Occupational Models: PEOP (Person-Environment-Occupation Performance)

Occupational Models: PEOP (Person-Environment-Occupation Performance)

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.

Person Environment Occupation Performance (PEOP) model
Person Environment Occupation Performance (PEOP) model

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.

Case study- orthopaedic OT and PEOP model
Case study: PEOP model & orthopaedic OT intervention

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.

 

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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.

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Sources:

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

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