occupational therapy goals during acute discharge for older adults · 2016-01-11 · acute...

ACUTE DISCHARGE GOALS FOR OLDER ADULTS 1!!

University of Sydney – Paige Waller

Occupational Therapy Goals during Acute Discharge for Older

Adults

Paige Waller

Master of Occupational Therapy

University of Sydney

2015

Research Supervisors: Professor Lindy Clemson

Associate Professor Natasha Lannin

Associate Professor Lynette Mackenzie



Table of Contents Acknowledgements 4

Thesis Abstract 5

List of Tables 6

List of Figures 7

Chapter One: Literature Review 8

Introduction 9

Search Strategy 9

Definitions 9

Theoretical Framework 10

Background 12

Acute Hospital Care 12

Occupational Therapy 12

Older Adults 13

Discharge Planning 15

Goal Setting 16

Successful Goal Setting 18

Barrier to Goal Setting 19

Rehabilitation Goals 20

Acute Discharge Goals 20

Conclusion 21

References 22

Chapter Two: Journal Manuscript 32

Title Page 33

Abstract and Key words 34

Introduction 35

Methods 36

Results 39

Discussion 43

Conclusion 46

Acknowledgement 47

References 48



Tables 52

Table 1. Participant and Goal Characteristics 53

Table 2. Associations between Goals and Participant Characteristics 55

Figures 58

Figure 1. Theme Map of Desire to Get Back to ‘Doing’ 59

Figure 2. Theme Map of Engaging in ‘Doing’ 60

Appendices 61

Appendix I: ‘Occupational Therapy Goal’ Table from HOME Trial 62

Appendix II: Data Collection Table from Current Study 63

Appendix III: Author Guidelines – Australian Occupational Therapy Journal 64



Acknowledgements This research project is unfunded and there are no conflicts of interest to declare.

I would like to express my thanks and appreciation to my supervisors, Professor Lindy

Clemson, Associate Professor Natasha Lannin and Associate Professor Lynette Mackenzie for

their guidance, support, patience and feedback during the completion of this thesis.



Thesis Abstract This thesis investigates the characteristics and nature of occupational therapy goals

during acute discharge for older adults. The thesis is presented in two chapters:

1. Literature review

2. Journal manuscript

The literature review chapter presented first provides a background of older adults and

their experiences with acute hospitalisation. The literature describes the role of goal setting

during discharge from acute and rehabilitation settings. The review examines existing

research on the types of goals set by clients of various ages within a range of clinical settings.

From this review it was identified that there is limited research into the characteristics and

nature of occupational therapy goals for older adults during discharge from acute

hospitalisation.

The findings from the literature review were used to inform the design and completion

of a parallel mixed methods study to identify the themes and categories of occupational goals

and determine if there is an association between the goals and participant characteristics. The

mixed methods study is presented as a journal manuscript in the second chapter of this thesis.

The manuscript describes the methods, the results and implications of this research. The

journal manuscript will be submitted to the Australian Occupational Therapy Journal.



List of Tables Chapter One: Literature Review

Table 1. 11

Type of Occupations and Definitions

Chapter Two: Journal Manuscript

Table 1. 53

Participant and Goal Characteristics

Table 2. 55

Associations between Goals and Participant Characteristics



List of Figures Chapter Two: Journal Manuscript

Figure 1. Theme Map of Desire to Get Back to ‘Doing’ (N = 414). Percentages do not

sum to 100% as goals were coded into more than one code. 59

Figure 2. Theme Map of Engaging in ‘Doing’ (N = 414). Percentages do not sum to

100% as goals were coded into more than one code. 60



Chapter One: Literature Review Introduction 9

Search Strategy 9

Definitions 9

Theoretical Framework 10

Background 12

Acute Hospital Care 12

Occupational Therapy 12

Older Adults 13

Discharge Planning 15

Goal Setting 16

Successful Goal Setting 18

Barrier to Goal Setting 19

Rehabilitation Goals 20

Acute Discharge Goals 20

Conclusion 21

References 22



Introduction This literature review provides an overview of research on the role of goal setting in

discharge planning for older adults from acute hospitalisation. The topic was considered

relevant because older adults make up a large proportion of all hospital admissions

(Australian Institute of Health and Welfare, 2015) and, the number of older adults is expected

to double in the next few decades (Australian Institute of Health and Welfare, 2015).

Discharge planning has been proposed as a way to prevent negative outcomes following

discharge. As part of discharge planning occupational therapists set goals, which are used to

guide the therapy.

Search Strategy

The following search strategies were undertaken to identify relevant literature for the

review. Science, medical and health databases were searched, including Medline, CINAHL,

AMED, Web of Science, Scopus, OT Seeker and the Cochrane Library. The databases were

searched using terms such as occupational therapy, allied health, goals, goal setting, set goals,

hospital, acute, discharge, follow up, elderly, aged and older people. Boolean operators

(AND, OR) and truncation were used to join terms into a search strategy. Example search:

[(“occupational therapy” OR “allied health”) AND (“acute discharge” OR “hospital

discharge” OR “patient discharge”) AND (“goal*” OR “goal* set*” OR “set* goal*”) AND

(“old*” OR “elder*” OR “aged”)]. Search results excluded publications unavailable in

English. From the identified articles, the references lists were reviewed to identify relevant

publications that were not found through the database searches. A search of the website the

Australian Institute for Health and Welfare was completed to obtain current statistics of the

ageing Australian population and to determine the prevalence of hospital admission.

Definitions

For the purposes of this literature review the following definitions will be used:

! Acute – A hospital setting which is concerned with preventing the client from

deteriorating (Bondoc et al., 2012) and stabilising medical issues that require

immediate treatment (Robinson & Shotwell, 2013).

! Goal – A future-oriented aim or objective to be worked towards as the desired

outcome (Trentham & Dunal, 2009). Goals can be written in lay terms or constructed

using a specific-measurable-achievable-realistic-time frame (SMART) approach.

! Discharge – The transition process from hospital admission to returning home.



! Older Adults – Throughout the research and literature older adults have been defined

using a variety of age ranges. The research reported in this literature review identifies

older adults as age 65 years or older. However, the completed HOME study from

which study data was obtained and analysed concerns adults aged 70 years or older.

Theoretical Framework

The ‘Occupational Therapy Practice Framework’ by the American Occupational

Therapy Association (2014) was selected to guide this project. First, the framework

summarises the main concepts that define occupational therapy practice, including definitions

of each type of occupation. The definition of the types of occupations has been central to data

collection and analysis for the current study. Using definitions set out in an established

clinical and research framework allows findings to be relevant, applicable and consistent with

current knowledge. The definitions of the occupations are outlined in Table 1. Second, the

‘Occupational Therapy Practice Framework’ (American Occupational Therapy Association,

2014) identifies the importance of goal setting to occupational therapy intervention. The

practice framework identifies goal setting as the beginning, midpoint and end of the

intervention plan. The goals are established early in therapy and give direction to the

intervention. The goals are then used during the midpoint and the end of therapy to evaluate

the intervention. Based on this the goals can be achieved or re-evaluated, including modifying

the intervention. Third, this framework describes the importance of occupational participation

and performance to the health and wellbeing of an individual. The framework defines

engagement as the completion of occupations, and participation as the active engagement in

roles, habits and routines (American Occupational Therapy Association, 2014). The

framework argues that through occupational engagement individuals participate in

meaningful and necessary life roles.



Table 1.

Type of Occupations and Definitions (American Occupational Therapy Association, 2014, pp.

S19-S21)

Occupation Definition

Activities of

Daily Living

Required for survival and wellbeing (e.g., bathing, toileting, dressing,

eating, feeding, functional mobility, personal device care, personal

hygiene and grooming, sexual activity).

Instrumental

Activities of

Daily Living

Activities that support living in the home and community (e.g., care of

others/pets, child rearing, communication management, driving and

community mobility, financial management, health management and

maintenance, home establishment and management, meal preparation,

religious/spiritual activities, safety and emergency maintenance,

shopping).

Rest and Sleep Rest, sleep preparation, sleeping.

Education Activities for learning and participation in learning environment (e.g.,

formal and informal education).

Work Productivity (e.g., employment, voluntary, retirement preparation and

adjustment).

Leisure Activity that is completed without obligation.

Social

Participation

Engagement in community, family, peer and/or friend activities.



Background In 2013-14 nearly half (40%) of Australian hospital admissions were older adults aged

65 years or older (Australian Institute of Health and Welfare, 2015). Every year, the

proportion of older adults admitted to Australian hospitals has increased (Australian Institute

of Health and Welfare, 2015). Further, increased average life expectancy has resulted in a

greater number of older Australians alive today (Australian Institute of Health and Welfare,

2014). By the year 2054-55, the number of Australians aged 65 years or older is predicted to

double (Commonwealth of Australia, 2015). Although an increase in life expectancy has been

perceived as a great achievement, it creates new challenges to health services caring for this

population (Hughes et al., 2011). An increase in hospital admissions is expected in line with

the ageing population (McMurdo, 2000). When admitted to hospital, older inpatients consume

a higher amount of resources compared to other age groups (Macaulay, Dingwall, & Preyde,

2009), and so returning older adults to their home following a hospital admission is cost

effective for the health service and beneficial for the older adult (Taylor, Kurytnik, & Pain,

2007). If an older adult ages in their own home, rather than in a hospital or supported

accomodation/nursing home setting, this is known as ageing in place (Fänge, Oswald, &

Clemson, 2012). However, returning an older adult to their home can be difficult as older

adults face different issues compared to younger age groups, including increased experience

of disability, mobility limitations (Fried & Guralnik, 1997), social/economic exclusion (Fänge

et al., 2012) and decreased activities of daily living (ADL) engagement (Wales, Clemson,

Lannin, & Cameron, 2012). The additional issues faced by older adults could be due to the

decline in physical, cognitive and/or sensory functioning that occurs with ageing (Hoy,

Wagner, & Hall, 2007; Wales, Clemson, Lannin, & Cameron, 2012). All of these factors

make efficient and safe hospital discharge important as we move towards an aged care model

that aims to facilitate aging in place. Efficient and safe discharge will enable ageing in place

to continue after a hospital admission.

Acute Hospital Care Occupational Therapy

When an older person is admitted to hospital they can be placed in an acute ward.

Acute hospital care aims to prevent the client from deteriorating (Bondoc et al., 2012) and

stabilise medical issues requiring immediate treatment (Robinson & Shotwell, 2013).

Occupational therapists in acute care aim to restore function, prevent further decline and

encourage mobilisation (Bondoc et al., 2012). Following this medical phase, acute wards then



organise for the client to be discharged home, or to another setting (Robinson & Shotwell,

2013), including referral to community-based services (Welch & Lowes, 2005). An

occupational therapist works within an acute setting to assess the occupational performance of

the client and use the information obtained from assessment to enable safe and timely

discharge (Welch & Lowes, 2005). This definition of an occupational therapist aligns well

with the physical, cultural and social environment of acute hospital care.

Multiple qualitative research studies have established that the high pressure and fast

paced hospital environment can result in occupational therapists focusing on safe and fast

discharge (Macaulay et al., 2009; Moats, 2006; Thomson & Black, 2008; Welch & Lowes,

2005). Within this environment the therapist has limited time to interact with the client due to

high patient turnover (Hamby, 2013; Thomson & Black, 2008), which can prevent the

therapist from gaining a thorough understanding of the needs and wants of the client and their

family. Pressure to quickly discharge in acute care results in discharge plans not being

thoroughly carried out and places the client at risk of re-admission and difficulties post

discharge (Kinsella, Park, Appiagyei, Chang, & Chow, 2008). Further, occupational therapists

have identified time and cost constraints as contributing to a focus on self-care and safety

during discharge from hospital to home (Craig, Robertson, & Milligan, 2004; Griffin, 2002).

A focus on self-care and safety does not ensure older adults are able to resume their pre-

admission roles and daily occupations outside of self-care, and such a focus may not be

adequate when older adults return to living in the community. A final issue raised in the

literature is that therapists may feel unable to advocate for clients being discharged who are

not ready (Craig et al., 2004). If a therapist believes a client is not ready to function

independently in the community post-discharge, then going ahead with a discharge could

result in increased re-admission rates and difficulties post-discharge. The above

environmental factors encountered by occupational therapists working in acute care can

therefore influence the quality of care clients receive.

Older Adults

Hospital admission for older adults frequently results in deconditioning (O'Brien,

Bynon, Morarty, & Presnell, 2011). During hospital admission older adults are not as active

as other age groups (Eyres & Unsworth, 2005). Following discharge older adults often do not

regain their pre-admission function (Lakhan et al., 2011) or mobility (Fried & Guralnik,

1997). Lakhan et al. (2011) compared self-reported pre-admission to post-discharge function

and found decreases in both ADL performance and cognition and increased incontinence at

discharge in older adults. Decreased function is detrimental to older adults and has been



correlated with increased prevalence of depression (Dunne, Wrosch, & Miller, 2011). The

decrease in cognitive and physical function makes older adults vulnerable at discharge, as

they may be unable to recommence their pre-admission lifestyle. When decreased physical

function is combined with acute discharge plans not being thoroughly carried out (Kinsella et

al., 2008), older adults can be returned to the community without suitable services to

remediate their decreased function.

Several factors have been identified to contribute to positive outcomes for older adults

during the acute discharge process. Encouraging the older person to do as much as they can

throughout their admission can reduce the severity of physical and cognitive deconditioning

during hospitalisation (McMurdo, 2000). Maintaining physical and cognitive function during

a hospital stay is beneficial as it leads to decreased rates of re-admission and death in the two

years following discharge (Inouye et al., 1998). Further, shorter hospital admissions are

favourable as older adults with shorter hospital stays score higher on functional and cognitive

assessments and have an increased likelihood of remaining in their homes in the 18 months

post discharge (Neufeld, Lysack, Macneill, & Lichtenberg, 2004). However, Neufeld et al.

(2004) found these results to be strongest for participants who returned home immediately

following discharge. Another supportive environmental factor related to successful discharge

home is living with a spouse prior to hospital admission (Huck, Penrod, Reinardy, & Kane,

1999; Stineman et al., 2014). Living with a partner before admission may increase motivation

to return home and once home the spouse can assist their partner. Differences were also found

in equipment use based on living arrangement. Individuals living alone are more likely to use

bathroom equipment than those living with a partner (Hoffmann & McKenna, 2004). This

suggests older adults living alone post-discharge are vulnerable during discharge as they do

not have the same care and support available within their home environment, compared to

those living with a partner. The above research identifies maintaining physical fitness during

admission, shorter hospital stays, discharging immediately to the home and living with others

as strengths and strategies to be used during the discharge process for older adults.

Other factors contribute to the vulnerability experienced by older adults when

discharged home. First, the high incidence of difficulties with self-care activities, higher risk

of falls, increased risk of hospital re-admission and decreased function in the home and

community (Cummings et al., 2010; Dossa, Bokhour, & Hoenig, 2012) make it difficult to re-

adapt to living independently following a hospital admission. Second, acute discharge is

perceived as challenging for older adults. Older adults are frequently concerned about losing

independence, control and fear of failure when discharged from acute hospital care (Atwal,

McIntyre, Craik, & Hunt, 2008; Bowman, 2001; Ramsdell, Jackson, Guy, & Renvall, 2004).



These concerns can make older adults hesitant to seek and accept services during discharge.

Lastly, the high prevalence of disability (Fried & Guralnik, 1997), increased social and

economic exclusion (Fänge et al., 2012) and limited ability to engage in occupations (Wales,

Clemson, Lannin, & Cameron, 2012) make older adults vulnerable when discharged into the

community. The psychological, physical, medical, environmental and occupational factors

listed above contribute to challenging cases during acute discharge for older adults. These

cases require comprehensive individualised discharge planning to adequately address the

needs of older adults.

Discharge Planning

Discharge planning is used to reduce length of hospital admission, prepare a person

for discharge home and prevent hospital re-admission following discharge (Chow & Wong,

2014; Shepperd et al., 2013). Discharge planning aims to achieve this by addressing the needs

of clients and minimise the risks associated with hospital discharge (Crennan & MacRae,

2010). A multi-disciplinary team typically completes discharge planning to decrease the

dependence of the client on others and promotes a safe transition home. Occupational

therapists are a member of this team who work from a client-centred perspective throughout

discharge planning. Occupational therapists look at what the person needs and wants to do

(Moats & Doble, 2006) and provide intervention to facilitate engagement in meaningful

occupations (Hamby, 2013; Taylor et al., 2007). Occupational therapists in an acute hospital

help older adults to re-develop functional ability and skills required for safe discharge

(Bondoc et al., 2012; Duxbury, DePaul, Alderson, Moreland, & Wilkins, 2012). As part of

discharge planning, occupational therapists may complete a pre-discharge home visit to assess

and make recommendations on the home environment (Horowitz, 2002; Wales, Clemson,

Lannin, Cameron, et al., 2012). Most commonly, discharge recommendations from an

occupational therapist involve safety in the home and equipment prescription (Harris, James,

& Snow, 2008), however skill retraining and development can also result in functional

improvements for older adults (Winkel, Langberg, & Wæhrens, 2015). The above duties are

carried out within the fast-paced, discharge-focused environment of an acute hospital setting

(Macaulay et al., 2009; Moats, 2006; Thomson & Black, 2008; Welch & Lowes, 2005),

which can place pressure on the way discharge planning is completed (Kinsella et al., 2008).

Discharge planning can be beneficial to older adults when it addresses common

problems they experience following discharge home. These problems include difficulty

returning to pre-admission occupations, concerns of caregiver burden, difficulty readjusting to

change, problems with home and community services, issues coordinating care between



different care providers, problems understanding the plan for follow-up care and medication

management (Altfeld et al., 2013; Söderback, 2008). A Cochrane review by Shepperd et al.

(2013) found discharge planning for older adults was related to decreased length of hospital

admission and reduced re-admission rates in the three months following discharge. However,

the review identified no strong evidence for differences in mortality rates or increased rates of

discharge home (Shepperd et al., 2013). Despite no difference in mortality rates or rates of

discharge home, Shepperd et al. (2013) concluded that decreased lengths of hospital

admission and reduced re-admission rates would reduce hospital bed blockages and improve

client flow through the hospital system. Other benefits of discharge planning include

improving mental health and lowering anxiety during discharge (Wressle et al., 2006). These

findings support discharge planning in acute hospital care for older adults.

Goal Setting As part of discharge planning, occupational therapists collaborate with clients to set

discharge goals. Goal setting is currently considered best practice throughout all areas of

occupational therapy to improve and maintain performance in occupations (Jackson, 2013).

Goal setting enables the client and other health professionals to communicate about the focus

of treatment during a hospital admission (Bovend'Eerdt, Botell, & Wade, 2009; Turner-

Stokes, 2009; Turner-Stokes & Williams, 2010). Through goal setting clients are able to plan

for the future, which can build a sense of hope surrounding discharge (Brown et al., 2014;

Spencer, Davidson, & White, 1997), and is associated with increased quality of life (Parsons,

Rouse, Robinson, Sheridan, & Connolly, 2012). Goal setting theory (Locke & Latham, 1990;

2002) argues that goals can also increase individual motivation, performance and persistence

towards goal attainment. The importance of goal setting to occupational therapy is identified

in the ‘Occupational Performance Process Model’ (Fearing, Law, & Clark, 1997). This model

highlights goals as emerging from assessment and being central to intervention, evaluation

and achievement in therapy. The goals set determine the types of intervention and should

reflect each client’s own goal priorities (Dyer et al., 2004; Timmer, Unsworth, & Taylor,

2015). Within occupational therapy, occupational performance issues are often identified first

and then goals are set to address the occupational performance issues (Trentham & Dunal,

2009). The goals identified with the client and the therapist can also be used to evaluate the

effect of intervention based on goal achievement (Gagne, 2001; Gagne & Hoppes, 2003;

Turner-Stokes, 2009).

Within acute hospital care goals are often set during the initial interview and are used

throughout occupational therapy as a measure of therapy outcomes and intervention



effectiveness (Melville, Baltic, Bettcher, & Nelson, 2002; Welch & Forster, 2003). Many goal

setting processes have been discussed in the literature, however a framework or approach to

goal setting is yet to be established as best practice (Scobbie, Duncan, Brady, & Wyke, 2015).

Scobbie, Dixon, and Wyke (2011) identified four steps of goal setting including: goal

negotiation; goal identification; planning or intervention; and goal appraisal and feedback.

This goal setting method is consistent with other literature on client-centred goals (Park,

2011). Tang Yan, Clemson, Jarvis & Laver (2014) identified six prominent features of

collaborative goal setting: rapport building; identification of client needs or concerns;

incorporation of the clients priorities; client involvement in problem solving to identify

strategies; clearly defined goals; and client engagement in monitoring progress towards goal

achievement. Other goal setting approaches are less specific, with Holliday, Antoun, and

Playford (2005) suggesting goals are set in response to a client’s problem. Despite different

processes to goal setting, the above papers are all consistent with the ‘Occupational

Performance Process Model’ (Fearing et al., 1997). This model highlights the centrality of

goals to all stages of therapy intervention.

In addition to methods of goal setting, the research has also identified what the goal

should contain. Occupational therapy students learn to write goals using the specific-

measurable-achievable-realistic-time based (SMART) approach (Bovend'Eerdt et al., 2009),

and this approach is sometimes used in practice. SMART goals are consistent with goal

setting theory (Locke & Latham, 1990, 2002), which argues goals should be specific,

measurable, difficult, meaningful promote self-efficacy, time-framed and involve strategies

for goal achievement. Varying qualities of SMART goals are observed in research and

clinical practice. Research has found goals frequently address the specific component, but less

than half of goals are measurable (Hassett et al., 2015). However, it is difficult for studies to

evaluate achievable and realistic components of SMART goals without detailed client and

context information. Writing SMART goals in therapy can result in increased goal

achievement, compared to non-SMART goals (Welch & Forster, 2003). The increased goal

achievement for SMART goals could be due therapists considering the achievable and

realistic nature of the goal and working within the resources and limitations of acute hospital

environment.

The goals for the current study were set using the ‘easy’ Goal Attainment Scaling

(GAS) (Turner-Stokes, 2009; Turner-Stokes & Williams, 2010). The ‘easy’ GAS is a

practical method for goal setting and evaluation through four steps. First, goals are identified

with the client, their family and the therapist. Throughout goal identification the therapist

assists the client on achievable and realistic goals and outcomes. These goals are recorded as



client-stated goals. Second, the therapist defines the expected outcomes from the client-stated

goal by generating therapist SMART goals. Third, the therapist assesses the clients’ baseline

performance in the goal activity. This is scored as some or no function. Fourth, the therapist

scores the clients performance at the end of a therapy. Performance is scored on a 5-point

scale, (1) much better than expected, (2) better than expected, (3) expected outcome, (4) less

than expected, (5) much less than expected. The ‘easy’ GAS allows client-centred goals to be

developed that can be used to evaluate therapeutic outcomes.

Successful Goal Setting

Research has identified many factors that contribute to successful goal setting for

older adults during acute discharge. Two factors are clear communication and collaboration

between the client and therapist. Communication allows the therapist and client to have the

same expectations and streamlines the goal setting process. Communication can contribute to

reduced re-admission and increased quality of life for clients following discharge (Dossa et

al., 2012). Communication can be achieved through therapist and client collaboration during

goal setting, which aligns with the healthcare paradigm shift to client-centred healthcare

(Palisano, 2014). Collaboration during goal setting can decrease anxiety by giving older

adults control of their circumstances (Brown, Craddock, & Greenyer, 2012), create a sense of

empowerment (Chow & Wong, 2014), improve satisfaction with care (McAndrew,

McDermott, Vitzakovitch, Warunek, & Holm, 1999) and promote active involvement in

therapy (Welch & Forster, 2003). Collaborative goal setting allows the client to identify what

is important to them and increases motivation to work towards and achieve therapy goals

(Bogardus et al., 2001; Brown et al., 2014; Winkel et al., 2015). Another factor is setting

realistic and achievable goals as they create feelings of success and increase motivation for

older adults (Melville et al., 2002). Realistic and achievable goals can improve the therapeutic

alliance (Alaszewski, Alaszewski, & Potter, 2004), promote behaviour change (Prochaska,

2008) and goal achievement (Potempa, Butterworth, Flaherty-Robb, & Gaynor, 2010). An

occupational therapist can work with clients to guide realistic and achievable goals and ensure

intervention is tailored towards goal achievement (Bovend'Eerdt et al., 2009; Turner-Stokes &

Williams, 2010).

A final factor is consideration of goal achievement in the natural environment. Harris

et al. (2008) identified understanding the older adults function in the hospital and their home

as necessary for returning and remaining at home following discharge. This suggests home

visits are important for discharge planning. Specific to goals, home visits could be used to

promote generalisation and transfer of goal outcomes from hospital to the home. Research



discusses the benefit of home visits to safe and timely discharge (Atwal et al., 2008), but is

yet to conclusively determine the effect of home visits on discharge outcomes (Lannin et al.,

2007; McKye, Naglie, Tierney, & Jaglal, 2009; Taylor et al., 2007). However, due to the high

cost of home visits occupational therapists have reported pressure to decrease the number of

home visits completed (Lannin, Clemson, & McCluskey, 2011). The factors of

communication, collaboration, realistic and achievable goal components and the performance

environment during goal setting have been argued to promote successful hospital discharge

for older adults.

Barriers to Goal Setting

Despite the benefits of collaborative goal setting, environmental barriers can hinder

this in an acute hospital. The high pressure, fast-paced discharge environment (Macaulay et

al., 2009; Moats, 2006; Thomson & Black, 2008; Welch & Lowes, 2005) can prevent

therapists from comprehensively understanding the client (Hamby, 2013) and completing

thorough discharge planning (Kinsella et al., 2008). Without a complete understanding of the

client and their context occupational therapists could incorrectly identify goal priorities.

Occupational therapists may also focus on self-care and safety goals (Craig et al., 2004),

without consideration of each person’s individual goals from a client-centred perspective. The

focus on fast discharge in acute care can take away from collaborative and holistic, client-

centred goal setting. Consistent with the time restrictions of an acute hospital Welch and

Forster (2003) found goals were often identified by the therapist and then communicated to

the client. This can result in clients feeling uninvolved in goal setting and intervention

planning (Almborg, Ulander, Thulin, & Berg, 2009; Atwal, Spiliotopoulou, Plastow,

McIntyre, & McKay, 2012; Eschenfelder, 2005). Although goals set by therapists may be

considered time effective, this approach conflicts with the Occupational Therapy Australia

(2014) code of ethics to respect clients’ autonomy if the goals are not consistent with the

clients’. Another factor influencing goal setting is the clients’ health. Maitra and Erway

(2006) argued it was difficult for therapists to set collaborative goals within an acute setting

when clients are unable to participate due illness. Therapists need to work within the

limitations of acute care to collaboratively set goals to promote active engagement and

achievement in therapy (Melville et al., 2002). Crennan (2010) highlight how occupational

therapy discharge assessment and decision making in acute care is a complex issue that is

unique to each individual and that training should be provided to ensure the process is client-

centred.



Rehabilitation Goals

Levack, Dean, Siegert, and McPherson (2006) acknowledge that goal setting research

has mainly been completed in rehabilitation settings compared to acute care. The literature is

clearer on the characteristics and nature of goals within rehabilitation. Goals are more

commonly achieved in rehabilitation when they are set over a short time frame, are realistic,

achievable, measurable, client identified and based on improving physical function (Barclay,

2002; Custer, Huebner, & Howell, 2015; Levack, Dean, Siegert, & McPherson, 2011). Client

goals in rehabilitation are generally broad compared to therapist goals (Brown et al., 2014;

Laver, Halbert, Stewart, & Crotty, 2010). When negotiating rehabilitation goals, differences

between the client and therapist in what is achievable lead to difficulty reaching agreement

during goal setting (Barnard, Cruice, & Playford, 2010; Glazier, Schuman, Keltz, Vally, &

Glazier, 2004). Research for clients with spinal cord injury has found no differences in the

goals set by males and females, however differences were found in the types of goals set

based on the severity of the injury (Wallace & Kendall, 2014). Adults with quadriplegia were

more likely to set personal care and ADL goals, while community access was often identified

by adults with paraplegia (Wallace & Kendall, 2014). In outpatient adult rehabilitation,

driving goals were identified most frequently, followed by employment, pain management,

leisure, personal and instrumental ADL (Custer, Huebner, Freudenberger, & Nichols, 2013).

Despite a variety of diagnoses it was found participants with a neurological diagnosis or

functional limitations, selected ADL goals more often (Custer et al., 2013). Participants with a

non-neurological diagnosis and fewer functional limitations selected employment-based goals

(Custer et al., 2013). The above rehabilitation literature suggests personal characteristics and

experience of illness or disability, not demographics, are related to the types of goals.

Acute Discharge Goals

There is limited research on the characteristics and nature of occupational therapy

goals set by older adults during acute discharge. Melville et al. (2002) identified older adults

set acute discharge goals with consideration of four elements: i) what is required for

discharge; ii) activities that are difficult, painful or requiring independence; iii) therapist

suggestions; and iv) personally valued occupations. Most goal setting studies have examined

the types of occupations in goals for older adults in acute and sub-acute settings. Within a

sub-acute setting older adults most frequently set personal and instrumental ADL goals, and

less frequently identified leisure and employment goals (Melville et al., 2002). This aligns

with other research that has found acute hospital therapists focused on self-care, safety (Craig

et al., 2004) and functional mobility goals (Welch & Forster, 2003). The high prevalence of



functional mobility goals identified by Welch and Forster (2003) could be due to the aim of

the study to audit functional assessment procedures in acute care, and so the focus on

functional assessment may have resulted in greater identification of mobility or function

goals. An increased prevalence of personal and instrumental ADL goals for older adults has

also been found in community (Fisher, Atler, & Potts, 2007; Kuluski et al., 2013) and

inpatient rehabilitation (Timmer et al., 2015). Although the methods used by Melville et al.

(2002) and Welch and Forster (2003) facilitated collaborative goal setting for the client, the

purpose of these studies was to look at the perspectives of the client during the goal setting

process and focused on occupation elements of the goal. Additionally, these studies did not

identify other characteristics of the goals set during the discharge process.

Conclusion As we move towards an ageing population, new and effective ways need to be

considered to economically meet the health demands of the ageing population. This includes

looking at the discharge process for older adults, due to their high admission rates and

vulnerability following discharge. Despite the benefits of successful discharge for older

adults, there has been little investigation into the types of occupational therapy goals set by

older adults and therapists during discharge from an acute hospital. Discharge goals are used

to guide recommendations and intervention, and so are vital to the outcomes experienced by

older adults during the transition home. Being able to set effective goals to promote positive

discharge outcomes will reduce the healthcare cost of the ageing population. Therefore, the

current study addresses the research question, what are the characteristics and nature of

occupational therapy goals set by older adults during and immediately following discharge

from an acute hospital setting? To achieve this, categories and themes will be identified

within each goal, goals set by occupational therapists and clients will be compared, and tests

for associations between the types of goals set and participant characteristics will be applied.

Gaining this knowledge will contribute to improving discharge for older adults.



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!



Chapter Two: Journal Manuscript Title Page 33

Abstract and Key words 34

Introduction 35

Methods 36

Results 39

Discussion 43

Conclusion 46

Acknowledgement 47

References 48

Tables 52

Table 1. Participant and Goal Characteristics 53

Table 2. Associations between Goals and Participant Characteristics 55

Figures 58

Figure 1. Theme Map of Desire to Get Back to ‘Doing’ 59

Figure 2. Theme Map of Engaging in ‘Doing’ 60

Appendices 61

Appendix I: ‘Occupational Therapy Goal’ Table from HOME Trial 62





Occupational Therapy Goals during Acute Discharge for Older Adults

Authors: Paige Waller

BSc.(Psych.)

Final year student – M. Occupational Therapy

Research Supervisors: Professor Lindy Clemson

Associate Professor Natasha Lannin

Associate Professor Lynette Mackenzie

Research Locations: University of Sydney

Cumberland Campus

Lidcombe, NSW 2006

Correspondence: Paige Waller [email protected]

7/14 Victoria Ave

Woollahra, NSW, 2025

Running Head: Acute Discharge Goals for Older Adults

Target Journal: Australian Occupational Therapy Journal (see Author

Guidelines, Appendix III)

Key Words: Aged; aged, 80 and over; patient discharge

Total Word Length: 4644

Number of References: 32

Number of Tables 2

Number of Figures 2



Abstract Background: As the population ages, the number of older adults admitted to hospital can be

expected to increase. Efficient and safe discharge planning, including goal setting, needs to be

achieved to effectively manage this.

Aim: To describe the characteristics and nature of occupational therapy goals set by older

adults during and immediately following discharge from an acute hospital. Exploration of the

characteristics and nature of goals and associations with specific characteristics of the sample

can identify the needs of the older adult population during discharge.

Methods: A parallel mixed-methods study design was conducted using secondary analysis of

data from a randomised trial. Content analysis was used to identify key themes and categories

within the goals. Descriptive statistics were used to describe characteristics of the participants.

Chi-square was used to determine associations between participant characteristics and goal

themes.

Results: From a random sample of 50 participant files, 414 goals were identified. Two key

themes, (a) ‘desire to get back to doing’, and (b) ‘engaging in doing’ emerged from the goals.

Four sub-themes were identified describing the ‘what’, ‘how’, ‘who’ and ‘where’ components

of goals. Instrumental activities of living goals were identified most frequently. An

association was found between type of goals and living arrangement, participation,

comorbidities and functional independence.

Conclusion: Older adults set goals based on their desire or want to engage in occupations.

The high frequency of instrumental activities of daily living goals needs to be considered in

delivering health services to effectively meet the needs of older people during discharge from

acute and medical wards.

Key words: Aged; aged, 80 and over; patient discharge



Introduction Nearly half (40%) of all Australian hospital admissions are older adults aged 65 years

or older (Australian Institute of Health and Welfare, 2015). Every year, there is a proportional

increase in the number of older adults admitted to Australian hospitals (Australian Institute of

Health and Welfare, 2015). By the year 2054-55, the number of older Australians is predicted

to double (Commonwealth of Australia, 2015), and an increase in hospital admissions is

expected in line with this ageing population. This increase in numbers will pose a greater

challenge to Australian health services. In addition to the projected increase in numbers, older

adults face different issues compared to younger age groups, including increased experience

of disability, mobility limitations (Fried & Guralnik, 1997), decreased social support (Fänge,

Oswald, & Clemson, 2012) and decreased engagement in activities of daily living (ADL)

(Wales, Clemson, Lannin, & Cameron, 2012). These factors need to be considered when

understanding the experiencethat older adult’s have during hospitalisation and discharge.

Older adults are vulnerable after discharge from acute hospitalisation. Older adults

frequently experience deconditioning during hospitalisation (O'Brien, Bynon, Morarty, &

Presnell, 2011), which is not regained following discharge (Lakhan et al., 2011). Post-

discharge, older adults have high incidences of difficulties with self-care, increased rates of

falls and high hospital re-admissions rates (Dossa, Bokhour, & Hoenig, 2012). Further, older

adults have identified feeling vulnerable during discharge with concerns about losing

independence and fear of failure (Atwal, McIntyre, Craik, & Hunt, 2008). Discharge from

hospital can be more challenging for adults living alone (Stineman et al., 2014), as those

living alone have less support available than those living with others. These challenges make

it difficult for older adults to resume their pre-admission function after discharge.

In attempting to address challenges experienced during and after acute discharge for

older adults, discharge planning is necessary to reduce length of hospital admission, prepare a

person for discharge home, and to prevent re-admission following discharge (Shepperd et al.,

2013). As part of discharge planning, occupational therapists set goals with clients.

Occupational therapy theory identifies therapy goals as arising from the therapists’

assessment with the client, as exemplified in the ‘Occupational Performance Process Model’

(Fearing, Law, & Clark, 1997). Goal theory identifies setting goals as beneficial to improve

collaborativbve agreement and understanding about the focus of treatment (Turner-Stokes &

Williams, 2010) and to increase motivation and persistence towards goal attainment (Locke &

Latham, 2002).

Within rehabilitation, client goals are broad (Brown et al., 2014) and therapist goals

are specific, but rarely measurable (Hassett et al., 2015). Differences in rehabilitation goals



are observed based on type of disability, diagnosis and the clients’ age (Custer, Huebner,

Freudenberger, & Nichols, 2013), but no differences based on gender (Wallace & Kendall,

2014). In a sub-acute setting, older adults have been shown to identify goals considering their

discharge requirements; activities that are painful, difficult or require independence; therapist

recommendations; and personally valued occupations (Melville, Baltic, Bettcher, & Nelson,

2002). Research in sub-acute care has also shown that older adults and therapists frequently

set goals to improve their performance of self-care and ADL (Craig, Robertson, & Milligan,

2004; Welch & Forster, 2003). While research has studied the occupational components of

goals, there is limited research identifying and describing occupational therapy goals set by

older adults during hospital discharge from acute care or medical wards.

Therefore, the current study addresses the research question, what are the

characteristics and nature of occupational therapy goals set by older adults during and

immediately following discharge from an acute hospital setting? To achieve this, categories

and themes will be identified within each goal, goals set by occupational therapists and clients

will be compared, and tests for associations between the types of goals set and participant

characteristics will be applied. It is hypothesised there will be a significant difference in the

types of goals between participants based on: age, living arrangement, comorbidities, and

levels of functional independence and participation. It is hypothesised their will be no

significant differences in the types of goals set between males or females.

Methods Study Design

Fifty intervention case notes were analysed from data collected in a large randomised

trial (HOME) (Clemson et al., in press). A parallel mixed-method study design was used

(Morse, 2010). Qualitative methods were used to analyse the content of goals and identify key

themes. Quantitative methods were used to identify participant demographics, comorbidities,

and levels of functional independence and participation. The qualitative and quantitative

results were analysed together to investigate the association between the content of the goals

and characteristics of the participants.

Data Source

Secondary data from the HOME trial was used in the current study. The HOME trial

evaluated the efficacy of a discharge planning intervention compared to an in hospital

consultation during discharge from acute care and medical wards for older adults (Clemson et

al., in press). Participants were recruited from six metropolitan hospitals in Sydney and



Melbourne, Australia. Participants were eligible for inclusion if they were aged 70 years or

older, living in the community prior to admission and expected to return to the community

after discharge, were conversational in English, and had no severe cognitive impairment.

Participants were excluded from the HOME trial if they had received an occupational therapy

home assessment in the past six months, had significant comorbidities, were expected to

require a wheelchair during discharge, or scored less than five on the locomotion subscale of

the Functional Independence Measure (Uniform Data System for Medical Rehabilitation,

2008). Participants were recruited from acute hospital wards and randomly allocated to

control or intervention groups. As the control group did not complete goal setting, only data

from the intervention group was used in the current study. The intervention group received an

occupational therapy discharge planning intervention (HOME) that focused on rapport and

client-centred practice, including collaborative goal setting. The participant and their family

set goals with occupational therapists trained in the ‘easy’ Goal Attainment Scaling (GAS)

method (Turner-Stokes, 2009; Turner-Stokes & Williams, 2010) which involved four steps:

(1) identify goals with the client, (2) define expected outcomes to be achieved at the end of

the intervention period, (3) score current baseline performance and then (4) score final

performance at 3 months follow-up. The goals set using this protocol were recorded on an

‘Occupational Therapy Goal’ table (Appendix I) and this was the main source of qualitative

data for the current study.

Quantitative data was obtained from clinical assessments completed as part of the

HOME trial and outlined in the protocol paper (Wales, xxxxx ref):

Baseline questionnaire. The questionnaire was completed using a semi-structured

interview to collect participant demographics.

Charlson Comorbidity Index (Charlson, Pompei, Ales, & MacKenzie, 1987). The

Charlson Comorbidity Index is a 16-item questionnaire used to identify if participants have

comorbidities known to influence health state. Comorbidities are given different weightings

depending on how they influence ten-year mortality.. As the score increases, the individual

has an increased risk of mortality in the next ten years.

Late Life Disability Index (LLDI): Frequency Dimension (Jette et al., 2002). The

LLDI is a 16-item self-report questionnaire asking participants how often they participate in

certain activities. Responses are given on a 5-point Likert scale; (1) very often, (2) often, (3)

once in a while, (4) almost never, (5) never. The LLDI was used as a measure of participation.

Nottingham Extended Activities of Daily Living (NEADL) (Nouri & Lincoln, 1987).

The NEADL is a 22-item self-report scale that was used to assess functional independence.



Participants are asked about their ADL performance in the past week. Participants score 0 for

answers ‘no’ or ‘with help’ and 1 for ‘on my own with difficulty’ or ‘on my own’..

Current Study

Sampling method. Fifty participant files were sampled from the total possible

participant files in the HOME intervention group (N =198). The intervention group files were

first stratified by gender to maintain equivalent male to female ratio, and then every fourth file

was systematically selected and de-identified.

Data collection. Written data was extracted from the ‘Occupational Therapy Goals’

table (Appendix I) and clinical notes of each participant file into an Excel spreadsheet

(Appendix II). Participant and therapist goals were entered into the database exactly as they

had been recorded in the notes, to keep authenticity to the participants/therapist goals and

prevent researcher interpretation of the goals during data collection. Additional demographic

and assessment data was obtained from the HOME trial database.

Ethical considerations. The Human Research Ethics Committee at the University of

Sydney granted ethical approval for the HOME trial (HREC/09/RRCS/07); individualised

written consent for the HOME trial included consent for data being used in future research

provided data were de-identified.

Data Analysis

Descriptive statistics. The data was quantitatively analysed using SPSS 22.

Descriptive statistics were applied to define the sample, including frequency, range, median

and mean of different variables. The variables of interest in the current study are gender, age,

living arrangements, participation level (LLDI), functional independence (NEADL), and

comorbidities. Obtaining the mean age, participation level, functional independence and

comorbidities allowed variables to be split into high and low categories in preparation for

mixed method analysis. The total count of goals, and frequencies of client and therapist goals

were identified.

Content analysis. The characteristics and nature of the goals was analysed using

inductive content analysis (Elo & Kyngäs, 2008). Content analysis was selected as it is

appropriate for analysing short qualitative data sources, such as single words or phrases

(Braun & Clarke, 2006). Content analysis places the broad data into fewer categories to

describe and quantify the goals (Elo & Kyngäs, 2008). First, a broad understanding the goals

and initial codeswere developed by investigators from the raw data goal sheets and supported

by reading and reflecting on therapist notes from 10 participant files.. Second, using the excel



spreadsheet of goals, two of the researchers [PW and LC] together coded 20 participant goals

to check and refine these initial codes. Third, researchers independently coded 100 goals to

determine if the initial codes were representative of the larger data set. Fourth, PW,LC &

NLmet to again check, refine and suggest additional codes, and reach consensus on

codesThen one researcher [PW] applied the codes to all goalsSeveral meetings were

conducted to review field notes and to continue consensus coding.. Final categories were

identified by all researchers at completion of coding through in-depth discussion and mapping

of themes and sub-themes.

Mixed Methods. Descriptive statistics and the final thematic findings were used to

determine if an association existed between the participant characteristics (gender, age, living

arrangements, participation level, functional independence and comorbidities) or the goal

author (client or therapist goal) and the types of goals. Independent sample chi-square tests

were used to determine significance.

Results Participants and Goals

From the 50 participant files sampled, 414 goals were identified. On average, each file

contained 9 goals set by the client or therapist.

Characteristics of participants and goals are presented in Table 1. The sample was

aged from 70 to 96 years with average age 80 years. Just over half of the participants were

female, received assistance from their family, and had previous hospital admissions in the

past year. Less than half were married and living alone in the community. Most participants’

income was a pension or similar benefit.

Goal Nature and Characteristics

A number of themes emerged from the content analysis of written goals. The two

main themes were (a) desire to get back to ‘doing’ and (b) engaging in ‘doing’. The four sub-

themes present in both of the main themes were (a) what ‘doing’, (b) how to ‘do’, (c) who

‘doing’ and (d) where ‘doing’. Goals often had each of the sub-themes and had one or more

components within the sub-themes. Table 2 lists the themes and categories. The main themes

of desire to get back to ‘doing’ and engaging in ‘doing’ have been mapped in Figures 1 and 2

respectively. These two figures show the relationship between the sub-themes and categories

within the themes. The quoted goals presented below are labeled as therapist (OT) or client

(CT) to identify the differences between the goals set by different authors.

Major Themes



1. Desire to get back to ‘doing’

Expressing the desire to get back to previous lifestyle or function was present in 36

(72%) of the participant files (N = 50). Goals captured the participants’ general wish to return

to something about their pre-admission life and included words such as ‘resume’, ‘usual’, ’get

back’ and ‘return’. The goals stated participation in their pre-admission lifestyle, returning to

their prior health or going home:

Get back to doing everything. (OT)

To return home. (OT)

2. Engaging in ‘doing’

Engaging in ‘doing’ involved goals that were based in activity, task or occupation.

This theme was present 379 times from the 50 participant files. Engaging in ‘doing’ goals had

an increase in the number and variety of sub-themes included, compared to desire to get back

to ‘doing’ goals. Goals expressed a specific activity that participants wanted or needed to

engage in:

Within one week client will return to cooking a simple meal for herself. (OT)

Independent with showering and dressing. (CT)

Sub-themes

What ‘doing’: Goals could be grouped based on the different types of ‘doings’, or

occupations. The types of occupations found throughout the analysis are located in the

‘doing’ box of both figures. The most frequent goal occupations were instrumental ADL,

leisure and community mobility. What ‘doing’ goals were in both themes, but were more

frequent and specific within the theme engaging in ‘doing’:

To be able to do what I was doing before I went into hospital. (Desire to get back to

‘doing’) (PT)

Walking Ollie her dog to park. (Engaging in ‘doing’) (CT)

The above goals also highlight the different activities. The first is a health

management goal. The second goal is leisure and community mobility, demonstrating how

goals can be grouped in to two different categories within the one sub-theme.

How to ‘do’: Goals stated the level of performance the participant would need to

achieve the goal. Achievement was most frequently participation or resumptions of pre-

admission lifestyle:



Return to fitness and social activities as able. (OT)

Some goals had multiple levels of achievement within the goal. The below example

describes achievement as participation, independence and use of strategy, modification or

equipment:

Within one week of discharge have vacuumed flat with three rest breaks (seated) with

nil assistance. (OT)

Other goals involved the participant’s attainment of a capability or skill development,

whether or not this skill was used functionally in a task:

To increase activity tolerance. (OT)

Increase physical endurance post discharge. (CT)

The above two capability goals demonstrate improvement, but goal improvement was

also observed in relation to specific task performance:

Improve walking. (CT)

Some goals identified goal achievement as making arrangements in preparation for

engagement in a task:

Client to look up local men’s sheds on the internet. (OT)

Goal achievement was also demonstrated by upgrading the demands of a previously

set goal:

Be able to write cards to family and friends again. (CT)

Write five thank you cards to friends and family. (OT) (Upgrade)

Who ‘doing’: Goals included whether the goal would be completed alone or with

others. Goals were more frequently completed alone. Alone was used as a default category.

Goals that were identified as alone often included words such as, independent, by myself and

without help/assistance:

Be able to walk by myself with no assistance. (CT)

If the goal was to be completed with others it included to what level the other person

would be involved. Some goals had another person involved for assistance or supervision:

Prepare meat and 3 veg meal and husband to put in oven. (OT)



Able to shower, dress, toilet & feed self with supervision from son-in-law. (CT)

Other goals involved the inclusion of others for social engagement rather than support:

Celebrate Christmas with whole family. (CT)

Where ‘doing’: Goals contained reference to an environment for goal performance.

The environment of goals was most frequently inside the home. Inside the home was used as

a default category. Goals inside and outside of the home frequently included personal ADL,

instrumental ADL and mobility:

Within 2 weeks negotiate stairs independently and use extra four wheeled walker to

collect mail. (OT)

Be safe using the shower. (CT)

Community goals identified various locations within the community, such as, clubs,

shopping centres and restaurants. Community goals included public and private transport:

To complete own grocery shopping with assistance from community transport to carry

items to bus by 28/4/13. (OT)

A small group of goals defined the performance environment as in the hospital before

the client was discharged:

Shower self while in hospital. (CT)

Association between Goals and Participant Characteristics

These results are presented in Table 2. Overall, there was little association between

goals and age or gender. The only differences in these groups were increased skill and ability

development goals in the older group compared to the younger, and increased personal ADL

goals for males compared to females.

Greater differences were observed based on living arrangement, participation and

comorbidities. The living alone group had more goals involving health management and

making arrangements, while participants living with others had increased personal ADL,

home mobility, independence and participation goals. Participants with high participation

scores had increased goals involving home mobility, personal ADL, skill and ability

development, independence, and within the home, compared to the low participation . The

low participation group had more leisure, and community-based goals. Participants with high

comorbidities had increased personal ADL, home mobility, independence and alone goals



compared to low comorbidities. The low comorbidity group had an increase in leisure,

resumption of previous lifestyle and goals completed socially with others.

The greatest differences in goals was observed based on functional independence. The

high functional independence group had more desire to get back to ‘doing’, leisure,

community mobility, resumption of previous lifestyle, making arrangements, and goals

completed in the community, compared to the low functional group. The low functional

independence group had an increase in engaging in ‘doing’, personal ADL, home mobility,

independence and strategy, modification or equipment goals that were completed within the

home.

Client and Therapist Goals

Client goals were more often completed alone. Therapist goals frequently were

completed with others for assistance or supervision, or using a strategy, modification or

equipment or requiring independence. There were no significant differences between client

and therapist goals for where ‘doing’ or the major themes, desire to get back to ‘doing’ and

engaging in ‘doing’.

Informal observation of the quality of therapist SMART goals throughout the content

analysis revealed most goals satisfied the specific SMART goal component. Measurable and

time-based components were included less frequently in therapist SMART goals. Therapist

goals included more SMART components than client goals, for example:

Weed front lawn. (CT)

In 2 weeks client will spend 1/2hr weeding front lawn from kneeling position 2x /week.

(OT)

Discussion The purpose of the current study was to explore the characteristic and nature of

occupational therapy goals set during discharge from acute hospital for older adults. The

findings suggest that central to all goals was a ‘desire to get back to doing’ or ‘engage in

doing’. The characteristics of goals were the goal components of what, who, where and how.

The secondary aims were to investigate the association between goals and participant

characteristics and to compare therapist and client goals. Generally, therapist goals were more

specific than client goals. There was little association found between goals and age or gender.

However goals were associated with living arrangements, functional independence,

participation and comorbidities suggesting that clinicians ought to pay greater attention to

these factors when goal setting for older adults during discharge from acute care.



Identifying that client and therapist goals could be grouped based on ‘desire to get

back to doing’ and ‘engaging in doing’ contained a broader range with both overall goals and

specific goals. Most participant files had one ‘desire to get back to a doing’ goal, and each

participant had multiple ‘engaging in doing’ goals. Brown et al. (2014) found adults in a

rehabilitation ward set broad goals to plan to be able to resume their pre-admission lifestyle.

This finding from Brown et al. (2014) has similarities with the ‘desire to get back to doing’

theme identified in the current study. The results of the current study differ to Brown et al.

(2014) as clients also identified specific occupation-based goals. As clients identified both

types of goals this suggests the older adults in the current study were informed about the

scope of therapy goals and actively participated in goal setting.

The sub-themes of the current study were the what, who, where, and how components

of goals. The sub-themes provided more goal specificity and identified the requirements for

goal achievement. Within the subthemes, instrumental ADL goals completed alone and

involving client participation within the home were identified most frequently. This finding of

the current study contrasts the typical acute hospital care focus on personal ADLs (Craig et

al., 2004; Welch & Forster, 2003). The high prevalence of instrumental ADL goals shows the

impact of the client-centered HOME intervention on goal setting. ‘What doing’ was present in

most goals and shows how goals could be grouped according to the categories of occupation

in occupational therapy models; the ‘who doing’ part of goals stated whether another person

would be present for the goal. Throughout analysis it became clear that goals could involve

another person for assistance, supervision or social reasons. During acute hospital discharge

goals within the home are expected, so it was interesting the goals in the current study were

split evenly between the home and community. This demonstrates the impact of the HOME

intervention on issues beyond ‘safe for discharge’. The ‘how to do’ subtheme was an

unexpected finding as the researchers expected goals to involve client improvement. However

a wider range of outcomes was observed, including, making arrangements towards a larger

goal, taking part in an activity, resuming previous lifestyle and using new strategies or

equipment.

The what, who, where and how of goals is new to research literature, however, has

been described previously in a physiotherapy goal setting guide. Randall and McEwen (2000)

described goals as including a general outcome, who, what, under what circumstances, how

well and by when. The components ‘how well’ and ‘by when’ described by Randall and

McEwen (2000) in their American study, were not consistently found in the current study,

and this may be due to international or inter-disciplinary differences in goal setting. ‘How

well’ allows goals to be measureable and ‘by when’ makes goals time-limited. Not including



the measurable component of goals was common in the current study and has been found in

other research (Hassett et al., 2015). Generally, therapists could improve goal setting by

ensuring goals are measurable and time-limited.

The results of the current study revealed similarities in the content of therapist and

client goals. This is unusual as acute therapists focus on safety and self-care (Craig et al.,

2004) and clients in the current study identified instrumental ADL goals most frequently. This

likely shows the influence of the HOME intervention on goal setting. The ‘easy’ GAS

resulted in paired goals as therapist goals came from the client-stated goal. From this it can be

concluded that the goals show older adults in the current study were able to identify needs

beyond self-care and safety and have these reflected in the therapists’ goals. Some differences

were observed in therapist and client goals. Overall, therapist goals were more specific than

client goals. Therapists included independence and strategy, equipment or modification

within goals more than clients, which aligns with equipment prescription and home safety

being the most frequent discharge recommendations (Harris, James, & Snow, 2008).

Rehabilitation literature has identified participant characteristics are more predictive

of goals (Custer et al., 2013) than demographics (Wallace & Kendall, 2014). The current

study was consistent with this and so while an association was found between living

arrangement, functional independence, participation and comorbidities, an association was not

found between goals and gender or age. Although discharge could be considered more

challenging for individuals living alone due to reduced social support and need for

independent occupational performance (Stineman et al., 2014), clients returning to live with

others set more goals. Clients living with others had greater desire to participate and complete

goals independently, suggesting client living with others set more goals to prevent them

burdening others they live with. This conclusion is comparable to that drawn by Hoffmann

and McKenna (2004) who found living with others was predictive of low use of bathroom

equipment and suggested this could be because of the inconvenience they felt this caused

others in the house. Overall clients with high functional independence and participation had a

greater number of goals compared to low counterparts. Those participants who were already

participating in community activities appeared to set goals to further increase their

occupational engagement. In regards to functional independence, high and low participants

seemed to demonstrate insight into their own abilities and incorporated this into their goals.

Client with high functional independence set more goals overall, with an increase in

community and leisure goals; clients with low functional independence focused on home-

based goals relating to personal ADL. Despite poorer health, the high comorbidity group set

more goals than the low comorbidity group. However the goals set by the high comorbidity



group focused on personal ADL tasks, home mobility and independence. This result shows

insight into realistic goals given the clients health. Similar results have been found in adult

spinal cord injury rehabilitation, where clients with quadriplegia set self-care goals, while

client with paraplegia identified community mobility goals (Wallace & Kendall, 2014). When

the association between personal characteristics and goals is considered in relation to existing

goal research,it suggests older adults set goals in the same way as other age groups.

Implications

This study shows older adults have broader goals than the traditional self-care and

safety focus of acute discharge planning. This has implications for clinical practice,

particularly when planning to work with the ageing population in acute hospital care.

Identifying goals to address all of the needs of older adults will provide holistic intervention

to meets the demands of returning to live in the community following an acute admission.

Identifying the broad scope of goals set when older adults are discharged home is vital to

increase community participation and decrease functional difficulties during and after

discharge.

Limitations and Future Research

One of the main limitations of this study was the use of secondary data. This

prevented member checking and the opportunity for in depth interpretation of goals with

therapists or participants. Further, missing data from the HOME trial therapist files (not

necessary as major outcomes to the trial and limited by therapist time for reporting additional

to usual care) prevented evaluation of goal achievement and therapist goals, as what was

achievable and realistic from the client’s and therapist’s perspectives was unknown. Although

a primary investigation into acute discharge goals for older adults would have had greater

reliability, secondary analysis was selected as it is a cost and time effective way to investigate

additional hypotheses identified during the primary investigation. The limitations of

secondary analysis were acknowledged during the design phase and methodologically

addressed by evaluating the dataset to ensure the research questions could be answered with

the existing data. Despite this, we recommend completion of a primary investigation in the

future to enable greater depth in knowledge regarding goal setting during acute discharge for

older adults. In particular, we recommend improving the accuracy of goal interpretation and

exploring the components of goal setting.

Conclusion



The research findings highlight the variety of occupational therapy goals older adults

identified during discharge from acute care and medical hospital wards. The variety of goals

identified shows that older adults have needs beyond the self-care and safety goals that are

commonly addressed during discharge. This study has shown older adults set different types

of goals based on their functional independence, participation levels, living arrangement and

comorbidities. This information needs to be considered for health services to effectively meet

the needs of this group during the crucial time of discharge home from hospital. Effectively

addressing the occupational therapy goals of older adults during discharge aims to enable

older adults to return to their pre-admission lifestyle and prevent re-admission.

Acknowledgements

The HOME trial was funded by an NHMRC project grant.

There are no conflicts of interest to declare.

The researchers would like to thank the occupational therapists at the Melbourne and Sydney

hospitals involved in the HOME trial for providing the data source for the current study.



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Fostering client and therapist alliances. Canadian Journal of Occupational Therapy,

64(1), 7-15. doi:10.1177/000841749706400103

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significance, etiology, and risk. Journal of the American Geriatrics Society, 45(1), 92-

100. doi:10.1111/j.1532-5415.1997.tb00986.x

Harris, S., James, E., & Snow, P. (2008). Predischarge occupational therapy home assessment

visits: Towards an evidence base. Australian Occupational Therapy Journal, 55(2),

85-95. doi:10.1111/j.1440-1630.2007.00684.x

Hassett, L., Simpson, G., Cotter, R., Whiting, D., Hodgkinson, A., & Martin, D. (2015). A

prospective interrupted time series study of interventions to improve the quality,

rating, framing and structure of goal-setting in community-based brain injury

rehabilitation. Clinical Rehabilitation, 29(4), 327-338.

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Hoffmann, T., & McKenna, K. (2004). A survey of assistive equipment use by older people

following hospital discharge. British Journal of Occupational Therapy, 67(2), 75-82.

doi:10.1177/030802260406700204

Jette, A. M., Haley, S. M., Coster, W. J., Kooyoomjian, J. T., Levenson, S., Heeren, T., &

Ashba, J. (2002). Late life function and disability instrument: I. Development and

evaluation of the disability component. Journal of Gerontology, 57(4), M209-M216.

doi:10.1093/gerona/57.4.M209

Lakhan, P., Jones, M., Wilson, A., Courtney, M., Hirdes, J., & Gray, L. C. (2011). A

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task motivation: A 35-year odyssey. American Psychologist, 57(9), 705-717.

doi:10.1037/0003-066X.57.9.705

Melville, L. L., Baltic, T. A., Bettcher, T. W., & Nelson, D. L. (2002). Patients' perspectives

on the self-identified goals assessment. American Journal of Occupational Therapy,

56(6), 650-659. doi:10.5014/ajot.56.6.650



Morse, J. M. (2010). Simultaneous and sequential qualitative mixed method designs.

Qualitative Inquiry, 16(6), 483-491. doi:10.1177/1077800410364741

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patients. Clinical Rehabilitation, 1(4), 301-305. doi:10.1177/026921558700100409

O'Brien, L., Bynon, S., Morarty, J., & Presnell, S. (2011). Targeted occupational therapy

service for older patients admitted with trauma: Improving patient outcomes.

Australian Occupational Therapy Journal, 58(Suppl. 1), 20-21. doi:10.1111/j.1440-

1630.2011.00937.x

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Therapy, 80(12), 1197-1203. Retrieved from

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(2013). Discharge planning from hospital to home. Cochrane Database of Systematic

Reviews, 1(1), CD000313. doi:10.1002/14651858.CD000313.pub4

Stineman, M. G., Kwong, P. L., Bates, B. E., Kurichi, J. E., Ripley, D. C., & Xie, D. (2014).

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Tables Table 1. 53


Table 2. 55




Table 1.


Participants (N = 50)

n (%)

Gender (female) 30 (60)

Cultural background (Australian) 30 (60)

Married 21 (42)

Lives alone 22 (44)

Receives support from family 28 (56)

Education: Completed year 11 or 12 14 (28)

Main income: Pension or benefit 40 (80)

Previous hospital admission in past year 30 (60)

M (SD)

Age (years) (range: 70-96) 80.8 (6.2)

Charlson Comorbidity Index† 5.3 (1.3)

NEADL‡ 12.9 (6.1)

Frequency Component LLDI§ 50.9 (10.0)

Number of goals (range: 3-22) 8.9 (3.4)

Goals (N = 414) n (%)

Age

≤ 79 years 217 (52.4)

≥ 80 years 197 (47.6)

Gender

Male 164 (39.6)

Female 250 (60.4)

Goal Author

Client Goals 182 (44)

Therapist Goals 232 (56)

Living Arrangements

Alone 174 (42)

With others 240 (58)

Charlson Comorbidity Index¶∆

Low Comorbidities 190 (50)

High Comorbidities 190 (50)



Functional Independence: NEADL¶

Low Functional Independence 166 (40.1)

High Functional Independence 248 (59.9)

Participation: LLDI¶

Low Participation 239 (57.7)

High Participation 175 (42.3) Note. †Charlson Comorbidity Index. Score 0-37, scores >3 are rare, scores ≥5 have increase 3-month mortality. ‡NEADL, Nottingham Extended Activities of Daily Living. Score 0-22, higher scores = greater independence. §LLDI, Late Life Disability Index. Score 16-80, lower scores = higher participation. ¶Groups were divided into high/low based on the mean. ∆Charlson Comorbidity (N = 390; 34 missing).



Table 2.


Participant Characteristics (N = 50)

Age Gender Living

Arrangement

Functional

Independence Participation Comorbidity Goal Author

Goal Themes/Sub-

themes/Categories

(N = 414)

≤ 79

(n =

23)

≥ 80

(n =

27)

Male

(n =

20)

Female

(n = 30)

Alone

(n =

22)

With

others

(n = 28)

High (n

= 30)

Low (n

= 20)

High

(n =

23)

Low (n

= 27)

Low (n

= 23)

High

(n =

23)

Client

Goal

Therapist

Goal

Desire to get back to

‘doing’ 15 21 15 21 19 17 28* 8* 15 21 21 12 19 17

Engaging in ‘doing’ 202 177 149 230 155 224 221* 158* 160 219 170 178 163 216

What ‘doing’

Personal ADL 19 17 20* 16* 5*** 31*** 4*** 32*** 22* 14* 8** 27** 16 20

Instrumental ADL 62 49 37 74 46 65 63 48 50 61 50 52 49 62

Home Mobility 17 17 12 22 5** 29** 8*** 26*** 23** 11** 6*** 25*** 9* 25*

Community

Mobility 40 48 35 53 34 54 61* 27* 30 58 33 46 40 48

Leisure 56 46 42 60 48 54 78*** 24*** 32* 70* 60** 34** 51 51

Social 22 19 12 29 21 20 28 13 21 20 21 12 14 27

Work &

Volunteering 3† 2† 0† 5† 4† 1† 3† 2† 2† 3† 5† 0† 2† 3†

Health 20 12 17 15 21** 11** 17 15 16 16 14 15 12 20




Age Gender Living

Arrangement

Functional


Goal Themes/Sub-

themes/Categories

(N = 414)

≤ 79

(n =

23)

≥ 80

(n =

27)

Male

(n =

20)

Female

(n = 30)

Alone

(n =

22)

With

others

(n = 28)

High (n

= 30)

Low (n

= 20)

High

(n =

23)

Low (n

= 27)

Low (n

= 23)

High

(n =

23)

Client

Goal

Therapist

Goal

Management

How to ‘do’

Participation 139 115 98 156 93** 161** 144 110 108 146 110 124 116 138

Independence 31 27 20 38 10*** 48*** 13*** 45*** 35** 23** 15*** 41*** 12*** 46***

Make

Arrangements 34 35 28 41 40** 29** 53** 16** 23 46 34 26 23 46

Strategy,

Modification or

Equipment 39 38 32 45 26 51 38* 39* 31 46 34 38 8*** 69***

Skill & Ability

Development 31* 43* 35 39 27 47 37 37 41* 33* 30 34 33 41

Upgrade on

Previous Goal 10 4 3 11 6 8 11 3 3 11 4 10 4 10

Improvement 12 12 13 11 10 14 12 12 9 15 12 11 11 13

Resume Previous

Lifestyle 66 50 43 73 53 63 84** 32** 41 75 74*** 36*** 52 64




Age Gender Living

Arrangement

Functional


Goal Themes/Sub-

themes/Categories

(N = 414)

≤ 79

(n =

23)

≥ 80

(n =

27)

Male

(n =

20)

Female

(n = 30)

Alone

(n =

22)

With

others

(n = 28)

High (n

= 30)

Low (n

= 20)

High

(n =

23)

Low (n

= 27)

Low (n

= 23)

High

(n =

23)

Client

Goal

Therapist

Goal

Who ‘doing’

Alone 165 150 124 191 129 186 186 129 131 184 135* 156* 155*** 160***

Supervision 10 10 9 11 7 13 13 7 8 12 12 7 3** 17**

Assistance 26 18 16 28 21 23 25 19 18 26 23 19 8*** 36***

Socially 21 23 18 26 24 20 31 13 22 22 26** 10** 19 25

Where ‘doing’

Inside Home 111 114 93 132 89 136 118** 107** 106* 119* 96 110 101 124

Outside Home 9 9 11 7 7 11 9 9 9 9 7 10 6 12

In the Community 92 79 65 106 81 90 127*** 44** 57** 114** 85 70 74 97

In Hospital 7† 1† 1† 7† 0† 8† 0† 8† 7† 1† 4† 4† 1† 7†

Note. †Expected frequencies < 5, chi-square could not be used. * p <.05. ** p <.01. *** p <.001



Figures Figure Legends

Figure 1. Theme Map of Desire to Get Back to ‘Doing’ (N = 414). Percentages do not sum to

100% as goals were coded into more than one code.

Figure 2. Theme Map of Engaging in ‘Doing’ (N = 414). Percentages do not sum to 100% as

goals were coded into more than one code.

ACUTE DISCHARGE GOALS FOR OLDER ADULTS 59 !


Figure 1.

!



Figure 2.

Acute Discharge Goals for Older Adults 61 !

Paige Waller – University of Sydney

Appendices Appendix I: ‘Occupational Therapy Goal’ Table from HOME trial 62





Appendix I: ‘Occupational Therapy Goal’ Table from HOME Trial Client Stated goal SMART goal Baseline Review Date Achieved Level of Attainment 1 ☐ Some Function

☐ No Function ☐ Yes

☐ No ☐ Much better than expected ☐ Better than expected ☐ As expected ☐ Less than expected ☐ Much less than expected

2 ☐ Some Function ☐ No Function

☐ Yes ☐ No

☐ Much better than expected ☐ Better than expected ☐ As expected ☐ Less than expected ☐ Much less than expected


☐ Yes ☐ No



☐ Yes ☐ No



☐ Yes ☐ No




Appendix II: Data Collection Table from Current Study

Participant ID

Goal Number

Goal Source

Client Stated Goal

SMART Goal

Additional Goal

Review Time

Achieved Review Time 2

Achieved 2

Level of Attainment



Appendix III: Author Guidelines – Australian Occupational Therapy

Journal

The Australian Occupational Therapy Journal is the official journal of Occupational Therapy

Australia. The journal publishes original articles dealing with theory, research, practice and

education in occupational therapy. Papers in any of the following forms will be considered:

Feature Articles, Research Articles, Reviews, Viewpoints, Critically Appraised Papers, and

Letters to the Editor.

Research Articles

Research Articles should contain the following:

Structured abstract: 250 word limit.

Introduction: The aims of the article should be clearly stated and a theoretical framework (if

applicable) should be presented with reference to established theoretical model(s) and

background literature. A succinct review of current literature should set the work in context.

The introduction should not contain findings or conclusions.

Methods: This should provide a description of the method (including subjects, procedures and

data analysis) in sufficient detail to allow the work to be repeated by others.

Results: Results should be presented in a logical sequence in the text, tables and figures. The

same data should not be presented repetitively in different forms.

Conclusion: The conclusion should consider the results in relation to the purpose of the article

advanced in the introduction. The relationship of your results to the work of others and

relevant methodological points could also be discussed. Implications for future research and

practice should be considered. The conclusion section of your structured abstract should

contain the key messages/take home points of your article.

Research Article manuscripts should not exceed 5000 words, and have no more than 35

references.

For manuscripts that report on randomised controlled trials, please include all the information

required by the CONSORT checklist. All manuscripts must include a flow chart showing the

progress of participants during the trial. Where applicable, reference should be made to the

extension to the CONSORT statement for non-pharmacological treatment and the CLEAR

NPT. When restrictions on word length make this difficult, this information may be provided

in a separate document submitted with the manuscript.



EDITORIAL REVIEW AND ACCEPTANCE

The acceptance criteria for all papers are quality, originality and significance to our

readership. Except where otherwise stated, Feature Articles, Research Articles, Reviews and

Viewpoint manuscripts are blind peer reviewed by two anonymous reviewers. Final

acceptance or rejection rests with the Editorial Board or the editor, who reserves the right to

refuse any material for publication.

Manuscripts should be written so that they are intelligible to the professional reader who is

not a specialist in the particular field. They should be written in a clear, concise, direct style.

Where contributions are judged as acceptable for publication on the basis of scientific content,

the Editor and the Publisher reserve the right to modify typescripts to eliminate ambiguity and

repetition and improve communication between author and reader. If extensive alterations are

required, the manuscript will be returned to the author for revision.

COVER LETTER AND ETHICAL CONSIDERATIONS

Papers are accepted for publication in the journal on the understanding that the content has

not been published or submitted for publication elsewhere, and this must be stated in the

covering letter. The covering letter must contain an acknowledgement that all authors have

contributed significantly, and that all authors are in agreement with the content of the

manuscript.

Authors must also state that the protocol for the research project has been approved by a

suitably constituted Human Research Ethics Committee of the institution within which the

work was undertaken and that it conforms to the provisions of the Declaration of Helsinki (as

revised in 2008). All investigations involving humans must include a statement about the

ethical review process. It is expected that most investigations will seek review by a Human

Ethics Review Committee. Where ethical review has not been sought or obtained,

justification must be provided. It is expected that most investigations involving humans will

require informed consent for participant data to be collected and/or used; this process should

be described. A statement is also required about preserving participant anonymity.

The Australian Occupational Therapy Journal retains the right to reject manuscripts which do

not describe these processes, or which describe unethical conduct related to human or animal

studies.

Pre-submission English-language editing

Authors for whom English is a second language may choose to have their manuscript

professionally edited before submission to improve the English. Visit our site to learn about



the options. All services are paid for and arranged by the author. Please note using the Wiley

English Language Editing Service does not guarantee that your paper will be accepted by this

journal.

STYLE OF THE MANUSCRIPT

Manuscripts should follow the style of the Publication Manual of the American Psychological

Association, 6th ed. (2009).

Spelling. The Journal uses Australian spelling and authors should therefore follow the latest

edition of the Macquarie Dictionary.

Units. All measurements must be given in SI or SI-derived units.

Abbreviations. Abbreviations should be used sparingly - only where they ease the reader's

task by reducing repetition of long, technical terms. Initially use the word in full, followed by

the abbreviation in parentheses. Thereafter use the abbreviation only. The abbreviation of OT

is not allowed in the manuscript.

PARTS OF THE MANUSCRIPT

Manuscripts should be presented in the following order: (i) title page, (ii) abstract and key

words, (iii) text, (iv)acknowledgements, (v) references, (vi) appendices, (vii) figure legends,

(viii) tables (each table complete with title and footnotes) and (ix) figures. Footnotes to the

text are not allowed and any such material should be incorporated into the text as

parenthetical matter.

Title page

The title page should contain (i) the title of the paper, (ii) the full names, qualifications and

designations of the authors and (iii) the addresses of the institutions at which the work was

carried out together with (iv) the full postal and email address, plus facsimile and telephone

numbers, of the author to whom correspondence about the manuscript should be sent. The

present address of any author, if different from that where the work was carried out, should be

supplied in a footnote.

The title should be short, informative and contain the major key words and consider including

the study design for research articles. Do not use abbreviations in the title. A short running

title (less than 40 characters) should also be provided.

All submitted manuscripts must indicate the total word length for the manuscript, word length

of the abstract, number of references, figures and tables on the title page of the manuscript.



Abstract and key words

Research, Feature and Review articles must have a structured abstract that states in 250 words

or fewer the purpose, basic procedures, main findings and principal conclusions of the study.

Divide the abstract with the headings: Background/Aim, Methods, Results, Conclusions and

significance of the study. Viewpoint articles should have an unstructured abstract of 150

words or fewer. Abstracts should not contain abbreviations or references.

Key words

Three to five key words must be supplied. They are required to index the content of the paper

and should be selected from the US National Library of Medicine's Medical Subject

Headings (MeSH) browser list. Key words should be arranged in alphabetical order. Please do

not use words already written in your title or abstract.

Text

Authors should use the following subheadings to divide the sections of their manuscript:

Introduction, Methods, Results and Conclusion. All articles should include an introduction

that provide a background to the article, describes its purpose and outlines its relevance to

occupational therapy. References should be made to an established theoretical background

and/or background literature. The implications of the work for occupational therapy practice,

and further research and/or conceptual development, should be clearly described.

Acknowledgements

The source of financial grants and other funding must be acknowledged, including a frank

declaration of the authors' industrial links and affiliations. Authors should state any potential

conflicts of interest. The contribution of colleagues or institutions should also be

acknowledged. Personal thanks and thanks to anonymous reviewers are not appropriate.

References

The American Psychological Association (author, date, title, source) system of referencing is

used (examples are given below). In the text give the author's name followed by the year in

parentheses: Smith (2000). If there are two authors use 'and': Smith and Jones (2001), but if

cited within parentheses use '&': (Smith & Jones, 2001). When reference is made to a work by

three to five authors, cite all the authors the first time: (Davis, Jones, Wilson, Smith, & Lee,

2000); and in subsequent citations, include only the name of the first author followed by et

al.: (Davis et al., 2000). When reference is made to a work by six or more authors, the first



name followed by et al. should be used in all instances: Law et al. (1997). If several papers by

the same author(s) from the same year are cited, a, b, c, etc. should be inserted after the year

of publication. Within parentheses, groups of authors should be listed alphabetically. In the

reference list, references should be listed in alphabetical order.

In the reference list, cite the names of all authors when there are six or fewer; when seven or

more, list only the first six followed by et al. Do not use ibid. or op cit. Reference to

unpublished data and personal communications should not appear in the list but should be

cited in the text only (e.g. A. Smith, unpublished data, 2000). All citations mentioned in the

text, tables or figures must be listed in the reference list.

Authors are responsible for the accuracy of the references.

We recommend the use of a tool such as Reference Manager for reference management and

formatting.

Journal article

Bennett, S., & Bennett, J. W. (2000). The process of evidence-based practice in occupational

therapy: Informing clinical decisions. Australian Occupational Therapy Journal, 47, 171-180.

doi: 10.1046/j.1440-1630.2000.00237.x.

Advanced online publication of journal article with DOI

Rodger, S., Clark, M., Banks, R., O'Brien, M., & Martinez, K. (2009a). A national evaluation

of the Australian Occupational Therapy Competency Standards (1994): A multistakeholder

perspective.Australian Occupational Therapy Journal. Advanced online publication. doi:

10.1111/j.1440-1630.2009.00794.x.

Book

Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, CA:

Sage.

Chapter in a book

Law, M., Cooper, B. A., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1997). Theoretical

context for the practice of occupational therapy. In: C. Christiansen & C. Baum

(Eds.), Occupational therapy: Enabling function and well-being (2nd ed., pp. 72-102).

Thorofare, NJ: Slack Inc.

Electronic media

Occupational Therapy Australia. (2003). Australian Occupational Therapy Journal author

guidelines. Retrieved from http://www.blackwell-publishing.com/journals/aot/submiss.htm.

Appendices

These should be placed at the end of the paper, numbered in Roman numerals and referred to



in the text. If written by a person other than the author of the main text, the writer's name

should be included below the title.

Tables

There is a limit of four tables or figures per manuscript. Tables should be self-contained and

complement, but not duplicate, information contained in the text. Number tables

consecutively in the text in Arabic numerals. Type tables on a separate sheet with the legend

above. Legends should be concise but comprehensive - the table, legend and footnotes must

be understandable without reference to the text. Vertical lines should not be used to separate

columns. Column headings should be brief, with units of measurement in parentheses; all

abbreviations must be defined in footnotes. Footnote symbols: †, ‡, §, ¶, should be used (in

that order) and *, **, *** should be reserved for P-values. Statistical measures such as SD or

SEM should be identified in the headings.

Figures

There is a limit of four tables or figures per manuscript. All illustrations (line drawings and

photographs) are classified as figures. Figures should be cited in consecutive order in the text.

Each figure should be labelled on the back in very soft marker or chinagraph pencil,

indicating name of author(s), figure number and orientation. Do not use adhesive labels as

this prohibits electronic scanning. Figures should be sized to fit within the column (80 mm),

intermediate (114 mm) or the full text width (171 mm).

Line figures should be supplied as sharp, black and white graphs or diagrams, drawn

professionally or with a computer graphics package. Lettering must be included and should be

sized to be no larger than the journal text. Photographs should be supplied as sharp, glossy,

black-and-white or colour photographic prints and must be unmounted. Individual

photographs forming a composite figure should be of equal contrast, to facilitate printing, and

should be accurately squared.

Magnifications should be indicated using a scale bar on the illustration.

If supplied electronically, graphics must be supplied as high resolution (at least 300 d.p.i.)

files, saved as .eps or .tif. A high-resolution print-out must also be provided. Digital images

supplied only as low-resolution print-outs and/or files cannot be used.

Colour figure publication charges

A charge of A$1000/US$530/¥64000 for the first three colour figures and

A$500/US$265/¥32000 for each extra colour figure thereafter will be charged to the author.



Figure legends

Type figure legends on a separate sheet. Legends should be concise but comprehensive - the

figure and its legend must be understandable without reference to the text. Include definitions

of any symbols used and define/explain all abbreviations and units of measurement.

AUTHOR SERVICES

Author Services enables authors to track their article, once it has been accepted, through the

production process to publication online and in print. Authors can check the status of their

articles online and choose to receive automated emails at key stages of production so they do

not need to contact the production editor to check on progress. Visit the Author Services

website for more details on online production tracking and for a wealth of resources,

including FAQs and tips on article preparation, submission and more.

PROOFS

It is essential that corresponding authors supply an email address to which correspondence

can be emailed while their article is in production. Notification of the URL from where to

download a Portable Document Format (PDF) typeset page proof, associated forms and

further instructions will be sent by email to the corresponding author. The purpose of the PDF

proof is a final check of the layout, and of tables and figures. Alterations other than the

essential correction of errors are unacceptable at PDF proof stage. The proof should be

checked, and approval to publish the article should be emailed to the Publisher by the date

indicated, otherwise, it may be signed off on by the Editor or held over to the next issue.

OFFPRINTS

Free access to the final PDF offprint of your article will be available via Author Services

only. Please therefore sign up for Author Services if you would like to access your article

PDF offprint and enjoy the many other benefits the service offers. A minimum of 50

additional offprints will be provided upon request, at the author's expense. These paper

offprints may be ordered online. Please visithttp://offprint.cosprinters.com, fill in the

necessary details and ensure that you type information in all of the required fields. If you have

any queries about offprints, please email [email protected].

EARLY VIEW

The Australian Occupational Therapy Journal is covered by our Early View service. Early



View articles are complete full-text articles published online in advance of their publication in

a printed issue. Articles are therefore available as soon as they are ready, rather than having to

wait for the next scheduled print issue. Early View articles are complete and final. They have

been fully reviewed, revised and edited for publication, and the authors' final corrections have

been incorporated. Because they are in final form, no changes can be made after online

publication. The nature of Early View articles means that they do not yet have volume, issue

or page numbers, so Early View articles cannot be cited in the traditional way. They are

therefore given a Digital Object Identifier (DOI), which allows the article to be cited and

tracked before it is allocated to an issue. After print publication, the DOI remains valid and

can continue to be used to cite and access the article. More information about DOIs can be

found athttp://www.doi.org/faq.html.

SUBMISSION OF MANUSCRIPTS

To submit a manuscript, please visit the Australian Occupational Therapy

Journal's ScholarOne Manuscripts homepage.

COPYRIGHT, LICENSING AND ONLINEOPEN

Accepted papers will be passed to Wiley's production team for publication. The author

identified as the formal corresponding author for the paper will receive an email prompting

them to login into Wiley's Author Services, where via the Wiley Author Licensing Service

(WALS) they will be asked to complete an electronic license agreement on behalf of all

authors on the paper. FAQs about the terms and conditions of the standard copyright transfer

agreements (CTA) in place for the journal, including terms regarding archiving of the

accepted version of the paper, are available at: CTA Terms and Conditions FAQs

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Meg A’Hearn – Editorial Assistant

Australian Occupational Therapy Journal

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occupational therapy goals during acute discharge for older adults · 2016-01-11 · acute...

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