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The American Journal of Occupational Therapy 609

Occupational therapy is an evolving profession. Over the years, the study ofhuman occupation and its components has enlightened the profession aboutthe core concepts and constructs that guide occupational therapy practice. In addi-tion, occupational therapys role and contributions to society have continued toevolve. The Occupational Therapy Practice Framework: Domain and Process (alsoreferred to in this document as the Framework) is the next evolution in a series ofdocuments that have been developed over the past several decades to outline lan-guage and constructs that describe the professions focus.

The Framework was developed in response to current practice needstheneed to more clearly affirm and articulate occupational therapys unique focus onoccupation and daily life activities and the application of an intervention processthat facilitates engagement in occupation to support participation in life. Theimpetus for the development of the Framework was the review process to updateand revise the Uniform Terminology for Occupational TherapyThird Edition (UT-III) (American Occupational Therapy Association [AOTA], 1994). The back-ground for the development of the Framework is provided in a section at the endof this document. As practice continues to evolve, the field should consider thecontinued need for the Occupational Therapy Practice Framework: Domain andProcess and should evaluate and modify its format as appropriate.

The intended purpose of the Framework is twofold: (a) to describe the domainthat centers and grounds the professions focus and actions and (b) to outline theprocess of occupational therapy evaluation and intervention that is dynamic andlinked to the professions focus on and use of occupation. The domain and processare necessarily interdependent, with the domain defining the area of human activ-ity to which the process is applied.

This document is directed to both internal and external audiences. The inter-nal professional audienceoccupational therapists and occupational therapy assis-tantscan use the Framework to examine their current practice and to considernew applications in emerging practice areas. Occupational therapy educators mayfind the Framework helpful in teaching students about a process delivery modelthat is client centered and facilitates engagement in occupation to support partici-pation in life. As occupational therapists and occupational therapy assistants moveinto new and expanded service arenas, the descriptions and terminology providedin the Framework can assist them in communicating the professions unique focuson occupation and daily life activities to external audiences. External audiences canuse the Framework to understand occupational therapys emphasis on supportingfunction and performance in daily life activities and the many factors that influ-ence performance (e.g., performance skills, performance patterns, context, activitydemands, client factors) that are addressed during the intervention process. The

Occupational Therapy Practice Framework: Domain and Process

ContentsDomain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .610

The Domain of Occupational Therapy . . . . . . . . .610Engagement in Occupation to Support Participation in Context . . . . . . . . . . . . . . . . . . . .611

Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .613The Process of Occupational Therapy: Evaluation, Intervention, and Outcome . . . . . . . . .613Framework Process Organization . . . . . . . . . . . . .613Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . .615Intervention Process . . . . . . . . . . . . . . . . . . . . . . .617Outcomes Process . . . . . . . . . . . . . . . . . . . . . . . .618

An Overview of the Occupational Therapy Practice Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . .619Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .620

Table 1. Areas of Occupation . . . . . . . . . . . . . . . .620Table 2. Performance Skills . . . . . . . . . . . . . . . . .621Table 3. Performance Patterns . . . . . . . . . . . . . . .623Table 4. Context or Contexts . . . . . . . . . . . . . . . .623Table 5. Activity Demands . . . . . . . . . . . . . . . . . .624Table 6. Client Factors . . . . . . . . . . . . . . . . . . . . .624Table 7. Occupational Therapy InterventionApproaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .627Table 8. Types of Occupational Therapy Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628Table 9. Types of Outcomes . . . . . . . . . . . . . . . . .628Table 10. Occupational Therapy Practice Framework Process Summary . . . . . . . . . . . . . . .629

Glossary (Framework) . . . . . . . . . . . . . . . . . . . . . . . . .630References (Framework) . . . . . . . . . . . . . . . . . . . . . . . .634Bibliography (Framework) . . . . . . . . . . . . . . . . . . . . . .635Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .636

Background of Uniform Terminology . . . . . . . . . .636Development of the Occupational Therapy Practice Framework: Domain and Process . . . . . .636Relationship of the Framework to the Rescinded UT-III and the ICF . . . . . . . . . . . . . . . .637Comparison of Terms . . . . . . . . . . . . . . . . . . . . . .637

References (Background) . . . . . . . . . . . . . . . . . . . . . . .639Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .639

When citing this document the preferred reference is:

American Occupational Therapy Association. (2002).Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy,56, 609639.

description of the process will assist external audiences inunderstanding how occupational therapists and occupa-tional therapy assistants apply their knowledge and skills inhelping people attain and resume daily life activities thatsupport function and health.

The Occupational Therapy Practice Framework: Domainand Process begins with an explanation of the professionsdomain. Each aspect of the domain is fully described. Anintroduction to the occupational therapy process followswith key statements that highlight important points. Eachsection of the process is then specifically described.Numerous resource materials, including an appendix, aglossary, references, a bibliography, and the background ofthe development of the Framework are supplied at the endof the document.

DomainThe Domain of Occupational Therapy

A professions domain of concern consists of those areas ofhuman experience in which practitioners of the professionoffer assistance to others (Mosey, 1981, p. 51). Occupa-tional therapists and occupational therapy assistants focuson assisting people to engage in daily life activities that theyfind meaningful and purposeful. Occupational therapysdomain stems from the professions interest in humanbeings ability to engage in everyday life activities. Thebroad term that occupational therapists and assistants use tocapture the breadth and meaning of everyday life activityis occupation. Occupation, as used in this document, isdefined in the following way:

[A]ctivitiesof everyday life, named, organized, and givenvalue and meaning by individuals and a culture.Occupation is everything people do to occupy themselves,including looking after themselvesenjoying lifeandcontributing to the social and economic fabric of theircommunities. (Law, Polatajko, Baptiste, & Townsend,1997, p. 32)

Occupational therapists and occupational therapy assis-tants expertise lies in their knowledge of occupation andhow engaging in occupations can be used to affect humanperformance and the effects of disease and disability. Whenworking with clients, occupational therapists and occupa-tional therapy assistants direct their effort toward helpingclients perform. Performance changes are directed to sup-port engagement in meaningful occupations that subse-quently affect health, well-being, and life satisfaction.

The profession views occupation as both means andend. The process of providing occupational therapy inter-vention may involve the therapeutic use of occupation as ameans or method of changing performance. The end of

the occupational therapy intervention process occurs withthe clients improved engagement in meaningful occupa-tion.

Both terms, occupation and activity, are used by occu-pational therapists and occupational therapy assistants todescribe participation in daily life pursuits. Occupations aregenerally viewed as activities having unique meaning andpurpose in a persons life. Occupations are central to a per-sons identity and competence, and they influence how onespends time and makes decisions. The term activitydescribes a general class of human actions that is goal direct-ed (Pierce, 2001). A person may participate in activities toachieve a goal, but these activities do not assume a place ofcentral importance or meaning for the person. For example,many people participate in the activity of gardening, butnot all of those individuals would describe gardening as anoccupation that has central importance and meaning forthem. Those who see gardening as an activity may reportthat gardening is a chore or task that must be done as partof home and yard maintenance but not one that they par-ticularly enjoy doing or from which they derive significantpersonal satisfaction or fulfillment. Those who experiencegardening as an occupation would see themselves as gar-deners, gaining part of their identity from their participa-tion. They would achieve a sense of competence by theiraccomplishments in gardening and would report a sense ofsatisfaction and fulfillment as a result of engaging in thisoccupation. Occupational therapists and occupational ther-apy assistants value both occupation and activity and recog-nize their importance and influence on health and well-being. They believe that the two terms are closely related yetrecognize that each term has a distinct meaning and thatindividuals experience each differently. In this documentthe two terms are often used together to acknowledge theirrelatedness yet recognize their different meanings.

The domain of occupational therapy frames the arenain which occupational therapy evaluations and interven-tions occur. To make the domain more understandable toreaders and easier to visualize, the content of the domainhas been illustrated in Figure 1. At the top of the page is theoverarching statementEngagement in Occupation toSupport Participation in Context or Contexts. This state-ment describes the domain in its broadest sense. The otherterms outlined in the figure identify the various aspects ofthe domain that occupational therapists and occupationaltherapy assistants attend to during the process of providingservices. The three terms at the bottom of the figure (con-text, activity demands, and client factors) identify areas thatinfluence performance skills and patterns. The two terms inthe middle of the figure (performance skills and performancepatterns) are used to describe the observed performance that

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the individual carries out when engaging in a range of occu-pations. No one aspect outlined in the domain figure isconsidered more important than another. Occupationaltherapists are trained to assess all aspects and to apply thatknowledge to an intervention process that leads to engage-ment in occupations to support participation in context orcontexts. Occupational therapy assistants participate in thisprocess under the supervision of an occupational therapist.The discussion that follows provides a brief explanation ofeach term in the figure. Tables included in the appendixprovide full lists and definitions of terms.

Engagement in Occupation to Support Participation in Context

Engagement in occupation to support participation in con-text is the focus and targeted end objective of occupationaltherapy intervention. Engagement in occupation is seen asnaturally supporting and leading to participation in con-text.

When individuals engage in occupations, they are com-mitted to performance as a result of self-choice, motivation,and meaning. The term expresses the professions belief in

the importance of valuing and considering the individualsdesires, choices, and needs during the evaluation and inter-vention process. Engagement in occupation includes boththe subjective (emotional or psychological) aspects of per-formance and the objective (physically observable) aspectsof performance. Occupational therapists and occupationaltherapy assistants understand engagement from this dualand holistic perspective and address all the aspects of per-formance (physical, cognitive, psychosocial, and contextu-al) when providing interventions designed to supportengagement in occupations and in daily life activities.

Occupational therapists and occupational therapy assis-tants recognize that health is supported and maintainedwhen individuals are able to engage in occupations and inactivities that allow desired or needed participation inhome, school, workplace, and community life situations.Occupational therapists and occupational therapy assistantsassist individuals to link their ability to perform daily lifeactivities with meaningful patterns of engagement in occu-pations that allow participation in desired roles and life sit-uations in home, school, workplace, and community. TheWorld Health Organization (WHO), in its effort to broad-


ENGAGEMENT IN OCCUPATION TO SUPPORT PARTICIPATION IN CONTEXT OR CONTEXTS

n Performance in Areas of OccupationActivities of Daily Living (ADL)*

Instrumental Activities of Daily Living (IADL)Education

WorkPlay

LeisureSocial Participation

(For definitions, refer to Appendix, Table 1)

n Performance SkillsMotor Skills

Process SkillsCommunication/Interaction Skills


n Performance PatternsHabits

RoutinesRoles


n ContextCulturalPhysicalSocial

PersonalSpiritualTemporal

Virtual(For definitions, refer to Appendix, Table 4)

n Activity DemandsObjects Used and Their Properties

Space DemandsSocial Demands

Sequencing and TimingRequired Actions

Required Body FunctionsRequired Body Structures


n Client FactorsBody FunctionsBody Structures


Figure 1. Domain of Occupational Therapy. This figure represents the domain of occupational therapy and is included to allow readers to visualizethe entire domain with all of its various aspects. No aspect is intended to be perceived as more important than another.

*Also referred to as basic activities of daily living (BADL) or personal activities of daily living (PADL).

en the understanding of the effects of disease and disabilityon health, has recognized that health can be affected by theinability to carry out activities and participate in life situa-tions as well as by problems that exist with body structuresand functions (WHO, 2001). Occupational therapys focuson engagement in occupations to support participationcomplements WHOs perspective.

Occupational therapists and occupational therapyassistants recognize that engagement in occupation occursin a variety of contexts (cultural, physical, social, person-al, temporal, spiritual, virtual). They also recognize thatthe individuals experience and performance cannot beunderstood or addressed without understanding the manycontexts in which occupations and daily life activitiesoccur.

Performance in Areas of Occupation

Occupational therapists and occupational therapy assistantsdirect their expertise to the broad range of human occupa-tions and activities that make up peoples lives. When occu-pational therapists and assistants work with an individual, agroup, or a population to promote engagement in occupa-tions and in daily life activities, they take into account all ofthe many types of occupations in which any individual,group, or population might engage. These human activitiesare sorted into categories called areas of occupationactivities of daily living, instrumental activities of daily liv-ing, education, work, play, leisure, and social participation(see Appendix, Table 1). Occupational therapists and occu-pational therapy assistants under the supervision of anoccupational therapist use their expertise to address perfor-mance issues in any or all areas that are affecting the personsability to engage in occupations and in activities.Addressing performance issues in areas of occupationrequires knowledge of what performance skills are neededand what performance patterns are used.

Performance Skills

Skills are small units of performance. They are features ofwhat one does (e.g., bends, chooses, gazes), versus underly-ing capacities or body functions (e.g., joint mobility, moti-vation, visual acuity). Skills are observable elements ofaction that have implicit functional purposes (Fisher &Kielhofner, 1995, p. 113). For example, when observing aperson writing out a check, you would notice skills of grip-ping and manipulating objects and initiating and sequenc-ing the steps of the activity to complete the writing of thecheck.

Execution of a performance skill occurs when the per-former, the context, and the demands of the activity cometogether in the performance of the activity. Each of these

factors influences the execution of a skill and may supportor hinder actual skill execution.

When occupational therapists and occupational therapyassistants, who have established competency under thesupervision of occupational therapists, analyze performance,they specifically identify the skills that are effective or inef-fective during performance. They use skilled observationsand selected assessments to evaluate the following skills: Motor skillsobserved as the client moves and interacts

with task objects and environments. Aspects of motor skillinclude posture, mobility, coordination, strength andeffort, and energy. Examples of specific motor perfor-mance skills include stabilizing the body, bending, andmanipulating objects.

Process skillsobserved as the client manages and modi-fies actions while completing a task. Aspects of processskill include energy, knowledge, temporal organization,organizing space and objects, and adaptation. Examples ofspecific process performance skills include maintainingattention to a task, choosing appropriate tools and mate-rials for the task, logically organizing workspace, oraccommodating the method of task completion inresponse to a problem.

Communication/Interaction skillsobserved as the clientconveys his or her intentions and needs and coordinatessocial behavior to act together with people. Aspects ofcommunication/interaction skills include physicality,information exchange, and relations. Examples of specificcommunication/interaction performance skills includegesturing to indicate intention, asking for information,expressing affect, or relating in a manner to establish rap-port with others.

Skilled performance (i.e., effective execution of perfor-mance skills) depends on client factors (body functions,body structures), activity demands, and the context.However, the presence of underlying client factors (bodyfunctions and structures) does not inherently ensure theeffective execution of performance skills. (See Appendix,Table 2, for complete list of performance skills)

Performance Patterns

Performance patterns refer to habits, routines, and roles thatare adopted by an individual as he or she carries out occu-pations or daily life activities. Habits refer to specific, auto-matic behaviors, whereas routines are established sequencesof occupations or activities that provide a structure for dailylife. Roles are a set of behaviors that have some sociallyagreed upon function and for which there is an acceptedcode of norms (Christiansen & Baum, 1997, p. 603).

Performance patterns develop over time and are influ-enced by context (See Appendix, Table 3).


Context

Context refers to a variety of interrelated conditions withinand surrounding the client that influence performance.These contexts can be cultural, physical, social, personal,spiritual, temporal, and virtual. Some contexts are externalto the client (e.g., physical context, social context, virtualcontext); some are internal to the client (e.g., personal, spir-itual); and some may have external features, with beliefs andvalues that have been internalized (e.g., cultural). Contextsmay include time dimensions (e.g., within a temporal con-text, the time of day; within a personal context, ones age)and space dimensions (e.g., within a physical context, thesize of room in which activity occurs). When the occupa-tional therapist and occupational therapy assistant areattempting to understand performance skills and patterns,they consider the specific contexts that surround the per-formance of a particular occupation or activity. In this pro-cess, the therapist and assistant consider all the relevant con-texts, keeping in mind that some of them may not beinfluencing the particular skills and patterns beingaddressed. (See Appendix, Table 4, for a description of thedifferent kinds of contexts that occupational therapists andoccupational therapy assistants consider.)

Activity Demands

The demands of the activity in which a person engages willaffect skill and eventual success of performance.Occupational therapists and occupational therapy assistantsapply their analysis skills to determine the demands that anactivity will place on any performer and how thosedemands will influence skill execution. (See Appendix,Table 5, for complete list of activity demands.)

Client Factors

Performance can be influenced by factors that reside withinthe client. Occupational therapists and occupational thera-py assistants are knowledgeable about the variety of physi-cal, cognitive, and psychosocial client factors that influencedevelopment and performance and how illness, disease, anddisability affect these factors. The occupational therapistand occupational therapy assistant recognize that client fac-tors influence the ability to engage in occupations and thatengagement in occupations can also influence client factors.They apply their understanding of this interaction and useit throughout the intervention process.

Client factors include the following: Body functionsphysiological function of body systems

(including psychological functions) (WHO, 2001, p.10). (See Appendix, Table 6, for complete list.) The occu-pational therapist and occupational therapy assistantunder the supervision of an occupational therapist use

knowledge about body functions to evaluate selectedclient body functions that may be affecting his or her abil-ity to engage in desired occupations or activities.

Body structuresanatomical parts of the body such asorgans, limbs, and their components (WHO, 2001, p.10). (See Appendix, Table 6.) Occupational therapists andoccupational therapy assistants under the supervision ofan occupational therapist apply their knowledge aboutbody structures to determine which body structures areneeded to carry out an occupation or activity.

The categorization of client factors outlined in Table 6is based on the International Classification of Functioning,Disability and Health proposed by the WHO (2001). Theclassification was selected because it has received wide expo-sure and presents a common language that is understood byexternal audiences. The categories include all those areasthat occupational therapists and assistants address and con-sider during evaluation and intervention.

ProcessThe Process of Occupational Therapy: Evaluation, Intervention, and Outcome

Many professions use the process of evaluating, intervening,and targeting intervention outcomes that is outlined in theFramework. However occupational therapys focus on occu-pation throughout the process makes the professions appli-cation and use of the process unique. The process of occu-pational therapy service delivery begins by evaluating theclients occupational needs, problems, and concerns.Understanding the client as an occupational human beingfor whom access and participation in meaningful and pro-ductive activities is central to health and well-being is a per-spective that is unique to occupational therapy. Problemsand concerns that are addressed in evaluation and interven-tion are also framed uniquely from an occupational per-spective, are based on occupational therapy theories, and aredefined as problems or risks in occupational performance.During intervention, the focus remains on occupation, andefforts are directed toward fostering improved engagementin occupations. A variety of therapeutic activities, includingengagement in actual occupations and in daily life activities,are used in intervention.

Framework Process Organization

The Occupational Therapy Practice Framework process is orga-nized into three broad sections that describe the process ofservice delivery. A brief overview of the process as it is appliedwithin the professions domain is outlined in Figure 2.

Figure 3 schematically illustrates how these sections arerelated to one another and how they revolve around the col-


laborative therapeutic relationship between the client andthe occupational therapist and occupational therapy assis-tant.

To help the reader understand the process, key state-ments highlight important points about the process out-lined below.

The process outlined is dynamic and interactive innature. Although the parts of the Framework are describedin a linear manner, in reality, the process does not occur ina sequenced, step-by-step fashion. The arrows in Figure 3that connect the boxes indicate the interactive and nonlin-ear nature of the process. The process, however, does alwaysstart with the occupational profile. An understanding of theclients concerns, problems, and risks is the cornerstone ofthe process. The factors that influence occupational perfor-mance (performance skills, performance patterns, contextor contexts, activity demands, client factors) continuallyinteract with one another. Because of their dynamic inter-action, these factors are frequently evaluated simultaneous-ly throughout the process as their influence on performanceis observed.

Context is an overarching, underlying, embeddedinfluence on the process of service delivery. Contextsexist around and within the person. They influence boththe clients performance and the process of delivering ser-vices. The external context (e.g., the physical setting, socialand virtual contexts) provide resources that support orinhibit the clients performance (e.g., presence of a willingcaregiver) as well as the delivery of services (e.g., limitsplaced on length of intervention in an inpatient hospitalsetting). Different settings (i.e., community, institution,home) provide different supports and resources for service

delivery. The clients internal context (personal and spiritu-al contexts) affects service delivery by influencing personalbeliefs, perceptions, and expectations. The cultural context,which exists outside of the person but is internalized by theperson, also sets expectations, beliefs, and customs that canaffect how and when services may be delivered. Note that inFigure 3, context is depicted as surrounding and underlyingthe process.

The term client is used to name the entity thatreceives occupational therapy services. Clients may be


n Evaluation

Occupational profileThe initial step in the evaluation process that provides an understanding of the clients occupational history and experiences, patterns of dailyliving, interests, values, and needs. The clients problems and concerns about performing occupations and daily life activities are identified, and the clients prioritiesare determined.

Analysis of occupational performanceThe step in the evaluation process during which the clients assets, problems, or potential problems are more specificallyidentified. Actual performance is often observed in context to identify what supports performance and what hinders performance. Performance skills, performance patterns, context or contexts, activity demands, and client factors are all considered, but only selected aspects may be specifically assessed. Targeted outcomes areidentified.

n Intervention

Intervention planA plan that will guide actions taken and that is developed in collaboration with the client. It is based on selected theories, frames of reference,and evidence. Outcomes to be targeted are confirmed.

Intervention implementationOngoing actions taken to influence and support improved client performance. Interventions are directed at identified outcomes.Clients response is monitored and documented.

Intervention reviewA review of the implementation plan and process as well as its progress toward targeted outcomes.n Outcomes (Engagement in Occupation To Support Participation)

OutcomesDetermination of success in reaching desired targeted outcomes. Outcome assessment information is used to plan future actions with the client and toevaluate the service program (i.e., program evaluation).

Figure 2. Framework Process of Service Delivery as Applied Within the Professions Domain.

INTERVENTION

Figure 3. Framework Collaborative Process Model. Illustration ofthe framework emphasizing clientpractitioner interactive relationshipand interactive nature of the service delivery process.

OUTCOMES

CollaborativeProcess Between

Practitioner and Client

OccupationalProfile

Analysis ofOccupationalPerformance

Intervention Plan

InterventionImplementation

InterventionReview

Engagement inOccupation to Support

Participation

EVALUATION

CONTEXT

CONTEXT

CONTEXT

CONTEXT

categorized as (a) individuals, including individuals whomay be involved in supporting or caring for the client (i.e.,caregiver, teacher, parent, employer, spouse); (b) individu-als within the context of a group (i.e., a family, a class); or(c) individuals within the context of a population (i.e., anorganization, a community). The definition of client isconsistent with The Guide to Occupational Therapy Practice(Moyers, 1999) and is indicative of the professions grow-ing understanding that people may be served not only asindividuals, but also as members of a group or a popula-tion. The actual term used for individuals who are servedwill vary by practice setting. For example, in a hospital, theperson might be referred to as a patient, whereas in aschool, he or she might be called a student. Clients maybe served as individuals, groups, or populations. Althoughthe most common form of service delivery within the pro-fession now involves a direct individual client to serviceprovider model, more and more occupational therapistsand occupational therapy assistants are beginning to serveclients at the group and population level (i.e., organization,community). When providing interventions other than ina one-to-one model, the occupational therapist and occu-pational therapist assistant are seen as agents who help oth-ers to support client engagement in occupations ratherthan as those who personally provide that support. Often,they use education and consultation as interventions.When occupational therapists and occupational therapyassistants are collaborating with clients to provide servicesat the group or population level, an important point to rec-ognize is that although interventions may be directed to agroup or population (i.e., organization, community), theindividuals within those entities are the ones who are beingevaluated and served. The wants, needs, occupational risksor problems, and performance patterns and skills of indi-viduals within the group or population (i.e., organization,community) are evaluated as an aggregate, and informa-tion is compiled to determine group or population occu-pational issues and solutions.

A client-centered approach is used throughout theFramework. The Framework incorporates the value ofclient-centered evaluation and intervention by recognizingfrom the outset that all interventions must be focused onclient priorities. The very nature of engagement in occupa-tionwhich is internally motivated, is individually defined,and requires active participation by the clientmeans thatthe client must be an active participant in the process.Clients identify what occupations and activities are impor-tant to them and determine the degree of engagement ineach occupation. However, in some circumstances theclients ability to provide a description of the perceived ordesired occupations or activity may be limited because of

either the nature of the clients problems (e.g., autism,dementia) or the stage of development (e.g., infants). Whenthis occurs, the occupational therapist and occupationaltherapy assistant must then take a broader view of the clientand seek input from others such as family or significant oth-ers who would have knowledge and insight into the clientsdesires. By involving the family or significant others, theoccupational therapist and assistant can better understandthe clients history, developmental stage, and current con-texts. Inclusion of others in these circumstances allows theclient to be represented in intervention planning and imple-mentation.

The entire process of service delivery begins with a col-laborative relationship with the client. The collaborativerelationship continues throughout the process and affectsall phases of the process. The central importance of this col-laboration is noted in Figure 3.

The Framework is based on the belief that the occu-pational therapist, occupational therapy assistant, and theclient bring unique resources to the Framework process.Occupational therapists and occupational therapy assis-tants bring knowledge about how engagement in occupa-tion affects health and performance. They also bringknowledge about disease and disability and couple thisinformation with their clinical reasoning and theoreticalperspectives to critically observe, analyze, describe, andinterpret human performance. Therapists and assistantscombine their knowledge and skills to modify the factorsthat influence engagement in occupation to improve andsupport performance. Clients bring knowledge about theirlife experiences and their hopes and dreams for the future.Clients share their priorities, which are based on what isimportant to them, and collaborate with the therapist andassistant in directing the intervention process to those pri-orities.

Engagement in occupation is viewed as the over-arching outcome of the occupational therapy process.The Framework emphasizes occupational therapys uniquecontribution to health by identifying engagement in occu-pation to support participation as the end objective of theoccupational therapy process. The profession recognizesthat in some areas of practice (e.g., acute rehabilitation,hand therapy) occupational therapy intervention may focusprimarily on performance skills or on client factors (i.e.,body functions, body structures) that will enable engage-ment in occupations later in the continuum of care.

Evaluation Process

The evaluation process sets the stage for all that follows.Because occupational therapy is concerned with perfor-mance in daily life and how performance affects engage-


ment in occupations to support participation, the evalua-tion process is focused on finding out what the client wantsand needs to do and on identifying those factors that act assupports or barriers to performance. During the evaluationprocess, this information is paired with the occupationaltherapists knowledge about human performance and theeffect that illness, disability, and engagement in occupationhave on performance. The occupational therapist considersperformance skills, performance patterns, context, activitydemands, and client factors and determines how each influ-ences performance. The occupational therapists skilledobservation, use of specific assessments, and interpretationof results leads to a clear delineation of the problems andprobable causes. The occupational therapy assistant maycontribute to the evaluation process based on establishedcompetencies and under the supervision of an occupation-al therapist.

During the evaluation, a collaborative relationship withthe client is established that continues throughout theentire occupational therapy process. The evaluation processis divided into two substeps, the first of which is the occu-pational profilethe initial step during which the clientsneeds, problems, and concerns about occupations and dailylife activity performance are identified and priorities andvalues ascertained. The clients background and history inreference to engagement in occupations and in activities arealso explored. The second substep of the evaluation process,analysis of occupational performance, focuses on morespecifically identifying occupational performance issues andevaluating selected factors that support and hinder perfor-mance. Although each subsection is described separatelyand sequentially, in actuality, information pertinent to bothsubsections may be gathered during either one. The clientsinput is central in this process, and the clients prioritiesguide choices and decisions made during the process ofevaluation.

Occupational Profile

An occupational profile is defined as information thatdescribes the clients occupational history and experiences,patterns of daily living, interests, values, and needs. Theprofile is designed to gain an understanding of the clientsperspective and background. Using a client-centeredapproach, information is gathered to understand what iscurrently important and meaningful to the client (what heor she wants and needs to do) and to identify past experi-ences and interests that may assist in the understanding ofcurrent issues and problems. During the process of collect-ing this information, the clients priorities and desired tar-geted outcomes that will lead to engagement in occupationto support participation in life are also identified. Only

clients can identify the occupations that give meaning totheir lives and select the goals and priorities that are impor-tant to them. Valuing and respecting the clients input helpsto foster client involvement and can more efficiently guideinterventions.

Information about the occupational profile is collectedat the beginning of contact with the client. However, addi-tional information is collected over time throughout theprocess, refined, and reflected in changes subsequentlymade to targeted outcomes.

Process. The theories and frames of reference that theoccupational therapist selects to guide his or her reasoningwill influence the information that is collected during theoccupational profile. Scientific knowledge and evidenceabout diagnostic conditions and occupational performanceproblems is used to guide information gathering.

The process of completing the occupational profilewill vary depending on the setting and the client. Theinformation gathered in the profile may be obtained bothformally and informally and may be completed in one ses-sion or over a much longer period while working with theclient. Obtaining information through both formal inter-view and casual conversation is a way of beginning toestablish a therapeutic relationship with the client. Ideally,the information obtained through the occupational profilewill lead to a more individualized approach in the evalua-tion, intervention planning, and intervention implementa-tion stages.

Specifically, the following information is collected: Who is the client (individual, caregiver, group, popula-

tion)? Why is the client seeking service, and what are the clients

current concerns relative to engaging in occupations andin daily life activities?

What areas of occupation are successful, and what areasare causing problems or risks? (see Figure 1)

What contexts support engagement in desired occupa-tions, and what contexts are inhibiting engagement?

What is the clients occupational history (i.e., life experi-ences, values, interests, previous patterns of engagementin occupations and in daily life activities, the meaningsassociated with them)?

What are the clients priorities and desired targeted out-comes (see Appendix, Table 9)? Occupational performance Client satisfaction Role competence Adaptation Health and wellness Prevention Quality of life


After profile data are collected, the therapist reviews theinformation and develops a working hypothesis regardingpossible reasons for identified problems and concerns andidentifies the clients strengths and weaknesses. Outcomemeasures are preliminarily selected.

Analysis of Occupational Performance

Occupational performance is defined as the ability to carryout activities of daily life, including activities in the areas ofoccupation: activities of daily living (ADL) [also called basicactivities of daily living (BADL) and personal activities ofdaily living (PADL)], instrumental activities of daily living(IADL), education, work, play, leisure, and social participa-tion. Occupational performance results in the accomplish-ment of the selected occupation or activity and occurs througha dynamic transaction among the client, the context, and theactivity. Improving or developing skills and patterns in occu-pational performance leads to engagement in one or moreoccupations (adapted in part from Law et al., 1996, p. 16).

When occupational performance is analyzed, the per-formance skills and patterns used in performance are iden-tified, and other aspects of engaging in occupation thataffect skills and patterns (e.g., client factors, activitydemands, context or contexts) are evaluated. The analysisprocess identifies facilitators as well as barriers in variousaspects of engagement in occupations and in daily life activ-ities. Analyzing occupational performance requires anunderstanding of the complex and dynamic interactionamong performance skills, performance patterns, context orcontexts, activity demands, and client factors rather than ofany one factor alone.

The information gathered during the occupational pro-file about the clients needs, problems, and priorities guidesdecisions during the analysis of occupational performance.The profile information directs the therapists selection ofthe specific occupations or activities that need to be furtheranalyzed and influences the selection of specific assessmentsthat are used during the analysis process.

Process. Using available evidence and all aspects of clin-ical reasoning (scientific, narrative, pragmatic, ethical), thetherapist selects one or more frames of reference to guidefurther collection of evaluation information. The followingactions are taken: Synthesize information from the occupational profile to

focus on specific areas of occupation and their contextsthat need to be addressed.

Observe the clients performance in desired occupationsand activities, noting effectiveness of the performanceskills and performance patterns. May select and use spe-cific assessments to measure performance skills and pat-terns as appropriate.

Select assessments, as needed, to identify and measuremore specifically context or contexts, activity demands,and client factors that may be influencing performanceskills and performance patterns.

Interpret the assessment data to identify what supportsperformance and what hinders performance.

Develop and refine hypotheses about the clients occupa-tional performance strengths and weaknesses.

Create goals in collaboration with the client that addressthe desired targeted outcomes. Confirm outcome measureto be used.

Delineate potential intervention approach or approachesbased on best practice and evidence.

Intervention Process

The intervention process is divided into three substeps:intervention plan, intervention implementation, and inter-vention review. During the intervention process, informa-tion from the evaluation step is integrated with theory,frames of reference, and evidence and is coupled with clin-ical reasoning to develop a plan and carry it out. The planguides the actions of the occupational therapist and occu-pational therapy assistant and is based on the clients prior-ities. Interventions are carried out to address performanceskills, patterns, context or contexts, activity demands, andclient factors that are hindering performance. Periodicreviews throughout the process allow for revisions in theplan and actions. Again, collaboration with the client is vitalin this section of the process to ensure effectiveness and suc-cess. All interventions are ultimately directed toward achiev-ing the overarching outcome of engagement in occupationto support participation.

Intervention Plan

An intervention plan is defined as a plan that is developedbased on the results of the evaluation process and describesselected occupational therapy approaches and types of inter-ventions to reach the clients identified targeted outcomes.An intervention plan is developed collaboratively with theclient (including, in some cases, family or significant others)and is based on the clients goals and priorities.

The design of the intervention plan is directed by the clients goals, values, and beliefs; the health and well-being of the client; the clients performance skills and performance patterns,

as they are influenced by the interaction among the con-text or contexts, activity demands, and client factors;and

the setting or circumstance in which the intervention isprovided (e.g., caregiver expectations, organizations pur-pose, payers requirements, or applicable regulations).


Interventions are designed to foster engagement inoccupations and in activities to support participation in life.The selection and design of the intervention plan and goalsare directed toward addressing the clients current andpotential problems related to engagement in occupations orin activities.

Process. Intervention planning includes the followingsteps:1. Develop the plan. The occupational therapist develops

the plan. The occupational therapy assistant, based onestablished competencies and under the supervision ofthe occupational therapist, may contribute to the plansdevelopment. The plan includes the following:

Objective and measurable goals with a timeframe Occupational therapy intervention approach or

approaches based on theory and evidence (seeAppendix, Table 7). Create or promote Establish or restore Maintain Modify Prevent

Mechanisms for service delivery Who will provide intervention Types of interventions Frequency and duration of service

2. Consider potential discharge needs and plans.3. Select outcome measures.4. Make recommendation or referral to others as needed.

Intervention Implementation

Intervention is the process of putting the plan into action.Intervention implementation is defined as the skilled pro-cess of effecting change in the clients occupational perfor-mance, leading to engagement in occupations or in activi-ties to support participation. Intervention implementationis a collaborative process between the client and the occu-pational therapist and assistant.

Interventions may be focused on changing the contextor contexts, activity demands, client factors, performanceskills, or performance patterns. Occupational therapists andoccupational therapy assistants recognize that change in onefactor may influence other factors. All factors that affectperformance are interrelated and influence one another in acontinuous dynamic process that results in performance indesired areas of occupation. Because of this dynamic inter-relationship, dynamic assessment continues throughout theimplementation process.

Process. Intervention implementation includes the fol-lowing steps:1. Determine and carry out the type of occupational ther-

apy intervention or interventions to be used (seeAppendix, Table 8).

Therapeutic use of self Therapeutic use of occupations or activities

Occupation-based activity Purposeful activity Preparatory methods

Consultation process Education process

2. Monitor clients response to interventions based onongoing assessment and reassessment.

Intervention Review

Intervention review is defined as a continuous process forreevaluating and reviewing the intervention plan, the effec-tiveness of its delivery, and the progress toward targeted out-comes. This process includes collaboration with the client(including, in some cases, family, significant others, andother service providers). Reevaluation and review may leadto change in the intervention plan. The intervention reviewprocess may be carried out differently in a variety of settings.

Process. The intervention review includes the followingsteps:1. Reevaluate the plan and how it is carried out with the

client relative to achieving targeted outcomes.2. Modify the plan as needed.3. Determine the need for continuation, discontinuation,

or referral.

Outcomes Process

Outcomes are defined as important dimensions of healththat are attributed to interventions, including ability tofunction, health perceptions, and satisfaction with care(adapted from Request for Planning Ideas, 2001). Theimportant dimension of health that occupational therapistsand occupational therapy assistants target as the professionsoverarching outcome is engagement in occupation to sup-port participation. The two concepts included in this out-come are defined as follows: Engagement in occupationThe commitment made to

performance in occupations or activities as the result ofself-choice, motivation, and meaning, and includes theobjective and subjective aspects of carrying out occupa-tions and activities that are meaningful and purposefulto the person.

Participationinvolvement in a life situation (WHO,2001, p. 10).

Engagement in occupation to support participation isthe broad outcome of intervention that is designed to fosterperformance in desired and needed occupations or activities.When clients are actively involved in carrying out occupa-


tions or daily life activities that they find purposeful andmeaningful in home and community settings, participationis a natural outcome. Less broad and more specific outcomesof occupational therapy intervention (see Appendix, Table 9)are multidimensional and support the end result of engage-ment in occupation to support participation.

In targeting engagement in occupation to support par-ticipation as the broad, overarching outcome of the occu-pational therapy intervention process, the profession under-scores its belief that health and well-being are holistic andthat they are developed and maintained through activeengagement in occupation.

The focus on outcomes is interwoven throughout theprocess of service delivery within occupational therapy.During the evaluation phase of the process, the clients ini-tial targeted outcomes regarding desired engagement inoccupation or daily life activities are identified. As furtheranalysis of occupational performance and development ofthe treatment plan take place, targeted outcomes are furtherrefined. During intervention implementation and reevalua-tion, targeted outcomes may be modified based on chang-ing needs, contexts, and performance abilities. Outcomeshave numerous definitions and connotations for differentclients, payers, regulators, and organizations. The specificoutcomes chosen will vary by practice setting and will beinfluenced by the particular stakeholders in each setting.

Process. Implementation of the outcomes processincludes the following steps:1. Select types of outcomes and measures, including, but

not limited to occupational performance, client satisfac-tion, adaptation, role competence, health and wellness,prevention, and quality of life.

Selection of outcome measures occurs early in theintervention process (see Evaluation Process,Occupational Profile section).

Outcome measures that are selected are valid, reliable,and appropriately sensitive to change in the clientsoccupational performance, and they match the tar-geted outcomes.

Selection of an outcome measure or instrument for aparticular client should be congruent with client goals.

Selection of an outcome measure should entail con-sidering its actual or purported ability to predictfuture outcomes.

2. Measure and use outcomes. Compare progress toward goal achievement to target-

ed outcomes throughout the intervention process. Assess outcome results and use to make decisions

about future direction of intervention (i.e., continueintervention, modify intervention, discontinue inter-vention, provide follow-up, refer to other services).

An Overview of the Occupational Therapy Practice ProcessTable 10 in the Appendix summarizes the process thatoccurs during occupational therapy service delivery. Thearrow placed between the Occupational Profile andAnalysis of Occupational Performance evaluation substepsindicates the interactions between these two. However, asimilar interaction occurs among all of the steps and sub-steps. The process is not linear but, instead, is fluid anddynamic, allowing the occupational therapist and occupa-tional therapy assistant to operate with an ongoing focuson outcomes while continually reflecting and changing anoverall plan to accommodate new developments andinsights along the way.

AcknowledgmentsThe Commission on Practice (COP) would like to thankand acknowledge all those who participated in the reviewand comment process associated with the development ofthe Occupational Therapy Practice Framework: Domain andProcess. The COP has found this process invaluable andenriching. Everyones input has been carefully reviewedand considered. Often, small comments repeated by manycan lead to significant discussion and change. The COPhopes that all those who contributed to this process willcontinue to do so for future documents and will encourageothers to participate. The profession is richer for this process.

The COP would like to thank the following individu-als for their significant contributions to the direction andfinal content of this document: Carolyn Baum, PhD, OTR,FAOTA; Elizabeth Crepeau, PhD, OTR, FAOTA; Patricia A.Crist, PhD, FAOTA; Winifred Dunn, PhD, OTR, FAOTA;Anne G. Fisher, PhD, OTR, FAOTA; Gail S. Fidler, OTR,FAOTA; Mary Foto, OT, FAOTA; Nedra Gillette, SCD (HON),MEd, OTR, FAOTA; Jim Hinojosa, PhD, OT, FAOTA; Margo B.Holm, PhD, OTR, FAOTA; Gary Kielhofner, DRPH, OTR/L,FAOTA; Paula Kramer, PhD, OTR, FAOTA; Mary Law, PhD,OT(C); Linda T. Learnard, OTR/L; Anne Mosey, PhD, OTR,FAOTA; Penelope A. Moyers, EDd, OTR, FAOTA; DavidNelson, PhD, OTR, FAOTA; Marta Pelczarski, OTR; KathlynL. Reed, PhD, OTR, FAOTA; Barbara Schell, PhD, OTR/L,FAOTA; Janette Schkade, PhD, OTR; Wendy Schoen; CarolSiebert, MS, OTR/L; V. Judith Thomas, MGA; LindaKohlman Thomson, MOT, OT, OT(C), FAOTA; Amy L.Walsh, OTR/L; Wendy Wood, PhD, OTR, FAOTA; BostonUniversity OT Students mentored by Karen Jacobs, EDd,OTR/L, CPE, FAOTA; and the University of KansasOccupational Therapy Education Faculty.



Appendix

TABLE 1. AREAS OF OCCUPATION Various kinds of life activities in which people engage, including ADL, IADL, education, work, play, leisure, and social participation.

n ACTIVITIES OF DAILY LIVING (ADL)

Activities that are oriented toward taking care ofones own body (adapted from Rogers & Holm,1994, pp. 181202)also called basic activities ofdaily living (BADL) or personal activities of dailyliving (PADL).

Bathing, showeringObtaining and using sup-plies; soaping, rinsing, and drying body parts;maintaining bathing position; and transferring toand from bathing positions.

Bowel and bladder management Includescomplete intentional control of bowel movementsand urinary bladder and, if necessary, use of equip-ment or agents for bladder control (Uniform DataSystem for Medical Rehabilitation [UDSMR], 1996,pp. III20, III24).

DressingSelecting clothing and accessoriesappropriate to time of day, weather, and occasion;obtaining clothing from storage area; dressing andundressing in a sequential fashion; fastening andadjusting clothing and shoes; and applying andremoving personal devices, prostheses, ororthoses.

EatingThe ability to keep and manipulatefood/fluid in the mouth and swallow it (OSullivan,1995, p. 191) (AOTA, 2000, p. 629).

FeedingThe process of [setting up, arranging,and] bringing food [fluids] from the plate or cup tothe mouth (OSullivan, 1995, p. 191) (AOTA, 2000,p. 629).

Functional mobilityMoving from one positionor place to another (during performance of every-day activities), such as in-bed mobility, wheelchairmobility, transfers (wheelchair, bed, car, tub, toilet,tub/shower, chair, floor). Performing functionalambulation and transporting objects.

Personal device careUsing, cleaning, andmaintaining personal care items, such as hearingaids, contact lenses, glasses, orthotics, prosthetics,adaptive equipment, and contraceptive and sexualdevices.

Personal hygiene and groomingObtainingand using supplies; removing body hair (use ofrazors, tweezers, lotions, etc.); applying and remov-ing cosmetics; washing, drying, combing, styling,brushing, and trimming hair; caring for nails(hands and feet); caring for skin, ears, eyes, andnose; applying deodorant; cleaning mouth; brush-ing and flossing teeth; or removing, cleaning, andreinserting dental orthotics and prosthetics.

Sexual activityEngagement in activities thatresult in sexual satisfaction.

Sleep/restA period of inactivity in which onemay or may not suspend consciousness.

Toilet hygieneObtaining and using supplies;clothing management; maintaining toileting posi-tion; transferring to and from toileting position;cleaning body; and caring for menstrual and conti-nence needs (including catheters, colostomies, andsuppository management).

n INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

Activities that are oriented toward interacting withthe environment and that are often complexgenerally optional in nature (i.e., may be delegatedto another) (adapted from Rogers & Holm, 1994,pp. 181202).

Care of others (including selecting andsupervising caregivers)Arranging, supervis-ing, or providing the care for others.

Care of petsArranging, supervising, or provid-ing the care for pets and service animals.

Child rearingProviding the care and super-vision to support the developmental needs of achild.

Communication device useUsing equipmentor systems such as writing equipment, telephones,typewriters, computers, communication boards, calllights, emergency systems, braille writers, telecom-munication devices for the deaf, and augmentativecommunication systems to send and receive infor-mation.

Community mobilityMoving self in the com-munity and using public or private transportation,such as driving, or accessing buses, taxi cabs, orother public transportation systems.

Financial managementUsing fiscalresources, including alternate methods of financialtransaction and planning and using finances withlong-term and short-term goals.

Health management and maintenanceDeveloping, managing, and maintaining routinesfor health and wellness promotion, such as physi-cal fitness, nutrition, decreasing health risk behav-iors, and medication routines.

Home establishment and managementObtaining and maintaining personal and householdpossessions and environment (e.g., home, yard,garden, appliances, vehicles), including maintain-ing and repairing personal possessions (clothingand household items) and knowing how to seekhelp or whom to contact.

Meal preparation and cleanupPlanning,preparing, serving well-balanced, nutritional mealsand cleaning up food and utensils after meals.

Safety procedures and emergency responsesKnowing and performing preventiveprocedures to maintain a safe environment as wellas recognizing sudden, unexpected hazardous situ-ations and initiating emergency action to reduce thethreat to health and safety.

ShoppingPreparing shopping lists (grocery andother); selecting and purchasing items; selectingmethod of payment; and completing money trans-actions.

n EDUCATION

Includes activities needed for being a student andparticipating in a learning environment.

Formal educational participationIncludingthe categories of academic (e.g., math, reading,working on a degree), nonacademic (e.g., recess,lunchroom, hallway), extracurricular (e.g., sports,band, cheerleading, dances), and vocational (pre-vocational and vocational) participation.

Exploration of informal personal educational needs or interests (beyond formal education)Identifying topics and meth-ods for obtaining topic-related information or skills.

Informal personal education participationParticipating in classes, programs, and activitiesthat provide instruction/training in identified areasof interest.

n WORK

Includes activities needed for engaging in remunerative employment or volunteer activities(Mosey, 1996, p. 341).

Employment interests and pursuitsIdentifying and selecting work opportunities basedon personal assets, limitations, likes, and dislikesrelative to work (adapted from Mosey, 1996, p. 342).

Employment seeking and acquisitionIdentifying job opportunities, completing and submitting appropriate application materials,preparing for interviews, participating in interviewsand following up afterward, discussing job benefits,and finalizing negotiations.

Job performanceIncluding work habits, forexample, attendance, punctuality, appropriate relationships with coworkers and supervisors, completion of assigned work, and compliance withthe norms of the work setting (adapted from Mosey,1996, p. 342).

Retirement preparation and adjustmentDetermining aptitudes, developing interests andskills, and selecting appropriate avocational pursuits.

(Continued)


Volunteer explorationDetermining community causes, organizations, or opportunitiesfor unpaid work in relationship to personal skills,interests, location, and time available.

Volunteer participationPerforming unpaidwork activities for the benefit of identified selectedcauses, organizations, or facilities.

n PLAY

Any spontaneous or organized activity that provides enjoyment, entertainment, amusement, ordiversion (Parham & Fazio, 1997, p. 252).

Play explorationIdentifying appropriate playactivities, which can include exploration play, practice play, pretend play, games with rules, constructive play, and symbolic play (adapted fromBergen, 1988, pp. 6465).

Play participationParticipating in play; main-taining a balance of play with other areas of occu-pation; and obtaining, using, and maintaining, toys,equipment, and supplies appropriately.

n LEISURE

A nonobligatory activity that is intrinsically motivat-ed and engaged in during discretionary time, that is,time not committed to obligatory occupations suchas work, self-care, or sleep (Parham & Fazio, 1997,p. 250).

Leisure explorationIdentifying interests,skills, opportunities, and appropriate leisure activities.

Leisure participationPlanning and partici-pating in appropriate leisure activities; maintaininga balance of leisure activities with other areas ofoccupation; and obtaining, using, and maintainingequipment and supplies as appropriate.

n SOCIAL PARTICIPATION

Activities associated with organized patterns ofbehavior that are characteristic and expected of anindividual or an individual interacting with otherswithin a given social system (adapted from Mosey,1996, p. 340).

CommunityActivities that result in successfulinteraction at the community level (i.e., neighbor-hood, organizations, work, school).

Family[Activities that result in] successfulinteraction in specific required and/or desiredfamilial roles (Mosey, 1996, p. 340).

Peer, friendActivities at different levels of inti-macy, including engaging in desired sexual activity.

TABLE 1. AREAS OF OCCUPATION (Continued)

Note. Some of the terms used in this table are from, or adapted from, the rescinded Uniform Terminology for Occupational TherapyThird Edition (AOTA, 1994, pp. 10471054).

TABLE 2. PERFORMANCE SKILLSFeatures of what one does, not what one has, related to observable elements of action that have implicit functional purposes (adapted from Fisher & Kielhofner, 1995, p. 113).

n MOTOR SKILLSskills in moving and interacting with task, objects, and environment (A. Fisher, personal communication, July 9, 2001).

PostureRelates to the stabilizing and aligning ofones body while moving in relation to task objectswith which one must deal.

StabilizesMaintains trunk control and balancewhile interacting with task objects such that there isno evidence of transient (i.e., quickly passing) prop-ping or loss of balance that affects task performance.

AlignsMaintains an upright sitting or standingposition, without evidence of a need to persistentlyprop during the task performance.

PositionsPositions body, arms, or wheelchair in relation to task objects and in a manner that promotes the use of efficient arm movements duringtask performance.

MobilityRelates to moving the entire body or abody part in space as necessary when interactingwith task objects.

WalksAmbulates on level surfaces and changesdirection while walking without shuffling the feet,lurching, instability, or using external supports orassistive devices (e.g., cane, walker, wheelchair)during the task performance.

ReachesExtends, moves the arm (and whenappropriate, the trunk) to effectively grasp or placetask objects that are out of reach, including skillfullyusing a reacher to obtain task objects.

BendsActively flexes, rotates, or twists the trunkin a manner and direction appropriate to the task.

CoordinationRelates to using more than onebody part to interact with task objects in a mannerthat supports task performance.

CoordinatesUses two or more body parts togetherto stabilize and manipulate task objects during bilateral motor tasks.

ManipulatesUses dexterous grasp-and-releasepatterns, isolated finger movements, and coordinat-ed in-hand manipulation patterns when interactingwith task objects.

FlowsUses smooth and fluid arm and handmovements when interacting with task objects.

Strength and effortPertains to skills thatrequire generation of muscle force appropriate foreffective interaction with task objects.

MovesPushes, pulls, or drags task objects alonga supporting surface.

TransportsCarries task objects from one place toanother while walking, seated in a wheelchair, orusing a walker.

LiftsRaises or hoists task objects, including liftingan object from one place to another, but withoutambulating or moving from one place to another.

CalibratesRegulates or grades the force, speed,and extent of movement when interacting with taskobjects (e.g., not too much or too little).

GripsPinches or grasps task objects with no gripslips.

EnergyRefers to sustained effort over the courseof task performance.

EnduresPersists and completes the task withoutobvious evidence of physical fatigue, pausing torest, or stopping to catch ones breath.

PacesMaintains a consistent and effective rate ortempo of performance throughout the steps of theentire task.

n PROCESS SKILLSSkillsused in managingand modifying actions en route to the completion ofdaily life tasks (Fisher & Kielhofner, 1995, p. 120).

EnergyRefers to sustained effort over the courseof task performance.

PacesMaintains a consistent and effective rate ortempo of performance throughout the steps of theentire task.

(Continued)


AttendsMaintains focused attention throughoutthe task such that the client is not distracted awayfrom the task by extraneous auditory or visual stimuli.

KnowledgeRefers to the ability to seek and usetask-related knowledge.

ChoosesSelects appropriate and necessary toolsand materials for the task, including choosing thetools and materials that were specified for use priorto the initiation of the task.

UsesUses tools and materials according to theirintended purposes and in a reasonable or hygienicfashion, given their intrinsic properties and the avail-ability (or lack of availability) of other objects.

HandlesSupports, stabilizes, and holds tools andmaterials in an appropriate manner that protectsthem from damage, falling, or dropping.

HeedsUses goal-directed task actions that arefocused toward the completion of the specified task(i.e., the outcome originally agreed on or specifiedby another) without behavior that is driven or guidedby environmental cues (i.e., environmentally cuedbehavior).

Inquires(a) Seeks needed verbal or written infor-mation by asking questions or reading directions orlabels or (b) asks no unnecessary information ques-tions (e.g., questions related to where materials arelocated or how a familiar task is performed).

Temporal organizationPertains to the begin-ning, logical ordering, continuation, and completionof the steps and action sequences of a task.

InitiatesStarts or begins the next action or stepwithout hesitation.

ContinuesPerforms actions or action sequencesof steps without unnecessary interruption such thatonce an action sequence is initiated, the individualcontinues on until the step is completed.

SequencesPerforms steps in an effective orlogical order for efficient use of time and energy

and with an absence of (a) randomness in the ordering and/or (b) inappropriate repetition(reordering) of steps.

TerminatesBrings to completion single actions orsingle steps without perseveration, inappropriatepersistence, or premature cessation.

Organizing space and objectsPertains toskills for organizing task spaces and task objects.

Searches/locatesLooks for and locates tools andmaterials in a logical manner, including lookingbeyond the immediate environment (e.g., looking in,behind, on top of).

GathersCollects together needed or misplacedtools and materials, including (a) collecting locatedsupplies into the workspace and (b) collecting andreplacing materials that have spilled, fallen, or beenmisplaced.

Accommodates to other peoples reactions and requests.

TABLE 2. PERFORMANCE SKILLS(Continued)

Note. The Motor and Process Skills sections of this table were compiled from the following sources: Fisher (2001), Fisher and Kielhofner (1995)updated by Fisher (2001).The Communication/Interaction Skills section of this table was compiled from the following sources: Forsyth and Kielhofner (1999), Forsyth, Salamy, Simon, and Kielhofner(1997), and Kielhofner (2002).

TABLE 3. PERFORMANCE PATTERNSPatterns of behavior related to daily life activities that are habitual or routine.

n HABITSAutomatic behavior that is integrated into more complex patterns that enable people to function on a day-to-day basis (Neistadt & Crepeau, 1998, p. 869).Habits can either support or interfere with performance in areas of occupation.

Type of Habit Examples

Useful habits

Habits that support performance in daily life and contribute to life satisfaction. Always put car keys in the same place so they can be found easily.

Habits that support ability to follow rhythms of daily life. Brush teeth every morning to maintain good oral hygiene.

Impoverished habits

Habits that are not established. Inconsistently remembering to look both ways before crossing the street.

Habits that need practice to improve. Inability to complete all steps of a self-care routine.

Dominating habits

Habits that are so demanding they interfere with daily life. Repetitive self-stimulation such as type occurring in autism. Use of chemical substances, resulting in addiction.

Habits that satisfy a compulsive need for order. Neatly arranging forks on top of each other in silverware drawer.

n ROUTINESOccupations with established sequences (Christiansen & Baum, 1997, p. 6).

n ROLESA set of behaviors that have some socially agreed upon function and for which there is an accepted code of norms (Christiansen & Baum, 1997, p. 603).

Note. Information for Habits section of this table adapted from Dunn (2000, Fall).


TABLE 4. CONTEXT OR CONTEXTSContext (including cultural, physical, social, personal, spiritual, temporal, and virtual) refers to a variety of interrelated conditions within and surrounding the clientthat influence performance.

Context Definition Example

Cultural Customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society of which the individual is a member. Includes political aspects, such as laws that affect access to resources and affirm personal rights. Also includes opportunities for education, employment, and economic support.

Physical Nonhuman aspects of contexts. Includes the accessibility to and performance within environments having natural terrain, plants, animals, buildings, furniture, objects, tools, or devices.

Social Availability and expectations of significant individuals, such as spouse, friends, and caregivers. Also includes larger social groups that are influential in establishing norms, role expectations, and social routines.

Personal [F]eatures of the individual that are not part of a health condition or health status (WHO, 2001, p. 17). Personal context includes age, gender, socioeconomic status, and educational status.

Spiritual The fundamental orientation of a persons life; that which inspires and motivates that individual.

Temporal Location of occupational performance in time (Neistadt & Crepeau, 1998, p. 292).

Virtual Environment in which communication occurs by means of airways or computers and an absence of physical contact.

Note. Some of the definitions for areas of context or contexts are from the rescinded Uniform Terminology for Occupational TherapyThird Edition (AOTA, 1994).

Ethnicity, family, attitude, beliefs, values

Objects, built environment, natural environment, geographicterrain, sensory qualities of environment

Relationships with individuals, groups, or organizations; relationships with systems (political, economic, institutional)

Twenty-five-year-old unemployed man with a high schooldiploma

Essence of the person, greater or higher purpose, meaning,substance

Stages of life, time of day, time of year, duration

Realistic simulation of an environment, chat rooms, radiotransmissions

TABLE 6. CLIENT FACTORSThose factors that reside within the client and that may affect performance in areas of occupation. Client factors include body functions and body structures.Knowledge about body functions and structures is considered when determining which functions and structures are needed to carry out an occupation/activity andhow the body functions and structures may be changed as a result of engaging in an occupation/activity. Body functions are the physiological functions of bodysystems (including psychological functions) (WHO, 2001, p. 10). Body structures are anatomical parts of the body such as organs, limbs and their components[that support body function] (WHO, 2001, p. 10).

Client Factor

n BODY FUNCTION CATEGORIESa

Mental functions (affective, cognitive, perceptual) Global mental functions

Specific mental functions


TABLE 5. ACTIVITY DEMANDSThe aspects of an activity, which include the objects, space, social demands, sequencing or timing, required actions, and required underlying body functions andbody structure needed to carry out the activity.

Activity Demand Aspects

Objects and their properties

Space demands (relates to physical context)

Social demands (relates to social and cultural contexts)

Sequence and timing

Required actions

Required body functions

Required body structures

Examples

Tools (scissors, dishes, shoes, volleyball)

Materials (paints, milk, lipstick)

Equipment (workbench, stove, basketball hoop)

Inherent properties (heavy, rough, sharp, colorful, loud, bittertasting)

Large open space outdoors required for a baseball game

Rules of game

Expectations of other participants in activity (e.g., sharing ofsupplies)

Stepsto make tea: gather cup and tea bag, heat water, pourwater into cup, etc.

Sequenceheat water before placing tea bag in water

Timingleave tea bag to steep for 2 minutes

Gripping handlebar

Choosing a dress from closet

Answering a question

Mobility of joints

Level of consciousness

Number of hands

Number of eyes

Definition

The tools, materials, and equipment used in the process of carrying outthe activity

The physical environmental requirements of the activity (e.g., size, ar-rangement, surface, lighting, temperature, noise, humidity, ventilation)

The social structure and demands that may be required by the activity

The process used to carry out the activity (specific steps, sequence, timing requirements)

The usual skills that would be required by any performer to carry out theactivity. Motor, process, and communication interaction skills shouldeach be considered. The performance skills demanded by an activitywill be correlated with the demands of the other activity aspects (i.e.,objects, space)

The physiological functions of body systems (including psychologicalfunctions) (WHO, 2001, p. 10) that are required to support the actionsused to perform the activity.

Anatomical parts of the body such as organs, limbs, and their compo-nents [that support body function] (WHO, 2001, p. 10) that arerequired to perform the activity.

Selected Classifications From ICF and Occupational Therapy Examples

Consciousness functionslevel of arousal, level of consciousness.

Orientation functionsto person, place, time, self, and others.

Sleepamount and quality of sleep. Note: Sleep and sleep patterns are assessed in relation to how they affect ability to effec-tively engage in occupations and in daily life activities.

Temperament and personality functionsconscientiousness, emotional stability, openness to experience. Note: These func-tions are assessed relative to their influence on the ability to engage in occupations and in daily life activities.

Energy and drive functionsmotivation, impulse control, interests, values.

Attention functionssustained attention, divided attention.

Memory functionsretrospective memory, prospective memory.

Perceptual functionsvisuospatial perception, interpretation of sensory stimuli (tactile, visual, auditory, olfactory, gustatory).

Thought functionsrecognition, categorization, generalization, awareness of reality, logical/coherent thought, appropriatethought content.

(Continued)


Sensory functions and pain

Seeing and related functions

Hearing and vestibular functions

Additional sensory functions

Pain

Neuromusculoskeletal and movement-related functions

Functions of joints and bones

Muscle functions

Movement functions

Cardiovascular, hematological, immunological, and respiratory system function

Cardiovascular system function

Hematological and immunological system function

Higher-level cognitive functionsjudgment, concept formation, time management, problem solving, decision-making.

Mental functions of languageable to receive language and express self through spoken and written or sign language. Note:This function is assessed relative to its influence on the ability to engage in occupations and in daily life activities.

Calculation functionsable to add or subtract. Note: These functions are assessed relative to their influence on the ability toengage in occupations and in daily life activities (e.g., making change when shopping).

Mental functions of sequencing complex movementmotor planning.

Psychomotor functionsappropriate range and regulation of motor response to psychological events.

Emotional functionsappropriate range and regulation of emotions, self-control.

Experience of self and time functionsbody image, self-concept, self-esteem.

Seeing functionsvisual acuity, visual field functions.

Hearing functionresponse to sound. Note: This function is assessed in terms of its presence or absence and its affect onengaging in occupations and in daily life activities.

Vestibular functionbalance.

Taste functionability to discriminate tastes.

Smell functionability to discriminate smell.

Proprioceptive functionkinesthesia, joint position sense.

Touch functionssensitivity to touch, ability to discriminate.

Sensory functions related to temperature and other stimulisensitivity to temperature, sensitivity to pressure, ability to dis-criminate temperature and pressure.

Sensations of paindull pain, stabbing pain.

Mobility of joint functionspassive range of motion.

Stability of joint functionspostural alignment. Note: This refers to physiological stability of the joint related to its structuralintegrity as compared to the motor skill of aligning the body while moving in relation to task objects.

Mobility of bone functionsfrozen scapula, movement of carpal bones.

Muscle power functionsstrength.

Muscle tone functionsdegree of muscle tone (e.g., flaccidity, spasticity).

Muscle endurance functionsendurance.

Motor reflex functionsstretch reflex, asymmetrical tonic neck reflex.

Involuntary movement reaction functionsrighting reactions, supporting reactions.

Control of voluntary movement functionseyehand coordination, bilateral integration, eyefoot coordination.

Involuntary movement functionstremors, tics, motor perseveration.

Gait pattern functionswalking patterns and impairments, such as asymmetric gait, stiff gait. (Note: Gait patterns areassessed in relation to how they affect ability to engage in occupations and in daily life activities.)

Blood pressure functionshypertension, hypotension, postural hypotension.

Occupational therapists and occupational therapy assistants have knowledge of these body functions and understand broadlythe interaction that occurs between these functions and engagement in occupation to support participation. Some therapistsmay specialize in evaluating and intervening with a specific function as it is related to supporting performance and engage-ment in occupations and activities targeted for intervention.

(Continued)

TABLE 6. CLIENT FACTORS(Continued)

Client Factor Selected Classifications From ICF and Occupational Therapy Examples

Respiratory system function

Additional functions and sensations of the cardiovascular and respiratory systems

Voice and speech functions

Digestive, metabolic, and endocrine system function

Digestive system function

Metabolic system and endocrine system function

Genitourinary and reproductive functions

Urinary functions

Genital and reproductive functions

Skin and related structure functions

Skin functions

Hair and nail functions

n BODY STRUCTURE CATEGORIESb

Structure of the nervous system

The eye, ear, and related structures

Structures involved in voice and speech

Structures of the cardiovascular,immunological, and respiratory systems

Structures related to the digestive

Structure related to the genitourinary and reproductive systems

Structures related to movement

Skin and related structures

Respiration functionsrate, rhythm, and depth.

Exercise tolerance functionsphysical endurance, aerobic capacity, stamina, and fatigability.


Protective functions of the skinpresence or absence of wounds, cuts, or abrasions.

Repair function of the skinwound healing.


Occupational therapists and occupational therapy assistants have knowledge of these body functions and understand broadlythe interaction that occurs between these structures and engagement in occupation to support participation. Some thera-pists may specialize in evaluating and intervening with a specific structures as it is related to supporting performance andengagement in occupations and activities targeted for intervention.


TABLE 6. CLIENT FACTORS(Continued)

Client Factor Selected Classifications From ICF and Occupational Therapy Examples

Note. The reader is strongly encouraged to use International Classification of Functioning, Disability and Health (ICF) in collaboration with this table to provide for in-depth informationwith respect to classification in terms (inclusion and exclusion).aCategories and classifications are adapted from the ICF (WHO, 2001). bCategories are from the ICF (WHO, 2001).

Client Factor Classifications (Classification are not delineated in the Body Structure section of this table)


TABLE 7. OCCUPATIONAL THERAPY INTERVENTION APPROACHESSpecific strategies selected to direct the process of intervention that are based on the clients desired outcome, evaluation data, and evidence.

Approach

Create, promote (health promotion)aan inter-vention approach that does not assume a disabilityis present or that any factors would interfere withperformance. This approach is designed to provideenriched contextual and activity experiences that willenhance performance for all persons in the naturalcontexts of life (adapted from Dunn, McClain,Brown, & Youngstrom, 1998, p. 534).

Establish, restore (remediation, restoration)aan intervention approach designed to change clientvariables to establish a skill or ability that has notyet developed or to restore a skill or ability that hasbeen impaired (adapted from Dunn et al., 1998, p. 533).

Maintainan intervention approach designed toprovide the supports that will allow clients to pre-serve their performance capabilities that they haveregained, that continue to meet their occupationalneeds, or both. The assumption is that without con-tinued maintenance intervention, performance woulddecrease, occupational needs would not be met, orboth, thereby affecting health and quality of lif

Download - Occupational Therapy Practice Framework

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