Responsiveness and predictive validity of selfidentified

Transcription

1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Responsiveness and predictive validity of selfidentified goals Shawna K. Semer 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: VALIDITY OF SELF-IDENTIFIED GOALS 1 Responsiveness and Predictive Validity of Self-Identified Goals Shawna K. Semer Advisor: David Nelson, Ph.D., OTR/L 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 VALIDITY OF SELF-IDENTIFIED GOALS 2 Abstract Client-centered practice requires input from patients in terms of goals and self-assessment. The purpose of this study was to further investigate the responsiveness and predictive validity of patients self-identified goals in a skilled nursing facility (SNF) using the Self-Identified Goals Assessment (SIGA). Participating were 9 males and 26 females with a mean age of 76.6 (SD = 10.0). The research design included: (a) admission administration of the SIGA, (b) discharge administration of the SIGA, (c) home follow-up administration of the SIGA with additional questions regarding a) duration of assistance needed per day and b) possible differences between the home and the SNF (the Home/SNF Comparison Scale). All five tests of positive responsiveness on individually identified goals from admission to discharge were statistically significant, with p <.0001 and with large effect sizes. Ratings of individual goals at discharge did predict how well the participants rated themselves at home on the same goals, with statistically significant positive correlations ranging from.45 to.83. However, self-ratings on five self-identified goals at discharge did not predict the number of hours of home help needed, with correlations ranging from -.25 to.21. Participants required substantial help at home: an average of 4.9 hours per day (SD = 7.8). The Home/SNF Comparison Scale did not explain somewhat lower self-ratings at home compared to ratings at discharge. In conclusion, this study provides evidence that therapists can be confident in the SIGA's ability to elicit goals that are very responsive to change and that are quite predictive of self-ratings after discharge in the home. However, achievement of individualized goals does not necessarily result in less overall dependence after discharge.

4 VALIDITY OF SELF-IDENTIFIED GOALS 3 Introduction In the Conceptual Framework of Therapeutic Occupation, the patient and the therapist collaborate to determine goals that are meaningful and purposeful to the individual. According to Nelson and Thomas (2003), the patient is considered an active participant in the therapy process, rather than a passive recipient of treatment as seen in the medical model of practice. Nelson and Thomas (2003) also discussed two types of success the individual experiences: personal success and sociocultural success. Personal success is a judgment about the degree to which one s own occupational performance and/or impact matches one s purposes (Nelson & Thomas, 2003, p. 123). Personal success does not take into account the judgments of others. On the other hand, sociocultural success is the degree to which a person s occupational performance and/or impact matches sociocultural norms (Nelson & Thomas, 2003, p. 124). Sociocultural success depends on the judgments of others and of society. In the client-centered model of practice the patient is an active participant, not a passive participant as used in the medical model of practice. According to Law, Baptiste, and Mills (1995, p. 253), Client-centred practice is an approach to providing occupational therapy, which embraces a philosophy of respect for, and partnership with, people receiving services. Client-centred practice recognizes the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist partnership and the need to ensure that services are accessible and fit the context in which a client lives.

5 VALIDITY OF SELF-IDENTIFIED GOALS 4 The origin of the client-centered model of practice came from the works of Carl Rogers, an influential American psychologist, just prior to World War II (Law et al., 1995). Although his client-centered practice may be different from occupational therapy client-centered practice, his main focus was similar to occupational therapy s interpretation (Law et al., 1995). Rogers emphasized the dynamic nature of the therapist-client interaction and the need for clients to have an active role in their treatment. He also emphasized the need for honesty and openness within the clinical relationship (Law et al., 1995). Client-centeredness became popular in the profession of occupational therapy with the development of the Canadian Occupational Performance Measurement. The Canadian Occupational Performance Measure (COPM) is an individualized measure designed for use by occupational therapists to detect change in a client s self-perception of occupational performance over time (Law, Baptiste, Carswell, McColl, Polatajko, & Pollock, 1994, p. 1). This measure was developed by the Canadian Association of Occupational Therapists (CAOT) in collaboration with the Health and Welfare of Canada. The COPM is based on the fundamental belief that the person is a fundamental part of the therapeutic process, and describes a person s occupational performance as a balance of performance in three areas: self-care, productivity, and leisure (Pollock, 1993, p. 299). The COPM is to be used as an outcome measure that is intended to: identify problem areas in occupational performance, evaluate performance and satisfaction relative to those problem areas, and measure changes in a client s perception of his/her occupational performance over the course of occupational therapy (Law et al., 1994). The COPM is used to show change in the client over time. In a study of the COPM in adult neurorehabilitation, the ability of the COPM to measure change over a one-month period

6 VALIDITY OF SELF-IDENTIFIED GOALS 5 was studied as well as occupational therapists perception of the use of the COPM. In this study the COPM was used in conjunction with the Reintegration to Normal Living Index (RNL). Both were administered before treatment and after one month of treatment to investigate the sensitivity of the COPM in measuring change (Chen, Rodger, & Polatajko, 2002). The results of the study show that the COPM was sensitive to change from pre-test to post-test. The clients had improvement in their self-ratings of performance and satisfaction between pre-and post-test. A matched t-test indicated that change in the performance sub-scale between pre-and post-test was highly significant (Chen et al., 2002). In another study of 139 clients on the validity of the COPM, there was a statistically significant difference in the means between initial assessment and reassessment (Law et al., 1994). The Self-Identified Goals Assessment, similar to the COPM in attempting to identify and rate client goals, is an assessment developed for skilled nursing facilities and sub-acute rehabilitation facilities. It is used to help patients identify purposeful and meaningful goals for occupational therapy. According to Melville and Nelson (2001), the principles that were applied in the development of the SIGA include: (a) consistency with the Conceptual Framework of Therapeutic Occupation and with traditional principles of occupational therapy, (b) principles of measurement validity; and (c) practicality within the regulatory and administrative constraints of the United States settings for subacute rehabilitation, which include assigned subacute beds in skilled nursing facilities and hospitals (Melville & Nelson, 2001). An advantage of the SIGA is brevity. In a recent study by Stuber and Nelson (2010), the SIGA required much less time (median = 5.0 minutes) to administer than the COPM (median = 17.5). In other studies the COPM actually took 20 to 40 minutes to administer (Toomey et al., 1995).

7 VALIDITY OF SELF-IDENTIFIED GOALS 6 The establishment of reliability and validity for each instrument is a high priority. According to Coster (2006, p. 210), responsiveness is the capacity of an instrument to demonstrate change and is necessary for clinical or real life meaning. It is important to measure the responsiveness of the SIGA to see if positive change in the client s daily occupations can be detected. Another important aspect of measurement is predictive validity, which is the correlation with a future criterion (Kielhofner, 2006, p. 168). This study is similar to a previous study conducted by Hasenmeier (2008), who studied the responsiveness and predictive validity of the SIGA in skilled nursing rehabilitation patients. Her study included 21 participants. The responsiveness of the SIGA was determined by comparing the SIGA scores from postadmission to predischarge, and the predictive validity was assessed by correlating the SIGA scores from predischarge to home. Hasenmeier (2008) concluded that the SIGA was highly responsive to change from postadmission to predischarge, t = 13.78, p < There was also a statistically significant correlation between postdischarge SIGA scores and duration of assistance per day by others postdischarge (r = -.53, p =.01). Hasenmeier (2008) also concluded that the SIGA scores for overall ability declined significantly from predischarge (M =9.1, SD = 1.3) to postdischarge in the home (M = 7.1, SD = 1.8). Even though there was a decline in the SIGA scores postdischarge in the home, the postdischarge scores were still much higher than the postadmission SIGA scores (Hasenmeier, 2008). The main purpose of this study was to further investigate the relationships among patients self-identified goals at admission, at discharge, and at home follow-up. Is the SIGA responsive over the course of therapy, and is the SIGA score at discharge predictive of selfratings and independence in the home? In addition, possible explanations of the decline in SIGA scores after discharge to the home were explored.

8 VALIDITY OF SELF-IDENTIFIED GOALS 7 Method Participants Recruitment and informed consent as approved by the University of Toledo Biomedical Institutional Review Board took place at two skilled nursing home facilities in Northern Ohio: Kingston Care Center of Sylvania and Kingston Care Center of Vermilion. Four licensed occupational therapists collected data. Three of the four occupational therapists were from Kingston of Sylvania, and one from Kingston of Vermilion. As in the study by Hasenmeier (2008), inclusion criteria were as follows: must be 50 years of age or older, must voluntarily consent to release necessary medical records (age, gender, primary diagnosis, contact information for follow-up interview), must have a plan for discharge to a private residence (home, friend or family member s home, assisted living facility), and must have a plan of stay of a minimum of seven days in the skilled nursing home facility. Of the 54 participants providing informed consent, 35 completed the entire study, with 10 being discharged to hospitals during the study, with five being no longer appropriate for the study due to changes in cognitive status, with one participant s caregiver declining further participation, with one participant being unavailable for the home follow-up interview, and with two participants expiring. Of the 35 participants participating in all phases, 9 were male and 26 were female. The mean age of the participants was 76.6 years old with a standard deviation of 10.0 years. Diagnoses varied widely: right total knee arthroplasty (5), pneumonia (3), acute renal failure (2), chronic obstructive pulmonary disease (2), general weakness (2), right total hip arthroplasty (2), chronic heart failure (1), left total knee arthroplasty (1), atrial fibrillation with permanent pacemaker placement (1), gastrointestinal bleed (1), pelvic fracture (1), spinal surgery

9 VALIDITY OF SELF-IDENTIFIED GOALS 8 (1), abdominal pain (1), left radial fracture with a left pelvic fracture (1), right femur fracture (1), coronary artery bypass graft 3 (1), gallbladder surgery (1), compression fracture with kyphoplasty (1), right hip fracture with open reduction internal fixation (1), left wrist fracture with a left pelvis fracture (1), chest pain (1), lumbar spondylosthesis (1). In three cases the therapist did not record the diagnoses given. Instrument The Self-Identified Goals Assessment (SIGA) Protocol is available for retrieval at The University of Toledo website (Melville & Nelson, 2001). The purpose of the SIGA is to help patients identify meaningful goals for therapy and to evaluate changing levels of patientidentified success in those goals (Melville, Baltic, Bettcher, & Nelson, 2002). A study conducted by Melville et al. (2002) studied patients perspectives on the SIGA. Of the 30 participants in the study, 29 confirmed the personal meaningfulness of goals identified by the SIGA interview and 28 stated the assessment helped the therapist realize what was meaningful to them (Melville et al., 2002). The clinical utility of the SIGA has been studied by Cassidy (2000) through three focus group interviews with occupational therapists. Overall, the therapists found the instrument to be clinically useful. The therapists stated that they felt they were able to build better rapport with their clients and the clients felt more in control of their therapy (Cassidy, 2000). Convergent validity was investigated by Stuber and Nelson (2010) who hypothesized a positive correlation among the COPM performance scale, the Occupational Self Assessment (OSA) competence scale, and the SIGA overall score. The study concluded that all three assessments were positively inter-correlated, with the COPM and the SIGA more strongly correlated with each other than with the OSA (Stuber & Nelson, 2010, p. 19).

10 VALIDITY OF SELF-IDENTIFIED GOALS 9 The SIGA Protocol calls for the occupational therapist to ask the patient about prior functioning, home situation, life work, interests, and customary routines (Melville & Nelson, 2001). Next, the occupational therapist is supposed to ask the patient to think about all the things they want to be able to do. The patient also asks the patient to describe what types of things he or she wants to improve on in therapy. During this process, the therapist ensures that the patient is not just trying to tell the therapist what he or she seems to want to hear. The therapist also asks the patient what sorts of things seem difficult at that time. If the patient is able to identify goals, the occupational therapist records one to five patient identified goals on the evaluation sheet. Next, the therapist is supposed to ask the patient to rate how well he or she can do all the things he or she wants to do on a 0 to 10 scale, with 0 being not able and 10 being full ability. The protocol next calls for the patient to rate each individual goal on the same 0 to 10 scale (Melville & Nelson, 2001). In the current study, the overall SIGA scores were not collected as originally planned; only individual self-identified goals were collected from each participant. Previous research has concluded that participant s SIGA scores tend to go down after being discharged from the SNF (Hasenmeier, 2008). The Home-SNF Comparison Scale was created to investigate this. The Home-SNF Comparison Scale (Table 1) was developed with the idea that part of disability is in the occupational form and part is in the developmental structure, as defined by Nelson and Thomas (2003). The Home-SNF Comparison Scale was administered by telephone by the student investigator after discharge from the skilled nursing facility. The participants were asked to choose only one of the levels on the five-level scale if they expressed a wish to choose between the levels. Procedure Data were collected from June of 2009 to April The research design involved a

11 VALIDITY OF SELF-IDENTIFIED GOALS 10 three-step process: the therapist's admission administration of the SIGA, the therapist's discharge administration of the SIGA, and home follow-up administration of the SIGA with a telephone interview. The home follow-up was administered via telephone interview by the student investigator, who was masked to the admission and discharge scores of the SIGA. After telephone administration of the SIGA, the student researcher asked the following questions: a) How much help [in hours] did you receive yesterday with your everyday tasks? b) How much help [in hours] did you receive the day before yesterday with your everyday tasks? and c) How much help [in hours] did you receive two days before yesterday with your everyday tasks? The Home-SNF Comparison Scale was then administered last, so that it had no effect on the other scores. Data Analysis Responsiveness was assessed in three different ways: a t test for related measures; (admission vs. discharge scores); the effect size for the t test for related measures as calculated by Cohen (1988, p.48); and the effect size recommended for testing responsiveness (Stratford, Binkley, & Riddle, 1996). For predictive validity, the Spearman rank ordered correlation was used between the patients self-identified individual goals at discharge and a) the mean duration of help needed per day for everyday occupations and b) the individual self-identified goals score in the home follow-up. This nonparametric statistic was planned because Hasenmeier (2008) had found skewness in reports of mean duration of help needed per day. All hypotheses were tested at alpha =.05. For the Home-SNF Comparison Scale, the plan for analysis was to conduct correlations between a) individual items and b) the difference scores between discharge and home follow-up

12 VALIDITY OF SELF-IDENTIFIED GOALS 11 scores (whether the score went up or down). This analysis might provide some insight as to the expected decline in participants scores from discharge to home follow-up. Results Responsiveness Of the 35 participants, all reported at least three self-identified goals, whereas 24 participants reported four goals and 18 reported all five self-identified goals. Figure 1 displays the mean of each ordered self-identified goal at admission, discharge, and home follow-up. The high level of responsiveness that is seen so clearly in Figure 1 can be viewed statistically in Table 2. This table shows the participants scores from admission to discharge, the gain score between the two, and the effect sizes (Cohen s and SBR). All five tests of responsiveness were statistically significant, with p <.0001 and with large effect sizes. Therefore, it can be concluded that self-identified goals were highly responsive to change from admission to discharge. There was a slight decline from discharge to home follow-up in all individual SIGA scores, but the home follow-up scores are still much higher than admission scores. Predictive Validity Individual goals at discharge did predict how well the participants did at home on the same goal, as can be seen by the statistically significant positive correlations between discharge goals and home goals (the correlations range from.45 to.83). However, self-ratings on five selfidentified goals at discharge did not predict the number of hours of home help needed, as can be seen by the relatively small correlations ranging from -.25 to.21. Participants required substantial help at home: an average of 4.9 hours per day (SD = 7.8). This variable is positively skewed because a few individuals required help almost around the clock.

13 VALIDITY OF SELF-IDENTIFIED GOALS 12 Other Findings Table 4 displays the Spearman correlation coefficients between the Home/SNF Comparison Scale scores and change scores on goals for discharge to home. The correlations were not statistically significant at the.05 level except for a single correlation of.36, p =.04. When only one of several correlations is statistically significant, the apparent relationship might well be due to chance. The relatively weak correlations indicate that the four items comparing the home and the skilled nursing facility do not explain the decline in scores from discharge to home. Table 5 exhibits all of the types of goals the participants identified and how they prioritized their goals. Each goal is listed by number of participants and order. The types of goals ranged from self-care occupations to leisure and work occupations, as well as functional mobility. Each area of occupation was categorized following the Occupational Therapy Practice Framework (AOTA, 2008). Functional mobility goals consisted of goals that included mobility to complete certain occupations (e.g., walking to bathroom to toilet self). When looking at the total number of goals listed in each area of occupation, it was concluded that the area of occupation listed the most overall were goals pertaining to home management (N = 19). On the other hand, the areas of occupation that patients identified the least were shopping (N = 1) and financial management (N = 1). To determine how patients prioritized their self-identified goals, the amount of times the area of occupation was identified for each goal was counted. It was then determined which area was identified the most for goals one through five. When looking at the first goal identified by the participants, functional mobility was listed most often (N = 6). For the second goal, bathing/showering was listed the most (N = 6). Of all the remaining goals listed,

14 VALIDITY OF SELF-IDENTIFIED GOALS 13 bathing/showering goals were listed most frequently for goal three (N = 7), and home management was listed most frequently for goal four (N = 7) and goal five (N = 5). This suggests that this group of participants found greatest priority in functional mobility, followed by bathing/showering and home management. Discussion The purpose of this study was to further investigate the responsiveness and predictive validity of patients self-identified goals in a skilled nursing facility. Through the results, it can be stated that patients self-identified goals from admission to discharge were highly responsive to change. All levels of the goals increased significantly from admission to discharge and then slightly declined from discharge to home follow-up. Admission scores ranged means of 1.6 to 3.6. At discharge, the SIGA scores ranged from 7.1 to 8.4. This suggests that when looking just at individual self-identified goals, the Self-Identified Goals Assessment (Melville & Nelson, 2001) is highly responsive to change. These findings can be compared to the study conducted by Hasenmeier (2008) who found similar results; however, Hasenmeier looked at overall SIGA scores in addition to individual goals. In a comparable study looking at the responsiveness of a Swedish version of the COPM, Wressle, Samuelsson, and Henriksson (1999) found the COPM to be highly responsive to change with 73% of the problem areas identified by the participants having a change score of two points or more (N = 108) (Wressle et al., 1999). In terms of predictive validity the individual goals did not predict the amount of help needed in the home. If overall SIGA scores had been recorded, the score may have predicted functional independence in the home environment. In the Hasenmeier (2008) study, the predischarge overall SIGA score and time of help required in the home were correlated

15 VALIDITY OF SELF-IDENTIFIED GOALS 14 moderately but not statistically significantly at the.05 level (r = -.41, p =.06, n = 21). The negative correlation occurred because the high levels of ability are associated with low levels of assistance. In the current study, the individual self-identified goals at discharge did, however, predict how well the participant would do at home on the same self-identified goals. Hasenmeier s study (2008) also displayed a slight decline in SIGA scores from discharge to home follow-up in the first four self-identified goals. The Home/SNF Comparison Scale was created to determine why these scores tend to go down when the patients are in their home environment. The four items included in the Home/SNF Comparison Scale were statements looking at the occupational form (environment) and the developmental structure (person) at home compared to the skilled nursing facility. The rationale was to determine if the occupational form or the developmental structure of the person was the cause for the decrease in self-ratings of self-identified goals. The weak correlations in Table 3 show that the items on the Home/SNF Comparison Scale cannot explain why a decrease in scores tends to occur. It is a possibility that when in the home environment the participants may have a different perspective on both intrinsic factors (developmental structure) and extrinsic factors (environment). In the current study, the most frequently identified area of occupation was home management. The least identified areas of occupation were leisure and financial management. In a study conducted by Chan and Lee (1997), frequencies of activities identified by the participants in the COPM were studied. Chan and Lee (1997) found that participants showed more concern with self care and productivity occupations. Functional mobility was identified most frequently by participants, whereas driving and work was listed the least (Chan & Lee, 1997).

16 VALIDITY OF SELF-IDENTIFIED GOALS 15 When considering how participants prioritized goals, the results of the current study suggest that home management goals held the highest priority among the participants. Some of the home management goals identified by participants included: being able to do light housework (dusting) independently, being able to do laundry independently, and being able to complete daily chores. On the other hand, participants identified shopping and financial management as the least of priorities. The participants who chose home management goals may have felt confident in their abilities to complete self-care occupations at the time of the initial SIGA administration. It seems logical that participants in the skilled nursing setting would not choose shopping and financial management occupations as the greatest priority if basic and instrumental occupations of daily living skills were not yet performable. This study has several implications for occupational therapy practice. By using a clientcentered assessment tool such as the SIGA (Melville & Nelson, 2001) occupational therapists will have a better understanding of what is important to the patient. The current study suggests patients goals as identified through the SIGA are sensitive; this provides partial evidence of construct validity to the occupational therapy profession. The results of the current study have also provided information regarding which areas of occupation patients consider important in the early stages of the rehabilitation process. Knowing what is meaningful to the patient will help the occupational therapist provide client-centered care to the individual, may enhance the therapeutic relationship, and may increase the patient s motivation for rehabilitation. The results of the current study also suggest that patients ratings of specific areas of occupation at discharge upon a skilled nursing facility do not strongly predict overall independence when in the home. Therapists should consider these results when preparing discharge plans for patients.

17 VALIDITY OF SELF-IDENTIFIED GOALS 16 The small sample size is a limitation. The participants of the study were from only two skilled nursing facilities in Northern Ohio. The fact that only individualized goals were collected instead of the overall SIGA scores is also a limitation of this study. By collecting the overall SIGA scores, a better understanding of the predictive validity of the entire SIGA could be obtained. Future research to determine why SIGA scores tend to go down when the patients are in their home environment is needed. Acknowledgments I would like to sincerely express my appreciation to Cindy Lemont, OT/L, Breanne Bates, OTD, OTR/L, Fran Hensen, OTR/L who collected data from Kingston Care Center of Sylvania and Melissa Hasenmeier, OTD, OTR/L who collected data from Kingston Care Center of Vermilion. I would also like to thank the administrative staff at both facilities for allowing data to be collected and David L. Nelson, PhD, OTR/L, my faculty advisor, for his mentorship.

18 VALIDITY OF SELF-IDENTIFIED GOALS 17 References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd. Ed.). American Journal of Occupational Therapy, 62, Cassidy, J.L. (2000). Clinical utility of a measure of self-identified goals in occupational therapy. (Unpublished master s manuscript). The University of Toledo Medical Center, Toledo, Ohio. Chan, C.C.H., & Lee, T.M.C. (1997). Validity of the Canadian Occupational Performance Measure. Occupational Therapy International, 4, Chen, Y., Rodger, S., & Polatajko, H. (2002). Experiences with the COPM and Client-centred practice in adult neurorehabilitation in Taiwan. Occupational Therapy International, 9, Cohen, J. (1998). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Coster, W.J. (2006). Evaluating the use of assessments in practice and research. In G. Kielhofner (Ed.), Research in occupational therapy: Methods of inquiry for enhancing practice (pp ). Philadelphia: F.A. Davis Company. Hasenmeier, M.A. (2008). Responsiveness and predictive validity of the Self-Identified Goals Assessment. (Unpublished doctoral manuscript). The University of Toledo Medical Center, Toledo, Ohio. Kielhofner, G. (2006). Developing and evaluating quantitative data collection instruments. In G. Kielhofner (Es.), Research in occupational therapy: Methods of inquiry for enhancing practice (pp ). Philadelphia: F.A. Davis Company.

19 VALIDITY OF SELF-IDENTIFIED GOALS 18 Law, M., Baptiste, S., Carswell, A., McColl, M.A., Polatajko, H., & Pollock, N. (1994). Canadian Occupational Performance Measure (2nd ed.). Toronto, ON: CAOT Publications ACE. Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice: What does it mean and does it make a difference. Canadian Journal of Occupational Therapy, 62, 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, Melville, L. L., & Nelson, D. L. (2001). Self-Identified Goals Assessment (SIGA) protocol. Retrieved February 26, 2009, from The University of Toledo, Occupational Therapy Website: Nelson, D. L., & Thomas, J. J. (2003). Occupational form, occupational performance, and a conceptual framework for therapeutic occupation. In P. Kramer, J. Hinojosa, & C. Royeen (Eds.), Perspectives on human occupation: Participation in life (pp ). Philadelphia: Lippincott, Williams, & Wilkins. Pollock, N. (1993). Client-Centered Assessment. American Journal of Occupational Therapy, 47, Stratford, P.W., Binkley, J.M., & Riddle, D.L. (1996). Health status measures: Strategies and analytic methods for assessing change scores. Physical Therapy, 76, Stuber, C. J., & Nelson, D. L. (2010). Construct validity of three occupational self-assessments. Physical & Occupational Therapy in Geriatrics, 28, Toomey, M., Nicholson, D., & Carswell, A. (1995). The clinical utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 62,

20 VALIDITY OF SELF-IDENTIFIED GOALS Wressle, E., Samuelsson, K., & Henriksson, C. (1999). Responsiveness of the Swedish version of the Canadian occupational Performance Measure. Scandinavian Journal of Occupational Therapy, 6,

21 VALIDITY OF SELF-IDENTIFIED GOALS 20 Table 1. Home-SNF Comparison Scale to be administered by telephone Please rate the following statements. 1. The physical part of my home is more difficult than the physical part of Kingston of Sylvania or Vermilion: Agree Strongly Agree Somewhat Neutral Disagree Somewhat Disagree Strongly 2. I had more help from people in the SNF than I have at home: Agree Strongly Agree Somewhat Neutral Disagree Somewhat Disagree Strongly 3. I overestimated my strengths when I completed the SIGA in the SNF and was not as well as I thought I was: Agree Strongly Agree Somewhat Neutral Disagree Somewhat Disagree Strongly 4. I am now sicker at home as compared to the SNF: Agree Strongly Agree Somewhat Neutral Disagree Somewhat Disagree Strongly

22 VALIDITY OF SELF-IDENTIFIED GOALS 21 Table 2. Responsiveness of self-identified goals from admission to discharge. Admission Discharge Gain t p Cohen s Effect Sizeª Variable M SD M SD M SD SBR Effect Size b Goal 1 (n = 35) Goal 2 (n = 35) Goal 3 (n = 35) Goal 4 (n = 26) Goal 5 (n =18) < < < < < ªCohen s effect size for a correlated t-test is calculated as the change score divided by its standard deviation and then divided by the square root of the difference between 1 and the correlation between the admission and discharge score (Cohen, 1988, p. 48). b Stratford, Binkley, and Riddle (1996) recommended calculating the effect size as the change score divided by the standard deviation of the admission score.

23 VALIDITY OF SELF-IDENTIFIED GOALS 22 Table 3. Spearman correlations between participants self-identified goals at discharge and follow-up measures in the home. Discharge Scores for Goals Hours Per Day of Help Home Home Scores for Goals r p r p Goal Goal <.0001 Goal <.0001 Goal Goal <.0001

24 VALIDITY OF SELF-IDENTIFIED GOALS 23 Table 4. Spearman correlations between change scores (discharge minus home) and items of the Home/SNF Comparison Scale. The relatively weak correlations indicate that the four items comparing the home and the skilled nursing facility do not explain the decline in scores from discharge to home. Home/SNF 1 Home/SNF 2 Home/SNF 3 Home/SNF 4 Variable r p r p r p r p D/C - Home1 D/C Home 2 D/C Home 3 D/C Home 4 D/C Home

25 VALIDITY OF SELF-IDENTIFIED GOALS 24 Table 5. Self-identified goals of participants Goals Total Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Bathing/Showering Dressing Personal Hygiene and Grooming Toilet Hygiene Driving Home Management Functional Mobility Meal Preparation and Cleanup Leisure Care of Pets/Others Shopping Financial Management Volunteering Overall Self-care Work

26 VALIDITY OF SELF-IDENTIFIED GOALS Self-Identified Goal Scores Goal #1 Goal #2 Goal #3 Goal #4 Goal #5 0 Admission Discharge Home Follow-Up Figure 1. Mean self-identified goals scores at admission, discharge, and home follow-up.