, a mind–body–spirit union. Because human existence could not otherwise be, humankind is, in essence, establishing a therapeutic relationship with each client occupational by nature. (p. 46) and designing a treatment plan based on knowledge Occupational science is important to the practice of about the client’s environment, values, goals, and desires occupational therapy and “provides a way of thinking that (Meyer, 1922). They advocated for scientific practice enables an understanding of occupation, the occupational based on systematic observation and treatment (Dunton, nature of humans, the relationship between occupation, 1934). Paraphrased using today’s lexicon, the founders health and well-being, and the influences that shape proposed a vision that was occupation based, client occupation” (WFOT, 2012b, p. 2). Many of its concepts are centered, contextual, and evidence based—the vision emphasized throughout the OTPF–4, including articulated in the OTPF–4. occupational justice and injustice, identity, time use, satisfaction, engagement, and performance. Introduction OTPF Organization The purpose of a framework is to provide a structure or The OTPF–4 is divided into two major sections: (1) the base on which to build a system or a concept domain, which outlines the profession’s purview and the (“Framework,” 2020). The OTPF describes the central areas in which its members have an established body concepts that ground occupational therapy practice and of knowledge and expertise, and (2) the process, builds a common understanding of the basic tenets and which describes the actions practitioners take when vision of the profession. The OTPF–4 does not serve as a providing services that are client centered and taxonomy, theory, or model of occupational therapy. By focused on engagement in occupations. The design, the OTPF–4 must be used to guide occupational profession’s understanding of the domain and process therapy practice in conjunction with the knowledge and of occupational therapy guides practitioners as they evidence relevant to occupation and occupational seek to support clients’ participation in daily living, therapy within the identified areas of practice and with the which results from the dynamic intersection of clients, appropriate clients. In addition, the OTPF–4 is intended their desired engagements, and their contexts to be a valuable tool in the academic preparation of (including environmental and personal factors; 4 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p4 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES Figure 1. Occupational Therapy Domain and Process D OM A I N Oc c up at ions C rs Intervention on to tex c Fa ts on Client Ou Achieving health, Evaluati tcomes well-being, and participation in life s through engagement t t ern in occupation. Pe r f Pa PR OCESS or ce an n m ce m a Ski o r lls Pe r f Christiansen & Baum, 1997; Christiansen et al., 2005; n Well-being—“a general term encompassing the total Law et al., 2005). universe of human life domains, including physical, “Achieving health, well-being, and participation in life mental, and social aspects, that make up what can be through engagement in occupation” is the overarching called a ‘good life’” (WHO, 2006, p. 211). statement that describes the domain and process of n Participation—“involvement in a life situation” (WHO, occupational therapy in its fullest sense. This statement 2008, p. 10). Participation occurs naturally when clients acknowledges the profession’s belief that active are actively involved in carrying out occupations or daily engagement in occupation promotes, facilitates, life activities they find purposeful and meaningful. More supports, and maintains health and participation. These specific outcomes of occupational therapy intervention interrelated concepts include are multidimensional and support the end result of n Health—“a state of complete physical, mental, participation. and social well-being, and not merely the n Engagement in occupation—performance of absence of disease or infirmity” (WHO, 2006, occupations as the result of choice, motivation, and p. 1). meaning within a supportive context (including AOTA OFFICIAL DOCUMENT 5 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p5 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES environmental and personal factors). Engagement Occupational therapy cornerstones provide a includes objective and subjective aspects of clients’ fundamental foundation for practitioners from which to experiences and involves the transactional interaction view clients and their occupations and facilitate the of the mind, body, and spirit. Occupational therapy occupational therapy process. Practitioners develop the intervention focuses on creating or facilitating cornerstones over time through education, mentorship, opportunities to engage in occupations that lead to and experience. In addition, the cornerstones are ever participation in desired life situations (AOTA, 2008). evolving, reflecting developments in occupational therapy practice and occupational science. Although the domain and process are described Many contributors influence each cornerstone. Like separately, in actuality they are linked inextricably in a the cornerstones, the contributors are complementary transactional relationship. The aspects that constitute and interact to provide a foundation for practitioners. the domain and those that constitute the process exist in The contributors include, but are not limited to, the constant interaction with one another during the delivery of following: occupational therapy services. Figure 1 represents aspects of the domain and process and the overarching n Client-centered practice goal of the profession as achieving health, well-being, and n Clinical and professional reasoning participation in life through engagement in occupation. n Competencies for practice Although the figure illustrates these two elements in n Cultural humility distinct spaces, in reality the domain and process interact n Ethics in complex and dynamic ways as described throughout n Evidence-informed practice this document. The nature of the interactions is n Inter- and intraprofessional collaborations impossible to capture in a static one-dimensional image. n Leadership n Lifelong learning Cornerstones of Occupational Therapy Practice n Micro and macro systems knowledge The transactional relationship between the domain and n Occupation-based practice process is facilitated by the occupational therapy n Professionalism practitioner. Occupational therapy practitioners have n Professional advocacy distinct knowledge, skills, and qualities that contribute to the n Self-advocacy success of the occupational therapy process, described in n Self-reflection this document as “cornerstones.” A cornerstone can be n Theory-based practice. defined as something of great importance on which everything else depends (“Cornerstone,” n.d.), and the Domain following cornerstones of occupational therapy help distinguish it from other professions: Exhibit 1 identifies the aspects of the occupational therapy domain: occupations, contexts, performance n Core values and beliefs rooted in occupation (Cohn, patterns, performance skills, and client factors. All 2019; Hinojosa et al., 2017) aspects of the domain have a dynamic interrelatedness. n Knowledge of and expertise in the therapeutic use of All aspects are of equal value and together interact to occupation (Gillen, 2013; Gillen et al., 2019) affect occupational identity, health, well-being, and n Professional behaviors and dispositions (AOTA participation in life. 2015a, 2015c) Occupational therapists are skilled in evaluating all n Therapeutic use of self (AOTA, 2015c; Taylor, 2020). aspects of the domain, the interrelationships among the These cornerstones are not hierarchical; instead, each aspects, and the client within context. Occupational concept influences the others. therapy practitioners recognize the importance and 6 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p6 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES Exhibit 1. Aspects of the Occupational Therapy Domain All aspects of the occupational therapy domain transact to support engagement, participation, and health. This exhibit does not imply a hierarchy. Performance Performance Occupations Contexts Patterns Skills Client Factors Activities of daily living (ADLs) Environmental Habits Motor skills Values, beliefs, Instrumental activities of daily factors Routines Process skills and spirituality living (IADLs) Personal factors Roles Social interaction skills Body functions Health management Rituals Body structures Rest and sleep Education Work Play Leisure Social participation impact of the mind–body–spirit connection on to a specific client’s engagement or context (Schell et al., engagement and participation in daily life. Knowledge of 2019) and, therefore, can be selected and designed to the transactional relationship and the significance of enhance occupational engagement by supporting the meaningful and productive occupations forms the basis for development of performance skills and performance the use of occupations as both the means and the ends patterns. Both occupations and activities are used as of interventions (Trombly, 1995). This knowledge sets interventions by practitioners. For example, a practitioner occupational therapy apart as a distinct and valuable may use the activity of chopping vegetables during an service (Hildenbrand & Lamb, 2013) for which a focus on intervention to address fine motor skills with the ultimate the whole is considered stronger than a focus on isolated goal of improving motor skills for the occupation of aspects of human functioning. preparing a favorite meal. Participation in occupations is The discussion that follows provides a brief considered both the means and the end in the explanation of each aspect of the domain. Tables included occupational therapy process. at the end of the document provide additional Occupations occur in contexts and are influenced by descriptions and definitions of terms. the interplay among performance patterns, performance skills, and client factors. Occupations occur over time; Occupations have purpose, meaning, and perceived utility to the client; Occupations are central to a client’s (person’s, group’s, or and can be observed by others (e.g., preparing a meal) or population’s) health, identity, and sense of competence be known only to the person involved (e.g., learning and have particular meaning and value to that client. “In through reading a textbook). Occupations can involve the occupational therapy, occupations refer to the everyday activities that people do as individuals, in families, and with execution of multiple activities for completion and can communities to occupy time and bring meaning and result in various outcomes. purpose to life. Occupations include things people The OTPF–4 identifies a broad range of occupations need to, want to and are expected to do” (WFOT, 2012a, categorized as activities of daily living (ADLs), instrumental para. 2). activities of daily living (IADLs), health management, rest In the OTPF–4, the term occupation denotes and sleep, education, work, play, leisure, and social personalized and meaningful engagement in daily life participation (Table 2). Within each of these nine broad events by a specific client. Conversely, the term activity categories of occupation are many specific occupations. For denotes a form of action that is objective and not related example, the broad category of IADLs has specific AOTA OFFICIAL DOCUMENT 7 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p7 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES occupations that include grocery shopping and money Because occupational performance does not exist in a management. vacuum, context must always be considered. For example, When occupational therapy practitioners work with for a client who lives in food desert, lack of access to a clients, they identify the types of occupations clients grocery store may limit their ability to have balance in their engage in individually or with others. Differences among performance of IADLs such as cooking and grocery clients and the occupations they engage in are complex shopping or to follow medical advice from health care and multidimensional. The client’s perspective on how an professionals on health management and preparation of occupation is categorized varies depending on that nutritious meals. For this client, the limitation is not caused by client’s needs, interests, and contexts. Moreover, values impaired client factors or performance skills but rather is attached to occupations are dependent on cultural and shaped by the context in which the client functions. This sociopolitical determinants (Wilcock & Townsend, 2019). context may include policies that resulted in the decline of For example, one person may perceive gardening as commercial properties in the area, a socioeconomic status leisure, whereas another person, who relies on the food that does not enable the client to live in an area with access produced from that garden to feed their family or to a grocery store, and a social environment in which lack of community, may perceive it as work. Additional examples access to fresh food is weighed as less important than the of occupations for persons, groups, and populations can social supports the community provides. be found in Table 3. Occupational therapy practitioners recognize that The ways in which clients prioritize engagement in health is supported and maintained when clients are able selected occupations may vary at different times. For to engage in home, school, workplace, and community example, clients in a community psychiatric rehabilitation life. Thus, practitioners are concerned not only with setting may prioritize registering to vote during an election occupations but also with the variety of factors that disrupt season and food preparation during holidays. The unique or empower those occupations and influence clients’ features of occupations are noted and analyzed by engagement and participation in positive health- occupational therapy practitioners, who consider all promoting occupations (Wilcock & Townsend, 2019). components of the engagement and use them effectively Although engagement in occupations is generally as both a therapeutic tool and a way to achieve the considered a positive outcome of the occupational therapy targeted outcomes of intervention. process, it is important to consider that a client’s history The extent to which a client is engaged in a particular might include negative, traumatic, or unhealthy occupation is also important. Occupational therapy occupational participation (Robinson Johnson & Dickie, practitioners assess the client’s ability to engage in 2019). For example, a person who has experienced a occupational performance, defined as the traumatic sexual encounter might negatively perceive and accomplishment of the selected occupation resulting from react to engagement in sexual intimacy. A person with an the dynamic transaction among the client, their contexts, eating disorder might engage in eating in a maladaptive and the occupation. Occupations can contribute to a well- way, deterring health management and physical health. balanced and fully functional lifestyle or to a lifestyle that is In addition, some occupations that are meaningful to a out of balance and characterized by occupational client might also hinder performance in other occupations dysfunction. For example, excessive work without or negatively affect health. For example, a person who sufficient regard for other aspects of life, such as sleep or spends a disproportionate amount of time playing video relationships, places clients at risk for health problems. games may develop a repetitive stress injury and may External factors, including war, natural disasters, or have less balance in their time spent on IADLs and other extreme poverty, may hinder a client’s ability to create forms of social participation. A client engaging in the balance or engage in certain occupations (AOTA, 2017b; recreational use of prescription pain medications may McElroy et al., 2012). experience barriers to participation in previously 8 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p8 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES important occupations such as work or spending time with of assistance required, if clients are satisfied with their family. performance. In contrast to definitions of independence Occupations have the capacity to support or promote that imply direct physical interaction with the environment other occupations. For example, children engage in play or objects within the environment, occupational therapy to develop the performance skills that later facilitate practitioners consider clients to be independent whether engagement in leisure and work. Adults may engage in they perform the specific occupations by themselves, in an social participation and leisure with an intimate partner adapted or modified environment, with the use of various that may improve satisfaction with sexual activity. The devices or alternative strategies, or while overseeing goal of engagement in sleep and health management activity completion by others (AOTA, 2002b). For includes maintaining or improving performance of work, example, a person with spinal cord injury who directs a leisure, social participation, and other occupations. personal care assistant to assist them with ADLs is Occupations are often shared and done with others. demonstrating independence in this essential aspect of Those that implicitly involve two or more individuals are their life. termed co-occupations (Zemke & Clark, 1996). Co- It is also important to acknowledge that not all clients occupations are the most interactive of all social view success as independence. Interdependence, or occupations. Central to the concept of co-occupation is that co-occupational performance, can also be an indicator two or more individuals share a high level of physicality, of personal success. How a client views success may emotionality, and intentionality (Pickens & Pizur-Barnekow, be influenced by their client factors, including their 2009). In addition, co-occupations can be parallel (different culture. occupations in close proximity to others; e.g., reading while others listen to music when relaxing at home) and shared Contexts (same occupation but different activities; e.g., preparing Context is a broad construct defined as the environmental different dishes for a meal; Zemke & Clark, 1996). and personal factors specific to each client (person, group, Caregiving is a co-occupation that requires active population) that influence engagement and participation participation by both the caregiver and the recipient of in occupations. Context affects clients’ access to care. For the co-occupations required during parenting, occupations and the quality of and satisfaction with the socially interactive routines of eating, feeding, and performance (WHO, 2008). Practitioners recognize that comforting may involve the parent, a partner, the child, for people to truly achieve full participation, meaning, and and significant others (Olson, 2004). The specific purpose, they must not only function but also engage occupations inherent in this social interaction are comfortably within their own distinct combination of reciprocal, interactive, and nested (Dunlea, 1996; Esdaile contexts. & Olson, 2004). Consideration of co-occupations by In the literature, the terms environment and context practitioners supports an integrated view of the client’s often are used interchangeably, but this may result in engagement in the context of relationship to significant confusion when describing aspects of situations in which others. occupational engagement takes place. Understanding the Occupational participation can be considered contexts in which occupations can and do occur provides independent whether it occurs individually or with others. It practitioners with insights into the overarching, underlying, is important to acknowledge that clients can be and embedded influences of environmental factors and independent in living regardless of the amount of personal factors on engagement in occupations. assistance they receive while completing occupations. Clients may be considered independent even when they Environmental Factors direct others (e.g., caregivers) in performing the actions Environmental factors are aspects of the physical, social, necessary to participate, regardless of the amount or kind and attitudinal surroundings in which people live and AOTA OFFICIAL DOCUMENT 9 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p9 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES conduct their lives (Table 4). Environmental factors n For groups, absence of healthy social opportunities influence functioning and disability and have positive for those abstaining from alcohol use aspects (facilitators) or negative aspects (barriers or n For populations, businesses that are not welcoming hindrances; WHO, 2008). Environmental factors include to people who identify as LGBTQ+. (Note: In this n Natural environment and human-made changes to document, LGBTQ+ is used to represent the large the environment: Animate and inanimate elements of and diverse communities and individuals with the natural or physical environment and nonmajority sexual orientations and gender components of that environment that have been identities.) modified by people, as well as characteristics of human populations within that environment. Addressing these barriers, such as by widening a doorway Engagement in human occupation influences the to allow access, results in environmental supports that sustainability of the natural environment, and enable participation. A client who has difficulty performing changes to human behavior can have a positive effectively in one context may be successful when the impact on the environment (Dennis et al., 2015). natural environment has human-made modifications or if the n Products and technology: Natural or human-made client uses applicable products and technology. In addition, products or systems of products, equipment, and occupational therapy practitioners must be aware of norms related to, for example, eating or deference to medical technology that are gathered, created, produced, or professionals when working with someone from a culture or manufactured. socioeconomic status that differs from their own. n Support and relationships: People or animals that provide practical physical or emotional support, Personal Factors nurturing, protection, assistance, and connections to Personal factors are the unique features of a person that other persons in the home, workplace, or school or at are not part of a health condition or health state and that play or in other aspects of daily occupations. constitute the particular background of the person’s life n Attitudes: Observable evidence of customs, and living (Table 5). Personal factors are internal practices, ideologies, values, norms, factual beliefs, influences affecting functioning and disability and are not considered positive or negative but rather reflect the and religious beliefs held by people other than the essence of the person—“who they are.” When clients client. provide demographic information, they are typically n Services, systems, and policies: Benefits, describing personal factors. Personal factors also structured programs, and regulations for operations include customs, beliefs, activity patterns, behavioral provided by institutions in various sectors of society standards, and expectations accepted by the society or designed to meet the needs of persons, groups, and cultural group of which a person is a member. populations. Personal factors are generally considered to be When people interact with the world around them, enduring, stable attributes of the person, although some environmental factors can either enable or restrict personal factors change over time. They include, but are not limited to, the following: participation in meaningful occupations and can present barriers to or supports and resources for service delivery. n Chronological age n Sexual orientation (sexual preference, sexual Examples of environmental barriers that restrict identity) participation include the following: n Gender identity n For persons, doorway widths that do not allow for n Race and ethnicity wheelchair passage n Cultural identification and attitudes 10 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p10 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES n Social background, social status, and socioeconomic occupations and occupational justice complements status WHO’s (2008) perspective on health. To broaden the n Upbringing and life experiences understanding of the effects of disease and disability on n Habits and past and current behavioral patterns health, WHO emphasized that health can be affected by the n Psychological assets, temperament, unique inability to carry out occupations and activities and character traits, and coping styles participate in life situations caused by contextual barriers n Education n Profession and professional identity and by problems that exist in body structures and body n Lifestyle functions. The OTPF–4 identifies occupational justice as n Health conditions and fitness status (that may affect both an aspect of contexts and an outcome of intervention. the person’s occupations but are not the primary Occupational justice involves the concern that concern of the occupational therapy encounter). occupational therapy practitioners have with respect, fairness, and impartiality and equitable opportunities For example, siblings share personal factors of race when considering the contexts of persons, groups, and and age, yet for those separated at birth, environmental populations (AOTA, 2015a). As part of the occupational differences may result in divergent personal factors in therapy domain, practitioners consider how these terms of cultural identification, upbringing, and life aspects can affect the implementation of occupational experiences, producing different contexts for their therapy and the target outcome of participation. individual occupational engagement. Whether separated Practitioners recognize that for individuals to truly or raised together, as siblings move through life, they may achieve full participation, meaning, and purpose, they develop differences in sexual orientation, life experience, must not only function but also engage comfortably within habits, education, profession, and lifestyle. their own distinct combination of contexts (both Groups and populations are often formed or identified environmental factors and personal factors). on the basis of shared or similar personal factors that make Examples of contexts that can present occupational possible occupational therapy assessment and justice issues include the following: intervention. Of course, individual members of a group or n An alternative school placement for children with population differ in other personal factors. For example, a mental health and behavioral disabilities that group of fifth graders in a community public school are provides academic support and counseling but likely to share age and, perhaps, socioeconomic status. limited opportunities for participation in sports, Yet race, fitness, habits, and coping styles make each music programs, and organized social activities group member unlike the others. Similarly, a population of n A residential facility for older adults that offers safety older adults living in an urban low-income housing and medical support but provides little opportunity for community may have few personal factors in common other engagement in the role-related occupations that were than age and current socioeconomic status. once a source of meaning n A community that lacks accessible and inclusive Application of Context to Occupational Justice physical environments and provides limited services Interwoven throughout the concept of context is that of and supports, making participation difficult or even occupational justice, defined as “a justice that dangerous for people who have disabilities (e.g., recognizes occupational rights to inclusive participation lack of screening facilities and services resulting in in everyday occupations for all persons in society, higher rates of breast cancer among community regardless of age, ability, gender, social class, or other members) differences” (Nilsson & Townsend, 2010, p. 58). n A community that lacks financial and other necessary Occupational therapy’s focus on engagement in resources, resulting in an adverse and AOTA OFFICIAL DOCUMENT 11 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p11 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES disproportionate impact of natural disasters and Time use is the manner in which a person manages their severe weather events on vulnerable populations. activity levels; adapts to changes in routines; and organizes their days, weeks, and years (Edgelow & Krupa, 2011). Occupational therapy practitioners recognize areas of Habits are specific, automatic adaptive or maladaptive occupational injustice and work to support policies, behaviors. Habits may be healthy or unhealthy (e.g., actions, and laws that allow people to engage in exercising on a daily basis vs. smoking during every occupations that provide purpose and meaning in their lunch break), efficient or inefficient (e.g., completing lives. By understanding and addressing the specific homework after school vs. in the few minutes before the justice issues in contexts such as an individual’s home, a school bus arrives), and supportive or harmful (e.g., group’s shared job site, or a population’s community setting an alarm clock before going to bed vs. not doing center, practitioners promote occupational therapy so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019). outcomes that address empowerment and self- Routines are established sequences of occupations or advocacy. activities that provide a structure for daily life; they can also promote or damage health (Fiese, 2007; Koome et al., Performance Patterns 2012; Segal, 2004). Shared routines involve two or more Performance patterns are the acquired habits, routines, people and take place in a similar manner regardless of roles, and rituals used in the process of engaging the individuals involved (e.g., routines shared by parents consistently in occupations and can support or hinder to promote the health of their children; routines shared by occupational performance (Table 6). Performance coworkers to sort the mail; Primeau, 2000). Shared patterns help establish lifestyles (Uyeshiro Simon & routines can be nested in co-occupations. For example, Collins, 2017) and occupational balance (e.g., proportion a young child’s occupation of completing oral hygiene of time spent in productive, restorative, and leisure with the assistance of an adult is a part of the child’s daily occupations; Eklund et al., 2017; Wagman et al., 2015) routine, and the adult who provides the assistance may and are shaped, in part, by context (e.g., consistency, also view helping the young child with oral hygiene as a work hours, social calendars) and cultural norms (Eklund part of the adult’s own daily routine. et al., 2017; Larson & Zemke, 2003). Roles have historically been defined as sets of Time provides an organizational structure or rhythm for behaviors expected by society and shaped by culture and performance patterns (Larson & Zemke, 2003); for context; they may be further conceptualized and defined example, an adult goes to work every morning, a child by a person, group, or population (Kielhofner, 2008; completes homework every day after school, or an Taylor, 2017). Roles are an aspect of occupational organization hosts a fundraiser every spring. The manner identity—that is, they help define who a person, group, or in which people think about and use time is influenced by population believes themselves to be on the basis of their biological rhythms (e.g., sleep–wake cycles), family of occupational history and desires for the future. Certain origin (e.g., amount of time a person is socialized to roles are often associated with specific activities and believe should be spent in productive occupations), work occupations; for example, the role of parent is associated and social schedules (e.g., religious services held on the with feeding children (Kielhofner, 2008; Taylor, 2017). same day each week), and cyclic cultural patterns (e.g., When exploring roles, occupational therapy practitioners birthday celebration with cake every year, annual cultural consider the complexity of identity and the limitations festival; Larson & Zemke, 2003). Other temporal factors associated with assigning stereotypical occupations to influencing performance patterns are time management and specific roles (e.g., on the basis of gender). Practitioners time use. Time management is the manner in which a also consider how clients construct their occupations and person, group, or population organizes, schedules, and establish efficient and supportive habits and routines to prioritizes certain activities (Uyeshiro Simon & Collins, 2017). achieve health outcomes, fulfill their perceived roles and 12 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p12 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES identity, and determine whether their roles reinforce their foundation for understanding performance (Fisher & values and beliefs. Marterella, 2019). Rituals are symbolic actions with spiritual, cultural, or Performance skills can be analyzed for all occupations social meaning. Rituals contribute to a client’s identity and with clients of any age and level of ability, regardless of the reinforce the client’s values and beliefs (Fiese, 2007; Segal, setting in which occupational therapy services are 2004). Some rituals (e.g., those associated with certain provided (Fisher & Marterella, 2019). Motor and process holidays) are associated with different seasons or times of skills are seen during performance of an activity that the year (e.g., New Year’s Eve, Independence Day), involves the use of tangible objects, and social whereas others are associated with times of the day or days interaction skills are seen in any situation in which a of the week (e.g., daily prayers, weekly family dinners). person is interacting with others: Performance patterns are influenced by all other n Motor skills refer to how effectively a person moves aspects of the occupational therapy domain and develop self or interacts with objects, including positioning the over time. Occupational therapy practitioners who body, obtaining and holding objects, moving self and consider clients’ past and present behavioral and objects, and sustaining performance. performance patterns are better able to understand the n Process skills refer to how effectively a person frequency and manner in which performance skills and organizes objects, time, and space, including healthy and unhealthy occupations are, or have been, sustaining performance, applying knowledge, integrated into clients’ lives. Although clients may have the organizing timing, organizing space and objects, and ability to engage in skilled performance, if they do not adapting performance. embed essential skills in a productive set of engagement n Social interaction skills refer to how effectively a patterns, their health, well-being, and participation may be person uses both verbal and nonverbal skills to negatively affected. For example, a person may have communicate, including initiating and terminating, skills associated with proficient health literacy but not producing, physically supporting, shaping content of, embed them into consistent routines (e.g., a dietitian who maintaining flow of, verbally supporting, and adapting consistently chooses to eat fast food rather than prepare social interaction. a healthy meal) or struggle with modifying daily performance patterns to access health systems effectively For example, when a client catches a ball, the (e.g., a nurse who struggles to modify work hours to get a practitioner can analyze how effectively they bend and routine mammogram). reach for and then grasp the ball (motor skills). When a client cooks a meal, the practitioner can analyze how Performance Skills effectively they initiate and sequence the steps to Performance skills are observable, goal-directed actions complete the recipe in a logical order to prepare the meal and consist of motor skills, process skills, and social in a timely and well-organized manner (process skills). Or interaction skills (Fisher & Griswold, 2019; Table 7). The when a client interacts with a friend at work, the occupational therapist evaluates and analyzes practitioner can analyze the manner in which the client performance skills during actual performance to smiles, gestures, turns toward the friend, and responds to understand a client’s ability to perform an activity (i.e., questions (social interaction skills). In these examples, smaller aspect of the larger occupation) in natural many other motor skills, process skills, and social contexts (Fisher & Marterella, 2019). This evaluation interaction skills are also used by the client. requires analysis of the quality of the individual actions By analyzing the client’s performance within an (performance skills) during actual performance. occupation at the level of performance skills, the Regardless of the client population, the performance skills occupational therapist identifies effective and ineffective defined in this document are universal and provide the use of skills (Fisher & Marterella, 2019). The result of this AOTA OFFICIAL DOCUMENT 13 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p13 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES analysis indicates not only whether the person is able to services. To plan appropriate interventions, the complete an activity safely and independently but also practitioner considers the underlying reasons for the gaps, the amount of physical effort and efficiency the client which may involve performance skills, performance demonstrates in activities. patterns, and client factors. The hypothesis is generated After the quality of occupational performance skills has on the basis of what the practitioner analyzes when the been analyzed, the practitioner speculates about the client is actually performing occupations. reasons for decreased quality of occupational Regardless of the client population, the universal performance and determines the need to evaluate performance skills defined in this section provide the potential underlying causes (e.g., occupational demands, foundations for understanding performance (Fisher & environmental factors, client factors; Fisher & Griswold, Marterella, 2019). The following example crosses many 2019). Performance skills are different from client factors client populations. The practitioner observes as a client (see the “Client Factors” section that follows), which rushes through the steps of an activity toward completion. include values, beliefs, and spirituality and body On the basis of what the client does, the practitioner may structures and functions (e.g., memory, strength) that interpret this rushing as resulting from a lack of impulse reside within the person. Occupational therapy control. This limitation may be seen in clients living with practitioners analyze performance skills as a client anxiety, attention deficit hyperactivity disorder, dementia, performs an activity, whereas client factors cannot be traumatic brain injury, and other clinical conditions. The directly viewed during the performance of occupations. behavior of rushing may be captured in motor performance For example, the occupational therapy practitioner skills of manipulates, coordinates, or calibrates; in process cannot directly view the client factors of cognitive ability or performance skills of paces, initiates, continues, or memory when a client is engaged in cooking but rather organizes; or in social interaction performance skills of notes ineffective use of performance skills when the takes turn, transitions, times response, or times duration. person hesitates to start a step or performs steps in an Understanding the client’s specific occupational challenges illogical order. The practitioner may then infer that a enables the practitioner to determine the suitable possible reason for the client’s hesitation may be intervention to address impulsivity to facilitate greater diminished memory and elect to further assess the client occupational performance. Clinical interventions then factor of cognition. address the skills required for the client’s specific Similarly, context influences the quality of a client’s occupational demands on the basis of their alignment with occupational performance. After analyzing the client’s the universal performance skills (Fisher & Marterella, 2019). performance skills while completing an activity, the Thus, the application of universal performance skills guides practitioner can hypothesize how the client factors and practitioners in developing the intervention plan for specific context might have influenced the client’s performance. clients to address the specific concerns occurring in the Thus, client factors and contexts converge and may specific practice setting. support or limit a person’s quality of occupational performance. Application of Performance Skills With Groups Analysis of performance skills is always focused on Application of Performance Skills With Persons individuals (Fisher & Marterella, 2019). Thus, when When completing the analysis of occupational analyzing performance skills with a group client, the performance (described in the “Evaluation” section later in occupational therapist always focuses on one individual this document), the practitioner analyzes the client’s at a time (Table 8). The therapist may choose to analyze challenges in performance and generates a hypothesis some or all members of the group engaging in relevant about gaps between current performance and effective group occupations over time as the group members performance and the need for occupational therapy contribute to the collective actions of the group. 14 AOTA OFFICIAL DOCUMENT The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p14 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES If all members demonstrate effective performance be adversely affected. It is through this interactive skills, then the group client may achieve its collective relationship that occupations and interventions to support outcomes. If one or more group members demonstrate occupations can be used to address client factors and vice ineffective performance skills, the collective outcomes versa. may be diminished. Only in cases in which group Values, beliefs, and spirituality influence clients’ members demonstrate ongoing limitations in motivation to engage in occupations and give their life or performance skills that hinder the collective outcomes of existence meaning. Values are principles, standards, or the group would the practitioner recommend interventions qualities considered worthwhile by the client who holds for individual group members. Interventions would then them. A belief is “something that is accepted, considered be directed at those members demonstrating diminished to be true, or held as an opinion” (“Belief,” 2020). performance skills to facilitate their contributions to the Spirituality is “a deep experience of meaning brought collective group outcomes. about by engaging in occupations that involve the enacting of personal values and beliefs, reflection, and Application of Performance Skills With Populations intention within a supportive contextual environment” Using an occupation-based approach to population (Billock, 2005, p. 887). It is important to recognize health, occupational therapy addresses the needs of spirituality “as dynamic and often evolving” (Humbert, populations by enhancing occupational performance 2016, p. 12). and participation for communities of people (see “Service Body functions and body structures refer to the Delivery” in the “Process” section). Service delivery to “physiological function of body systems (including populations focuses on aggregates of people rather than psychological functions) and anatomical parts of the on intervention for persons or groups; thus, it is not body such as organs, limbs, and their components,” relevant to analyze performance skills at the person level respectively (WHO, 2008, p. 10). Examples of body in service delivery to populations. functions include sensory, musculoskeletal, mental (affective, cognitive, perceptual), cardiovascular, Client Factors respiratory, and endocrine functions. Examples of body Client factors are specific capacities, characteristics, or structures include the heart and blood vessels that beliefs that reside within the person, group, or population support cardiovascular function. Body structures and and influence performance in occupations (Table 9). body functions are interrelated, and occupational therapy Client factors are affected by the presence or absence of practitioners consider them when seeking to promote illness, disease, deprivation, and disability, as well as by clients’ ability to engage in desired occupations. life stages and experiences. These factors can affect Occupational therapy practitioners understand that the performance skills (e.g., a client may have weakness in presence, absence, or limitation of specific body functions the right arm [a client factor], affecting their ability to and body structures does not necessarily determine a manipulate a button [a motor and process skill] to button client’s success or difficulty with daily life occupations. a shirt; a child in a classroom may be nearsighted [a client Occupational performance and client factors may benefit factor], affecting their ability to copy from a chalkboard [a from supports in the physical, social, or attitudinal motor and process skill]). contexts that enhance or allow participation. It is through In addition, client factors are affected by occupations, the process of assessing clients as they engage in contexts, performance patterns, and performance skills. occupations that practitioners are able to determine the For example, a client in a controlled and calm transaction between client factors and performance skills; environment might be able to problem solve to complete an to create adaptations, modifications, and remediation; and occupation or activity, but when they are in a louder, more to select occupation-based interventions that best chaotic environment, their ability to process and plan may promote enhanced participation. AOTA OFFICIAL DOCUMENT 15 The American Journal of Occupational Therapy, August 2020, Vol. 74, Suppl. 2 7412410010p15 Downloaded from http://ajot.aota.org on 09/07/2020 Terms of use: http://AOTA.org/terms  GUIDELINES Exhibit 2. Operationalizing the Occupational Therapy Pr