Difference in goals elicited by the Canadian Occupational Performance Measure and the Self- Identified Goals Assessment

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1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Difference in goals elicited by the Canadian Occupational Performance Measure and the Self- Identified Goals Assessment Angelique M. Wilcox The University of Toledo Follow this and additional works at: This Scholarly Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 Running Head: DIFFERENCE IN GOALS 1 Difference in Goals Elicited by the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment Angelique Wilcox Research Advisor: David L. Nelson, Ph.D., OTR/L, FAOTA Occupational Therapy Doctorate Program Department of Rehabilitation Sciences The University of Toledo May 2011 Note: This scholarly project reflects individualized, original research conducted in partial fulfillment of the requirements for the Occupational Therapy Doctorate Program, The University of Toledo.

3 Running Head: DIFFERENCE IN GOALS 2 Abstract In the interests of client-centered care, it is desirable for patients to participate in setting their goals for therapy. Two assessments designed to help patients identify goals are the Canadian Occupational Performance Measure (COPM) and the Self-Identified Goals Assessment (SIGA). This study was conducted as a preliminary investigation of the difference in goals elicited by the COPM and the SIGA in patients admitted to the rehabilitation unit for occupational therapy at a long term care facility. Ten males and eight females with a mean age of 70.6 (SD =8.8) participated. Within 36 hours of admission, participants were administered 36 hours the SIGA and the COPM in an unsystematic counterbalanced order. Evaluations were completed by the student investigator or by either of two occupational therapists assigned to the patients. With complete data on 12 of 18 subjects, the correlation between the overall SIGA score and the overall COPM score was moderate: r =.47, p >.05. In terms of agreement between the two instruments on elicited goals, means for matches, near matches, and no-matches were 1.3, 0.67, and 2.17 respectively (N = 18). In two prior studies with re-analyzed data, means for matches, near matches, and no-matches were 1.53, 0.29, and 0.94, respectively (Irwin, 2002) (N = 17), and 0.97, 0.40, and 2.57, respectively (Eason, 2005), (N = 30). In summary, there was a degree of agreement yet considerable disagreement between the SIGA and the COPM both in terms of quantitative ratings and identified specific goals. Major limitations include missing data and errors of ordering the assessments as planned. Additional training may be needed by those who administer assessments of patients selfidentified goals. It is important for occupational therapists to understand that many factors may influence the goals identified by patients.

4 Running Head: DIFFERENCE IN GOALS 3 Difference in Goals Elicited by the Canadian Occupational Measure and the Self-Identified Goals Assessment Client-centered principles assert that the client or patient is the ultimate decision-maker instead of a passive recipient of care, and present healthcare views are growing to include the patient as part of the decision-making process. This trend can be seen in a growing body of literature, as well. Patients are seeking to be active partners and autonomous decision-makers (Law & Mills, 1998). Occupational therapy must then evolve to accommodate a client-centered practice. Kielhofner asserts that, Client-centered principles define therapy as a process that respects, informs, and enables clients to become active partners in determining the goals and strategies of therapy (Kielhofner, p. 163, 2002). This is based on his premise that people are volitional beings, meaning that people need to feel competent and effective with regard to what they enjoy doing and what has meaning and importance to them. Additionally, client-centered practice falls in the realm of ethical considerations. The Occupational Therapy Code of Ethics (2000) asserts that, Occupational therapy practitioners shall collaborate with service recipients or their surrogate(s) in setting goals and priorities throughout the intervention process (p. 614). If patients are to be the center of therapy, then their goals and success must be of the utmost importance. Personal success is defined in the Conceptual Framework for Therapeutic Occupation as a judgment about the degree to which one s own occupational performance and/or impact matches one s purposes. Purpose is unique to each person and unobservable, unlike sociocultural success which measures the person s occupational performance and/or impacts against sociocultural norms. This unobservable personal success is what is sought by client-centered practice (Nelson & Jepson-Thomas, 2003). In order to learn these purposes and goals which cannot be seen, therapists must ask patients to explain their purposes to produce concrete goals to address in therapy.

5 Running Head: DIFFERENCE IN GOALS 4 Two assessments designed to facilitate patient generated goals are the Canadian Occupational performance Measure (COPM) and the Self-Identified Goals Assessment (SIGA). The COPM is a product of client-centered therapy, developed in the 1980 s in Canada. With the COPM patients are able to identify and rate their own goals within the construct of the assessment, that is, goals which address an area of self-care, productivity or leisure. The COPM is usually administered upon admission and again at a later time determined by the patient and the therapist, with the requisite that the patient is able to identify problems to work on in therapy. The test is comprised of four steps: identifying problems areas in occupational performance, rating the importance of each, scoring each in terms of performance and satisfaction on a scale of 1-10, and a re-assessing at a later date. It is intended that goals remain the same throughout treatment (Law et al., 1998). Hence patients can focus on those things that they find meaningful and important. Because there are specific instructions and methods for administering the test, the COPM is a standardized instrument. However, it is not a norm-referenced test because each patient is compared only to him- or herself, the subjectivity of which makes it difficult to compare individuals to each other. The individualistic nature of the measure, though, satisfies the premise that each client is a unique individual with unique needs and goals. The SIGA is also intended for patients to identify their own therapeutic goals. It was designed by Nelson and Melville (2002) to be used in sub-acute rehabilitation and nursing homes. Like the COPM, the SIGA is administered upon admission and involves identifying and rating personal goals. Information on the patient s prior level of functioning and occupations is gathered and then the patient is asked to think about what he or she would like to be able to do and what he or she would like to work on in therapy. The patient identifies one to five occupational goals that are personally meaningful. The patient is asked how well he or she can perform all of the

6 Running Head: DIFFERENCE IN GOALS 5 occupations listed on a scale of 0 to 10, with 10 meaning that he or she can do them the best. The patient is then asked to rate each individual goal in the same way. Ratings can be updated in progress notes, and unlike the COPM, goals can be added or changed (Melville & Nelson, 1996). In following with client-centered principles, the SIGA also is intended to help patients identify goals which are meaningful and important to them. Prior research conducted by Irwin (2003) investigated the relationship between Mini-Mental State exam scores and ability to take the COPM and the SIGA assessments in patients receiving transitional care. Each subject received both the COPM and the SIGA, with half of the sample receiving the COPM first and the other half receiving the SIGA first. A follow-up study by Eason (2005) was conducted the same way with patients in acute rehabilitation. An unanticipated finding in these studies was that these instruments, though both designed to elicit self-identified goals, appeared to elicit somewhat different goals, as can be seen by tables describing the goals elicited for each subject on each instrument. This inconsistency poses interesting questions concerning the COPM and the SIGA. The current study investigated the relationships between goals elicited by two assessments designed to elicit patient-identified goals. What is the correlation between the overall SIGA score and the overall COPM score? Do the SIGA goals match the COPM goals? Additional secondary analyses included quantitative re-analysis of agreements between the SIGA and the COPM in the two prior studies mentioned above (Irwin, 2003; Eason, 2005). Method Participants The subjects for this study were receiving occupational therapy at the therapy unit of Fox Run Manor, a long-term care facility. Subjects were either residents from the nursing home

7 Running Head: DIFFERENCE IN GOALS 6 receiving therapy or patients admitted for sub-acute rehabilitation. Approximately 85% of therapy patients leave the facility after discharge from therapy, either to another facility or a residence. In order to be included in the study, subjects were to be a) at least 60 years of age, b) willing to participate, and c) able to competently complete an informed consent form approved by the Institutional Review Board. All diagnoses were to be included, provided the subject was able to answer the questions related to each instrument. At least 40 subjects were desired for this study. Unforeseeable events resulted in modifications to the participant requirements and the procedure. An unexpected and sustained drop in the census severely reduced the pool of potential participants. This event was complicated by a second problem: staff turnover. In addition, problems in data collection resulted in missing data. To increase sample size as much as possible, subjects less than 60 years of age were permitted prior to identifying the final four subjects. Further information about subjects is provided at the beginning of the Results section below. Instruments The first instrument to be used in this study is the Canadian Occupational Performance Model. After identifying possible goals, up to five goals are rated on a 1 to 10 scale in terms of how he or she performs the goal presently and how satisfied he or she is with the performance. The COPM has been found to be reliable, valid and responsive. In a phase two pilot study, test-retest reliability was found to be satisfactory, with ICC scores of.63 for Performance and.84 for Satisfaction (Sanford et al., 1994). In another study using the COPM for clients with mental health issues, ICC scores for Performance were.84 and.85 for Satisfaction (Pan, Chung, & Hsin-Hwei, 2003). The COPM satisfies requirements for content, criterion and construct validity. For content validity, the COPM is based on Client-centered Guidelines for Occupational Therapy (McColl, Paterson, Davies, Doubt, & Law, 2000) in order to apply those theories to practice. Criterion

8 Running Head: DIFFERENCE IN GOALS 7 validity was shown by relating it to other accepted measures, such as the SF-36 (Bosch, 1995). A study on the use of the COPM with a pain management program (Carpenter, Baker, & Tyldesly, 2001) found that criterion validity was demonstrated through significant correlations between the COPM and other assessments for psychological functioning. In a study on the construct validity of the COPM (McColl et al., 2000), the COPM correlated with the Satisfaction with Performance Scaled Questionnaire (SPSQ), with r =.39, p <.05; and it correlated with the Reintegration to Normal Living (RNL), with r =.22, p <.05. Significant differences between initial and reassessment scores for satisfaction and performance were found in pilot studies (Law et al., 1998). The second instrument used is the Self-Identified Goals Assessment. The subjects were asked to identify five goals for this study. In a pilot study, 90% of participants stated at admission and discharge that the goals identified were their own. In a study conducted by Melville, Baltic, Bettcher, & Nelson (2002), 29 of 30 subjects said that the goals they identified were meaningful, and 27 said that the scores determined were accurate self-assessments. Like the COPM, the SIGA is intended to elicit concrete goals which are meaningful to the patient. However, the SIGA rates goals on a scale of 0 to 10 instead of 1 to 10, and unlike the COPM, it allows for goals to be modified or added. Another difference is that with the SIGA clients are also asked to rate how they perform collectively on their goals in addition to their performance on each individual goal. Generally, the SIGA also takes less time to administer than the COPM -- only a few minutes compared to an average of 20 to 40 minutes. Procedure The three data collectors included the student investigator and two licensed occupational therapists (HJ and LT) employed at the data collection site. Upon admission subjects would be given an explanation and given the option for participation. If the subject was able to complete the

9 Running Head: DIFFERENCE IN GOALS 8 informed consent form and answer questions, the SIGA and the COPM were administered within no more than 36 hours of each other, one by the student investigator, and one by an OTR/L. To control for order effects, the original plan was to randomize subjects into four groups. One group was to receive the SIGA first from the OTR, and the COPM from the student investigator. The second group was to receive the SIGA first from the student investigator, and the COPM from the OTR. The third group was to receive the COPM first from the OTR, and the SIGA from the student investigator. The last group was to receive the COPM first from the student investigator, and the SIGA from the OTR. The list was to be prepared independently from the OTR and the student investigator using five blocks of eight. For each subject, the student investigator was not to be present for the therapist s assessment, nor made aware of the results until data were compiled. The therapist was also to be masked to the student investigator s measure. In actuality as opposed to the plan, randomization and strict controls for order were not possible given the constraints of the facility. In addition, because of staff turnover at the data collection site, data on the final five subjects were collected only by the student investigator, who was not masked to the prior instrument s development. Plan for data analysis Data were analyzed by categorizing each subject s goals on the two measures into three categories: goals that are exact matches, goals that are near or overlapping matches, and goals that do not match at all. For example, if cooking was identified on both assessments, an exact match was recorded. If home mobility was listed on one assessment and walking on the other, a near match was identified. But if shopping was identified on one assessment and golf on the other, then there was a non-match. Exact matches were checked for first, then near matches. If five goals were identified on both assessments, then there would be a total of five when adding matches, near

10 Running Head: DIFFERENCE IN GOALS 9 matches, and non-matches. If four goals were identified on the first assessment administered and five on the other, there would be a total of four when adding matches, near matches, and nonmatches (matches were always judged in terms of whether the goals of the first assessment had matches in the second. This categorization was done independently by the student investigator and by a research assistant trained in the rules of categorization. A 3 X 3 kappa was conducted to test for inter-rater reliability. Next, a Pearson correlation tested the relationship between the COPM overall score and the SIGA overall score. To deal with the secondary research problem involving past data collected by Irwin (2002) and Eason (2005), the student investigator categorized subjects goals as exact matches, somewhat or overlapping matches, and non-matches in the same way as outlined above. Results Data were available on goals for a total of 18 participants who completed the study. Participant ages ranged from 57 to 89 (one person s age was missing) with an average age of 70.6 (SD = 8.8). The most common diagnosis was total knee replacement surgery. Four participants had right knee replacements, and one had a left knee replacement. Two participants had hip fractures due to falls. Additional diagnoses included preparing for knee surgery; left total hip arthroplasty infection with revision; weakness/fatigue; pneumonia; penile infection with uncontrolled blood sugar; urosepsis; surgery for brain hemorrhage; brain lesion; undetermined gastrointestinal problems with recent gall bladder surgery with complications; and cancer. One diagnosis was not reported. An additional eleven individuals started but did not complete the study. Of the eleven, eight signed the informed consent and were administered one of the two assessments, always by the student investigator. The second assessment was either not completed by the OTR or was not

11 Running Head: DIFFERENCE IN GOALS 10 included with the appropriate data. One of the eleven signed the informed consent form, was administered an assessment, but was dropped from the study at the request of his wife. Two of the eleven were determined to be inappropriate for the study after signing the informed consent form. In both cases the individuals agreed to participate and stated understanding of the study, but were then unable to continue due to lack of insight. For the 18 subjects, 13 were completed under masked conditions, and the remaining 5 were completed entirely by the student investigator. Of the 18, 10 did the SIGA first (9 of which were done by therapists as opposed to the student investigator), and 8 did the COPM first (see Figures 1 and 2). As can be seen in Figures 1 and 2, fewer goals were noted on the SIGA when done first (mean = 3.5) than when done second (mean = 4.9). This discrepancy reflects the fact that therapists collected fewer SIGA goals than the student, who collected 5 goals on every subject she tested on the SIGA. Moreover, therapists tended to do the SIGA and to do it first. The student investigator completed 15 of 18 COPMs. In six cases, therapists did not elicit an overall score on the SIGA. For the remaining 12, the correlation between the overall SIGA score and the overall COPM score was r =.47, p >.05), a moderate but statistically non-significant correlation (possibly due to the small sample). When looking at individual goals, means for matches, near matches, and no-matches as calculated by the student investigator independently of the research assistant were 1.33, 0.67, and 2.17, respectively. The test for level of agreement in classifying matches, near matches, and no matches between independent observers resulted in a weighted kappa of.81, indicating substantial agreement and a reasonable level of objectivity in the classification process. As can be seen in Figures 1 and 2, most patient-identified goals elicited on the COPM and the SIGA were in the areas of basic and instrumental occupations of daily living (ten mentioned

12 Running Head: DIFFERENCE IN GOALS 11 showering/bathing, nine persons mentioned cooking, and five persons mentioned driving). However, there were also personally identified goals involving work (e.g., farm work), leisure (date with wife), and religious observance (attending church). Four persons mentioned occupations with grandchildren. Results for the secondary analyses of Irwin (2002) and Eason (2005) are as follows. As with the present study, matches, near matches, and non-matches were analyzed by counting the number of goals elicited by the first assessment administered and determining if each goal had a matching goal, near matching goal, or no matching goal in the second assessment. In Irwin s study of 17 patients, means for elicited goals were 1.53, 0.29, and 0.94 for exact matches, overlapping matches, and no match at all, respectively. This means that there were more than 50% more agreements than disagreements, with very few goals that fell in the overlapping goals category. In Eason s study of 30 participants, means for elicited goals were 0.97, 0.40, and 2.57 for exact matches, overlapping matches, and no matches at all, respectively. Hence there was twice as much disagreement than agreement. Discussion The Pearson correlation between the overall SIGA score and the overall COPM score was.47, a moderate but statistically non-significant correlation at the.05 level. A Type II error is possible because of low power (N = 12) and the fact that therapists did not elicit overall SIGA scores on one/third of the already small sample. Despite the limitations, it is remarkable that two measures of self-identified goals involved so little consistency from measure to measure. Disagreements on ratings can also be seen in numerical ratings on individual goals. One subject rated dressing a 9 on the SIGA and a 1 on the COPM, and another rated cooking as a 10 on the SIGA and a 2 on the COPM. It is possible that some subjects did not understand the numerical

13 Running Head: DIFFERENCE IN GOALS 12 rating system. It does not make sense that a patient would identify a goal at admission when simultaneously claiming full competence in completing that goal (a score of 10). Perhaps the subject was thinking that the goal was to be able to do the occupation at a 10 level after therapy as opposed to current ability. Or, perhaps the patient thought that a 10 indicated dysfunction, as in the commonly used pain scale. The second question posed was, do the SIGA goals match the COPM goals? Given the argument that a near-match indicates some correspondence between the two measures, the fact is that there was still slightly more disagreement between the SIGA and the COPM even after adding near matches to matches (there was an average of 2.17 disagreements versus 2.00 agreements plus near-agreements). These data are parallel in some respects to re-analyzed data (N = 30) collected by Eason (2005), who found means of.97,.40, and 2.57 for exact matches, near matches, and no matches, respectively. In contrast, the re-analyzed data (N = 17) from Irwin (2002) indicates more agreement found than disagreement, with means of 1.53,.29, and.94 for exact matches, overlapping matches, and no matches, respectively. On average, 55% of goals in Irwin (2002) had exact matches, compared to approximately 32% in the present study and only 25% in Eason (2005). In search of an explanation for the differences in levels of agreement between the SIGA and the COPM across the three studies, it is interesting to note that Irwin (the study with the highest agreement) was also the study with the fewest goals elicited (a mean of 2.76 goals in Irwin versus 4.17 goals in the current study and 3.94 goals in Eason). It is possible that patients are more consistent from instrument to instrument when prioritizing and limiting the number of goals. Another possibility is that the patients or the therapists in the three studies were different from each other.

14 Running Head: DIFFERENCE IN GOALS 13 As discussed in Eason s (2005) study, differences in wording for the assessments may result in the identification of different goals. In administering the COPM, the therapist mentions specific categories with accompanying examples. It may be easier for participants to identify problem areas from examples than without that guidance. Such a practice might bias the subject toward the examples. Eason also proposed that participants may change their answers for the second assessment so that the investigator receives new information (Eason, 2005, p. 18). Additionally, participants ability to accurately and/or consistently assess their strengths and challenges may be impaired by other factors such as pain, medication side effects, physiological co-morbidities, or psychological co-morbidities. Some of these may be temporary, such as pain from surgery or medication side effects. Others may be more permanent, such as cognitive disorders. In contrast to Irwin (2002) and Eason (2005), mental status was not assessed in the current study. Depression, whether acute or chronic, could also affect goal identification, consistency, and every method of goal rating. Inaccurate or inconsistent self-evaluation can also be caused by the absence of a physical demonstration of abilities to test one s perception of ability to actual occupational performance. Fears and expectations, as well as innate factors such as personality and disposition, may result in patients overestimating or underestimating their performance rating for identified problem areas. For example: a patient who is fearful of being forced to live in a facility may overestimate his or her performance score in an attempt to hide his or her deficits. Similarly, a patient with learned helplessness may underestimate his or her performance score to satisfy a psychological need to be cared for. Additionally, patients may be unaware of how much assistance they receive at a facility, which may make it difficult for them to assess what tasks will be most difficult for them when they go home.

15 Running Head: DIFFERENCE IN GOALS 14 Differences in approaches and roles between the therapists and the student investigator may also have influenced how participants responded. Out of consideration for the therapists' productivity requirements, they could use goals identified in this study in their own evaluation paperwork for each participant. Although there is an established protocol for each assessment, there is also allowance for flexibility of discussion and probing to elicit goals from patients. This could allow the therapists to gauge the discussion toward goals more appropriate for their scope of practice as established by the department or therapy team they work with. Reimbursement practices might also bias therapists against leisure goals and unusual goals. No such role expectations existed for the student investigator. Therapists time constraints may also have been a factor not only in the number of goals elicited, but also in the nature of those goals. Although completing each assessment in a timely factor was desirable, the student investigator did not have to meet productivity requirements. Therefore, the student investigator may have allotted participants more time to reflect on and discuss their goals than the therapists. Overall, the COPM elicited more goals than the SIGA. A possible explanation was that for the 13 masked participants the student investigator tended to do more COPM administrations (N = 10) whereas the therapists tended to do more SIGA administrations (N = 10), possibly under time pressures. Averages for goals elicited per participant were 4.96 for the student investigator, and 3.77 for the therapists. An unexpected observation was that rating the Satisfaction level on the COPM was difficult for several participants. Many participants required in-depth explanation of the rating system. All participants rated by the student investigator seemed able to understand how to rate their goals in terms of Importance and Performance with minimal to moderate explanation. However, several participants required extensive explanation of how to rate their goals in terms of Satisfaction level,

16 Running Head: DIFFERENCE IN GOALS 15 and at least two appeared to rate a high level of satisfaction for goals also rated as low on Performance while high on Importance. One possible explanation is that participants confused Satisfaction with Importance, or were confused about satisfaction with present performance versus previous or anticipated performance. Several participants, especially those recovering from orthopedic surgery, stated that even though certain tasks were difficult at the time, they anticipated dramatically improved performance after therapy. This study has several limitations. One limitation was the small sample size, compounded by the fact that six subjects did not receive an overall SIGA score. To compensate for this, data earlier collected in two other studies were re-analyzed, thus adding 47 subjects to the total. Another limitation was that the original plan called for participants to be divided into four groups to control for order effects by having the therapists and the student investigator take turns administering both assessments first and second. Due to work-related time constraints, the therapists favored doing the SIGA first because it took less time to administer than the COPM. Although approximately half of the participants received the SIGA first and a little more than half received the COPM first, the student investigator usually administered the COPM. Therefore, there was a confounding between type of administrator and order, even though there was counterbalancing. An additional limitation was that the student investigator administered both assessments to the last five participants. Ideally, all participants would have received the masked protocol. Because the five participants tested on both instruments by the student investigator identified more goals, a greater opportunity for matching goals was presented. Although it was desired that participants identify five goals for each assessment, it can be seen in Figure 1 that this was often not the case. Lastly, although the student investigator did not knowingly prompt participants to repeat goals from the first assessment

17 Running Head: DIFFERENCE IN GOALS 16 administered, it is possible that the student s mannerisms or method of interviewing may have unintentionally influenced the last five participants responses on the second assessment. In the future it may be beneficial to investigate participant perceptions of each assessment after completion. It may also be beneficial to evaluate the impact of diagnosis and co-morbidities on goal agreement. In addition, the investigation of cognitive status in relation to self-identified goals should be continued because Irwin (2002) and Eason (2005) studied few subjects with substantial cognitive deficits. Finally, it would be interesting to see if goals change from admission, through rehabilitation, to discharge, and to status in the home after discharge. Additional training may be needed by those who administer assessments of patients self-identified goals. Acknowledgments Sincere appreciation is expressed to Holly Johns, OTR/L, and Lauren Tooman, OTR/L, for their help in collecting data; to Dawn Laytart, PTA, for helping identify appropriate participants; and to Alyson Williams for completing match comparisons for inter-rater reliability. Appreciation is also expressed to Fox Run Manor and to the residents and patients therein who donated their time to participate in the study.

18 Running Head: DIFFERENCE IN GOALS 17 References American Occupational Therapy Association. (2000). Occupational therapy code of ethics (2000). American Journal of Occupational Therapy, 54, Bosch, J. (1995). The reliability and validity of the Canadian Occupational Performance Measure. Unpublished master s thesis. McMaster University, Hamilton, Ontario, Canada. Carpenter, L., Baker, G.A., & Tyldesley, B. (2001). The use of the Canadian occupational performance measure as an outcome of a pain management program. Canadian Journal of Occupational Therapy, 68, Eason, C.A. (2005). Mental capacity required for the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment. Unpublished scholarly project. Toledo, OH: Medical College of Ohio. Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, Irwin, B.M. (2003). Mental status required for the Canadian Occupational Performance Measure and the Self-Identified Goals Assessment. Unpublished scholarly project. Toledo, OH: Medical College of Ohio. Kielhofner, G. (2002). Model of human occupation: Theory and application (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins. Law, M., & Mills, J. (1998). Client-centered occupational therapy. In M. Law (Ed.), Client-centred occupational therapy (pp.1-18). Thorofare, NJ: Slack. Law, M., Russell, D., Pollock, N., Rosenbaum, P., Walter, S., & King, G. (1997). A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy

19 Running Head: DIFFERENCE IN GOALS 18 program for children with cerebral palsy. Developmental Medicine & Child Neurology,39, McColl, M.A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67, Melville, L.L., Baltic, T.A., Bettcher, T.W., & Nelson, D.L. (2002). Patient s perspectives on the Self-Identified Goals Assessment. American Journal of Occupational Therapy,56, Nelson, D.L., & Jepson-Thomas, J. (2003). Occupational form, occupational performance, and a Conceptual Framework for Therapeutic Occupation. In P. Kramer, J. Hinojosa, & C.B. Royeen (Eds.), Perspectives in human occupation: Participation in life (pp ). Philadelphia: Lippincott, Williams, and Wilkins. Pan, A.W., Chung, L., & Hsin-Hwei, G. (2003). Reliability and validity of the Canadian Occupational Performance Measure for clients with psychiatric disorders in Taiwan. Occupational Therapy International, 10, Sanford, J., Law, M., Swanson, L., & Guyatt, G. (1994). Assessing clinically important change in an outcome of rehabilitation in older adults. Paper presented at the Conference of the American Society of Aging, San Francisco, CA.

20 Running Head: DIFFERENCE IN GOALS 19 Figure 1. Goals (with ratings on 0 to 10 scale in parentheses) for ten subjects who did the SIGA first. The ratio column gives the numbers of goals that are matches, near matches, and no matches respectively. IDs marked a indicate therapist HJ did the first assessment (SIGA) and that the student investigator did the second assessment (COPM). IDs marked b indicate therapist LT did the first assessment (SIGA) and that the student investigator did the second assessment (COPM). IDs marked c indicate the student investigator did the first assessment (SIGA) and that therapist HJ did the second assessment (COPM). IDs marked d indicate the student investigator did the first assessment (SIGA) and that therapist LT did the second assessment (COPM). ID SIGA Goals (first) Ratio COPM Goals (second) 1 c Walking (0) Volunteer work Driving (3) Housekeeping (3) Gardening (0) 1:1:3 Bathing Driving (1) Cooking (1) Laundry (3) Attend church (1) 4 a Farm work (1) Self care (1) Driving (0) 2:1:0 Driving (1) Use farm machinery (1) Showering (4) Computer use (3) Feeding self 5 b Walking Mow yard (0) Paint porch (0) Carpentry (0) 1:0:3 Walking/ transfers Driving (1) Work part time (1) Car/mower repairs (1) Traveling (8) 6 a Cleaning (3) Self care (6) Make bed (6) Prepare meals 0:0:4 Walking Pastoral duties (4) Traveling Reading (4) Shopping (7) 8 b Computer use (8) Toileting (8) Ride bike (3) Dressing (4) 1:0:3 Dressing (4) Bathing/ hygiene Shopping Housework laundry Plan routes walk (9) 9 a Walk down hall (8) Cooking (8) Showering (7) 1:0:2 Driving (6) Shopping (6) Exercising (7) Cooking (8) Fishing/ boating (8) 10 b Showering (3) Bed transfer Wash dishes (10) Sweeping (3) 1:1:2 Traveling (3) Clean house (7) Showering Cooking Shopping 11 b Run dish washer (10) Dress lower body (0) 0:0:2 Showering (7) Car transfer (1) Gardening/ mowing (1) Home repairs (4) Volunteer at church (1) 12 b Walking (3) Dressing (8) Shopping (0) 0:1:2 Don left shoe (2) Showering (1) Join a church Transfer (bed) (6) Family date night 13 b Wash dishes (10) Prepare meals (10) Dressing (10) 2:0:1 Church/ ministry (2) Dressing (6) Cooking (2) Laundry (1)

21 Running Head: DIFFERENCE IN GOALS 20 Figure 2. Goals (with ratings on 0 to 10 scale in parentheses) for ten subjects who did the COPM first. The ratio column gives the numbers of goals that are matches, near matches, and no matches respectively. IDs marked a indicate therapist HJ did the first assessment (COPM) and that the student investigator did the second assessment (SIGA). IDs marked b indicate the student investigator did the first assessment (COPM) and that therapist HJ did the second assessment (SIGA). IDs marked c indicate the student investigator did both assessments. ID COPM Goals (first) Ratio SIGA Goals (second) 2 a Bathing (2) Toileting (1) Transfers Chair (2) Rec room (1) Play Frisbee (1) 0:1:4 Standing (2) Concentrate (6) Driving (7) Transfers Car (6) Swimming (0) 3 b Driving (1) Fishing (6) Dressing (1) Lift more weight (4) Cooking (6) 1:1:3 Breakfast prep (10) Laundry Dressing (9) Showering (10) 7 a Bathing Dressing (7) Mobility (4) Dates with wife (1) Grandkids play 3:1:1 Grooming bathing (4) Climb stairs (1) Grandkids / play (0) Work labor (0) Dates with wife (8) 14 c Transfers Shopping Cooking (6) Cleaning (2) Grandkids play 3:1:1 Bathroom use Cleaning Basic (3) Fix meals (8) Swimming (7) Grandkids play 15 c Cleaning (2) Attend church (1) Grandkids / watch (3) Sewing (1) Cooking (1) 2:0:3 Driving Cleaning Laundry Cooking Showering 16 c Visit friends Grandkids play (2) Clean house Laundry Shopping 3:0:2 Toileting Fixing meals Cleaning Laundry Visit friends 17 c Showering (1) Dressing (4) Clean house (1) Cooking Volunteer work 1:1:3 Cooking (3) Shopping Dress lower body (7) Walk to toilet (10) Driving (10) 18 c Showering Dressing Cooking Simple (3) Shopping Toileting 2:3:0 Dress lower body Bathe lower body Hygiene toilet Cooking Simple Shopping