Early Occupational Therapy Intervention: Patients’ Occupational Needs

Abstract

The occupational therapy management involves the assessment of the individual’s specific needs. This kind of assessment facilitates the therapeutic relationship and boosts the person’s motivation, as he or she feels valued and heard. Early-stage collection of information about meaningful activities for the individual helps them project themselves outside the context of illness. Collecting occupational need at an early stage, permits “Engagement”, which means participating in activities even without actually doing them. An occupational therapy model called “Personal Environment Occupation Model” suggests that already at an early stage we should make the environment and occupations meaningful to the person in order to maximise the patient’s performance. An observational study on stroke patients shows how people have personal occupational needs beyond simple self-care, including productive life and leisure time, already in the subacute phase. A further study is underway to demonstrate the effectiveness of early occupational therapy intervention, including complex patients regardless of diagnosis and taking into account their need for care and disability in order to promote their participation and maximise their autonomy.

1. Introduction

The occupational therapy (OT) treatment is a “client-centred” rehabilitation approach based on the occupational needs of the person as a unique individual. People identify with their occupations [1]; the loss of these occupations causes a decline in the perception of self-efficacy and depression.

During the acute phase of the illness, the medical team’s main focus is on the person’s state of health in its organic and physical components. Occupational therapy, in this early phase, brings the focus back to the individual’s entire being and his or her position at the centre of the rehabilitation intervention. It has been shown that focusing rehabilitation on occupations that are meaningful to the person can improve their quality of life [1].

2. Relevance of assessment in occupational therapy

Occupational therapy focuses on occupations, i.e., everything a person does from the morning when they wake up until the evening when they go to sleep. This involves many different activities that each person does in his or her own unique way. Rehabilitation to occupations therefore means having individualised goals. The OT treatment is indeed individualised and varied.

There are no treatment protocols but reference models that guide the therapist in defining the objectives and setting the treatment. Goal setting is based on the person’s needs, taking into account the value the person places on the activities and their perception of the urge to recover them. The occupational therapist will negotiate treatment goals with the patient based on occupations that are meaningful to the person.

It is therefore necessary to be able to identify occupational needs, which is why it is important to use assessment tools and outcome measures. Assessing needs in a pre- and post-intervention phase of OT means monitoring the change in the person, and thus verifying the impact and effectiveness of the treatment itself. Assessing also means tailoring the treatment to the person’s characteristics, needs and wishes. The evaluation serves to establish goals that are a priority for the individual. The most important part is the individual’s perceived functioning and disability, regardless of the diagnosis. Finally, evaluation means being able to show the results of one’s work to the scientific community, sharing experiences and promoting evidence-based practice.

2.1 Occupational therapy assessment characteristics

Both performance in everyday life and occupational problems encountered can be assessed. The focus of the evaluation in occupational therapy remains on the needs of the person. This evaluation is done using a variety of tools, semi-structured interviews, collection of stories, or similar, all aimed at getting to know the person and establishing a good therapeutic relationship. The advantage is that the person feels listened to, at the centre of their treatment, welcomed and projected into his or her reality even outside the context of the illness. This has a positive impact on treatment compliance and motivation. The more motivation/desire a client has to engage in activities, the better he/she will be able to cope with the impairment [2].

2.2 Some occupational therapy-specific evaluation tools

Among the most widely used tools in Occupational Therapy is the Canadian occupational performance measure (COPM) [3]. COPM is a semi-structured interview, which allows the analysis of the areas of self-care, productivity and leisure time of the person, identifying problems that may arise within the normal routine. In addition to being a cognitive tool that helps to establish the therapeutic relationship, it also helps the patient and therapist to establish, or rather to negotiate, the objectives of the occupational therapy treatment. It is also an outcome measure as it scores the patient’s subjective perception of the performance of the activities and the degree of satisfaction in performing them.

The post-treatment evaluation makes it possible to understand if the objectives have been achieved or if it is necessary to modify the action plan. By providing this evaluation with two measurement times (an initial and a final one) it allows to understand if the treatment leads to a clinically significant result for the patient, that is a real positive change in daily activities and autonomy. This instrument is non-dependent from the pathology, it can be administered to the person or to the patient’s caregiver. Another tool is the daily diary (Activity Daily Log). The Activity Daily Log allows the person to collect his/her occupations reflecting on the time spent performing them and the emotions felt while doing so. The collection of these activities will serve as a starting point for goal setting. It is a widely used tool for orthopaedic patients [4] and patients with chronic fatigue [5].

Both tools allow an assessment aimed at collecting the person’s own needs and guarantee a person-centred practice, favouring the therapeutic relationship.

2.3 Results of a study on the occupational needs of complex sub-acute patients

The cross-sectional observational study “Occupational therapy for complex inpatients with stroke: identification of occupational needs in post-acute rehabilitation setting” [6] identifies the characteristics and occupational needs of stroke inpatients who are considered as “complex”, focusing on function and ability, regardless of diagnosis. In this study, the occupational therapist identified occupational needs through the COPM.

The results found that the enrolled patients were dependent in basic activities of daily living (ADLs), limited in instrumental ADLs and easily fatigued. Their occupational needs were related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure time (10%). According to the results of the inpatient survey, the rehabilitation process should primarily address self-care needs, followed by productivity and leisure time activities.

Despite the small sample size, this study described the patterns of occupational needs in complex stroke patients and pointed out that, although to a lesser extent than self-care needs, productivity and leisure issues also arise in the early post-acute phase.

Client-centred rehabilitation programmes must address self-care needs, as well as focusing on the recovery of family and social roles, both in the productive and leisure sectors.

Addressing these needs helps the patient to project himself into the home dimension, boosting motivation, recovering his role in the community and occupying time in a meaningful way.

2.4 Early occupational therapy: engagement and personal environment occupation model

Having explained the relevance of the needs assessment, it is important to underline that taking care of patients in the acute phase is crucial because occupational therapy has the peculiarity not only to engage the person in doing activities, but also simply to make him/her participate in the activity. If it is not possible to carry out the activity in practice, the person can be engaged, giving him or her the role of coordinator of the activity, which is physically carried out by another person, who performs it according to the given instructions. The performance of occupation may provide a means to engagement; however, it is not necessary for engagement, acknowledging that an individual may engage in occupation passively [7].

This concept is defined in literature as “Engagement”.

Engaging in occupations that are meaningful to the person is seen as a fundamental prerequisite for good health and well-being [7] and it is the basis of the Occupational Therapy practice [8].

The concept of occupational engagement first emerged in the work of Wilcock in 1993 [8], who described occupational engagement as something that goes beyond performing occupations in the physical sense, including engagement in the occupation on a mental and spiritual level.

The conceptual model personal environment occupation model (PEO) [9] is an excellent tool to be used at an early stage to promote the recovery of the maximum level of autonomy of the person by making the best use of his or her resources. This model explains that the rehabilitation process must necessarily start from the analysis of the characteristics of the individual, understood as a physical, emotional and psychological being (“P”). It is then necessary to analyse the significant occupations for the person (O) and finally the context in which the occupations are normally carried out (E). From the intersection of this information we obtain the “occupational performance” (Figure 1).

Figure 1.

Personal environment occupation model.

If one of these areas is reduced, the intersection with the others is also reduced, which means that the performance may no longer be possible or may not be satisfactory for the person performing it. At the reduction of the person’s area (P), which occurs when a deficit and/or illness appears, the model stresses the importance of expanding the other areas (environment and occupation) to allow the person to maintain his/her occupational performance and as much as possible a satisfactory routine (graphically maintain an area of intersection between the three circles, namely performance, Figure 2).

Figure 2.

Reduction of the person’s area (P).

In the case of the acute phase, therefore, it is essential to expand the area of the environment, which is the only area that can have a significant impact on performance, reducing disability. Expanding the area of the environment (E) can mean eliminating physical barriers, favouring accessibility, or educating and training the population to favour the reception of a person with disabilities, reducing the difficulty of social integration and promoting participation (Figure 3).

Figure 3.

Expanding the area of the environment (E).

Expanding the area of occupations means considering whether, in order to improve performance, it may be necessary to do the activity differently, to use strategies or aids, or simply to train oneself to perform the activity more efficiently and effectively.

This model underlines the importance of addressing treatment to environments and occupations that the health care system fails to take into account very often, focusing, almost uniquely, on resolving the deficit and pathology or reducing the effects caused by it, which is important but not the only aspect to provide the person with the highest possible quality of life.

2.5 Future scope of occupational therapy

In order to promote the motivation and engagement of the person, it seems useful to include an early assessment not only in neurological patients, but also in patients with other diseases. For referral to the specific assessment of the occupational therapist, the complexity criterion could be used. According to the agency for healthcare research and quality (AHRQ), the patient described as complex “is a person with two or more chronic diseases, in which each of the conditions present is able to influence the outcome of the care of the other coexisting conditions in various ways: limitation of life expectancy, increased morbidity, interactions between drug therapies, and the impossibility of full use of appropriate treatment due to contraindications” [10]. The measurability of this criterion seems to us to be expressed by the rehabilitation complexity scale extended (RCS-E) [11].

Our experience described in Section 2.3 is extending the selection of patients on the basis of their RCS-E score, extending the sample under examination regardless of pathology.

Sharing the early assessment of occupational needs with the specialists in the care team can avoid a delay in the rehabilitation programme.

3. Conclusion

Occupational therapy at an early stage is necessary to set up a client-centred treatment that reflects the person’s occupational needs, impacting on their motivation and compliance in the rehabilitation treatment. Of fundamental importance is the detection of the person’s occupational problems and performance difficulties in the person’s meaningful activities. This is carried out through specific tools such as the COPM and the daily diary.

Engagement is crucial to encourage participation at an early stage.

Through the PEO model we can decrease disability already in the acute phase, regardless of health conditions, by enabling occupational performance by implementing the “environment” and “occupation” areas.

A study on the occupational needs of “complex” patients in the subacute phase is under way.

Conflict of interest

The authors declare no conflict of interest.

Acronyms and abbreviations

OT

Occupational therapy

COPM

Canadian occupational performance measure

ADL

Activities of daily living

PEO

Personal environment occupation model

RCSE

Rehabilitation complexity scale extended