Clinical utility of the Canadian Occupational Performance Measure - Swedish version

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1 Clinical utility of the Canadian Occupational Performance Measure - Swedish version Ewa Wressle Jan Marcusson Chris Henriksson Key words Client-centred practice Canadian Occupational Performance Measure Evaluation Process, occupational therapy Copyright of articles published in the Canadian Journal of Occupational Therapy (CJOT) is held by the Canadian Association of Occupational Therapists. Permission must be obtained in writing from CAOT to photocopy, reprint, reproduce (in print or electronic format) any material published in CJOT.There is a per page, per table or figure charge for commercial use.when referencing this article, please us APA style, citing both the date retrieved from our web site and the URL. For more information, please contact: copyright@caot.ca. Abstract The Canadian Occupational Performance Measure (COPM) is an individualised outcome measure intended to detect change in a client s perception of occupational performance over time. The aim of this study was to test the clinical utility of the Swedish version of the COPM. Data was collected from 27 occupational therapists in six focus groups. Emerging themes included goal-setting, preparations, limitations, interactions with clients, and impact on practice. The results indicated that the COPM is helpful in the goal-setting process and in planning treatment interventions. Therapists need knowledge about the theoretical foundation of the instrument and a personal interview technique. Problems were found using the instrument with clients who had poor insight or in acute settings.the COPM facilitated feedback on improvement over time. In summary, the COPM ensures a client-centred approach, facilitates communication within the rehabilitation team, and encourages therapists in their professional role. Ewa Wressle, M.Sc., O.T., is a Senior Occupational Therapist at the Geriatric Clinic, University Hospital, S Linköping, Sweden Ewa.Wressle@lio.se Jan Marcusson is a Professor, Department of Neuroscience and Locomotion: Geriatrics, Faculty of Health Sciences, Linköping, Sweden Chris Henriksson, M.Sc.O.T., PhD, is a lecturer, Department of Neuroscience and Locomotion: Occupational Therapy, Faculty of Health Sciences, Linköping, Sweden Résumé La Mesure canadienne du rendement occupationnel (MCRO) est une mesure individualisée des résultats, ayant pour but de détecter le changement survenu dans la perception qu'a un client de son rendement occupationnel, au fil du temps. Le but de cette étude était d'évaluer l'utilité clinique de la version suédoise de la MCRO. Des données ont été recueillies auprès de 27 ergothérapeutes répartis dans six groupes de discussion. Les thèmes communs étaient, entre autres, la fixation des objectifs, la préparation, les limites, l'interaction avec le client et les effets sur la pratique. Les résultats indiquent que la MCRO est utile pour fixer des objectifs et pour planifier les interventions. Les ergothérapeutes doivent acquérir des connaissances sur les fondements théoriques de l'instrument ainsi qu'une technique d'entrevue individuelle. Les problèmes ciblés étaient l'utilisation de l'instrument auprès des clients ayant une faible capacité d'introspection ou dans des unités de soins aigus. La MCRO a permis de recueillir des commentaires et suggestions pour l'amélioration au fil du temps. En résumé, la MCRO facilite l'approche client et la communication au sein de l'équipe de réadaptation et elle soutient les ergothérapeutes dans leur rôle professionnel. 40 REVUE CANADIENNE D ERGOTHÉRAPIE FÉVRIER 2002

2 The Canadian Occupational Performance Measure (COPM) is designed as an individualised outcome measure to detect change in a client s perception of occupational performance over time (Law et al., 1998). The COPM is also a tool for identifying problem areas within self-care, productivity and leisure. It evaluates performance and satisfaction relative to identified problem areas and measures change. The therapist works in co-operation with the client, relying on a client-centred practice and focusing on occupational performance. The theoretical foundation is the Canadian Model of Occupational Performance that defines occupational performance as the result of interactions between the person, environment and occupation (Law et al., 1998). Client-centred practice refers to collaborative approaches to enable occupations with clients. The practice embraces a philosophy of respect for clients, involving them in decision making, advocating with and for clients and recognising clients experiences and knowledge (Canadian Association of Occupational Therapists [CAOT], 1997). The COPM is more than an outcome measure; it is also helpful in the goal formulation process to prioritize problem areas for intervention and program planning. The identified problems serve as the basis for specification of targeted outcomes and establishment of intervention priorities (Law et al., 1998). The intention of goal setting is to facilitate the decision-making process for the therapist and the client to achieve optimum function relevant to the client s needs and the environment (Canadian Association of Occupational Therapists, 1991). Aspects of clinical utility, validity, and responsiveness have been published. The pilot study of the COPM indicated that it has considerable utility in identifying clients occupational performance issues (Law et al., 1994). Toomey, Nicholson and Carswell (1995) found that the utility depended on the therapist s incorporation of the clientcentred approach in clinical practice, support from management and the flexibility of the COPM. Wressle, Samuelsson and Henriksson (1999) reported that the Swedish version of the COPM was responsive to changes. Chan and Lee (1997) studied the content-related and criterion-related validity and claimed that the assessment content and processes reflected the client s occupational performance issues. The study of the COPM by McColl, Paterson, Davies, Doubt and Law (2000) support construct and criterion validity and utility for community practice. Client centred practice and clinical reasoning, in relation to the use of the COPM, have also been examined. Sumsion and Smyth (2000) studied barriers to client-centred practice. The highest ranked barriers were therapists and clients having different goals, therapists not accepting clients goals and therapists feeling uncomfortable letting clients choose their own goals. A qualitative single-case study by Mew and Fossey (1996) explored the client-centred aspects of one occupational therapist s clinical reasoning while using the COPM. Identified themes concerned collaboration to define problems and negotiate goals, therapist s acknowledgement of the client s feelings and understanding of the client. The study highlighted a need to define what client-centred practice means to occupational therapy. Client-centred practice is strongly supported philosophically by the profession, but the way to use the approach consistently in daily practice demands knowledge about the collaboration process. Studies by Neistadt (1995) and Northen, Rust, Nelson & Watts (1995) indicate that there is a need for a model or theory for patient participation. The COPM has been translated to Swedish (Förbundet Sveriges Arbetsterapeuter [FSA], 1999) and tested for responsiveness. Indications are that the Swedish version of the COPM is responsive to change (Wressle et al., 1999). Important aspects of clinical utility concern whether the instrument is easy to administer, takes an acceptable amount of time for administration, is in a format that is acceptable both to the client and the therapist, and provides useful clinical information (Law et al., 1990). The clinical utility of this instrument has been proven in Canada (Law et al., 1994; McColl et al., 2000). The rationale for testing the clinical utility in Sweden is that different cultures and health care systems may require different tools for clientcentred practice. There is a lack of knowledge with reference to Swedish occupational therapists experiences of using the COPM. Therefore, the aim of this study was to examine the clinical utility of the Swedish version of the COPM. Method Design The focus group technique was used to test the clinical utility of the instrument. A focus group is a group of individuals with shared key characteristics who are selected to discuss, from personal experience, the subject of research. The goal is to obtain lively interaction between the participants (Powell & Single, 1996). The size of the groups normally ranges from 6 to 10 participants. Small groups work best when the participants are interested in the topic and respectful of each other. The number of groups is usually three to five. The discussions in focus groups depend on both the individuals in the group and on the dynamics of the group as a whole (Morgan, 1997). Participants contributions may be influenced by the group effect, but the technique is flexible enough to elicit divergent opinions and experiences, rather than seek a consensus (Powell & Single, 1996). A moderator performs the focus groups interviews and a note-taker or assistant moderator may also be present. The moderator facilitates the dialogue FEBRUARY 2002 CANADIAN JOURNAL OF OCCUPATIONAL THERAPY 41

3 TABLE I Areas of practice for interviewed occupational therapists Type of care Number Neurology 8 Geriatrics 7 Home rehabilitation 5 Primary care 2 Rheumatology 2 Pain rehabilitation 1 Day rehabilitation 1 Community care 1 and is receptive to relevant issues raised by the participants, and should encourage equal participation of all group members (Powell & Single, 1996). A semi-structured interview guide or list of questions helps the moderator to focus the research topic (Asbury, 1995). Sample A strategic sample of occupational therapists was selected. They all had experience with the Swedish version of the COPM and included therapists who had performed at least four interviews with the instrument. Invitations to participate in focus groups were sent out to units with occupational therapists in the area around a university hospital in Sweden. The therapists had participated in education about the COPM and used COPM in clinical practice. Those who were interested signed up for an interview date, with initially five alternative dates. One extra interview opportunity was added when requested. The groups were mixed so that occupational therapists represented as many different areas of practice as possible in the different groups. Out of 33 eligible occupational therapists, 30 accepted the invitation to participate, and 27 finally participated. Reasons for not participating were sick leave (3), heavy workload (2) and a feeling of insufficient experience of the COPM (1). Participants represented both in patient and outpatient care in different areas of practice (see table I). There were 6 focus groups: one with 2 participants, one with 3 participants, two with 5 participants and two with 6 participants. All occupational therapists were female, whose age ranged from 24 to 58 years. Procedures A semi-structured interview guide was developed containing question areas and open-ended sub-questions within the following main topics: experience using the COPM, the instrument itself, client participation, clinical usefulness in daily practice and what a client-centred perspective implies. At the end of all sessions the moderator asked whether the participants intended to continue to use the COPM. The topic of research, information about the focus group technique and the roles of the moderator and assistant moderator were presented as an introduction to each focus group. The interviews were performed as dialogues within the groups. All questions in the interview guide were asked in each group. Two university lecturers, with experience in group discussions but no experience with using the COPM, performed the interviews, as moderator and as assistant moderator and made field notes. The meeting place for the focus groups was in a neutral location outside the participants working areas. The interviews, taking about 60 minutes each, were taped and transcribed verbatim by the interviewers. All interview sessions were held in Swedish, the home language of the participants. Quotations used in the Results section have been translated to English. In this study, the investigator was not present at the focus groups interviews. This was to avoid therapists feeling inhibited from making negative statements about the COPM since the investigator who was a senior occupational therapist had introduced the COPM to the area. Thus, two independent people, the moderator and the assistant moderator, performed the interviews. The material was taped and transcribed, and field notes were taken. The investigator who analysed the data used all available information. In the end, results were confirmed with the interviewers (Krueger, 1998). Analysis The constant comparative method was used in the analysis in order to identify themes relating to the clinical utility of the COPM (Strauss & Corbin, 1990). The analysis, conducted by the first author, began by listening to the tapes and reading the transcripts several times. The analysis was conducted systematically across transcripts from all focus groups. All sections relevant to the research question were identified. The transcribed text was broken down into units of information, using the question areas as initial categories. All the responses were examined for patterns or trends relating to clinical utility, as well as for divergent opinions. In the next step, categories were grouped together to highlight major issues. This generated new categories, and relevant quotes were placed in these categories. Descriptive summaries of each theme were written, constantly comparing similarities and differences in opinions. The analysis concluded by arranging the material based on the research question and the areas of greatest importance (Krueger, 1998). These final themes were also labeled. Themes and summaries were validated and confirmed with the moderator and the assistant moderator. No changes or additions were made. 42 FÉVRIER 2002 REVUE CANADIENNE D ERGOTHÉRAPIE

4 Results The analysis of the data resulted in five themes: goal setting, preparations, limitations, interaction with client, and impact on practice. A summary of each theme is presented, with data emerging from the informants in the focus groups. Results are illustrated by quotations from the transcripts of the focus groups interviews. Goal-setting The occupational therapists viewed the COPM as a resource in the goal-setting process, stating that the COPM provides a goal-oriented structure that focuses on the clients problems. They also stressed that the COPM was helpful in formulating treatment goals and facilitated the rehabilitation process. Even though the COPM is a tool for problem identification, they talked about it as a goal formulation tool: "You got a structure for the problem formulation process, that makes it [the problem] more obvious to the patient, more focused on the patients terms than on mine." As the clients identified their problems, motivation and involvement in the rehabilitation process increased. Problems identified related to activity and occupational performance, not only function. When clients, for example with pain syndromes, put the consequences of the pain into words, their problems in occupational performance became very obvious. The clients were made aware of their own problems. I also feel that when you work in groups with patients with pain syndromes and they tell you the consequences of their pain in words they get such an "aha!" reaction. It is so obvious to them what they have to work with to come to grips with the pain. Therapists reported that the use of the COPM raised new dimensions. Client-identified problems appeared concerning areas that the occupational therapists did not ask about. Aspects that were important to the individual, but not familiar to the therapist, were identified: "I think that other requests come from the patients, things we perhaps would not ask about." During in-patient care, clients lives and preferences outside the ward could be emphasized in the COPM interview. Even though clients sometimes had another underlying diagnosis, they were capable of relating activity problems caused by a specific dysfunction: "You get information about what is meaningful; things that you did not know were meaningful for the patient." Another strength mentioned was its usefulness for caregivers, or ward staff. When the client was not able to perform the COPM interview, it could be performed with another person, close to the client. In this way the information necessary for adequate goal setting could be obtained. The structure of the COPM supported the therapist to ascertain important goals that would most effectively meet the clients needs. When we work with patients with aphasia, we sometimes choose to perform the interview with a caregiver instead of the patient. Sometimes we do it with both a caregiver and with the patient with brain injury. This gives us reasonable information about their understanding and perception of the situation. Preparations In the focus groups it was pointed out that the therapist must have knowledge about the instrument and its theoretical basis before performing the COPM interview: Knowledge is needed in order to use the instrument correctly. You can t just put it in the hands of anybody and just read it. I don t think so. A certain body of knowledge is required. It was said that each individual also has to find a personal interview technique. This could be facilitated by a training period, as it takes some time to get used to the instrument. The therapist has to be mentally prepared and needs to use a pedagogical approach in order to achieve good results from the interview. As time goes by, I have somehow found my way of asking the questions, and how I can focus the patient so that the questions are not too difficult. It [the COPM] is not something you grab when you are in a hurry. Some mental preparation is needed. Emphasis was placed on really learning to focus on occupational performance instead of pain or impairment. Therapists found the COPM to be flexible and adaptable to different combinations of problems. It can be difficult to keep to the topic in the interview, to really focus on limitations in occupational performance, not on pain or something else. But I think that this is an advantage with the instrument, that it is easy to adjust to a specific problem, and that it is not very difficult to make the patients understand what I mean without having to use another instrument. The timing of the interview was said to be important. The therapist has to decide when it is appropriate to perform the interview, which should be completed without disturbances from the surroundings. There should be enough time to perform the interview without stressing the client. The interview process is facilitated when the client is prepared in advance. Informants stated that it was often easier for the client to identify problem areas after having had opportunities to test their ability to perform activities. This gives the client information about the current situation. tell the patient in advance that the next time we will take some time to sit down and talk... describe the intention [of the interview], so that the scoring does not come as a shock or surprise, but that [the patient] should know a little about what is going to happen. FEBRUARY 2002 CANADIAN JOURNAL OF OCCUPATIONAL THERAPY 43

5 Limitations Therapists stated that they found the COPM less suitable for clients in acute settings and clients with poor insight into their problems. The latter, often referred to as clients with cognitive disorders, could not always identify problems or might have unrealistic goals. This could obstruct the COPM interview. However, in these cases the COPM also indicated useful information for the therapist as a way of highlighting this situation. Through discussions and negotiations with the client, the therapist could help the client to sort out important activities and keep the goals at a relevant level. When working with patients with lack of insight, the instrument could still be useful, as it helps me to understand that this patient does not have insight into his problems. Then, you can discuss this with the patient. Perhaps this could help the patient to get better insight; it [the COPM] can work as a tool for this. When the COPM was performed in an acute phase, the client was not always able to detect the problems or cope with the situation well enough to proceed with the process. Clients with communication problems, such as aphasia, or with severe hearing problems, were also mentioned as difficult to interview with the COPM. It was stated that sometimes the time allocated for care was too short to finish rehabilitation interventions. Clients were discharged to their homes at an early phase and it was too soon to make the follow-up. There is not always someone that takes over the rehabilitation process who the occupational therapist can report to. Problems identified might also concern areas that were important to the client but were not in the therapist s domain of concern. Alternatively, the therapist may not have the ability to address the problems. Therapists perceived that clients occasionally demanded or requested tasks that were not available. In these cases, the client identified problems or goals that were unattainable during the short care time. Examples mentioned were different leisure activities: "It is not meaningful to ask [the client] for something that you cannot offer." At times in primary health care, interventions are aimed at a specific task and the COPM was reported as inappropriate. According to the therapist, in these cases the client was already oriented towards a specific problem and not interested in discussing other problems or in spending time on a COPM interview. For example, it might only be a specific technical aid that was needed. Some scoring problems were reported in the focus groups. One was when clients had difficulties in understanding the meaning of the scales. Sometimes therapists thought that scoring three times was too much. Some older clients were not familiar with scoring on scales at all, or were used to placing all responsibility on the hospital staff, resulting in difficulties even in the problem identification phase. Another scoring problem mentioned concerned the client s ability to perceive the difference between performance and satisfaction with performance scores. The therapist needed to explain this difference in other words. This scoring of performance and satisfaction, I think that it is difficult to make this difference clear to the patient. I try to use the words on the scales, and when I come to satisfaction, I sometimes think that this is very close to performance. The patients perhaps do not understand the difference. I usually say several times that this score shows how pleased you are. Interaction with clients The client-centred approach was reported as central in occupational therapy practice. Therapists found that using the COPM ensured that the clients needs were focused on during the rehabilitation process: "The most positive thing is that the patient is the one that evaluates his or her own activity and performance and satisfaction. This is the only instrument I have tried that focuses on the patient s own evaluation." The client is affirmed, and client participation increased. The therapist is not the expert in this situation; instead a partnership between the client and the therapist emerges. However, therapists must use their own experience and knowledge to support the client. It was pointed out that the structure of the COPM provides a new dimension, including the client identifying problems, making priorities and evaluating the outcome. You get information about what is important to the patient, and when the patient prioritises, perhaps problems in the leisure area seem more meaningful, like having enough strength to visit your daughter instead of managing to put your clothes on without help. This saves energy for what is important. Moreover, it was highlighted that the COPM as an outcome measure provides opportunities to detect changes over time, and assures that treatment focuses on the client s perspective. It feels so good to perform the re-assessment; you really feel that this is not just to obtain a new figure. Instead, I am getting more and more comfortable with this instrument because the re-assessment gives so much information to the clinical practice and especially the opportunity to give feedback to the patient. It is easier for clients to see their improvements, receive useful information and reflect over their situation. They become aware of problems in daily life in concrete situations. This was reported as speeding up the process for the clients, making the consequences of illness or trauma clear. 44 FÉVRIER 2002 REVUE CANADIENNE D ERGOTHÉRAPIE

6 The consequences of having pain become so obvious to the patient, it can also result in an accelerated process into sadness when the insight and putting these consequences into words make them realise how their total life situation is affected [by the pain]. The process is accelerated. Clients evaluations of what was meaningful to them became obvious. It was also mentioned that clients make more reflections when the COPM is used and their own responsibility for the rehabilitation process is accentuated. The client has to reflect over problems in occupational performance. This was interpreted as increasing their responsibility in the process in a positive way. The client s ability to cope with the situation was demonstrated. It was also pointed out that the COPM provided the therapist with knowledge about the client s coping ability in discussions about change in satisfaction with performance: "You get a picture of the patient s ability to cope with the situation, how it has changed [through the process]." The use of the COPM might also lead the occupational therapist to reflect about clinical practice: "Also for me as an occupational therapist something happens, I reflect deeply when I sit down and think in this way." Impact on practice Therapists considered this instrument more useful compared with other instruments and "a very good measure that detects changes over time." It provides opportunities to use measured outcomes at different levels in the organisation, such as in the ward but also towards politicians who demand outcome measures. Therapists expressed that the COPM was the only instrument used in which the client evaluates the outcome. We use it as an outcome measure to show results to the politicians. It is very popular nowadays to measure the patient s opinions this could mean that we might be able to keep allocated resources or try to enhance resources. The COPM was reported to facilitate treatment planning, not only for the occupational therapist but also for the whole team, even if the COPM is not usually used as a team instrument. The COPM was seen as a complement to other assessments. It made it easier to focus on clients own volition, and was a way to communicate within the team. Therapists were helped by the method in team conferences, and they felt more distinct in their professional role. We also use it [the COPM] in team conferences, we present to the team what the patient wants and everybody adopts the goals everybody knows what the patient wants, and everybody strives to get there. So this has facilitated the team conferences. Common goals, especially with physiotherapists, were strengthened. This advantage for the whole team was strongly stressed by the therapists, who reported that the process in the team was easier and faster. The patients are more aware of which problems they have. It also helps us make this [the goals] clear for the whole care team. It is not just me who works with the patient, but the whole ward has to work towards the goals. I get a clearer professional role in the team. Informants stated that focus for and choice of interventions changed when they used the instrument. When the clients identified unexpected problems, goals and treatment planning were affected in a positive way. For clients living in their own homes or in community settings, occupational performance problems in the leisure area were more frequently reported than problems in self-care and productivity. The interventions thus shifted from self-care to leisure: [In community care] we put results of COPM interviews together and the major part concerned leisure activities which I think is very interesting because it made me reflect on what I should work with as an occupational therapist. This has made me think about my work contributions as an occupational therapist, and I think the COPM has been helpful in this process. I am not sure that I can say that the COPM has changed clinical practice, but it has changed the direction of some of the treatment interventions. It has resulted in a broader spectrum. Therapists reported that even if the COPM interview takes more time than the informal interview usually does, it saves time and resources in the long run due to the fact that the treatment focus is on the clients needs: "I feel that the extra time that it might take [to perform the COPM interview], you save that by focusing on what is meaningful to the patient." Therapists in outpatient health care mentioned that clients felt that the COPM interview took too much time. The clients were already clear about the reason and perceived problem when contacting health care. A period of rehabilitation was not relevant and the interventions made were isolated. The majority (78%) of participating occupational therapists claim that they will continue to use the COPM. Discussion This study was conducted to gain a more complete understanding of what Swedish occupational therapists think about the clinical utility of the Swedish version of the COPM. The focus group technique was seen as an appropriate research method as it capitalises on the interaction within a group to elicit rich experiential data (Asbury, 1995). The inclusion criteria of the focus group partici- FEBRUARY 2002 CANADIAN JOURNAL OF OCCUPATIONAL THERAPY 45

7 pants to have performed at least four COPM interviews resulted in some participants having a rather limited experience of the COPM. A second study, when more experience has been gained, may give additional information about clinical utility. Each focus group ranged in size from two to six participants. Richness of data was important and all comments were significant. Also, attention was paid to the context in which it occured. Morgan (1995) reported that very small groups, even of two or three participants, could still be called a focus group. Such small groups could even be desirable with some research topics or some types of participants. Experts or people in authority may become irritated if they do not have enough time to say what they feel is important (Morgan, 1995). Dahlin Ivanoff, Sjöstrand, Klepp, Axelsson Lind, and Lundgren Lindqvist (1996) found small focus groups (three to six participants) very dynamic and noted that the outcome of the discussion depended more on the involvement of the participants in each group than on the actual number of participants. The two small groups could be a weakness in this study, but they are included in the analysis since they contain valuable information through broad discussions between participants from different areas of practice. Doubt exists about the extent to which the moderator and the group effect influence individual participation (Powell & Single, 1996). The data collected may represent opinions shaped by the group discussion, which are valid but affected by the measurement process. Concerning the trustworthiness of focus group data, the information given can be considered an accurate representation of the perceptions of reality for the group members and valid (Carey, 1995). However, results should be interpreted with caution. According to Guba and Lincoln (1989), transferability is parallel to the positivistic concept of generalisability, except that it is the receiver, not the sender or researcher, who decides whether the results can be applied to the next situation. After examining the strategies for procedures, methods and analysis, the receiver can decide the degree to which the study might be applied to their situation (Krueger, 1998). This study has to be seen from the perspective of the participating occupational therapists, representing different areas of practice from highly specialised areas to community care. The results section contains findings from the participants. It includes their experience performing the COPM interviews, as well as their opinions of experiences within the context of daily practice. It is obvious from the results that therapists regarded the COPM as a facilitator in goal setting, treatment planning and communication within the rehabilitation team. It is a major step in the right direction when therapists emphasise goals instead of problems in the rehabilitation process, even though the manual of the COPM describes the process as problem identification. The COPM broadens the area of identified problems and may extract unexpected goals. Furthermore, the goals are formulated in terms of occupational performance. This should be the focus of occupational therapy and is verified by Neistadt (1995), who claims that goals related to specific occupational behaviours are the appropriate concern of occupational therapists. The results showed that the use of the COPM with clients with cognitive disorders might be problematic. Unrealistic goals or lack of insight sometimes make the problem identification process cumbersome and timeconsuming. But it was also pointed out that this fact was useful information for the therapist, as well as a way to help the client reflect over the situation. Clients with cognitive deficits are not aware of their problems (Bodiam, 1999). When a specific task was to be accomplished, as in primary health care, the COPM seemed to be inappropriate. The study by Toomey and colleagues (1995) confirms this opinion. Difficulties using the COPM in acute settings are also reported by Ward, Jagger & Harper (1996). In our study, the participants addressed the importance of having a well-developed interview technique to meet the challenge that arises when clients formulate goals that are too vague or ambitious in their current situation. Therapists had to use their experience to negotiate smaller goals that would eventually lead to the development of a major goal. The results indicated that knowledge about the underlying theory and a good interview technique were essential components for clinical utility. The therapist must feel confident with the instrument. Northern et al. (1995) documented the need for therapists to have knowledge about the foundation for the instrument. Formal procedures for assessing clients goals are necessary in order to yield information about the activities that are most meaningful to them. Informal interviews are not effective in treatment planning (Neistadt, 1995). A good introduction to the instrument is important in order for the therapist to feel confident with the COPM. Therapists should be trained in using the COPM (Ward et al., 1996) and need to practice on case examples (Sumsion & Smyth, 2000). Though the manual is easy to read and the interview can be performed in personal styles, it is obvious that the therapist must learn the theory behind the instrument and develop a client-centred approach. This process takes time and considerable reflection. The therapist must be prepared to work with this instrument, an opinion confirmed by Toomey and colleagues (1995). The need to develop a personal interview technique was highlighted in this study, thereby confirming the result of the pilot study by Law et al. (1994). The area of identified problems expressed by the respondents was broader than expected. 46 FÉVRIER 2002 REVUE CANADIENNE D ERGOTHÉRAPIE

8 McColl and colleagues (2000) presented the same issue. In the present study, the possibility of giving the client feedback regarding outcome were stressed by the therapists. The COPM can work as a tool that enables the client to reflect on the actual situation, thereby emphasising the responsibility of the client. The client-centred approach is the focus in the underlying model, the Canadian Model of Occupational Performance, which clearly shows in the instrument. Performing client-centred practice challenges occupational therapists to recognise their own values and not impose them on clients (CAOT, 1997). The therapists in our study emphasized the need for a structure for client-centred practice in goal formulation and treatment planning. There may also be a need for therapists to reflect over their own values in collaborating with the client. The shift from being the expert to partnership with the client requires equality and humility, balanced with the therapist s experience and competence. It was clearly stated that using the COPM properly requires knowledge and training. The impact on team conferences and therapists professional roles was pointed out in the focus groups, in terms of a client-centred perspective, an enhanced goalsetting process, and a strengthened professional role. Even when the COPM is not used as a team instrument, therapists discuss the strength of having performed the goal formulation process when treatment planning is discussed in the team. The communication within the multidisciplinary team has to be open, and each team member must accept each profession s unique contributions, while ensuring a focus on the client. A single case study by Waters (1995) showed that the effective use of the COPM is dependent on the approach of the interdisciplinary team where the occupational therapist works. When the COPM is translated and tested in other countries and other cultures, the strength and utility of the instrument in clinical practice is demonstrated. In Sweden most occupational therapists work in multi-professional teams. This study confirms that the COPM is a useful tool in goal setting. It also focuses on occupational performance and strengthens the professional role of the occupational therapist. There is a great interest in the COPM in Sweden among occupational therapists but also among other professionals, such as physiotherapists, social workers and physicians. A common question is whether the COPM can be used within the team. Further research will examine whether and how the COPM work as a team instrument, from both client and staff perspectives. Another interesting topic that needs to be addressed is a comparison between client-identified problems and caregiver-identified problems with clients who have cognitive deficits. Conclusion In conclusion, the clinical utility of the Swedish version of the COPM is confirmed in this study. This study shows that the COPM is helpful in the goal-setting process and planning of treatment interventions. Even though problems are identified, they are directly related to and formulated as goals. Therapists need knowledge about the theoretical foundation of the instrument and have to develop a personal interview technique. Some problems were reported in using the instrument with clients who are not capable of identifying problems in occupational performance, but at the same time, this fact also provided the therapist with valuable information. The instrument makes it possible for the clients to receive feedback on improvement over time and help for their own reflection. The COPM ensures a client-centred approach, facilitates communication within the rehabilitation team, and encourages therapists in their professional role. Acknowledgement The authors would like to thank the occupational therapists that participated in the focus groups. Grants from King Gustaf V s and Queen Victoria s Foundation and the Swedish Association of Occupational Therapists made this study possible. References Asbury, J-E. (1995).Overview of focus group research. Qualitative Health Research, 5, Bodiam, C. (1999). The use of the Canadian Occupational Performance Measure for the assessment of outcome on a neurorehabilitation unit. British Journal of Occupational Therapy, 62, Canadian Association of Occupational Therapists (1991). Guidelines for client-centred practice of occupational therapy. Toronto, ON: CAOT Publications ACE. Canadian Association of Occupational Therapists (1997). Enabling occupation: An occupational therapy perspective. Ottawa, ON: CAOT Publications ACE. Carey, M.A. (1995). Comment: Concerns in the analysis of focus group data. Qualitative Health Research, 5, Chan, C.C.H., & Lee, T.M.C. (1997). 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