I’ve chosen to review the quality of a piece of qualitative research titled “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Katharine White and Lynette Mackenzie. I chose this because prior to starting my Masters I worked for a social inclusion charity with people with learning disabilities, so I was interested in whether the results were something that could have potentially influenced my work there.
This article is a research paper and not an opinion piece, which you can tell by the fact that it has an Abstract, collates data methodically from a subject group (Method section), analyses it (Data Analysis/ Results sections), and then draws conclusions based on the factual results (Discussion, Implications for Occupational Therapy sections).
The authors are Katharine White who is an Occupational Therapist with the Department of Aging, Disability & Care in Sydney, and Lynette Mackenzie who is an Associate Professor at the University of Sydney. They are both interested in researching the effects of aging on disabled individuals and this is plausible as Mackenzie is part of the ‘Aging and Health Research Team’ at the university and White currently specialises in aging and disability in her job role.
They have not declared any conflicts of interests and the research was not funded by anyone, but it was given ethical approval by the University of Sydney. It’s important to check these details because if the sponsor or researcher has a vested interest in the results of the study it’s possible they will be intentionally or unintentionally biased- for example the selection criteria for subjects may be manipulated in favour of one result, or only positive findings are published. Read more ›
This model was developed in 1985 (it was later revised in 2005 and 2015) by Baum and Christiansen in response to a move away from the biomedical model way of thinking which is very practitioner-based. Conversely, the PEOP model is much more client-based.
It considers the factors affecting a client’s occupations, and then groups them as either intrinsic or extrinsic. This is different to other models because it separates factors out as either intrinsic or extrinsic as well as further separating each of these at a personal, social and population level.
In the diagram below, the PEOP model itself is shown in purple and I have added examples of each intrinsic/extrinsic factor in grey boxes around the edge.
It uses the biopsychosocial approach since it takes into account the physical (bio), emotional (psycho), and social factors that can influence someone’s occupational performance. Because of its broad categories it can be applied to populations, groups of people in organisations, or individuals. In the 2015 revision of the model, alongside the model depicted above is a box feeding into the model. The box contains three segments each labelled as personal narrative, organisational narrative, or population narrative. Under each segment it shows example information about what the perceptions, goals and needs for the narratives of an individual, an organisation, or a population would be. In this way it highlights which type of information needs to be elicited, and so which questions an OT would need to ask, from whomever they were assessing in order to create a narrative or ‘occupational profile’.
The OT Process using PEOP
As part of the process when using the PEOP model, the client’s history, perceptions, and short & long-term goals are established which creates information about the client’s strengths and weakness.Then the OT’s evaluation occurs, and finally the OT and client work together to decide on the occupational goals for the client. In this way the model involves taking into account many sources of knowledge, eg practitioner knowledge together with patient preference, so is a good example of evidence-based practice which is a core value of occupational therapy.
What’s good about it?
Emphasis on the interaction between person & environment, and how this affects occupation (Law et al 1996)
Client-centred approach, collaborate with patient to establish therapeutic goals
Top-down rather than bottom-up model, so is holistic and person-centred (Fawcett 2007)
Comprehensive list of factors; useful guide for a novice OT who leans towards more prescriptive frameworks until they acquire tacit expertise (Robertson 2012)
What’s bad about it?
No associated assessment tool and so no direct outcome measure (Christiansen et al 2015)
The challenge of judging the weighting of the different factors yourself, as the model does not make this clear (Duncan & Hagedorn 2011)
Isn’t a large literature base providing evidence for the model (Law et al 1996)
The model considers many longer-term factors (eg culture, economic systems, social support systems), may not be relevant if patient’s goals are short-term or resources are limited and the time the OT will have with the patient isn’t long enough to make changes to any of those areas
It is a model that takes a broad and holistic view of a person’s occupations, however the PEOP model places an emphasis on a client-centred approach and how the environment impacts someone’s occupational functioning. It details all the areas where strengths and weaknesses can occur, which can then be assessed together with the client to identify which factors are impacting occupational performance. The client’s own goals together with the OT’s intervention goals are then matched so it encourages collaboration together. Because of this the model is very client-centered as opposed to disability-centred, and encourages exploration in partnership with the client. It has a top-down approach in evaluating the client’s situation which reflects another of occupational therapy’s core values, a holistic approach. A top-down approach would be when you look all the things that cause an effect on occupational performance, whereas a bottom-up approach would be looking at and treating one symptom. Using the case study below as an example, a top-down approach would be looking at Barbara and everything affecting her everyday living tasks in the context of her current situation. A bottom-up approach would be looking at her symptom of restricted leg movement and how this affects her occupations.
Example Case Study using the PEOP model
‘Barbara’ is a 72yo female, widow, lives alone but family nearby
possible chest infection; admitted to A&E
while in hospital falls and fractures hip
hip operated on and stays in acute orthopaedic ward there
seen by a rehabilitation team OT
Because of the scope of the service they work in, an orthopaedic OT’s goal would be to get Barbara to get back to her home in the community.
In order to obtain the information necessary to create Barbara’s version of the PEOP model above, the following assessments are carried out:
CAM-ICU -Confusion Assessment Method, with either normal or an acute/ICU version (NICE 2008)
Canadian Occupational Performance Measure/COPM (Carswell et al 2004)
Barthel Index of ADL/Activities of Daily Living (Barthel & Mahoney 1965)
Home visit incorporating SAFER-HOME tool (Oliver et al 1993)
Use of CAM-ICU to quickly assess mental state. NICE guidelines state hip fracture patients over 65 are high-risk group for delirium. If positive for delirium, refer her to doctor or nurse for investigation of underlying issue eg chest infection, dehydration or pain.
Assess her occupational performance by using Barthel Index of ADL with activity analysis of washing, dressing, feeding, stairs & transfer tasks (working with physiotherapy and nursing teams).
Use the semi-structured interview tool Canadian Occupational Performance Measure to identify areas of occupational importance to Barbara, and her satisfaction with them. If Barbara wasn’t deemd to have capacity from the CAM-ICU the COPM can still be completed by proxy eg family member or healthcare staff.
Assess her home environment she will be returning to by conducting a home visit (or referral to Community OT/ Early Supported Discharge team), with the possible use of SAFER HOME tool to guide the assessment and to clearly document the limitations & risks.
If appropriate, offer Early Supported Discharge (NICE 2015) for Barbara to complete rehabilitation at home. This involves visits from health professionals at home with equipment loans & a social care package, if family is unable to assist with personal care.
The areas highlighted as important by Barbara will reflect the types of interventions carried out. For example, from feeding and mobility assessments in the Barthel Index of ADL Barbara has poor lower body strength and cannot fully weight bear for any length of time without pain, but is able to independently cut, prepare and eat food. From information obtained via COPM, Barbara reports that she is satisfied with not cooking a hot meal every day. She is used to preparing simple meals since widowed, and having hot meals only when she goes round her daughter’s house. Therefore perching stool in kitchen not necessary for long periods of standing. However difficulty in rising from seated position due to restriction on hip flexion beyond 90° (Randomski & Latham 2008) and poor lower body strength, meant a frame was offered to provide support when rising; together with bed, sofa and toilet heights raised with adaptive equipment.
For articles on other models such as MoCA, KAWA or MoHO, click on ‘OT Models & Process’ under the Categories section, in the menu to the right.
Barthel D & Mahoney F (1965) Functional evaluation: the Barthel index Maryland State Medical Journal 14(1):61-65
Carswell A, McColl M, Baptiste S, Law M, Polatajko H & Pollock N (2004) The Canadian Occupational Performance Measure: A Research and Clinical Literature Review Canadian Journal of Occupational Therapy 71(4): 210-222
Christiansen CH, Baum CM & Bass-Haugen J (2005) Occupational therapy: Performance, participation and well-being (3rd edition) Thorofare NJ: SLACK incorporated
Christiansen CH, Baum CM & Bass-Haugen J (2015) Occupational therapy: Performance, participation and well-being (4th edition) Thorofare NJ: SLACK incorporated
Duncan E & Hagedorn R (2011) Foundations for practice in occupational therapy (5th ed) Edinburgh: Elsevier Churchill Livingstone
Fawcett AL (2007) Principles of assessment and outcome measurement for occupational therapists and physiotherapists. Chichester: Wiley. pp 261-263
Law M, Cooper B, Strong S, Stewart D, Rigby P & Letts L (1996) The Person-Environment-Occupation Model: A Transactive Approach to Occupational Performance Canadian Journal of Occupational Therapy 63(1): 9-23
NICE (2008) Delirium:prevention, diagnosis and management London: NICE
NICE (2015) Transition between inpatient hospital settings & community or care home settings for adults with social care needs London: NICE
Oliver R, Blathwayt J, Brackley C &Tamaki T (1993) Development of the Safety Assessment of Function and the Environment for Rehabilitation (SAFER) Tool Canadian Journal of Occupational Therapy 60(2): 78-82
Radomski M & Latham C (2008) Occupational therapy for physical dysfunction (6th ed) Philadelphia: Lippincott Williams & Wilkins
Robertson L (2012) Clinical reasoning in occupational therapy Chichester: Wiley-Blackwell
There is an increasing paradigm shift towards including occupation (and defining it) within the wider professional OT theories, research and philosophies. Pereira looks at how we understand the term occupation in our professional language.
The etymology (origin of the word) is occupatio Latin noun for occupation. However when we talk about occupation it isn’t as a noun, it is as a verb where we describe to occupy, to possess, to take control of, etc. Therefore the Latin verb occupare (to occupy) is more representative of our use of the word occupation, he argues. When we think of occupation as something ‘doing’ rather than a ‘description’, it can influence how we think about it in everyday life; rather than focusing on what is being done in an isolated occupation task, we can think of the purpose of the goals achieved through occupation.
OTs may be unintentionally limiting their practice by misunderstanding the term occupation to mean occupatio and not occupare.
Basically, try thinking of the term occupation as a verb rather than a noun, and see how it changes your perception of situations for example when applying OT models to practice.
Robert Pereira (2015). Occupare, to seize: expanding the potential of occupation in contemporary practice. Australian Occupational Therapy Journal (2015) 62, 208–209
According to Riley (2012), this article uses occupational science to illustrate the meaning of ‘ identity’ in the CMOP-E.
It describes how a sense of self and social identity are represented by the objects someone makes or uses. Using objects in this context includes making, wearing, maintaining or restoring, displaying, collecting and consuming objects, operating or using objects as tools, as well as purchasing things (the focus of consumer research). Hocking used information from sources of psychology, consumer research, sociology, anthropology, disability studies and popular literature to make her conclusion. This aligns with the view that occupational science draws from many different disciplines to create its understanding of occupation.
Western people use objects to create and express a sense of self and an identity, and that the way they use objects to achieve this is placed in a cultural and historical context.
The selfis how we view ourselves internally, and our memories/knowledge of experiences that have shaped us.
Identity is how society views us, and assigns us a social identity.
Objects are used as mirrors of self, reflecting attitudes, values, relationships & achievements. People selecting objects for themselves choose those that represent their ideal self and not actual self. Objects are used as mirrors of identity, especially clothing, and offer the chance claim or to buy into a desired social identity. They reflect desired social position, status identity, gender identity.
People use objects to transform or develop their identity, to become more successful, exciting, attractive, or socially statused. Westerner culture assumes that that people have an individual rather than collective identity. In other cultures eg India people’s preferred objects are those relating to family or communal prestige, rather than ones with individual meaning.
The more insecure Western people become in relation to the identity they want, the more they want the material symbols of that identity.
For Westerners using objects is on a continuum between Stoicism (practical, puritan,rational decisions about need, spiritual, simple, long term gain over short term reward) and at the other end of the scale, Romanticism (emotional expression, beauty for sake of it, self-expression, freedom of desire, complexity, conspicuous consumption, hedonistic (note; not the same as happy).
Riley J (2012) Occupational science and occupational therapy: a contemporary relationship. Chapter 14 in Boniface G, Seymour A (eds) Using occupational therapy theory in practice. Oxford: Wiley Blackwell.
Hocking, Clare (2000) Having and using objects in the western world. Journal of Occupational Science vol 7 (issue 3), pp148-157.
Abstract: This interpretive study explores how Western people construct self and express identity though the objects they acquire, make and use in their day-to-day occupation. Drawing on literature from psychology, consumer research,sociology, anthropology, disability studies and popular literature, it proposes that people use objects to reflect self and identity, and to transform self and others. Using a history of ideas methodology, the author argues that Western people take for granted that the objects they have and use reflect an individual rather than collective identity, and suggests that the ways people use objects to construct self and identity are informed by the philosophies of both Stoicism, which emphasises self discipline and rational decision making, and romanticism which celebrates people’s emotional depth, creativity and self expression.
Occupational Science is an academic discipline concerned with the study of human occupation.
It is a new discipline that emerged in the late 1980’s to provide a scientific base for Occupational Therapy practice. It has a close relationship with Occupational Therapy since OT uses evidence from Occupational Science to inform practice, and they are both concerned with occupation and how it affects people. Some examples of areas studied in Occupational Science could be identifying the nature or characteristics of occupations themselves, investigating the processes or outcomes of occupational performance, or attempting to explain how occupation affects people’s health/quality of life/social structures/identity. This can help to explain effects such as occupational deprivation or occupational justice. By studying what the determinants of health are, it can also give weight to decisions aimed at overcoming occupational injustices (Yerxa 1993).
Like OT, Occupational Science draws on a wide range of other disciplines such as philosophy, anthropology, sociology, economics, and evolutionary biology in order to achieve this. Yerxa (2000) illustrated this in her keynote speech reflecting on her career, where she described undertaking ‘detective work’ in order to discover which elements had contributed to Occupational Therapy, and found that ideas from history, political science, disability studies and psychology had also influenced OT in addition to those mentioned above. The information created by occupational science is important to occupational therapy because it informs traditional practice whilst providing evidence for non-traditional practice areas, and has the potential to address practice dilemmas (Wilcock 2001).
OT is focussed on the individual, whereas for Occupational Science a wider view of occupation is necessary to provide a holistic understanding of what are complicated phenomena. Occupational science can provide the underlying rationale to OT models, for example explaining the ‘identity’ in the Canadian Model of Occupational Performance & Engagement (CMOP-E). Occupational Science has shown that our experiences and motivations for occupations creates our sense of self-identity (for example Wilcock 2006, Sennet 2008 or Hocking 2000).
Occupational science can inform traditional practice as well as provide evidence for non-traditional areas of work (Hocking 2009). Additionally it can be used to study determinants of health, address potential practice dilemmas and overcome occupational injustices (Wilcock 2001 and Yerxa 1993).
Further benefits of incorporating occupational science research into occupational therapy practice are…Occupational science: Adding value to occupational therapy’ New Zealand Journal of Occupational Therapy 58(1): 29-35
Hocking, C (2000) Having and using objects in the western world Journal of Occupational Science 7(3), 148-157
Hocking C (2009) ‘The challenge of Occupation: Describing the things people do’ Journal of Occupational Science 16(3): 140-150
Hocking C and Wright-St. Clair V (2011) ‘Occupational science: Adding value to occupational therapy’ New Zealand Journal of Occupational Therapy 58(1): 29-35
Sennet R (2008) The Craftsman. London: Penguin books
Riley J (2012) Occupational science and occupational therapy: a contemporary relationship. Chapter 14 in Boniface G, Seymour A (eds) Using occupational therapy theory in practice Oxford: Wiley Blackwell
Yerxa EJ (2000) Confessions of an Occupational Therapist Who Became a Detective British Journal of Occupational Therapy May 2000 vol. 63 no. 5 192-199
Yerxa E J (1993) Occupational science: a new source of power for participants in occupational therapy Occupational Science: Australia 1(1) 3-9
Wilcock A (2001) Occupational Science: the key to broadening horizons British Journal of Occupational Therapy 64(8) 412-17
Wilcock A (2006) An Occupational Perspective of Health (2nd edition) Thorofare NJ: Black
Evidence Based Practice (EBP) is made up of three components -scientific research, clinical expertise and patient preference- and each of these components have issues which could cause limitations to EBP as an effective practice method. There is also the additional component of health service limitations which is sometimes included in EBP, and this can also also pose its own barriers.
Greenhalgh et al. (2014) described authentic EBP as:
Makes the ethical care of the patient its top priority
Demands individualised evidence in a format that clinicians and patients can understand
Characterised by expert judgement rather than mechanical rule following
Shares decisions with patients through meaningful conversations
Builds on a strong clinician-patient relationship and the human aspects of care
Applies these principles at community level for evidence-based public health
And she says that good EBP can be achieved by:
Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
Clinical training must go beyond searching and critical appraisal to hone expert judgement and shared decision making skills
Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints
Publishers must demand that studies meet usability standards as well as methodological ones
Policy makers must resist the instrumental generation and use of “evidence” by vested interests
Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence
The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from over-diagnosis