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Jennifer Dulek
Introduction
and seek services to restore their occupational performance (Law & Baum, 2005). While many
healthcare consists of its focus on occupational performance as a desired outcome, while taking
into account not only the person (client), but also the dynamic interaction of the person with the
environment and occupation (Law et al., 1996). This dynamic interaction cannot be viewed
simply as the sum of its parts; measuring the capabilities of the person, taking into account
aspects of the environment, and analyzing the occupation separately is not sufficient. A
complete view of occupational performance must consider what people want and need to do in
their lives, their abilities and motivations to do these things, and how these characteristics
combine with the environment in which they are doing them (Law & Baum, 2005).
Because the goal of occupational therapy practice is to assist our clients to become
actively engaged in their life activities (Law & Baum, 2005), we must take this dynamic
interaction into account throughout the occupational therapy process. We must identify and use
assessment tools that truly measure occupational performance, rather than rely on measurements
of individual aspects such as body structures and body functions with the hope that these will
allow us to predict the end result for our clients. We must provide interventions that include the
desired occupations occurring with the natural environment. In doing so, we help our clients and
the general public to see the value and power of occupation (Law & Baum, 2005).
moving beyond them toward best practice (Law & Baum, 2005) is an important goal that will
EVALUATION OF OCCUPATIONAL PERFORMANCE 3
benefit our clients and our profession as a whole. Best practice involves using imagination,
creativity, and responsibility to solve performance problems such as those described above (Law
& Baum, 2005). In pursuing best practice, a thoughtful reflection of recent clinical practice and
an identification of ways that it can be improved are critical. Therefore, I will discuss here a
client I recently evaluated and treated, and will outline both standard practice as well as how it
could be improved to better measure and effect occupational performance and quality of life.
Client Information
About four months ago, Jackie was admitted to the inpatient psychiatric unit on a 72-hour
hold because she had been determined to be gravely disabled and unable to care for herself. She
was 34 years old, married, and had worked previously as a pediatric occupational therapist.
Despite having been diagnosed with bipolar disorder years earlier, she had been managing her
symptoms well and had a full and productive life. However, when she became pregnant two
months prior to her admission, her psychotropic medications had to be discontinued and she
in her hospitalization. At the time of her initial assessment, Jackie presented as disheveled,
irritable, and very distractible, and was hyper-verbal with poor social boundaries. She
demonstrated little insight into her condition, and her husband expressed a desire for her to “just
get better so she can go back to work and we can get on with our lives.”
members of the team complete, including recreation therapy, dance therapy, music therapy, and
occupational therapy. An occupational therapist was not involved in the design of the
admission; a long list of behaviors to be observed during group and individual interaction, and a
section for client self-report of leisure interests, current stressors, and goals.
and Health (ICF) (World Health Organization [WHO], 2001), this evaluation focused primarily
on body functions, with some inclusion of activity, as is evident in Table 1. These dimensions
are consistent with the medical concept of recovery, and do not adequately address occupational
performance, which is addressed at the activity, environmental factors, and participation levels
This assessment utilizes the bottom-up approach (Ideishi, 2003), in which component
skills are viewed as the basis for more complex actions and occupational performance. Because
Jackie’s evaluation focused primarily on specific deficits in body functions and activities, the
interventions I provided to her also took the bottom-up approach and focused on remediation of
the component deficits (Ideishi, 2003). My goals for Jackie were to increase attention, short-
term memory, and impulse control, with the hope that this would allow her to return to work, a
goal I adopted from her husband but did not speak about directly with Jackie herself. The
interventions I provided had nothing to do with her typical occupations, but instead were
contrived preparatory tasks (AOTA, 2014) aimed at influencing her mental functions.
Law and Baum (2005) argue that occupational therapists must focus primarily at the level
of the person-environment interaction in order to properly and effectively assess and address
occupational performance issues. As previously stated, within the ICF model this requires more
complete assessment of activity, environment, and participation (Law & Baum, 2005). This is
consistent with the top-down approach described by Ideishi (2003), as it requires the practitioner
to first examine the occupations and roles associated with what the client wants or needs to do.
In collaboration with the client, the therapist can then develop therapeutic goals that address the
As Law, King, and Russell (2005) describe, the first stage in the measurement process is
to identify the client’s perspectives about the issues to be addressed during intervention, but this
step is missing in my evaluation. It did not address her participation in things such as work
activities, community and social activities, maintenance of home, and care of others. It would
EVALUATION OF OCCUPATIONAL PERFORMANCE 6
have also been helpful to explore more about her environments, such as the attitudes of those
around her including her family and coworkers, as well as possible workplace accommodations.
Looking back, I believe that Jackie’s work activities are an area of occupational
performance dysfunction that warranted significant attention. She had been working until her
pregnancy required the medication change that led to her hospitalization, and in a proxy report,
her husband voiced the hope that Jackie would be able to return to work. As work can be central
to the concept of productivity and work allows for actualization of one’s life meaning (Baptiste,
Strong, & MacGuire, 2005), it is imperative that occupational therapy practitioners measure and
analyze their client’s participation and performance. Similarly, being off work frequently has
negative consequences, such as decreased health, well-being, and quality of life (Andersen,
Nielsen, & Brinkmann, 2012). In addition, because her husband had expressed concern about
her occupational performance in this area, a client-centered approach suggests that it be assessed
Alternative Evaluation
To meet this identified need, the Worker Role Interview (WRI) created by Braveman et
al. (2005) would have been an effective tool. The WRI assists the client and therapist to identify
the psychosocial and environmental variables influencing a worker returning to work (Baptiste,
Strong, & MacGuire, 2005). It requires the therapist to rate each of 17 factors influencing work
success on a four-point scale; these factors are included within six content areas: personal
causation, values, interests, roles, habits, and environments (Baptiste, Strong, & Law, 2005).
This assessment is clinician-rated, indicating that it relies on the therapist to assess clients’
performance based on an established and absolute criterion (Portney & Watkins, 2009) rather
Evidence supporting the use of the WRI with clients with mental illness is limited. A
thorough search identified only one such study, completed by Lohss, Forsyth, and Kottorp
(2012). These researchers examined the psychometric properties of the WRI with a psychiatric
population in the United Kingdom with the goal of determining its construct validity as a
baseline assessment and an outcome measure (Lohss, Forsyth, & Kottorp, 2012). They report
that all items except one demonstrated acceptable goodness-of-fit to the Rasch model, and that
“the study supports the use of the WRI as a standardised (sic) baseline assessment in a mental
Additionally, in a qualitative study conducted by Prior et al. (2013), the authors describe
the importance of understanding several factors which may impact a client’s participation and
engagement in work, including personal values, current roles and routines, coping strategies,
specifically in this research, the WRI is cited as a means to ensuring thorough initial assessment
(Prior et al., 2013). In addition, Getty (2015) suggests the WRI as a means of providing client-
Supporting Best Practice in Occupational Therapy (2nd ed.) by Law, Baum, and Dunn (Eds.)
(2005), but information is also available on the Model of Human Occupation page within the
University of Illinois website (“Worker Role Interview,” 2015), which is also where the tool can
be purchased at the cost of forty dollars. Law and Baum (2005) describe the WRI as a useful
measure of current status, as it is to be used in the initial rehabilitation assessment process for an
injured worker or worker with long-term disability (“Worker Role Interview,” 2015) such as
Jackie’s. The psychometric properties of the WRI are detailed below in Table 2:
EVALUATION OF OCCUPATIONAL PERFORMANCE 8
Client Summary
Strong and Rebeiro (2003) argue that work rehabilitation for clients with mental illness
needs to incorporate an integrated view of the person, the occupation, and the environment. In
addition, there is evidence that levels of self-efficacy predict how much a client will adhere to
treatment and eventually succeed in returning to work (Law & Baum, 2005). I believe that
engaging Jackie in the WBI would have been an important step toward assessing participation
and environment (WHO, 2001) and toward building her self-efficacy and engagement in
Completion of the WBI might have offered me insight and information regarding how
Jackie views herself as a worker within her work environment. I could have used this
information to better identify and justify evaluation needs within the activity and body function
dimensions, but even more importantly, I could have used this information to set realistic goals
for Jackie’s treatment on the inpatient psychiatric unit. Although she likely would not have been
ready to return to work upon discharge from the unit, information regarding possible barriers to
return to work could have influenced my interventions and recommendations for discharge
planning. For example, my interventions would have been more engaging and meaningful to her
if centered upon her interests in her work or designed to address her work habits and daily
routines for work. Data from the assessment might have provided justification and rationale for
accommodations to support her eventual return to work. Table 3 indicates dimensions addressed
Jackie’s work participation could have facilitated her eventual return to work. As demonstrated
in a study involving others like Jackie who have bipolar disorder, are hospitalized, and desired to
return to work, quality of life scores are significantly higher in clients who are employed
compared to those who are unemployed (Medard, Debertret, Perett, Ades, & D’escatha, 2010).
This suggests that Jackie’s quality of life too might have increased as a result of my evaluation
Practice Implications
As Law, Baum, and Dunn (2005) argue, occupational therapists must have reliable and
valid methods to document the effects of the services they provide. This benefits individual
clients as well as society and the profession as a whole, as it improves clients’ quality of life and
demonstrates occupational therapy’s uniqueness and effectiveness (Law, Baum, & Dunn, 2005).
For these reasons alone, I believe that it is my professional responsibility to improve my practice
Still, I identify with many of the barriers that Law, Baum, and Dunn (2005) cite within
their work on the topic. In my practice setting on the inpatient unit, I am part of a larger team
that contributes to and relies on my evaluation to include certain data. While we have discussed
the possibility that I could contribute information specific to occupational performance, this
involves obtaining standardized assessments, educating all the staff on their value and purpose,
and obtaining a doctor’s order for each assessment I complete. Although I know that this is
standard practice in many occupational therapy settings, it is not in psychosocial settings, and it
That said, Jackie’s case illustrates for me the value and power that could come of
engaging in more specific measurement and intervention. I am not certain that the WBI would
be the best choice of outcome measures for my population, considering the fact that many clients
stay on the unit for less than 72 hours and often are not working when they are hospitalized.
However, I could envision myself using the Canadian Occupational Performance Measure
(COPM) (Law et al., 2014) as a means of gaining clients’ perspective, establishing intervention
goals, and measuring the effects of intervention within several different areas relevant to all of
References
framework: Domain and process (3rd ed.). American Journal of Occupational Therapy,
Andersen M.F., Nielsen K.M., & Brinkmann S. (2012). Meta-synthesis of qualitative research
Baptiste, S., Strong, S., & MacGuire, B. (2005). Measuring work performance from an
Braveman, B., Robson, M., Velozo, C., Kielhofner, G., Fisher, G., Forsyth, K., & Kerschbaum,
J. (2005). Worker role interview (WRI), version 10.0 user’s manual. Chicago, IL:
University of Illinois.
Ekbladh, E., Haglund, L., & Thorell, L. (2004). The Worker Role Interview: Preliminary data
Getty, S. (2015). Implementing a mental health program using the recovery model. OT
Ideishi, R.I. (2003). The influence of occupation on assessment and treatment. In P. Kramer, J.
Hinojosa, & C.B. Royeen (Eds.), Perspectives in human occupation: Participation in life,
Law M., Baptiste S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock N. (2014) Canadian
Law, M. & Baum, C. (2005). Measurement in occupational therapy. In M. Law, C. Baum, &
Law, M., Baum, C., & Dunn, W.(2005). Challenges and strategies in applying an occupational
Law, M., Cooper, B., Strong, S., Stewart, S., Rigby, P., & Letts, L. (1996). The person-
Law, M., King, G., & Russell, D. (2005). Guiding therapist decisions about measuring
Lohss, I., Forsyth, K., & Kottorp, A. (2012). Psychometric properties of the Worker Role
75(4), 171-179.
Medard, E., Dubertret, C., Peretti, C.S., Ades, J., & D’escatha, A. (2010). Descriptive study of
Portney, L.G., & Watkins, M.P. (2009). Foundations of clinical research: Applications to
practice (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Prior, S., Maciver, D., Forsyth, K., Walsh, M., Meiklejohn, A., & Irvine, L. (2013). Readiness
for employment: Perceptions of mental health service users. Community Mental Health
Strong, S., & Rebiero, R. (2003). Creating supportive work environments for people with
mental illness. In L. Letts, P. Rigby, & D. Stewart (Eds.), Using environment to enable
University of Illinois. (2015). “Worker Role Interview: Model of Human Occupation Theory
?aid=11
Velozo, C.A. (1993). Work evaluations: Critique of the state of the art of functional assessment