Implementing occupation-based assessment.

In the early 1990s, occupational therapists were challenged to refocus their evaluation processes. Specifically, they were urged to focus on their clients’ abilities to do what they want and need to do and to carry out meaningful occupation rather than evaluating the components underlying occupational performance problems (Fisher, 1992a, 1994a; Law et al., 1994; Mathiowetz, 1993; Trombly, 1993). Subsequently, the call for occupation-based assessment has been repeated and amplified (cf., Baum & Law, 1997; Coster, 1998). Several compelling rationales for this refocusing have been offered. First, evaluations that do not focus on the occupations that clients find problematic will not communicate the purpose of occupational therapy to clients or colleagues and, thus, will contribute to confusion and dissatisfaction with occupational therapy services (Fisher & ShortDeGraff, 1993; Trombly, 1993). As Baum and Law (1997) noted, clients need to understand the purpose of occupational therapy and its potential outcomes as much as therapists need to understand clients’ occupational performance problems. Failure to communicate the purpose or anticipated outcomes of intervention would, in effect, compromise the principles of client-centered occupational therapy because clients cannot fully engage in processes they do not understand (Pollock & McColl, 1998). In addition, failing to communicate the purpose of intervention is contrary to the increasing consumer demand that any evaluation of function is both relevant and useful to the person being assessed (Batavia, 1992). A second area of concern is which aspect of a client’s performance to measure. Until recently, occupational therapists assumed that a strong correlation exists between performance components and occupational performance. Based on this assumption, evaluation of the components that underpin performance appeared to provide a good basis for intervention. A growing body of research, however, has revealed that improvement in performance components does not automatically translate into improved occupational performance (Fisher, 1992b; Mathiowetz & Haugen, 1995; Schmidt, 1988; Trombly, 1995, 1999). Thus, an increase in concentration span, for example, may not carry over into improved performance of work tasks. A third concern is that occupational therapists who focus their evaluations solely on performance components risk focusing treatment around those components, thus failing to address critical occupational issues. These issues might include, for example, volitional aspects of performance (Fisher, 1992b) or attitudinal, organizational, or physical environmental barriers to occupation (Roulstone, 1998). As Kielhofner (1993) argued, therapists’ attention can become diverted from the person who has the condition to the medical condition itself. In addition, evaluations that focus on performance components are unlikely to reveal clients’ capabilities and adaptive strategies or to contribute to understanding the interaction between people and their environments (Mathiowetz, 1993). Overall, a consensus seems to be developing that evaluations that focus directly on occupation are most true to the basic concepts of occupational therapy (Coster, 1998; Fisher, 1992a; Gillette, 1991; Trombly, 1993). The complexities of implementing occupation-based assessments, however, have received little attention. This article suggests that conceptualizing occupation in terms of meaning, function, form, and performance components may provide a useful framework to guide clinical reasoning about what to assess. I propose that occupational concerns become the primary consideration guiding the selection of assessments, and I outline three broad strategies to evaluate the use of available assessments within occupation-based evaluations. These strategies are presented in Figure 1. An assumption underlying the discussion is that occupational therapy evaluations and interventions are guided by theory. Examples of the influence of theoretical frameworks on clinical reasoning are incorporated throughout the discussion.