Uniting practice and theory in an occupational framework. 1998 Eleanor Clarke Slagle Lecture

Assessment of the Effect of Meaningful Occupations on Motivation by Orbitofrontal Cortex Activation Using Near-Infrared Spectroscopy

BACKGROUND

Meaningful occupations are those perceived as important by an individual. Research on meaningful occupations relies on subjective data and requires qualitative inquiries. Therefore, assessing the meaning of occupations using objective methods is challenging. As orbitofrontal cortex (OFC) activation is part of the reward system network involved in motivation, it could aid in assessing the meaning of occupations.

OBJECTIVE

We aimed to investigate the effect of meaningful occupations on motivation by measuring OFC activation using near-infrared spectroscopy (NIRS).

METHODS

Eight young and healthy participants were enrolled in this study. The occupation was set as "cooking," and its importance was confirmed using the Canadian Occupational Performance Measure (COPM). NIRS was performed using an OEG-16 (Spectareteh Inc.). The target task involved watching a cooking video, while the control task consisted of looking at a "+" sign on a blank sheet of paper. OFC activation was measured based on changes in oxygenated hemoglobin (oxy-Hb) concentration using a block design. Participants with COPM scores of eight or more were classified into the "meaningful occupation performance" group, while those with scores of seven or lower were classified into the "meaningful occupation non-performance" group. Changes in oxy-Hb concentrations between the two groups were compared using the Mann-Whitney U test.

RESULTS

Four participants were assigned to the meaningful occupation group (frequency of implementation: various times per week for all participants), and four participants were assigned to the meaningful occupation non-performance group (frequency of implementation: various times per week for one participant, various times per month for one participant, and various times per year for two participants). Statistical analysis revealed significant differences in the changes in the oxy-Hb concentration in the left and bilateral OFC.

CONCLUSION

This study suggests that it is important to focus on meaningful occupations that individuals consider important in order to activate the reward system and increase motivation.

Effectiveness of a multidisciplinary and transitional nutritional intervention compared with standard care on health-related quality of life among acutely admitted medical patients aged ≥65 years with malnutrition or risk of malnutrition: A randomized controlled trial

BACKGROUND & AIM

Malnutrition, risk of malnutrition, and risk factors for malnutrition are prevalent among acutely admitted medical patients aged ≥65 years and have significant health-related consequences. Consequently, we aimed to investigate the effectiveness of a multidisciplinary and transitional nutritional intervention on health-related quality of life compared with standard care.

METHODS

The study was a block randomized, observer-blinded clinical trial with two parallel arms. The Intervention Group was offered a multidisciplinary transitional nutritional intervention consisting of dietary counselling and six sub-interventions targeting individually assessed risk factors for malnutrition, while the Control Group received standard care. The inclusion criteria were a Mini Nutritional Assessment Short-Form score ≤11, age ≥65 years, and an acute admittance to the Emergency Department. Outcomes were assessed on admission and 8 and 16 weeks after hospital discharge. The primary outcome was the difference between groups in change in health-related quality of life (assessed by the EuroQol-5D-5L) from baseline to 16 weeks after discharge. The secondary outcomes were difference in intake of energy and protein, well-being, muscle strength, and body weight at all timepoints.

RESULTS

From October 2018 to April 2021, 130 participants were included. Sixteen weeks after discharge, 29% in the Intervention Group and 19% in the Control Group were lost to follow-up. Compliance varied between the sub-interventions targeting nutritional risk factors and was generally low after discharge, ranging from 0 to 61%. No difference was found between groups on change in health-related quality of life or on well-being, muscle strength, and body weight at any timepoint, neither using the intention-to-treat analysis nor the per-protocol analysis. The protein intake was higher in the Intervention Group during hospitalization (1.1 (Standard Deviation (SD) 0.4) vs 0.8 (SD 0.5) g/kg/day, p = 0.0092) and 8 weeks after discharge (1.2 (SD 0.5) vs 0.9 (0.4) g/kg/day, p = 0.0025). The percentual intake of calculated protein requirements (82% (SD 24) vs 61% (SD 32), p = 0.0021), but not of calculated energy requirements (89% (SD 23) vs 80% (SD 37), p = 0.2), was higher in the Intervention Group than in the Control Group during hospitalization. Additionally, the Intervention Group had a significantly higher percentual intake of calculated protein requirements (94% (SD 41) vs 74% (SD 30), p = 0.015) and calculated energy requirements (115% (SD 37) vs 94% (SD 31), p = 0.0070) 8 weeks after discharge. The intake of energy and protein was comparable between the groups 16 weeks after discharge.

CONCLUSION

We found no effect of a multidisciplinary and transitional nutritional intervention for acutely admitted medical patients aged ≥65 years with malnutrition or risk of malnutrition on our primary outcome, health-related quality of life 16 weeks after discharge. Nor did the intervention affect the secondary outcomes, well-being, muscle strength, and body weight from admission to 8 or 16 weeks after discharge. However, the intervention improved energy and protein intake during hospitalization and 8 weeks after discharge. Low compliance with the intervention after discharge may have compromised the effect of the intervention. The study is registered at ClinicalTrials.gov (identifier: NCT03741283).

Occupation as means and ends in paediatric occupational therapy - A systematic review

BACKGROUND

There is a lack of evidence-based knowledge in paediatric occupational therapy about the effectiveness of interventions using daily activities as a treatment modality in improving children's participation.

OBJECTIVE

This study aimed to evaluate the effectiveness of occupation-based and occupation-focused interventions in improving participation in everyday occupations for young children with a disability.

MATERIAL AND METHODS

A systematic review based on Joanna Briggs Institute methodology and critical appraisal tools was conducted. Six databases were searched for quantitative intervention studies aimed at improving participation in everyday occupations of young children with a disability through the use of everyday occupation.

RESULTS

The search yielded 3732 records, of which 13 studies met inclusion criteria. Ten studies met methodological quality criteria and were included in the synthesis, five randomised controlled trials and five quasi-experimental studies, involving a total of 424 children with a mean age of 6.5 years. The studies were classified into cognitive (n = 5), context-focussed (n = 2) and playgroup interventions (n = 3). Study quality ranged from low to moderate, only one study was rated high quality.

CONCLUSIONS AND SIGNIFICANCE

Occupation-based and occupation-focused interventions may have a positive effect on participation in everyday occupations for young children with a disability, but study design, risk of bias and insufficient reporting limit confidence in the body of evidence.

Evaluating the translation of implementation science to clinical artificial intelligence: a bibliometric study of qualitative research

Introduction

Whilst a theoretical basis for implementation research is seen as advantageous, there is little clarity over if and how the application of theories, models or frameworks (TMF) impact implementation outcomes. Clinical artificial intelligence (AI) continues to receive multi-stakeholder interest and investment, yet a significant implementation gap remains. This bibliometric study aims to measure and characterize TMF application in qualitative clinical AI research to identify opportunities to improve research practice and its impact on clinical AI implementation.

Methods

Qualitative research of stakeholder perspectives on clinical AI published between January 2014 and October 2022 was systematically identified. Eligible studies were characterized by their publication type, clinical and geographical context, type of clinical AI studied, data collection method, participants and application of any TMF. Each TMF applied by eligible studies, its justification and mode of application was characterized.

Results

Of 202 eligible studies, 70 (34.7%) applied a TMF. There was an 8-fold increase in the number of publications between 2014 and 2022 but no significant increase in the proportion applying TMFs. Of the 50 TMFs applied, 40 (80%) were only applied once, with the Technology Acceptance Model applied most frequently (n = 9). Seven TMFs were novel contributions embedded within an eligible study. A minority of studies justified TMF application (n = 51,58.6%) and it was uncommon to discuss an alternative TMF or the limitations of the one selected (n = 11,12.6%). The most common way in which a TMF was applied in eligible studies was data analysis (n = 44,50.6%). Implementation guidelines or tools were explicitly referenced by 2 reports (1.0%).

Conclusion

TMFs have not been commonly applied in qualitative research of clinical AI. When TMFs have been applied there has been (i) little consensus on TMF selection (ii) limited description of selection rationale and (iii) lack of clarity over how TMFs inform research. We consider this to represent an opportunity to improve implementation science's translation to clinical AI research and clinical AI into practice by promoting the rigor and frequency of TMF application. We recommend that the finite resources of the implementation science community are diverted toward increasing accessibility and engagement with theory informed practices. The considered application of theories, models and frameworks (TMF) are thought to contribute to the impact of implementation science on the translation of innovations into real-world care. The frequency and nature of TMF use are yet to be described within digital health innovations, including the prominent field of clinical AI. A well-known implementation gap, coined as the "AI chasm" continues to limit the impact of clinical AI on real-world care. From this bibliometric study of the frequency and quality of TMF use within qualitative clinical AI research, we found that TMFs are usually not applied, their selection is highly varied between studies and there is not often a convincing rationale for their selection. Promoting the rigor and frequency of TMF use appears to present an opportunity to improve the translation of clinical AI into practice.

Preliminary analysis of the clinical feasibility of a practice intervention derived from the occupational therapy intervention process model for patients with stroke in the convalescence stage

Introduction:

This study lays the groundwork for the Occupational Therapy Intervention Process Model (OTIPM) run by occupational therapy practitioners for patients with stroke. We explored the feasibility of a treatment approach based on the OTIPM for patients with stroke and the clinical feasibility of evaluating the degree of a collaborative relationship between patients and occupational therapists.

Method:

This pilot trial was conducted as a one-group pre-test–post-test study and two-group comparison on 16 patients with stroke in the convalescence stage. We used the Canadian Occupational Performance Measure (COPM), Assessment of Motor and Process Skills (AMPS), Functional Independence Measure, Japan Stroke Scale of Motor Function, and the Collaborative Relationship Scale between clients and occupational therapists to assess outcomes.

Results:

Patients demonstrated a significant improvement on the outcome measures after intervention. Moreover, the good collaborative relationship group demonstrated significantly higher process skills in AMPS and satisfaction in COPM than the poor collaborative relationship group.

Conclusion:

This preliminary study revealed that short-term OTIPM for patients with stroke may be a feasible clinical practice. In addition, evaluating the degree of the difference in the collaborative relationship between patients and occupational therapists would be a feasible clinical practice.

Development of the Japanese Version of the Engagement in Meaningful Activities Survey

OBJECTIVES

To create a Japanese version of the Engagement in Meaningful Activities Survey (EMAS) and assess internal consistency, test-retest reliability, convergent and structural validity.

METHOD

We conducted a cultural translation and validation study of the Japanese version of the EMAS (EMAS-J) in a sample of 96 community-dwelling older adults in the Tohoku Region of Japan.

RESULTS

Internal consistency of the EMAS-J (α = .91) was very good. Low to moderate correlations were found with indicators of health-related quality of life, depression, and life purpose and meaning. Exploratory factor analysis indicated a two-factor structure within the EMAS-J; cultural differences in item-factor composition compared with previously reported EMAS factor structures are discussed.

IMPLICATIONS

The EMAS-J is a reliable and valid assessment of engagement in meaningful activities for older adults in Japan. The assessment can be used to evaluate the effects of occupation-based interventions upon health and well-being.

Establishment of Reliability of the Occupation-Based Practice Assessment

The profession's foundational construct; occupation, is therapeutically effective, but there remains inconsistent use as a therapeutic medium. A psychometrically strong tool can measure and maximize the use of occupation. This study establishes preliminary psychometric properties of the Occupation-Based Practice Assessment (OBPA). This methodological study tested inter-rater reliability using simulated video cases to examine the OBPA. Overall reliability was acceptable with at .868. All subsections were acceptable including Meaning and Purposeful Occupation (.871), Therapeutic Intent (.819), and Engaged Participation (.807). Two items, Context (.946) and Actual Doing (.981), demonstrated excellent reliability; while three items, Meaning (.747), Adaptation (.799), and Participation (.735), fell slightly below the acceptable level. Preliminary investigation of the OBPA reveals acceptable inter-rater reliability and suggests potential for use following additional in-vivo testing to measure therapeutic interactions to enhance student learning, optimize clinical practice, facilitate professional development, evaluate programs, and quantify occupation-based practice in research.

Optimization of Nutrition And Medication (OptiNAM) for acutely admitted older patients: protocol for a randomized single-blinded controlled trial

BACKGROUND

Internationally, older patients (≥65 years) account for more than 40% of acute admissions. Older patients admitted to the emergency department (ED) are frequently malnourished and exposed to inappropriate medication prescribing, due in part to the inaccuracy of creatinine-based equations for estimated glomerular filtration rate (eGFR). The overall aims of this trial are to investigate: (1) the efficacy of a medication review (MED intervention) independent of nutritional status, (2) the accuracy of eGFR equations based on various biomarkers compared to measured GFR (mGFR) based on ^99mTechnetium-diethylenetriaminepentaacetic acid plasma clearance, and (3) the efficacy of an individualized multimodal and transitional nutritional intervention (MULTI-NUT-MED intervention) in older patients with or at risk of malnutrition in the ED.

METHODS

The trial is a single-center block randomized, controlled, observer-blinded, superiority and explorative trial with two parallel groups. The population consists of 200 older patients admitted to the ED: 70 patients without malnutrition or risk of malnutrition and 130 patients with or at risk of malnutrition defined as a Mini Nutritional Assessment-Short Form score ≤11. All patients without the risk of malnutrition receive the MED intervention, which consists of a medication review by a pharmacist and geriatrician in the ED. Patients with or at risk of malnutrition receive the MULTI-NUT-MED intervention, which consists of the MED intervention in addition to, dietary counseling and individualized interventions based on the results of screening tests for dysphagia, problems with activities of daily living, low muscle strength in the lower extremities, depression, and problems with oral health. Baseline data are collected upon study inclusion, and follow-up data are collected at 8 and 16 weeks after discharge. The primary outcomes are (1) change in medication appropriateness index (MAI) score from baseline to 8 weeks after discharge, (2) accuracy of different eGFR equations compared to mGFR, and (3) change in health-related quality of life (measured with EuroQol-5D-5L) from baseline to 16 weeks after discharge.

DISCUSSION

The trial will provide new information on strategies to optimize the treatment of malnutrition and inappropriate medication prescribing among older patients admitted to the ED.

TRAIL REGISTRATION

ClinicalTrials.gov NTC03741283 . Retrospectively registered on 14 November 2018.

Activities in Daily Living: The development of a new client-centred ADL intervention for persons with stroke

BACKGROUND

An intervention that contains several interacting components can be defined as a complex intervention. This intervention was developed in accordance with the Medical Research Council (MRC) guidance for complex interventions.

AIM

To describe the development, theoretical framework, and content of a client-centred activities in daily living intervention (CADL) for people with stroke.

MATERIAL AND METHODS

Different steps were used; identifying the evidence base, identifying/developing theory and the modelling process and outcomes in the development of the CADL. The remodelling of the process and content of the intervention that emerged are defined.

RESULTS

Findings from a series of qualitative studies of people with stroke demonstrated the need to develop an ADL intervention based on the clients' lived experiences. The theoretical framework is based on empirical research, theories about human occupation and client-centredness. The CADL is applying an occupational and phenomenological perspective in order to enable agency in daily activities and participation in everyday life among persons with stroke.

CONCLUSIONS AND SIGNIFICANCE

The article can be used as an example of how to present the development and theoretical framework of a new complex intervention in occupational therapy.

The influence of occupation on wellbeing, as experienced by the elderly: a systematic review

OBJECTIVE

The objective of this review was to synthesize knowledge regarding which types of occupations the elderly perceive as important to and supporting their overall wellbeing.

INTRODUCTION

Being active is an important part of managing the daily challenges of advanced old age. Occupational therapy and occupational science are based on the premise that a person's occupations are intertwined with their health and are thus needed for them to experience a meaningful life and improve their wellbeing.

INCLUSION CRITERIA

This review, which included independently living elderly people aged 65 and over living in Europe, the USA, Canada and Australia, sought to uncover if the elderly see any specific types of occupations as enhancing their wellbeing. This review included qualitative studies with designs including, but not limited to, phenomenology, grounded theory, ethnography and action research.

METHODS

A three-step search strategy using Joanna Briggs Institute methodology was utilized. Both published and unpublished studies were searched. The following databases were searched for studies up to 2017: CINAHL, Nursing and Allied Health Source, Web of Science, PubMed and OpenGrey. Using the JBI Critical Appraisal Checklist for Qualitative Research, two independent reviewers assessed whether each study had the methodological quality required to be included in the review. Any disagreements were resolved through discussion with a third reviewer. The standardized JBI data extraction tool for interpretive and critical research was used to extract data from the included studies. JBI tools were used to pool the qualitative research findings. The findings were then aggregated through a process of rating according to quality, and categorized according to similarity in meaning, which generated a set of statements for each category. These categories were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings useful as a basis for evidence-based practice.

RESULTS

All three of the included studies utilized qualitative interviews and followed a phenomenological approach. The studies included only participants aged 85 and over. Thirty-five findings were extracted and grouped into four categories, which were synthesized into two meta-syntheses: 1) The importance of "doing" alone - to feel good, I have to be the master of my own life; and 2) Old habits never die - a structured day is a good day. Based on the dependability and credibility of the three studies, the ranking was high (see Summary of Findings).

CONCLUSIONS

The present review shows that two factors enhance elderly people's wellbeing: first, variation and independence in undertaking activities; second, having a choice between the occupations and a structure of activities that make up daily life. The two factors are influenced by a balance between having activities alone and with others. This review is not intended to identify specific occupations that enhance elderly people's wellbeing, but rather to indicate which types of occupations enhance the wellbeing of the elderly, and provide value and meaning to their daily lives.Both the dependability and the credibility of the studies have been rated as moderate.

Lessons learned about occupation-focused and occupation-based interventions: A synthesis using group concept mapping methodology

Introduction: Occupational therapy (OT) is based on the core assumption that humans are active beings through engagement in occupations. Within OT, occupation is typically used as primary means and/or ends i.e. occupation-focused and/or occupation-based interventions are employed. Studies evaluating such interventions are limited.Objectives: To synthesize experiences about occupation-focused and/or occupation-based interventions. Hence, to identify, organize and prioritize experiences with employing occupation as a core element in OT intervention studies.Methods: Participants were OT PhD students and researchers involved in studies concerning occupation-focused and/or occupation-based interventions. Group Concept Mapping was applied.Results: Based on 133 ideas, a conceptual model emerged encompassing two overall dimensions concerning 'developing interventions' and 'planning intervention studies', respectively. Moreover, ten themes related to one or both dimensions were defined and 94 ideas across clusters had high importance ratings.Conclusion: Synthesis of participants' experiences indicates that 'doing' as agent of change is a core element of OT interventions. Moreover, a multi-level perspective is needed to reach sustainable changes in doing. Group- and peer-support can work as amplifier for change, and flexibility is important during intervention. Such complex interventions need special design and mixed methods in the development, and evaluation of outcome needs to address occupation.

The tailored activity program (TAP) to address behavioral disturbances in frontotemporal dementia: a feasibility and pilot study

PURPOSE

To explore the feasibility of implementing the Tailored Activity Program with a cohort of people with frontotemporal dementia and their carers (dyads).

METHODS

The Tailored Activity Program is an occupational therapy based intervention that involves working collaboratively with family carers and prescribes personalized activities for behavioral management in people with dementia. Twenty dyads randomized into the study (Tailored Activity Program: n = 9; Control: n = 11) were assessed at baseline and 4-months. Qualitative analyzes evaluated feasibility and acceptability of the program for the frontotemporal dementia cohort, and quantitative analyzes (linear mixed model analyzes, Spearman's rho correlations) measured the impact of the program on the dyads.

RESULTS

The Tailored Activity Program was an acceptable intervention for the frontotemporal dementia dyads. Qualitative analyses identified five themes: "carer perceived benefits", "carer readiness to change", "strategies used by carer to engage person with dementia", "barriers to the Tailored Activity Program uptake/implementation", and "person with dementia engagement". Quantitative outcomes showed an overall reduction of behavioral symptoms (F_18.34 = 8.073, p = 0.011) and maintenance of functional performance in the person with dementia (F_18.03 = 0.375, p = 0.548).

CONCLUSIONS

This study demonstrates the potential for using an activity-based intervention such as the Tailored Activity Program in frontotemporal dementia. Service providers should recognize that while people with frontotemporal dementia present with challenging issues, tailored therapies may support their function and reduce their behavioral symptoms. Implications for rehabilitation The Tailored Activity Program is an occupational therapy based intervention that involves prescribing personalized activities for behavioral management in dementia. The Tailored Activity Program is an acceptable and feasible intervention approach to address some of the unique behavioral and functional impairments inherent in frontotemporal dementia.

Re-establishing an occupational identity after stroke – a theoretical model based on survivor experience

Introduction

Annually, approximately five million people worldwide are left with a permanent disability following a stroke, often with ongoing occupational issues. A deeper understanding of the emerging picture of occupational disruption and identity reconstruction after stroke is needed to inform client-centred practice.

Method

In-depth interviews using constructivist grounded theory methodology were conducted with six Queensland (Australia) adult stroke survivors. Data analysis identified themes which were woven into an overarching theory about the process of reintegration back into the community and living a meaningful life.

Findings

The central process of adjustment for all participants was reconstruction of an occupational identity, facilitated through connections within and across three domains – self, others and reality. Connecting with self involved emotional management; motivation; confidence; occupational engagement; and seizing control. Connecting with others included being understood; belonging; receiving help; and interactions. Connecting with reality meant confronting the impact on daily life and one's unfolding life story according to three realities: past reality, the reality of the stroke and future reality.

Conclusion

Exploring how stroke survivors form and maintain connections across the domains of self, reality and others provides a framework to ground occupational therapy services in the reality of individual needs from an occupational perspective.

Psychometric Evaluation of the Occupation-Centered Intervention Assessment

A challenge of intervention research is the lack of a means to identify and measure clinical practice from an occupation-centered approach. The objective of this study is to establish basic psychometric properties of the Occupation-Centered Intervention Assessment (OCIA). The study is approached by establishing content validity and utility through expert panel and two focus groups. Interrater reliability (IRR) was determined through standardized video analysis and Krippendorff's alpha. Results from the expert panel and focus groups indicated an overall agreement that the OCIA was able to capture the full range of elements of rehabilitation-focused interventions for older adults (occupational, contextual, and personal relevance) and a good fit with the occupational therapy intervention process model. IRR found adequate level of agreement (α = .76). The OCIA has demonstrated initial basic psychometrics for observation of rehabilitation-focused interventions with older adults.

Perspectives of key stakeholders about vocational training and rehabilitation in Trinidad and Tobago

Introduction

Vocational training and rehabilitation programs are effective in increasing employability and community participation of individuals with intellectual disabilities. Much of the research on effective programming has been conducted in high-income countries with resources targeted at individuals with intellectual disabilities. Although Trinidad and Tobago is a high-income country, there is a dearth of services and resources available to individuals with intellectual disabilities. This article explores stakeholder perspectives on the current status of vocational training and rehabilitation programs for individuals with intellectual disabilities in Trinidad and Tobago.

Method

Participants from diverse groups were identified through snowball sampling. Data were collected in the form of semi-structured interviews conducted in person in Trinidad and Tobago and ranging from 45 to 75 minutes in duration. Interviews followed a loose structure of open-ended questions and the person–environment–occupation model helped inform the questions.

Results

Thirty participants completed the interviews including clients, parents, teachers, principals, non-governmental organization representatives and occupational therapists. Several themes and subthemes emerged including balancing the need for inclusion and segregation, stigma, social policy, issues in current vocational services and independence and expectations.

Conclusion

Vocational services in Trinidad and Tobago face many challenges including resource shortages and meeting the varying needs of clients. They also provide important safe spaces for socialization and acceptance. Resources are needed to improve the level of current services and to help address the competing and at times contradictory goals of differing stakeholders.

Occupational Therapy for People with Progressive Neurological Disorders: Unpacking the Black Box

Progressive neurological disorders often present a challenge to occupational therapists owing to their variable presentation and relentlessly deteriorating course. The literature available to guide therapists either is process driven or describes key roles without detail of the specific therapeutic intervention used. This report describes an occupational therapy programme provided for eight people with multiple system atrophy as part of a randomised controlled trial.

The framework given illustrates the three stages of the client-centred programme and provides a comprehensive account of the therapeutic interventions used to change occupational performance. The treatment included techniques to enhance skills, increase knowledge and change attitude. Upon completion of the 8-week programme, the clients reported benefit. Although it cannot be asserted that all these techniques are effective, the occupational therapy programme described constitutes a ‘black box’ and may be useful in formulating further research questions.

Scholarship of Practice: Making Occupation-Focused, Theory-Driven, Evidence-Based Practice a Reality

National and local policies require the profession to provide evidence on which practice is based. This paper illustrates an approach to meeting the expectations of these policies. Specifically, it describes the development of the United Kingdom Centre for Outcomes Research and Education (UKCORE).

UKCORE was developed within a ‘scholarship of practice’ framework, which supports the development of robust partnerships between academia and practice whereby academic knowledge influences practice and practice knowledge influences academia. Within the partnership, all academic participants (educators, researchers and students) and practice participants (clinicians, clients and administrators) are called ‘practice scholars’ and are focused on practice scholarship.

UKCORE was founded in London in 2001 in order to support the delivery of existing evidence into occupational therapy practice while simultaneously supporting practice to engage in generating new evidence for occupational therapy practice. This article provides an overview of the academic and practice changes that have been put into place. The changes are designed to support the development of practice that is occupation focused, theory driven and evidence based.

Occupational Therapy and Physiotherapy: Similar, but Separate

Three articles were published in the 1998 volume of the British Journal of Occupational Therapy which dealt with the issue of professional boundaries and role overlap between occupational therapy and physiotherapy. There has also been some recent debate on the same topic in the USA and Canada. This paper discusses issues related to the perceived professional role overlap between occupational therapy and physiotherapy. The implications for occupational therapy are discussed and recommendations are made.

An Evaluation of the Clinical Use of the Assessment of Motor and Process Skills with Children

This article reports on the use of the Assessment of Motor and Process Skills (AMPS) within a community paediatric occupational therapy service. The AMPS is a widely used observational assessment of functional ability for people from 3 years of age. There is extensive evidence of its validity and reliability, but there has been little published on its clinical use with children. This article describes the application of the AMPS as the first part of an audit in a service to children over a period of 15 months. The clinical utility of the AMPS is discussed.

Differences in Activities of Daily Living Process Skills of Persons with and without Alzheimer's Disease

The purpose of this study was to determine if persons with dementia of the Alzheimer type (DAT) differed from nondisabled older controls in the actual, experienced difficulty of specific process skills that affect performance of activities of daily living (ADL). A two-group comparison was performed and all participants were evaluated in either clinical or home environments to which they had been familiarized. Participants (341 persons with DAT and 287 controls) were selected from the standardization sample of the Assessment of Motor and Process Skills (AMPS) computer-scoring software. The demographic characteristics of the two groups were comparable. The AMPS was used to evaluate the effort, efficiency, safety, and independence of 20 ADL process skills that are compiled to enact performance of familiar ADL tasks. The raw data for each sample was subjected to many-faceted Rasch analysis to determine item difficulty calibrations of the ADL process skill items for each group. Actual item difficulty calibrations of 19 ADL process skills differed meaningfully between the two groups. The results indicated that it is possible to identify specific ADL process skills that are actually easier or more difficult for each group. In addition, the results supported earlier research that has demonstrated that the underlying cognitive and physical impairments demonstrated by persons with DAT do manifest as ADL disability, negatively impacting their ability to perform ADL tasks.

Epistemological Transformation in Occupational Therapy: Educational Implications and Challenges

An epistemological analysis of occupational therapy's history opens a novel perspective on the field's evolution and on important changes facing education and practice. Kegan's theory of epistemological transformation (e.g., how ways of knowing evolve) was used as an analytic tool to reexamine mostly secondary and some primary historical sources. Although the profession's history is often portrayed in terms of large and sweeping changes, this analysis suggests that little change occurred in occupational therapy's epistemology, making it difficult for the profession to become self-defined or easily adopt occupation, participation, and health as a focus for practice, education, and research. It is also suggested that recent developments in the field are at their core epistemological developments and serve as indicators that a new way of knowing has emerged in occupational therapy that is making new demands of practitioners and educators. Further, epistemological developments can help evaluate common educational assumptions and frame new educational approaches.

Participation in Occupational Performance: Reliability and Validity of the Activity Card Sort

The Activity Card Sort (ACS) is a comprehensive instrument for assessing participation in occupational performance of instrumental, social-cultural, and leisure activities. The purpose of the study was to determine the reliability and validity of the ACS within different adult and older adult groups. The study included 263 participants comprising 5 groups of 61 healthy adults, 61 healthy older adults, 40 spouses or caregivers of individuals with Alzheimer's, 45 individuals with multiple sclerosis, and 56 individuals 1 year after having a stroke. The ACS was adapted to the Israeli culture in a previous study with the author's permission. The final version that was used in this analysis included 88 picture cards of adults performing instrumental, social-cultural, and low and high physical leisure activities that the clients sort into five categories. The ACS provides a “retained activity level” score that is the percentage of activities in which a person is currently engaged divided by those with whom he or she was involved in the past. In addition, comparisons between all groups of current activity levels were analyzed. The ACS had high internal consistency (Cronbach alpha in each area) for instrumental activities of daily living (IADL) and social-cultural activities (.82, .80), and lower for low and high physical leisure activities (.66, .61). A one-way analysis of variance (ANOVA) that compared groups of participants on total retained activity level and individual activity areas showed a significant group effect on all comparisons (p<.000) that support construct validity. Post hoc Scheffe tests revealed significant differences between most groups. The same results were found for current activity level. The results support the reliability and validity of the ACS and provide a basis for its clinical use.

The Lived Experience of Memory Impairment in Daily Occupation after Acquired Brain Injury

The objective of this study was to identify what characterized the lived experience of memory impairment in daily occupations during the first year after acquired brain injury. Four participants were interviewed on four occasions during the year after the brain injury. The data were collected and analyzed using the Empirical Phenomenological Psychological method. The findings revealed four main characteristics that described the individual's experiences during the year of rehabilitation: a chaotic life-world, struggling for coherent doing in new contexts, conscious strategies in new contexts, and achieving new habits. After the brain injury, the life-world changed from a taken-for-granted existence to a chaotic world that was difficult to understand. The routine performance of daily activities and the habit patterns had broken down, so it was mostly the familiar activities that were already integrated in the “habit-body” that enabled coherent doings in everyday life during the year. The findings contribute to an understanding of how to use familiar and meaningful occupations as a therapeutic medium in the rehabilitation of clients with memory impairment following acquired brain injury.

Caregivers' Self-Initiated Support toward Their Partners with Dementia When Performing an Everyday Occupation Together at Home

The aim of this study was to identify the support caregivers provide by their own initiative when performing an everyday occupation together with their partner who has dementia. This is to identify what type of self-initiated caregiver support enhances or limits the performance of the person with dementia. Thirty cohabitating couples participated. One of the spouses in each couple was the primary caregiver for a partner with mild to moderate dementia. Observational data were collected in the participants' homes, where each couple was asked to prepare afternoon tea together. The performances were documented by video and supplementary field notes. Data were analyzed using a qualitative comparative approach. The results of the analyses identified two major themes related to support the caregivers provided: provision of a supportive working climate and provision of practical support. A third theme was related to negative aspects of caregiver support. The results of this study have implications for how occupational therapists and caregivers in dementia care can support and guide primary caregivers in their homes.

The use of occupation-based assessments and intervention in the hand therapy setting - A survey

STUDY DESIGN

Descriptive survey.

INTRODUCTION

This study specifically explored the use of occupation-based assessments and intervention in the hand therapy setting, but also more generally, current practice trends about all assessments being utilized in this setting, frequency of their use, and therapists' perceptions about them.

METHODS

An online survey was distributed via email to members of the American Society of Hand Therapists (ASHT). The survey consisted of ten questions and was administered via Survey Monkey.

RESULTS

Responses were received from 22% of those surveyed. A descriptive analysis was completed of the results and indicated that over half use occupation-based assessments on a daily basis; most are related to ADL function and used for the development of goals. The primary reason for not utilizing occupation-based assessments is time limitation. Seventy-nine percent believe these measures are important for the services provided in the hand therapy setting.

CONCLUSION

Occupation-based assessments and intervention are not utilized as much as therapists would like in the hand therapy setting, primarily due to time constraints. While not formally assessed, the majority of those who responded indicated that they do address occupation in their assessments and interventions.

LEVEL OF EVIDENCE

Not applicable.

Comparing and Using Occupation-Focused Models

As health care moves toward understanding the importance of function, participation and occupation, occupational therapists would be well served to use occupation-focused theories to guide intervention. Most therapists understand that applying occupation-focused models supports best practice, but many do not routinely use these models. Barriers to application of theory include lack of understanding of the models and limited strategies to select and apply them for maximum client benefit. The aim of this article is to compare occupation-focused models and provide recommendations on how to choose and combine these models in practice; and to provide a systematic approach for integrating occupation-focused models with frames of reference to guide assessment and intervention.

Participation in the workforce after a traumatic brain injury: a matter of control

PURPOSE

This study sought to explore individual experience in developing a mastery of daily activities and roles after a traumatic brain injury (TBI) with the objective of returning to work.

METHOD

Eight 30-60-year-old men, employed at the time of injury, were each interviewed three times over a 6-month period. Ten to 21 months after the injuries, four participants had returned to work at least part time. Grounded theory was adapted for analyses.

RESULTS

A single core category emerged: a desire for control: focusing on high-priority issues. Still, 2 years after injury, the participants were uncertain about their abilities with respect to what was expected of them at work. They felt they would do better as time progressed.

CONCLUSIONS

The participants' uncertainty about their efficacy cast doubt on their beliefs in improving their skills, balancing daily activities and work. They wondered about the sustainability of their health and efficacy at work. Wanting to control their own improvement, the participants asked for counselling in strategies and techniques to help with their progress. This issue could be taken into account in follow-up rehabilitation programmes. Additionally, the workplace might be the ideal context in which to develop the structures and routines necessary to master life in general.

IMPLICATIONS FOR REHABILITATION

Two years after injury, the participants remained uncertain about their abilities with respect to what was expected of them at work. The participants felt they would do better as time progressed. The participants, wanting to control their own improvement, sought counselling to help sort out their priorities and found it could contribute to help with their progress in finding a suitable balance between daily activities and work. A consequence of our main finding, in a multidisciplinary context, is that counselling in structures and routines with respect to work-related tasks should be considered to be an integral part of any rehabilitation programme after TBI.

Early rehabilitation of patients with severe acquired brain injury: strategies to promote participation

PURPOSE

The aim of this study was to explore the experiences of professional specialists in early rehabilitation who face demanding pedagogical challenges in facilitating and promoting participation of the severe acquired brain injury patient.

METHOD

In a qualitative study, using phenomenological philosophy and thinking, the experiences of specialist professional experts were investigated. Data were generated in five individual interviews and one focus-group interview. The interview questions were grounded in a preliminary field study. In a four-step phenomenological analysis, empirical themes were identified, using the computer program N-Vivo10; they were structured and organized, and the results were theoretically stated and supported.

RESULTS

Important practice knowledge emerged in this study that led to the proposal of a determined, client-centred approach when facilitating the promotion of severe acquired brain injury patients' participation in early rehabilitation. Four factors are important in this approach: (i) gain contact, (ii) register responses, (iii) intentional interaction, (iv) partial participation. Together they constitute the elements in a proposal for a new model: the GRIP model.

CONCLUSION

The four factors that shape the GRIP model can enrich neurorehabilitation services and support professional experts in early rehabilitation interventions with severe acquired brain injury patients regaining participation and functioning in everyday life.

A process for developing sustainable evidence-based occupational therapy practice

OBJECTIVE

The purpose of this qualitative descriptive study was to describe how long-term improvement work based on the Occupational Therapy Intervention Process Model (OTIPM) evolved in an occupational therapy unit.

METHOD

Data included written documents related to the improvement work (435 pages in total) from 2001 to 2013 that were analysed using pattern matching.

RESULTS

The findings from the analysis of the documents formed three main patterns describing reorientation towards the OTIPM, establishment of the implementation of the OTIPM, and ensuring the sustainability of the implementation. Each pattern contained a number of phases of the improvement work emanating from different reasons and resulting in different long-term achievements. The transformation between the phases was smooth, and several of the phases became starting points for improvement work that continued throughout the years.

CONCLUSION

The findings showed how an occupational therapy model of practice, such as the OTIPM, can guide an improvement process and keep it going over a long period of time, thereby supporting sustainable improvements in practice.

Evaluating the Impact of Audits and Feedback as Methods for Implementation of Evidence in Stroke Rehabilitation

Introduction:

This paper evaluates audits and feedback as methods to increase implementation of evidence in stroke rehabilitation.

Method:

The study used an action research approach and theories of knowledge translation. A sample of 22 occupational therapists participated from two Danish hospitals that admitted stroke patients. Data collection methods included audits of occupational therapy medical records, documentations of daily practice, and collaborative discussions. Active feedback and discussions of the findings took place, at a group level in four local clinical audits. Data analysis of daily self-reported recordings and audits was descriptive. Audit data were analysed using descriptive statistics. A phenomenological hermeneutical interpretive methodology was used for analysing qualitative data.

Findings:

Audits and feedback were based on clear standards and contextual developing action plans. Daily practice in both settings adapted to the clinical guidelines. Implementations of the standardized assessment tools seemed to be the most successful.

Conclusion:

The effects of audit and feedback profited from the active participation of the therapists, as well as local gatekeepers having formal responsibilities for implementing change. The process was strengthened by providing the audits and feedback more than once. The effect of audits and feedback was positively influenced by being in line with current conceptual frameworks, local policies, and values.

Occupation-Focused Practice: Challenges and Choices

Occupational therapy has undergone a paradigm shift from a more mechanistic to an occupation-focused perspective, which has influenced practice as well as the professional education curriculum. However, this shift has not been readily adopted in some practice settings. Anecdotal examples from students, and from practitioner colleagues, have led the authors, as experienced academics and practitioners, to consider what would further assist the profession in moving forward and embracing this change. In keeping with others in the profession, in this opinion piece we would like to support colleagues in practice by suggesting ways of progressing by small ‘nano steps’ along the continuum from medical to occupation-centred practice.

Toward a physical environmental continuum for occupational intervention in a rehabilitation hospital

ABSTRACT A study was conducted to explore occupational therapists' perceptions of rehabilitation environments and the influence of these perceptions on practice and occupational interventions. Traditionally, inpatient occupational therapists have a choice of intervention environments, ranging from a gym-like to a more home-like setting. Choosing to provide interventions in these different environments can have an impact on occupational performance. In this qualitative exploration, 21 occupational therapists participated in focus groups designed to explore their perceptions of practice environments. Analysis of the transcribed data revealed that therapists felt rehabilitation environments should offer choices and be flexible, that environments influenced intervention strategies, and that the practice environment had an impact on professional identity. On the basis of this data, a conceptual matrix of the intersection of environmental setting and occupation-based interventions is presented to highlight the importance of these two aspects of therapy. Future research in this understudied area is needed to transform this matrix into a clinically useful model.

A model of occupational empowerment for marginalized populations in community environments

Globally there are individuals who are marginalized from mainstream society due to problems such as physical or psychological impairment, poor socio-economic circumstances, and occupational deprivation. Many develop learned helplessness syndrome, rendering them unable to control their lives and their destinies. This paper proposes a Model of Occupational Empowerment for providing services to these community populations. The model, a grounded theory, emerged from our work at a homeless shelter for women and children. Disempowering environments in the past had caused learned helplessness in the women at the shelter. Occupational engagement was used to empower them. We contend that the model may be used to guide occupational therapy practice with marginalized individuals and families in a number of community environments.

Spirituality and disability: an analysis of select themes

This paper is a thematic analysis of the literature regarding spirituality, which is applied to the understanding of spirituality and disability. Implications for occupational therapy practice are suggested. The themes of "connectedness" and "expressiveness" as aspects of spirituality were generated from both the occupational therapy literature and literature from other health professions. A definition of spirituality is proposed by the author for use by the profession of occupational therapy, as follows: experiencing a meaningful connection to our core selves, other humans, the world, and/or a greater power as expressed through our reflections, narratives, and actions. Persons with disabilities described a sense of disconnectedness to others, to the world, and to a greater power. They expressed their spirituality through actions to rectify that sense of disconnection. This study suggests that further research is warranted that explores the scope of spirituality in the lives of individuals with disabilities and how spirituality relates to the theoretical and philosophical realm of occupational therapy.

Measurement characteristics of the engagement in meaningful activities survey in an age-diverse sample

OBJECTIVE

This study evaluated the measurement characteristics of the Engagement in Meaningful Activities Survey (EMAS) in an age-diverse sample.

METHOD

The sample included 154 older adults and 122 college students (age range = 18-100 yr). A Rasch-Andrich rating scale model was used to evaluate the EMAS. Analyses addressed rating scale design, person and item fit, item hierarchy, model unidimensionality, and differential item functioning.

RESULTS

Category functioning was improved by reducing the EMAS item responses to four categories. Adequate person response validity was established, and all but one EMAS item demonstrated an ideal fit to the Rasch measurement model. After establishing the item hierarchy, I found the EMAS to be a unidimensional measure. Differential item functioning was not detected using Bonferroni-adjusted statistical criteria.

CONCLUSION

The results confirm the potential to validly measure subjective qualities of meaningful activity participation. The EMAS can be used to evaluate processes and outcomes central to occupational therapy practice and to aid in the design of therapeutic occupations.

Arthritis-Related Occupational Therapy: Making Invisible Ruling Relations Visible Using Institutional Ethnography

Introduction:

Occupational therapists' intention of enabling women with rheumatoid arthritis to participate in everyday life is fraught with challenges in everyday practice.

Method:

Inspired by institutional ethnography, this paper aims to make explicit how the work of occupational therapists in an outpatient rheumatology hospital setting is governed within invisible, ruling relations. An analytical description of the first author's clinical experience was a standpoint from which to explicate how occupational therapy is coordinated to the ruling relations of the Austrian health care system.

Findings:

Occupational therapy practice and research are ruled within a positivist, body-focused, medical apparatus, which renders largely invisible occupational therapists' knowledge of enabling people to engage in occupations that are meaningful to them.

Conclusion:

Occupational therapists have professional power that can be asserted by strategically using occupational therapy specific knowledge and language in textually mediated practices, from assessments and case files to media images, to give greater visibility and influence to the profession's work of enabling occupation.

Optimal Positioning of Occupational Therapy

Background. Occupation is central to occupational therapy. Although occupation is a universal experience, occupational therapists need to consider the risks and opportunities of exploring new roles and maintaining existing services.

Purpose. I propose three questions to guide the optimal positioning of occupational therapy services. First, how proximal is occupation in the role? Second, how strong is the evidence to support occupational therapy in the role? Third, is the timing right for change? These questions are applied to the role of occupational therapy in primary health care.

Key Issues. Occupation is proximal and the evidence is emerging to support an occupational therapy role in primary health care. Reforms make timing ideal.

Implications. If we focus on the underlying principles of primary health care reform, the potential for an emerging role in primary health care is optimal. The same three questions can be used to transform and optimally position occupational therapy.

Occupational Gaps in Everyday Life after Stroke and the Relation to Functioning and Perceived Life Satisfaction

The objective of this study was to psychometrically evaluate the Persian version of the Occupational Gaps Questionnaire (OGQ-P) and LiSat-11 checklist, and to describe occupational gaps after stroke and their relation to aspects of functioning and perceived life satisfaction. A total of 102 individuals who had experienced a stroke were assessed for their occupational gaps, aspects of functioning, and life satisfaction. Psychometric analyses of the Persian versions of the OGQ and LiSat-11 were completed and the measures were applied for using univariate and multivariate analyses. The results provided evidence of internal scale validity, person response validity, and sensitivity for the instruments. The participants perceived the most common occupational gaps in “helping and supporting others.” Furthermore, perceived physical function including activities of daily living ability, motor function, and perceived life satisfaction were the most influential variables for the prediction of occupational gaps. It is essential to address the occupations such as “helping and supporting others” that are important from an individual perspective but overlooked in rehabilitation. A combination of physical function, motor function, and life satisfaction can predict occupational gaps after stroke.