Responsiveness of the Swedish Version of the Canadian Occupational Performance Measure

SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 1999;6:84 89 Responsiveness of the Swedish Version of the Canadian Occupational Performance Measure EWA WRESSLE 1, KERSTI SAMUELSSON 2 and CHRIS HENRIKSSON 1 From the Department of Neuroscience and Locomotion, 1 Occupational Therapy and 2 Rehabilitation Medicine, Faculty of Health Sciences, Linköping, Sweden Wressle E, Samuelsson K, Henriksson C. Responsi eness of the Swedish ersion of the Canadian Occupational Performance Measure. Scand J Occup Ther. 1999; 6: 84 89. In a client-centred approach, clients and therapists work together to define the occupational performance problem, the focus of and need for intervention and the preferred outcomes. Application of specific theories or techniques to involve clients in goal-setting may influence the therapist to use a client participation approach. The Canadian Occupational Performance Measure (COPM) presents a structure for formulating the treatment goals identified by the client in co-operation with the therapist. The aim of this study was to test the responsiveness of the Swedish version of the COPM. After translation into Swedish, the COPM was introduced to 21 occupational therapists who performed data collection. A sample of 18 clients within geriatric, neurologic and orthopaedic rehabilitation identified 418 problems at initial scoring and reassessment. Inclusion criteria for patients were the need for rehabilitation interventions and the ability to communicate well enough in an interview. The results indicate that the Swedish version of the COPM is responsive to change, with 7% of the problems identified having a change in score of 2 points or more. Key words: client-centred, occupational performance, occupational therapy, outcome, satisfaction. INTRODUCTION A central goal of rehabilitation is the achievement of autonomy, in terms of maximum physical independence or patients having control over their lives. Closely linked to autonomy is the opportunity for patients to play a central role in decision-making about care and rehabilitation goals [1]. When assessing functional or occupational performance, each person s unique needs and abilities, in addition to the environmental and social factors, must be considered. The evaluation tools must therefore be individualized and sensitive to varying needs. Pollock [2] argues for the use of a client-centred process for goal formulation and assessment of change. If individuals do not formulate goals themselves, they will not be able to meet them. As a result, patient participation and control over health is reduced. When the patient participates in the goal formulation process, the potential for acti e participation increases [2]. Söderback [] points out that major goals are outlined at team meetings, but individual goals are often not expressed, and when they are, they are not co-ordinated among team members. It is also vital that studies of the effectiveness of rehabilitation are performed from an individualized perspective, for example, in the evaluation of goal-related outcome effects, efficacy, and individual merits and values. According to Nordenfelt [4], the health of the individual should be defined as the ability to realize vital goals given reasonable circumstances. Patients perceptions of improvement or satisfaction with their levels of performance are largely responsible for predicting whether they seek care, accept treatment and consider themselves recovered [5]. Northen et al. [6] argue that factors influencing the therapist to use a patient participation approach include the application of a specific theory or technique to involve patients in goal-setting. Their predominant finding was that although therapists do involve patients and their families in goal-setting, they are not consistently involved to the maximum extent. Basic assumptions of a client-centred approach, according to Law et al. [7], are as follows: (i) clients and family members know themselves best; (ii) all clients and family members are different and unique; and (iii) optimum client performance occurs within a supportive family and community context. In a client-centred approach, clients and therapists work together to define the occupational performance problem, the focus of and need for intervention, and the preferred outcomes [8]. Clients and therapists can each focus on their unique contribution and responsibilities to form a client-centred partnership, where clients expect to lead the decision-making process. Clients require information to enable them to make decisions, and to define occupational performance priorities for intervention. They also expect to receive service and to be treated with respect and dignity. Therapists encourage clients to use their own resources to help solve problems, and support client decisions, or explain why they cannot do so. Each client s values, visions and coping style should be respected. Clients should be encouraged to recognize and build on their own strengths [8]. The Occupation Performance Model [9] is based on the assumption that the individual has a fundamental role to play in the therapeutic process. This model 1999 Scandinavian University Press. ISSN 11-8128

Responsi eness of the COPM 85 aims to maximize the individual s performance of activities of daily living (ADL), productivity and leisure. Based on this theoretical model, the Canadian Occupational Performance Measure (COPM) [1] provides a structure for formulating the treatment goals identified by the patient in co-operation with the therapist. The patient also evaluates perception of performance and satisfaction with the treatment results in relation to the previously formulated goals. The development of the COPM has been described by Law et al. [11]. The process is as follows. Using a semi-structured interview, the therapist administers the COPM. The process encompasses five steps: the client identifies problems within the three areas of self-care, productivity and leisure, weighs the importance of each problem in order to set priorities, and scores performance and satisfaction with performance. Reassessment is done after intervention, and a follow-up gives opportunity for further planning. For scoring self-perceived performance and satisfaction with this performance, 1 point scales, ranging from 1 (meaning not able to do it or not satisfied at all ) to 1 (meaning able to do it extremely well or extremely satisfied ), are used. In an earlier review, Pollock et al. [12] showed that most assessments available to measure outcomes in occupational therapy were directed at performance components, not occupational performance. Pilot testing of the COPM has been completed in Canada, New Zealand, Greece and Britain and has shown responsiveness to changes in perception of occupational performance over time [1]. The clinical utility of the COPM was investigated in a qualitative research project using focus groups to discuss why some of the occupational therapists used the COPM and why others did not. Five themes emerged referring to the use of the instrument: use, environment, administration, outcome and suggested changes, and these were validated during the plenary session. The results indicated that the usefulness of the instrument depended upon the degrees to which therapists had incorporated a client-centred approach in practice, management had valued and supported the use of the COPM, and the COPM had been flexible enough to fit practice context [14]. An earlier study among geriatric stroke patients [15] showed that they did not always participate in the goal-setting process, and that the vaguely expressed goals were not measurable. The most important issue involves taking advantage of and developing the patient s ability and capacity. Use of a standardized instrument for outcome measure and goal evaluation is also important. The aim of this study was to validate the Swedish version of the COPM as an outcome measure by testing its responsiveness to change over time, which is one aspect of validity. The basic criterion for responsiveness is whether the instrument is able to measure small changes within an individual over time [16]. METHOD The COPM was translated into Swedish and introduced to occupational therapists within geriatrics (n=6), neurology (n=1) and home rehabilitation (n=5) in a university hospital in Sweden. The therapists were trained to use the COPM. The responsiveness to change was measured on a sample of 18 clients. Assessments using the COPM were made before and after intervention. The median age of the patients was 78 years (range: 22 9), and most were women (Table I). Inclusion criteria were the need for rehabilitation intervention and the ability to communicate well enough for the interview. The number of days between initial scoring and reassessment ranged from to 262, with a median of 2 days. The inpatients were in geriatric or neurological wards and outpatients in neurological day-care. Home rehabilitation was performed in the patients homes by occupational therapists and physiotherapists visiting the patients daily for treatment interventions. These clients were discharged from inpatient care at an early phase, and home rehabilitation was provided instead of rehabilitation in the hospital. The author classified the problems into subgroups under the headings, selfcare, productivity and leisure. Table I. Demographics of the in estigated sample Gender Male 5 Female 7 67 Age 9 years 6 6 4 49 6 6 5 59 9 8 6 69 15 14 7 79 2 21 8 89 45 41 9 4 4 Diagnosis Neurologic 5 46 Orthopaedic 5 Other 2 21 Settings Inpatients 7 64 Home rehabilitation 25 2 Outpatients 1 12 n %

86 E. Wressle et al. The analyses of change were built on the assessments performed with the 1 graded COPM scale initially and after the rehabilitation period. The initial score is subtracted from the reassessment score, resulting in the difference obtained during the intervention period. This score could have a negative sign, indicating a decrease over time,, which means no difference at all, or a positive sign, indicating an increase. Since the COPM is an ordinal scale and data are not normally distributed, non-parametric statistics were used. Wilcoxon s signed-rank test was used to test differences between initial assessment and reassessment of performance and satisfaction, and Spearman s rank correlation test was used for testing the correlation between initial assessment and reassessment, and between change in performance and satisfaction scores. Correlations were tested to see whether an increased score in performance also resulted in an increased score in satisfaction. The computer program used was Statistica. RESULTS In all, 18 clients completed the performance and satisfaction with performance scores in the initial scoring and in the reassessment. In total, 418 problems were identified. Most of the clients identified three or more problems. Of these, most (74%) were in the ADL area (Table II). Changes of two or more points in self-perceived occupational performance and satisfaction with performance over time were shown in 7 (7%) of the 418 identified problems between the initial and second scoring. When the patient group was split into two age groups, one group consisting of patients 65 years of age (25%) and one of patients 65 years (75%), the problems showed a different pattern concerning the three areas self-care, productivity and leisure (Table III). There was a greater shift from self-care to leisure among the younger clients compared with the older. The median score change for performance was points (range: 2 6) and for satisfaction 4 points (range: 2 6). Changes in scores varied from 4 to +9 points (Table IV). Median score changes differed for the different settings (Fig. 1). The proportions of problems within the three areas also differed (Fig. 2). Significant differences were shown between initial assessment and reassessment for performance and satisfaction for the majority of problems (Table V). The correlation between initial performance and satisfaction scores (using Spearman s rank correlation) was.6 (p.5). The correlation between reassessments of performance and satisfaction was.84 Table II. Client-identified problems at initial assessment n % Number of problems One 6 6 Two 9 8 Three 24 22 Four 2 21 Five 44 41 Six 2 2 Self-care 9 74 Dressing 78 19 Walking 74 18 Hygiene 6 15 Transfers 4 1 Toileting 7 9 Feeding/drinking 8 2 Wheelchair mobility 1 Sitting 1 Productivity 62 15 Meal planning/preparation 5 12 Cleaning/laundry 12 Leisure 47 11 Quiet recreation 2 5 Active recreation 8 2 Social 19 5 (p.5), and the correlation between change in performance and satisfaction scores (between initial assessment and reassessment) was.75 (p.5). DISCUSSION Responsiveness is an important aspect of validity for an evaluative instrument. The most appropriate characteristics included are those which can be shown to be sensitive to change within an individual. Responsiveness should be determined for all evaluative instruments, according to Law [17]. Data measured by ordinal scales must be analysed by non-parametric methods [18]. There are differences in choice of statistical methods in different countries and between different researchers, which lead to difficulties when comparing results. In the COPM, each client s scores in performance and satis- Table III. Problems according to age Age 64 years Age 65 years n % n % Self-care 7 6 29 78 Productivity 16 14 46 15 Leisure 25 2 22 7

Responsi eness of the COPM 87 Table IV. Change in performance and satisfaction scores between initial assessment and reassessment (n=418) Performance Satisfaction Points n % n % 1 14 15 4 64 15 64 15 +1 8 2 8 +2 51 12 45 11 + 61 15 41 1 +4 51 12 69 16 +5 47 12 42 1 +6 8 9 5 8 +7 25 6 28 7 +8 18 4 28 7 +9 16 4 19 4 reported significant improvements in goal performance and satisfaction on the COPM. In the present study, 7% of the clients recorded a change of two or more points on the COPM, indicating high responsiveness to change. The COPM is designed to evaluate change in clients perceptions of their performance and satisfaction in identified activities; therefore the difference in scores between initial assessment and reassessment is clinically important. The interview process with the clients also provides guidance on what areas should be given greatest priority [1]. There is a need for outcome measurement in both occupational therapy and other disciplines within care. The measures should preferably be individualized, of use in daily clinical work and in research, should evaluate occupational performance, be sensitive enough to measure change over time and have a client-centred approach. The COPM fulfils these criteria. The sample studied showed that most problems identified were in the ADL area (74%), compared with the pilot study [1], in which 54% were identified as ADL problems. However, the clients in the present study were older; 67% were over 7 years of age compared with 8% in the pilot study. Considering the age of the sample (median 78 years) this picture is understandable. Productivity in terms of paid or unpaid work is not usual for this age group. There could be time for leisure activities, but perhaps not the motivation, energy or opportunity in their environments. Most clients were women in this study, a fact perhaps related to the high median age. This corresponds fairly well with the demographics in the Swedish population, which consists of 65% women in the group aged 8 years or over. In the group aged 65 or over, 58% were women [2]. If the clients are split into two age groups, before and after Swedish retirement age, the distribution pattern looks different in the areas of self-care, profaction are summed and divided by the number of problems in order to obtain a mean score for each domain (performance or satisfaction), and the mean score is then tested. In this study, however, each problem was presented and analysed as a unit because of the statistical limitations of treating an ordinal scale as an interval scale. Wilcoxon s signed-rank test is a powerful non-parametric method for evaluating dependent data. Criteria to be fulfilled are that the researcher is able to tell the sign of the difference between any pairs, and rank the differences in order of absolute size [18: 87]. Correlations between initial and reassessment scores and between change in performance and satisfaction scores were tested, and constituted an interesting additional finding, but were not part of the validation procedure. Earlier research has indicated that a change of two or more points on the COPM score is considered clinically important [1]. Changes of two points on the rating scales for performance and satisfaction were established as standard for a treatment program in an adult mental health setting [19]. In this program evaluation study, 78% of the respondents (n=49) Fig. 1. Median score change between patients in different settings. Fig. 2. Proportion of problems identified within the areas of self-care, productivity and leisure for inpatients, outpatients and home rehabilitation (%).

88 E. Wressle et al. ductivity and leisure. Younger clients identified about an equal percentage of problems in the productivity area as the older clients, but more on leisure problems than did the older clients. The shift between areas was not in the productivity area but from self-care to leisure area. The proportion of self-care problems was greater in the inpatient sample than in the two other settings. Inpatients often have debilitating medical conditions, which affect primary self-care activities. There were also differences in the median score change for the different settings, with home rehabilitation showing the largest median change between initial assessment and reassessment. The outpatients receiving home rehabilitation may be in better medical condition than the inpatients, or perhaps the fact that the clients are in familiar environments leads to differences in scores of performance and satisfaction. Schut & Stam [21] stated that treatment goals should be formulated in activities that are essential for the patient. They should be formulated in terms of performance, easy to understand for all team members, attainable, should facilitate program planning and be measurable. The COPM could be the answer to this proposition, as it is an individualized outcome measurement where the client is involved in the process. Using the COPM may save time in the long run, even if the interview takes some time, and it ensures that the client participates in the process. Problem identification is the first step in goal formulation and is necessary for planning treatment. The COPM works as a tool in this process, where both global and specified treatment goals could be expressed based on important occupational performance problems identified by the client. Whether, and how, therapists assess clients priorities was analysed in adult physical rehabilitation facilities in the United States [22], with findings indicating that formal methods of assessment, such as the COPM, were not used. The majority of therapists used informal interviews to determine clients priorities on admission; goals obtained this way were vague and seldom specified meaningful occupations. These findings correspond well with those of the study by Northen et al. [6], which showed that although therapists did involve patients and their families in a goal-setting process, they did not consistently involve patients to the maximum extent. The application of a theory could influence the use of a patient participation approach. Ward et al. [2] draw the conclusion from a study in an orthopaedic setting that it is important that everyone using the COPM be trained in its use. The present study with the Swedish version of the COPM Table V. Difference between initial assessment and reassessment scores for performance and satisfaction, Wilcoxon signed rank test (n=418) Performance Satisfaction Problem n Increased No change Decreased p-value Increased No change Decreased p-value Self-care Dressing 78 6 1 2. 6 14 1. Walking 74 62 9. 59 12. Hygiene 6 5 12 1. 51 9. Transfers 4 7 6. 6 7. Toileting 7 1. 2 2. Feeding/ 8 5 2 1.46 5 1 2 drinking Wheelchair mobility Sitting 2 1 2 1 Productivity Meal plan- 5 4 5 2. 42 7 1. ning/prep. Cleaning/ 12 9.8 11 1.5 laundry Leisure Quiet recreation 2 12 6 2.8 11 6.8 Active recre- 8 7 1.18 7 1.18 ation Social 19 16. 16. : not significant.

Responsi eness of the COPM 89 ensures that all participating patients have been involved in the problem-identifying process and outcome-measure process. Further research can perhaps provide the answer to the question as to whether the use of a systematic client-centred method makes any difference in the patients perceptions of participation. It would also be interesting to evaluate if the use of the COPM changes teamwork in a positive way. CONCLUSION The conclusion of this study is that the Swedish version of the COPM has high responsiveness to change over time, and could therefore serve as an outcome measure for occupational therapy. Furthermore, using this instrument facilitates client-centred treatment. ACKNOWLEDGMENTS The authors thank the occupational therapists and clients who participated in this study, and the management of the Geriatric Clinic at the University Hospital of Linköping, Sweden, for support. REFERENCES 1. Kane RL. Improving outcomes in rehabilitation. A call to arms (and legs). Med Care 1997; 5: 21 27. 2. Pollock N. Client-centered assessment. Am J Occup Ther 199; 47: 298 1.. Söderback I. Effectiveness of rehabilitation. Crit Rev Phys Rehabil Med 1995; 7: 275 286. 4. Nordenfelt L. On the notion of health as ability. Scand J Occup Ther 1996; : 11 15. 5. Bowling A. Measuring health. Suffolk: St. Edmundsbury Press, 1997; 1 8. 6. Northen JG, Rust DM, Nelson CE, Watts JH. Involvement of adult rehabilitation patients in setting occupational therapy goals. Am J Occup Ther 1995; 49: 214 22. 7. Law M, Baptiste S, Mills J. Client-centred practice: what does it mean and does it make a difference? Can J Occup Ther 1995; 62: 25 257. 8. Baum CM, Law M. Occupational therapy practice: focusing on occupational performance. Am J Occup Ther 1997; 51: 277 288. 9. Canadian Association of Occupational Therapists. Occupational therapy guidelines for client-centred practice. Toronto: CAOT Publications, 1991. 1. Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N. Canadian Occupational Performance Measure, 2nd edn. Toronto: CAOT Publications, 1994. 11. Law M, Baptiste S, McColl MA, Opzoomer A, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther 199; 57: 82 87. 12. Pollock N, Baptiste S, Law M, McColl MA, Opzoomer A, Polatajko H. Occupational performance measures: a review based on the guidelines for the client-centred practice of occupational therapy. Can J Occup Ther 199; 57: 77 81. 1. Law M, Polatajko H, Pollock N, McColl MA, Carswell A, Baptiste S. Pilot testing of the Canadian Occupational Performance Measure: clinical and measurement issues. Can J Occup Ther 1994; 61: 191 197. 14. Toomey M, Nicholson D, Carswell A. The clinical utility of the Canadian Occupational Performance Measure. Can J Occup Ther 1995; 52: 242 249. 15. Wressle E, O berg B, Henriksson C. The rehabilitation process for the geriatric stroke patient an exploratory study of goal setting and interventions. Disabil Rehabil. 1999; 21 (2): 8 87. 16. Kirschner B, Guyatt G. A methodological framework for assessing health and disease. J Chron Dis 1985; 8: 27 6. 17. Law M. Measurement in occupational therapy: scientific criteria for evaluation. Can J Occup Ther 1987; 54: 1 18. 18. Siegel S, Castellan NJ. Nonparametric statistics for the behavioral sciences, 2nd edn. Singapore: McGraw-Hill, 1988. 19. Mirkopoulos C, Butler K. Quality assurance: clients perceptions of goal performance and satisfaction. Paper presented at the 11th International Congress of the World Federation of Occupational Therapists, London, 1994. 2. Statistics Sweden (Statistiska Centralbyrån). Statistical Yearbook of Sweden 98. Stockholm: Norstedts Tryckeri, 1998: 8 9. 21. Schut HA, Stam HJ. Goals in rehabilitation work. Disabil Rehabil 1994; 16: 22 226. 22. Neistadt ME. Methods of assessing clients priorities: a survey of adult physical dysfunction settings. Am J Occup Ther 1995; 49: 428 46. 2. Ward GE, Jagger C, Harper WMH. The Canadian occupational performance measure: what do users consider important? Br J Occup Ther 1996; : 448 452. Accepted February, 1999 Address for correspondence: Ewa Wressle Department of Occupational Therapy Geriatric Clinic University Hospital SE-581 85 Linköping Sweden Tel:+46 1 22 4 68 Fax:+46 1 22 41 41