Running head: EVALUATION OF OCCUPATIONAL PERFORMANCE 1

Evaluation of Occupational Performance

Jennifer Dulek

Rocky Mountain University of Health Professions

EVALUATION OF OCCUPATIONAL PERFORMANCE 2

Evaluation of Occupational Performance

Introduction

Clients of occupational therapy often experience difficulties in performing occupations

and seek services to restore their occupational performance (Law & Baum, 2005). While many

disciplines may focus on a client’s function, occupational therapy’s unique contribution to

healthcare consists of its focus on occupational performance as a desired outcome, while taking

into account not only the person (client), but also the dynamic interaction of the person with the

environment and occupation (Law et al., 1996). This dynamic interaction cannot be viewed

simply as the sum of its parts; measuring the capabilities of the person, taking into account

aspects of the environment, and analyzing the occupation separately is not sufficient. A

complete view of occupational performance must consider what people want and need to do in

their lives, their abilities and motivations to do these things, and how these characteristics

combine with the environment in which they are doing them (Law & Baum, 2005).

Because the goal of occupational therapy practice is to assist our clients to become

actively engaged in their life activities (Law & Baum, 2005), we must take this dynamic

interaction into account throughout the occupational therapy process. We must identify and use

assessment tools that truly measure occupational performance, rather than rely on measurements

of individual aspects such as body structures and body functions with the hope that these will

allow us to predict the end result for our clients. We must provide interventions that include the

desired occupations occurring with the natural environment. In doing so, we help our clients and

the general public to see the value and power of occupation (Law & Baum, 2005).

Many barriers to measuring occupational performance exist in today’s practice, but

moving beyond them toward best practice (Law & Baum, 2005) is an important goal that will
EVALUATION OF OCCUPATIONAL PERFORMANCE 3

benefit our clients and our profession as a whole. Best practice involves using imagination,

creativity, and responsibility to solve performance problems such as those described above (Law

& Baum, 2005). In pursuing best practice, a thoughtful reflection of recent clinical practice and

an identification of ways that it can be improved are critical. Therefore, I will discuss here a

client I recently evaluated and treated, and will outline both standard practice as well as how it

could be improved to better measure and effect occupational performance and quality of life.

Client Information

About four months ago, Jackie was admitted to the inpatient psychiatric unit on a 72-hour

hold because she had been determined to be gravely disabled and unable to care for herself. She

was 34 years old, married, and had worked previously as a pediatric occupational therapist.

Despite having been diagnosed with bipolar disorder years earlier, she had been managing her

symptoms well and had a full and productive life. However, when she became pregnant two

months prior to her admission, her psychotropic medications had to be discontinued and she

experienced an exacerbation of symptoms and a significant decrease in functioning that resulted

in her hospitalization. At the time of her initial assessment, Jackie presented as disheveled,

irritable, and very distractible, and was hyper-verbal with poor social boundaries. She

demonstrated little insight into her condition, and her husband expressed a desire for her to “just

get better so she can go back to work and we can get on with our lives.”

Evaluation and Intervention Focus

My evaluation consisted of the standard Rehabilitation Therapy Assessment that all

members of the team complete, including recreation therapy, dance therapy, music therapy, and

occupational therapy. An occupational therapist was not involved in the design of the

assessment. It consists of a short demographics section including client-reported reason for

EVALUATION OF OCCUPATIONAL PERFORMANCE 4

admission; a long list of behaviors to be observed during group and individual interaction, and a

section for client self-report of leisure interests, current stressors, and goals.

According to the framework of the International Classification of Functioning, Disability,

and Health (ICF) (World Health Organization [WHO], 2001), this evaluation focused primarily

on body functions, with some inclusion of activity, as is evident in Table 1. These dimensions

are consistent with the medical concept of recovery, and do not adequately address occupational

performance, which is addressed at the activity, environmental factors, and participation levels

(Law & Baum, 2005).

Table 1. ICF Outcome Assessment based on actual evaluation.

EVALUATION OF OCCUPATIONAL PERFORMANCE 5

This assessment utilizes the bottom-up approach (Ideishi, 2003), in which component

skills are viewed as the basis for more complex actions and occupational performance. Because

Jackie’s evaluation focused primarily on specific deficits in body functions and activities, the

interventions I provided to her also took the bottom-up approach and focused on remediation of

the component deficits (Ideishi, 2003). My goals for Jackie were to increase attention, short-

term memory, and impulse control, with the hope that this would allow her to return to work, a

goal I adopted from her husband but did not speak about directly with Jackie herself. The

interventions I provided had nothing to do with her typical occupations, but instead were

contrived preparatory tasks (AOTA, 2014) aimed at influencing her mental functions.

Area of Occupational Performance Dysfunction

Law and Baum (2005) argue that occupational therapists must focus primarily at the level

of the person-environment interaction in order to properly and effectively assess and address

occupational performance issues. As previously stated, within the ICF model this requires more

complete assessment of activity, environment, and participation (Law & Baum, 2005). This is

consistent with the top-down approach described by Ideishi (2003), as it requires the practitioner

to first examine the occupations and roles associated with what the client wants or needs to do.

In collaboration with the client, the therapist can then develop therapeutic goals that address the

role and/or occupational performance dysfunction (Ideishi, 2003).

As Law, King, and Russell (2005) describe, the first stage in the measurement process is

to identify the client’s perspectives about the issues to be addressed during intervention, but this

step is missing in my evaluation. It did not address her participation in things such as work

activities, community and social activities, maintenance of home, and care of others. It would
EVALUATION OF OCCUPATIONAL PERFORMANCE 6

have also been helpful to explore more about her environments, such as the attitudes of those

around her including her family and coworkers, as well as possible workplace accommodations.

Looking back, I believe that Jackie’s work activities are an area of occupational

performance dysfunction that warranted significant attention. She had been working until her

pregnancy required the medication change that led to her hospitalization, and in a proxy report,

her husband voiced the hope that Jackie would be able to return to work. As work can be central

to the concept of productivity and work allows for actualization of one’s life meaning (Baptiste,

Strong, & MacGuire, 2005), it is imperative that occupational therapy practitioners measure and

analyze their client’s participation and performance. Similarly, being off work frequently has

negative consequences, such as decreased health, well-being, and quality of life (Andersen,

Nielsen, & Brinkmann, 2012). In addition, because her husband had expressed concern about

her occupational performance in this area, a client-centered approach suggests that it be assessed

and addressed (Baptiste, Strong, & MacGuire, 2005).

Alternative Evaluation

To meet this identified need, the Worker Role Interview (WRI) created by Braveman et

al. (2005) would have been an effective tool. The WRI assists the client and therapist to identify

the psychosocial and environmental variables influencing a worker returning to work (Baptiste,

Strong, & MacGuire, 2005). It requires the therapist to rate each of 17 factors influencing work

success on a four-point scale; these factors are included within six content areas: personal

causation, values, interests, roles, habits, and environments (Baptiste, Strong, & Law, 2005).

This assessment is clinician-rated, indicating that it relies on the therapist to assess clients’

performance based on an established and absolute criterion (Portney & Watkins, 2009) rather

than relying on the client to rate his or her own performance.

EVALUATION OF OCCUPATIONAL PERFORMANCE 7

Evidence supporting the use of the WRI with clients with mental illness is limited. A

thorough search identified only one such study, completed by Lohss, Forsyth, and Kottorp

(2012). These researchers examined the psychometric properties of the WRI with a psychiatric

population in the United Kingdom with the goal of determining its construct validity as a

baseline assessment and an outcome measure (Lohss, Forsyth, & Kottorp, 2012). They report

that all items except one demonstrated acceptable goodness-of-fit to the Rasch model, and that

“the study supports the use of the WRI as a standardised (sic) baseline assessment in a mental

health population” (Lohss, Forsyth, & Kottorp, 2012, p. 171).

Additionally, in a qualitative study conducted by Prior et al. (2013), the authors describe

the importance of understanding several factors which may impact a client’s participation and

engagement in work, including personal values, current roles and routines, coping strategies,

environmental supports, and perceptions of environmental barriers. Although not used

specifically in this research, the WRI is cited as a means to ensuring thorough initial assessment

(Prior et al., 2013). In addition, Getty (2015) suggests the WRI as a means of providing client-

centered services in a recovery-oriented mental health program.

I initially found information about this tool in Measuring Occupational Performance:

Supporting Best Practice in Occupational Therapy (2nd ed.) by Law, Baum, and Dunn (Eds.)

(2005), but information is also available on the Model of Human Occupation page within the

University of Illinois website (“Worker Role Interview,” 2015), which is also where the tool can

be purchased at the cost of forty dollars. Law and Baum (2005) describe the WRI as a useful

measure of current status, as it is to be used in the initial rehabilitation assessment process for an

injured worker or worker with long-term disability (“Worker Role Interview,” 2015) such as

Jackie’s. The psychometric properties of the WRI are detailed below in Table 2:
EVALUATION OF OCCUPATIONAL PERFORMANCE
Property Findings
Reliability – Test/Retest 0.95 (Law & Baum, 2005)
Reliability – Test/Re-test Intraclass correlation
reliability coefficients coefficients ranged from 0.86
to 0.94. (Law & Baum, 2005).
Reliability – Internal Person separation reliability
consistency indicates that the WRI reliably
differentiates between workers
based on ability levels (Law &
Baum, 2005)
Reliability - Interrater: Ranges from 0.46 to
Interrater/Intrarater 0.92 for six content areas, with
reliability a total of 0.81 (Law & Baum,
2005).
Intrarater: Not reported.
Validity – content Yes. Items are based on
Kielhofner’s (1995) Model of
Human Occupation (MOHO)
(Law & Baum, 2005).
Validity – criterion Evidence that it discriminates
between clients on
psychosocial capacity for work
(Law & Baum, 2005).
Personal Causation had best
predictive validity, while other
items had none (Ekbladh,
Haglund, & Thorell, 2004).
Validity – construct Measures as uni-dimensional
Convergent and construct (Velozo et al., 1999).
discriminant
Clinically important Not applicable; assessment
difference as judged by used only once in OT process.
clients/families
Table 2. Psychometric properties of WRI.
8
What it means.
In this case, test-retest reliability is good,
indicating that there is less variance among
scores and a decreased likelihood that observed
scores vary from true scores and that one would
get the same findings with repeated testing
(Portney & Watkins, 2009).
High reliability from one testing to another
(Portney & Watkins, 2009).
How much the items are homogenous within
groups of items in the test (Portney & Watkins,
2005). In this case, the WRI rating scale and
subtests accurately differentiate between
workers, showing good internal consistency.
Amount of agreement between two raters
assessing the same construct. In this case, the
lower scores in 3 content areas suggest the
need for refinement and training. Overall,
interrater reliability is good (Portney &
Watkins, 2005).
The degree to which a test is not influenced by
other factors irrelevant to its purpose (Portney
& Watkins, 2005). In this case, it means that I
can count on the WRI to address items having
to do with the MOHO.
The degree to which the test is related to or
predicts performance on an already-established
test (Portney & Watkins, 2005). In this case,
because I am seeking to measure psychosocial
capacity to work, I can trust that this test will
serve that purpose. However, for injured
workers, I should recognize that the WRI may
not predict worker success at work.
The ability of an instrument to measure the
concept it intends to measure (Portney &
Watkins, 2005). In this case, the WRI seeks to
measure whether or not a client is ready to
return to work, which is considered a uni-
dimensional construct.
This has to do with a test’s responsiveness to
change over time (Portney & Watkins, 2005).
Because this tool is meant to be used only in the
initial assessment, this has not been measured.
EVALUATION OF OCCUPATIONAL PERFORMANCE 9

Client Summary

Strong and Rebeiro (2003) argue that work rehabilitation for clients with mental illness

needs to incorporate an integrated view of the person, the occupation, and the environment. In

addition, there is evidence that levels of self-efficacy predict how much a client will adhere to

treatment and eventually succeed in returning to work (Law & Baum, 2005). I believe that

engaging Jackie in the WBI would have been an important step toward assessing participation

and environment (WHO, 2001) and toward building her self-efficacy and engagement in

treatment, and positively influencing her eventual therapeutic outcomes.

Completion of the WBI might have offered me insight and information regarding how

Jackie views herself as a worker within her work environment. I could have used this

information to better identify and justify evaluation needs within the activity and body function

dimensions, but even more importantly, I could have used this information to set realistic goals

for Jackie’s treatment on the inpatient psychiatric unit. Although she likely would not have been

ready to return to work upon discharge from the unit, information regarding possible barriers to

return to work could have influenced my interventions and recommendations for discharge

planning. For example, my interventions would have been more engaging and meaningful to her

if centered upon her interests in her work or designed to address her work habits and daily

routines for work. Data from the assessment might have provided justification and rationale for

continued occupational therapy services or other psychosocial support and/or workplace

accommodations to support her eventual return to work. Table 3 indicates dimensions addressed

by this suggested assessment.

EVALUATION OF OCCUPATIONAL PERFORMANCE 10

Table 3. ICF Outcome Assessment based on suggested assessment with WRI.

I believe that overall, a heightened focus on the occupational performance deficits in

Jackie’s work participation could have facilitated her eventual return to work. As demonstrated

in a study involving others like Jackie who have bipolar disorder, are hospitalized, and desired to

return to work, quality of life scores are significantly higher in clients who are employed

compared to those who are unemployed (Medard, Debertret, Perett, Ades, & D’escatha, 2010).

This suggests that Jackie’s quality of life too might have increased as a result of my evaluation

and intervention focusing on her work performance.

EVALUATION OF OCCUPATIONAL PERFORMANCE 11

Practice Implications

As Law, Baum, and Dunn (2005) argue, occupational therapists must have reliable and

valid methods to document the effects of the services they provide. This benefits individual

clients as well as society and the profession as a whole, as it improves clients’ quality of life and

demonstrates occupational therapy’s uniqueness and effectiveness (Law, Baum, & Dunn, 2005).

For these reasons alone, I believe that it is my professional responsibility to improve my practice

through occupational performance measurement.

Still, I identify with many of the barriers that Law, Baum, and Dunn (2005) cite within

their work on the topic. In my practice setting on the inpatient unit, I am part of a larger team

that contributes to and relies on my evaluation to include certain data. While we have discussed

the possibility that I could contribute information specific to occupational performance, this

involves obtaining standardized assessments, educating all the staff on their value and purpose,

and obtaining a doctor’s order for each assessment I complete. Although I know that this is

standard practice in many occupational therapy settings, it is not in psychosocial settings, and it

seems time-consuming and expensive.

That said, Jackie’s case illustrates for me the value and power that could come of

engaging in more specific measurement and intervention. I am not certain that the WBI would

be the best choice of outcome measures for my population, considering the fact that many clients

stay on the unit for less than 72 hours and often are not working when they are hospitalized.

However, I could envision myself using the Canadian Occupational Performance Measure

(COPM) (Law et al., 2014) as a means of gaining clients’ perspective, establishing intervention

goals, and measuring the effects of intervention within several different areas relevant to all of

the clients I treat.

EVALUATION OF OCCUPATIONAL PERFORMANCE 12

References

American Occupational Therapy Association. (2014). Occupational therapy practice

framework: Domain and process (3rd ed.). American Journal of Occupational Therapy,

68(Supplement 1), S1-S51.

Andersen M.F., Nielsen K.M., & Brinkmann S. (2012). Meta-synthesis of qualitative research

on return to work among employees with common mental disorders. Scandinavian

Journal of Work Environment and Health, 38(2), 93-104.

Baptiste, S., Strong, S., & MacGuire, B. (2005). Measuring work performance from an

occupational performance perspective. In M. Law, C. Baum, & W. Dunn (Eds.),

Measuring occupational performance: Supporting best practice in occupational therapy

(2nd ed.) (151-178). Thorofare, NJ: Slack, Incorporated.

Braveman, B., Robson, M., Velozo, C., Kielhofner, G., Fisher, G., Forsyth, K., & Kerschbaum,

J. (2005). Worker role interview (WRI), version 10.0 user’s manual. Chicago, IL:

University of Illinois.

Ekbladh, E., Haglund, L., & Thorell, L. (2004). The Worker Role Interview: Preliminary data

on the predictive validity of return to work clients after an insurance medicine

investigation. Journal of Occupational Rehabilitation, 14(2), 131-141.

Getty, S. (2015). Implementing a mental health program using the recovery model. OT

Practice, 20(3), CE1-CE8.

Ideishi, R.I. (2003). The influence of occupation on assessment and treatment. In P. Kramer, J.

Hinojosa, & C.B. Royeen (Eds.), Perspectives in human occupation: Participation in life,

(278-298). Philadelphia, PA: Lippincott, Williams, & Wilkins.

EVALUATION OF OCCUPATIONAL PERFORMANCE 13

Law M., Baptiste S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock N. (2014) Canadian

occupational performance measure: Fifth edition. Ottawa: CAOT Publications.

Law, M. & Baum, C. (2005). Measurement in occupational therapy. In M. Law, C. Baum, &

W. Dunn (Eds.), Measuring occupational performance: Supporting best practice in

occupational therapy (2nd ed.) (3-20). Thorofare, NJ: Slack, Incorporated.

Law, M., Baum, C., & Dunn, W.(2005). Challenges and strategies in applying an occupational

performance measurement approach. In M. Law, C. Baum, & W. Dunn (Eds.),

Measuring occupational performance: Supporting best practice in occupational therapy

(2nd ed.) (375-382). Thorofare, NJ: Slack, Incorporated.

Law, M., Cooper, B., Strong, S., Stewart, S., Rigby, P., & Letts, L. (1996). The person-

environment-occupation model: A transactive approach to occupational performance.

Canadian Journal of Occupational Therapy, 63, 9-23.

Law, M., King, G., & Russell, D. (2005). Guiding therapist decisions about measuring

outcomes in occupational therapy. In M. Law, C. Baum, & W. Dunn (Eds.), Measuring

occupational performance: Supporting best practice in occupational therapy (2nd ed.)

(33-48). Thorofare, NJ: Slack, Incorporated.

Lohss, I., Forsyth, K., & Kottorp, A. (2012). Psychometric properties of the Worker Role

Interview (Version 10.0) in mental health. British Journal of Occupational Therapy,

75(4), 171-179.

Medard, E., Dubertret, C., Peretti, C.S., Ades, J., & D’escatha, A. (2010). Descriptive study of

the occupational outcomes of bipolar patients. The Journal of Occupational

Rehabilitation, 20, 293-298.

EVALUATION OF OCCUPATIONAL PERFORMANCE 14

Portney, L.G., & Watkins, M.P. (2009). Foundations of clinical research: Applications to

practice (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc.

Prior, S., Maciver, D., Forsyth, K., Walsh, M., Meiklejohn, A., & Irvine, L. (2013). Readiness

for employment: Perceptions of mental health service users. Community Mental Health

Journal, 49, 658-667.

Strong, S., & Rebiero, R. (2003). Creating supportive work environments for people with

mental illness. In L. Letts, P. Rigby, & D. Stewart (Eds.), Using environment to enable

occupational performance, (137-154). Thorofare, NJ: Slack, Incorporated.

University of Illinois. (2015). “Worker Role Interview: Model of Human Occupation Theory

and Application.” Retrieved from http://www.cade.uic.edu/moho/productDetails.aspx

?aid=11

Velozo, C.A. (1993). Work evaluations: Critique of the state of the art of functional assessment

of work. American Journal of Occupational Therapy, 47, 203-209.

World Health Organization. (2001). International classification of functioning, disability, and

health (ICF). Geneva, Switzerland: Author.