Teaching Activities in Occupational Therapy
Why occupational therapists teach activities
Procedural and declarative learning
After studying this chapter, the student or practitioner will be able to do the following:
1 Discuss specific outcome goals for which occupational therapists teach activities.
2 Analyze how therapeutic interventions will differ, depending on the types of learning processes a client needs to develop.
3 Apply to occupational therapy interventions current knowledge about factors that influence motivation and active participation.
4 Provide appropriate instruction, feedback, and practice tailored to individual tasks and client goals.
5 Promote transfer of learning to real-life situations through effective approaches to teaching activity.
6 Implement occupational therapy interventions designed to promote active strategy development.
Case Study: Li
Li is a 67-year-old retired high school science teacher who was hit by a car as he walked across a city street. Before his accident, he was active in a variety of volunteer activities that included teaching English as a second language at the local adult education program, working as a docent at the local botanical gardens, and leading nature hikes in a nearby county park. He also was an amateur watercolor artist who had recently begun to receive recognition for his landscape paintings.
Upon referral to occupational therapy, he was nonambulatory because of a fracture of the pelvis and right femur. He also had fractures of his right clavicle and humerus, and multiple fractures of his dominant right forearm and hand. He had a severe concussion and experienced dizziness and impaired balance, memory loss and confusion, and episodes of agitation.
Teaching is a fundamental skill for occupational therapists. Therapists spend much of their time with clients teaching a variety of activities. Effectiveness as a teacher depends on the therapist’s ability to organize the environment and the instructional methods to meet the learning needs of the individual client. This chapter discusses the process of teaching for occupational therapists working with clients who have physical disabilities, and presents the reasons why occupational therapists teach activities, the phases and types of learning, and principles of teaching and learning with this population.
Why Occupational Therapists Teach Activities
Occupational therapists use a variety of teaching techniques in their interventions. Occupational therapists engage in teaching activities for the following reasons:
1. To help clients relearn skills that have been lost as a result of illness or injury. Clients may need to relearn how to perform daily tasks such as eating and dressing. They may also need to relearn basic performance skills such as the ability to maintain sitting or standing balance, reaching, or grasping. In the case of Li, his head injury affected both short- and long-term memory, impairing his ability to perform self-care skills. One of the first goals of his OT program was to relearn hygiene and grooming skills so that he could regain independence in this aspect of self-care.
2. To develop alternative or compensatory strategies for performing valued activities or occupations. Clients may need to be taught new ways to perform familiar activities. Alternative or compensatory strategies can also be taught to prevent injury and increase safety. These strategies may be temporary, as in the case of an individual who needs to learn hip precautions after hip replacement surgery, or permanent, as in the case of an individual who needs to learn to use a tenodesis grasp after a complete spinal cord injury at the C6 level. In some cases, adaptive equipment may be needed to achieve independence, and instruction in the use of adaptive equipment must be included in the teaching of compensatory strategies. Li’s occupational therapist instructed him in adaptive dressing and bathing techniques so that he could maintain independence in these activities while his fractures healed.
3. To develop new performance skills to support role performance in the context of a disabling condition. In some cases, clients will need to learn new skills to enable participation in daily occupations. Driving a wheelchair, operating a prosthetic device, and managing a bowel and bladder program are examples of new skills that clients with specific disabilities must learn. Li’s therapist worked with him to develop a reminder system to compensate for his memory loss. He learned to record and keep important information with him in a small notebook so that he could easily access phone numbers, appointments, and other needed information.
4. To provide therapeutic challenges that will help to improve performance skills to support participation in areas of occupation. Therapists may teach clients activities that provide physical and/or cognitive challenges to facilitate the rehabilitation process. Activities such as board games and crafts can be used to improve strength, dexterity, postural control, and problem-solving and sequencing skills, among others. Clients may need to be instructed on the rules or procedures of the activity, as well as on how to position or organize themselves to engage in the activity. To improve dexterity in Li’s injured right arm after the cast was removed, as well as to improve his attention and task orientation, his therapist instructed him in paint-by-number activities. These activities addressed his deficits in both motor and process skills, and supported his return to participation in his valued occupation of watercolor painting.
5. To instruct family members or caregivers in activities that will enhance the client’s independence and/or safety in daily occupations. If the client is not able to learn to perform an activity using compensatory and/or adaptive strategies, it is necessary to teach family members or caregivers how to assist or supervise the client in the activity. Many self-care and home activities may require assistance or supervision to ensure safety. Environmental modifications may need to be made to ensure the safety of the client and the caregiver and to facilitate maximal independence for the client. Li’s wife was instructed on how to help him with wheelchair transfers. She was also instructed on how to cue him to use his reminder notebook at home.
Phases of Learning
Learning generally proceeds through three phases. These phases include the acquisition phase, the retention phase, and the generalization, or transfer, phase. The acquisition, or learning, phase that occurs during initial instruction and practice is often characterized by numerous errors of performance, as the learner develops strategies and schemata for how to successfully complete the task. The retention phase is demonstrated during subsequent sessions, when the learner demonstrates recall or retention of the task in a similar situation. Transfer of learning, or generalization of skill, is seen when the learner is able to spontaneously perform the task in different environments, such as the client who is able to correctly apply hip precautions at home after learning the precautions in the therapy clinic.
Learning Capacities
Not all clients are able to transfer skills learned in one environment into other contexts. Clients who cannot transfer learning will need environmental modifications, supervision, and/or cueing to engage successfully in the activity being taught. Therefore, the therapist needs to determine each client’s capacity for retaining and transferring knowledge, so that therapist and client can establish appropriate goals and use appropriate teaching methods.
Dynamic assessment is one approach used to determine an individual’s capacity to benefit from instruction. In this assessment framework, an interactive process is used whereby the therapist uses feedback, encouragement, and guidance to facilitate an individual’s optimal performance using a test-teach-retest format.27 Dynamic assessment complements more traditional assessment methods, giving therapists the opportunity to observe learning and change, which can help guide intervention.
Transfer of knowledge can be evaluated by changing one or more attributes of the task and observing whether the client is still able to perform the task. For instance, a therapist who has been teaching upper body dressing can change the type of garment used in the task, the location or orientation of the garment relative to the client, or the client’s positioning. A client who is not able to perform the task with one or more attributes changed may not be capable of transferring new skills.
OT Practice NoteProcedural and Declarative Learning
Therapists teach tasks in which learning occurs both consciously and unconsciously. Knowledge is demonstrated in different ways for the two types of tasks. Procedural learning occurs for tasks that are typically performed automatically, without attention or conscious thought, such as many motor and perceptual skills. Procedural knowledge is developed through repeated practice in varying contexts. An individual learns to maneuver a wheelchair through a process of procedural learning, while gradually developing a movement schema for the activity.24 Verbal instruction alone is of little value. Rather, the procedures for performing this activity are learned through opportunities to experiment with different combinations of arm or arm and leg movements to achieve propulsion in a variety of directions and speeds. Learning is expressed through performance; therefore, individuals who have limitations in cognition or language can still demonstrate procedural knowledge.
Declarative learning creates knowledge that can be cognitively recalled. Learning a multistep activity such as tying a shoelace or performing a transfer is often facilitated if the client can verbalize the steps of the task while completing it. Learning can also be demonstrated by verbally describing (declaring) the steps involved in completing the activity. Through repetition of an activity, declarative knowledge can become procedural, as the movement becomes more automatic and requires less cognitive attention. Mental rehearsal is an effective technique for enhancing declarative learning. During mental rehearsal, the individual practices the activity sequence by reviewing it mentally or by verbalizing the process. This method can be used effectively with clients who because of weakness or fatigue are limited in their ability to physically practice an activity. However, because of the cognitive requirements, clients with significant cognitive or language deficits may not be able to express declarative knowledge.
Principles of Teaching and Learning in OT
The process of teaching activities involves a sequence of clinical reasoning decisions. Regardless of the characteristics of the client and the activity, basic learning principles can be applied to any teaching and learning situation. These principles are presented in Box 7-1.
The principles listed in Box 7-1 illustrate that before initiating a teaching activity, the occupational therapist must be aware of (1) the client’s cognitive capacity, (2) occupations that have value to the client and the family, (3) the attributes of the task being taught, and (4) the context in which the client will be expected to perform the activity after discharge from therapy. The therapist needs to gather this information during the initial assessment to create an accurate knowledge base from which to develop the intervention plan, the choice of activities, and the method of teaching. Effective intervention requires appropriate, evidence-based application of these principles to each client’s unique situation. Two examples of this include the framework of occupational gradation and goal-directed training. The framework of occupational gradation is a method of systematically manipulating properties of the task, the person, the object, and the environment to optimally challenge an individual’s functional performance, specifically in terms of upper extremity motor skills. This framework incorporates principles of motor learning, motor control, personal factors, environmental factors, and properties of tasks and objects. Meaningfulness of the task, client goals, and ability to incorporate the task into daily life are also key considerations.21 The goal-directed training approach uses client-selected goals to create active problem-solving opportunities for the client. Intervention is focused on the task to be achieved, rather than on impairments that may limit performance. This approach is based on the dynamical systems models of motor control and motor learning, and the ecologic occupation-based models of intervention. Goal attainment scaling is used to measure progress.16 Each of these approaches combines occupation-centered activities and active engagement of the client with application of specific motor learning and teaching techniques tailored to the cognitive and motor abilities of the client. Procedural reasoning and narrative reasoning assist the therapist in determining the appropriate configuration of goals, activities, and teaching methods for each individual. The principles of teaching and learning in occupational therapy are further discussed in the following sections.
Identify a Meaningful Activity
When conducting a client-centered assessment, the therapist explores which occupations have the greatest value and importance to the client. Engagement in these occupations can serve both as outcomes of intervention and as activities used in the intervention process. The client will be motivated to be an active partner in the therapy process if the activities are perceived to be meaningful.28 If the client does not have the capability to engage in the occupation itself, performance skills and activities that contribute to participation in the occupation are often addressed in the intervention. The client needs to be informed of how developing or improving these skills will contribute to the ability to engage in the valued occupation. Doing so helps the client ascribe meaning to the activities and facilitates optimal participation.
Li’s occupational therapist learned of his skill as a painter during the initial interview with Li and his wife. The therapist was able to use Li’s motivation to return to this valued occupation to guide the choice of drawing and painting activities to improve function in his injured arm. The therapist also was able to explain to Li how his participation in other therapeutic activities to improve strength, range of motion, and endurance would contribute to his ability to resume his occupation of painting, as well as independence in daily living skills. The therapist’s attention to Li’s interests and values created trust that led to a productive learning partnership.6
Choose Instructional Mode Compatible With Client’s Cognition
When many people think about the act of teaching, verbal instruction is what comes to mind. Verbal instruction is an effective means of conveying information in many situations. It is an efficient method for instructing groups, such as in back safety classes, during training in hip precautions after hip replacement surgery, and through instruction in body mechanics and ergonomic principles for employee groups. Verbal instruction can also be used effectively when instructing individual clients. Verbal cues can be used to provide reinforcement or to give information about the next step in the sequence or the quality of performance. Verbal cues can be an effective way to provide feedback in the early and middle stages of learning but, if possible, should be phased out as soon as possible so that the client does not become dependent on verbal cues to complete the task. Family members and caregivers can be instructed on how to provide appropriate verbal cues if the client is unable to recall a task sequence independently.
Visual instruction is effective for clients who have cognitive and/or attention deficits and difficulty processing verbal language, as well as for tasks that are too complex to describe verbally. The therapist demonstrates the activity, and the client observes the therapist and follows the therapist’s example. The therapist can repeat the demonstration as many times as is necessary for the client to accurately reproduce the task. The therapist can also break the task into steps, demonstrating one step at a time and continuing to the next step as the client completes the previous step. Other forms of visual instruction include drawings or photographs that can be used to remind a client and/or caregiver about the task sequence or desired performance outcome. Visual instruction can effectively be paired with verbal instruction, but therapists must avoid overwhelming the client with combined verbal and visual input.
Somatosensory instruction is a third mode of instruction. This involves the use of tactile, proprioceptive, and kinesthetic cues to help guide the speed and direction of a movement. Manual guidance is a form of somatosensory instruction that is especially effective for procedural learning, such as the process of weight shifting and postural adjustment involved in coming from sit to stand. Hand-over-hand assistance is effective in teaching activities to clients who have cognitive and/or sensory processing deficits; the therapist guides the client’s hands in completion of a task.
Li’s therapist used all three instructional modes. Verbal instruction was most effective for reteaching self-care skills; verbal cueing was used to orient Li to the task sequence during the acquisition phase of learning. Visual instruction was used to teach many of the therapeutic activities the therapist used to enhance upper extremity function. Somatosensory instruction was effective for balance retraining.
Structure the Learning Environment
Choosing the appropriate environment in which to instruct a client is critical to teaching success. If a client is confused or easily distracted, a quiet environment with minimal visual distraction is often needed when teaching of a task is begun. As the client becomes more proficient in the skill being taught, visual and auditory distractions need to be introduced, so that the environment more closely resembles the one in which the client will eventually engage in the activity. For instance, a therapist working with a client on self-feeding may initially conduct the intervention in the client’s room. As the client becomes more proficient and confident, the therapist may move the intervention to the facility dining room, where multiple distractions are present. While providing challenges to the client’s attention, the dining room also provides opportunities for social interaction, which may act as a motivator for the client to further improve self-feeding skills. Similarly, clients need opportunities to practice new skills in a variety of environments, so that they are proficient in meeting environmental challenges. A client who is learning how to control a wheelchair needs to practice both outdoors and indoors on a variety of surfaces. A client who is working on refining grasp and dexterity needs experience in manipulating objects of a variety of sizes, shapes, and weights, while engaging in functional tasks with a variety of demands similar to those that will be encountered in the client’s daily activities.
Li’s therapist determined that his initial confusion and agitation necessitated a quiet, minimally stimulating environment for initiation of teaching in self-care skills. As Li’s confusion cleared, he was able to work in the therapy clinic on activities to improve balance and upper extremity skills, and later worked in the kitchen and garden areas on more demanding and varied home skills.
Provide Reinforcement and Grading of Activities
The concept of reinforcement comes from operant conditioning theory, which states that behaviors that are rewarded or reinforced tend to be repeated.11 Many types of reinforcement may be used. For some clients, social reinforcement such as a smile or verbal encouragement creates motivation to continue. Other clients may require more tangible rewards, such as rest periods, snacks, favorite activities, etc. Still other clients are motivated by visible indications of their progress. Use of a graph or chart to demonstrate daily improvement in performance skills or client factors such as grip strength, sitting tolerance, or range of motion can help a client to engage more actively in the therapy process. These are examples of extrinsic reinforcement.
Many clients are motivated by completion of a task, for instance, preparing a snack and then eating it, or dressing themselves independently so they can visit with friends. Completion of the task provides intrinsic reinforcement, seen in the individual’s satisfaction in his or her ability to participate in desirable activities as a result of completing the task. An activity that is motivating and meaningful to the client can increase active participation and improve intervention outcomes.
Several studies have shown (1) that adding purposeful or imagery-based occupations to rote exercise results in more repetitions than are used for rote exercise alone,8 (2) that clients select occupationally embedded activities over rote exercise tasks,31 and (3) that added purpose occupations result in greater retention and transfer of motor learning than occur with rote exercise.5 Sietsema and colleagues25 found that better scapular abduction and efficiency of forward reach were achieved when clients with traumatic brain injury focused on reaching to control a game panel than when they focused on how far they could reach an arm forward.25 Similarly, Nelson and associates19 showed that intervention to improve coordinated forearm pronation-supination was more effective in stroke rehabilitation when clients focused on turning an adapted dice thrower in the context of a game than when they focused on the movement itself. Wu and coworkers29 found that intervention to improve symmetric posture in adults with hemiplegia had significantly better outcomes when subjects focused on wood sanding and bean bag toss games.
In addition to structuring the type of reinforcement, the therapist needs to carefully grade the challenges of the activity, so the client can experience success and mastery during the process of learning the activity. If the client has too much difficulty completing a task, social reinforcement or inherent meaningfulness of the activity will not be enough to override frustration or fatigue. Therefore, therapists must analyze the activity and determine how to grade the activity to meet the learning and reinforcement needs of the individual client. This includes deciding on the most appropriate mode of instruction as described in the previous section, what type of reinforcement will facilitate intrinsic motivation, and how best to structure feedback and practice schedules; these decisions are discussed in the next section.
Li’s therapist knew that his strong desire to return to his occupation of leading nature hikes would motivate him to improve his balance and standing tolerance. The therapist explained how a variety of activities involving challenges to Li’s sitting and standing balance would help him regain his postural stability. Li participated actively in these tasks and generated ideas for additional tasks that could be incorporated into his OT program; he also practiced outside of the therapy environment. His intrinsic motivation to perform these tasks in varied contexts was evident in his improved balance skills.
Structure Feedback and Practice
Feedback is information about a response20 that can provide knowledge about the quality of the learner’s performance or the results of the performance. Intrinsic feedback is generated by an individual’s sensory systems. An individual learning to hit a golf ball uses visual and somatosensory feedback to evaluate performance. The visual system is used to align the head of the golf club and the golfer’s body in correct orientation to the ball. Kinesthetic and proprioceptive inputs inform the golfer about joint position and the location of body segments in space; this allows the golfer to make the necessary postural adjustments and upper extremity movements to bring the club head into contact with the ball while using appropriate speed and force.
Extrinsic feedback is information from an outside source. The trajectory of the golf ball, the distance of the drive, and the location of the ball on the fairway all provide extrinsic feedback about the results of the golfer’s actions. An observer can provide extrinsic feedback about task performance by giving the golfer information such as, “Your stance was too open,” “You did not follow through far enough on the swing,” or “Your head position was good.” For clients whose sensory recognition or processing abilities have been impaired, extrinsic feedback from a therapist or technological device can provide useful supplementary information to facilitate learning during the acquisition phase. Technological feedback mechanisms include biofeedback systems and digital displays of kinetic or cardiovascular data on exercise equipment. These feedback systems provide more immediate and consistent feedback than can be obtained from a therapist.
Although extrinsic feedback may be helpful early in the learning process, clients will achieve greater independence and efficiency in activities by developing the ability to continue learning through intrinsic rather than extrinsic feedback. In fact, extrinsic feedback may not produce optimal learning and may create dependency, with deterioration in performance if the feedback is removed.12 Therefore, extrinsic feedback must be gradually decreased if the client’s goal is independent performance in a variety of performance contexts.
Practice is a powerful component of the occupational therapy process. The ways in which a therapist structures practice conditions can influence a client’s success in retention and transfer of learning. Several aspects of practice are discussed in the following paragraphs.
Li experienced mild sensory loss in his right arm as part of his injury. When his cast was removed and active rehabilitation commenced, he benefited from extrinsic verbal and somatosensory feedback provided by his therapist about the quality of his movement. As his upper extremity function improved, the therapist gradually decreased the amount of extrinsic feedback provided. Li learned to use intrinsic feedback to adjust the timing, speed, and direction of his movements while engaged in a variety of functional activities designed to improve strength, range of motion, and dexterity. Participation in practice sessions that included varied task challenges helped him to learn strategies that could be transferred to many activities.
Contextual Interference
Contextual interference refers to factors in the learning environment that increase the difficulty of initial learning. Limiting extrinsic feedback provided about the results of performance is one example of contextual interference. A therapist who is attempting to limit extrinsic feedback will minimize the amount of verbal feedback about performance and/or the amount of manual guidance provided during the task. Performance during the acquisition phase may be poorer with high contextual interference; retention and generalization are more effective. This may occur because a high level of contextual interference forces the learner to rely on intrinsic feedback and to adapt motor and cognitive strategies to complete the task, resulting in more effective learning.9
Blocked and Random Practice Schedules
Blocked and random practice schedules are examples of low and high contextual interference, respectively. During blocked practice, clients practice one task until they master it. This is followed by practice of a second task until it is also mastered. In random practice, clients attempt multiple tasks or variations of a task before they have mastered any one of the tasks. A random practice schedule may be used to teach wheelchair transfer skills. The client practices each of several transfers during the course of a single session. For example, the client will practice moving between the wheelchair and a therapy mat, between the wheelchair and a chair, and between a toilet and the wheelchair. A random practice schedule for improving postural stability might include having the client stand on a variety of unstable surfaces such as an equilibrium board, a balance beam, or a foam cushion while playing a game of catch. These types of practice schedules may slow the initial acquisition of skills but are better for long-term retention of these skills23 and for transfer of the learning to another context or task.7
Whole Versus Part Practice
Breaking a task into its component parts for teaching purposes is useful only if the task can naturally be divided into discrete, recognizable units.29 This is so because continuous skills (or whole task performance) are easier to remember than discrete responses.23 For example, once a person has learned to ride a bicycle, this motor skill will be retained even without practicing for many years. Continuous skills should be taught in their entirety rather than in segments. For example, the activity of making vegetable soup includes several discrete tasks, including chopping vegetables, measuring ingredients, assembling the ingredients in the soup pot, and cooking the ingredients. During one session, the therapist could teach a client to chop the vegetables; the other components of the task could be taught in subsequent sessions. However, for the activity of making a pot of coffee, the task components (measuring the water, pouring it into the coffeemaker, measuring the coffee, putting the coffee into the coffeemaker, turning on the coffeemaker) need to be completed in a specific order. Teaching any of these task components in isolation would not result in meaningful learning or independent activity performance. For best retention and generalization, making coffee should be taught as a complete task, rather than having the client practice a different portion of the task during each therapy session.
To facilitate the learning process, the therapist may provide demonstration, verbal cueing, or manual guidance as needed for selected aspects of the task. This way, the client experiences completion of the task on each trial, and the therapist gradually gives less assistance as practice sessions continue.
Cognitive Strategies
A growing body of literature supports the efficacy of cognitive strategies in helping individuals to learn motor skills. Cognitive strategies are goal-directed, consciously controlled processes that support motor learning and include memory, problem solving, mental imagery, perception, and metacognition.18 Cognitive strategies can be general or specific. General strategies are used in a variety of situations, and specific strategies are used for a particular task. Evidence from a variety of studies suggests that cognitive strategies can assist individuals with stroke to transfer skills to different environments.13,14,18 Cognitive strategies can be used in conjunction with practice in variable contexts to facilitate learning of motor and functional performance skills.
Practice Contexts
Practice under variable contexts enhances transfer of learning. Optimal retention and transfer of motor skills occur when the practice context is natural, rather than simulated.15,17 This may reflect the fact that the enriched, natural environment provides more sources of feedback and information about performance than the more impoverished simulated environment. However, transfer of learning is better when the demands of the practice environment more closely resemble the demands of the environment in which the client will eventually be expected to perform.30 Therefore, teaching kitchen skills in a client’s own home or in a kitchen environment that is very similar to the client’s kitchen will result in better task performance when the client engages in the task at home.
Client factors may also influence outcomes related to the practice context. A meta-analysis of the effects of context found that treatment effects were much greater for populations with neurologic impairments than for those without neurologic impairment.12 Errorless learning is an intervention paradigm based on the principle that learning will occur more quickly and efficiently if the learner does not engage in trial and error throughout the learning process. This learning strategy has been used most frequently with individuals who have cognitive or memory deficits, but it has also been effective in facilitating learning of a practical skill (fitting a prosthetic limb) during the rehabilitation process.4
One aspect of the practice context that has received little research attention is the role of the social environment in task learning. The importance of the social context of occupational performance and of the occupation of social participation is endorsed by the Occupational Therapy Practice Framework-2.1 Working with other clients in a group promotes socialization, cooperation, and competition, which can increase clients’ motivation. Acquisition of skills is enhanced through observation of others who are learning a task. Additionally, group intervention can promote the development of problem-solving skills and can create a bridge between the supervised therapy environment and the unsupervised home environment.3
Help Client Develop Self-Awareness and Self-Monitoring Skills
To maximize the retention and transfer of learning, clients must develop the ability to self-monitor, so they are not dependent on extrinsic feedback and reinforcement. The knowledge and regulation of personal cognitive processes and capacities is known as metacognition.10 It includes awareness of personal strengths and limitations and the ability to evaluate task difficulty, to plan ahead, to choose appropriate strategies, and to shift strategies in response to environmental cues. Although metacognition is typically discussed in relation to improving cognitive skills, self-awareness and monitoring of relevant performance skills may be equally important prerequisites to developing effective motor, interpersonal, and coping strategies. Specifically, an intervention directed toward helping clients develop enhanced awareness of body kinematics and alignment may be an important component of motor learning.2 Self-review of performance and guided planning for tackling the challenges of future tasks are key factors in the therapeutic process and are critical prerequisites to a person’s ability to generate and apply appropriate strategies.
Strategies are organized plans or sets of rules that guide action in a variety of situations.22 Motor strategies include the repertoire of kinematic linkages and schemata that underlie the performance of skilled, efficient movement. The process of stepping to the side when one is abruptly jostled is a motor strategy for the maintenance of standing balance.24 Cognitive strategies include the variety of tactics used to facilitate processing, storage, retrieval, and manipulation of information. Using a mnemonic device to remember a phone number is a cognitive strategy. Interpersonal strategies help in social interactions with other individuals. A person who uses direct eye contact and greets another by name when being introduced is using an interpersonal strategy. Coping strategies allow people to adapt constructively to stress. Coping strategies can include deep breathing, exercise, or relaxation activities.
Strategies provide individuals with foundational skills that can be adapted to the changing demands of occupational tasks within a variety of contexts. Thus, learning is more likely to be transferred to new situations when opportunities arise to develop foundational strategies.26 Individuals develop strategies through a process of encountering problems, implementing solutions, and monitoring the effects of these solutions. Occupational therapists use activities to help clients develop useful strategies by presenting task challenges within a safe environment that provide opportunities to try out different solutions.22
As Li was nearing discharge from occupational therapy services, the therapist worked with him to develop strategies to facilitate his occupational performance. Although his memory was improved, recall of names and numbers was still poor, so the cognitive strategy of using a notebook for recording important information was continued. In addition, to cope with persistent mild deficits in balance, Li and his therapist developed a motor strategy of keeping a sturdy table nearby when he stood to talk to visitors at the botanical gardens. This strategy provided a support that he could lean on or hold onto if needed and was a strategy that could be used in other situations as well.
Factors That Influence the Learning Process
The ultimate goal of learning is to create strategies and skills that individuals can apply flexibly in a variety of contexts and occupations. As this chapter has presented, occupational therapists have many methods available to them to help their clients achieve this goal. The concepts discussed in this chapter that facilitate transfer of learning to other environments are listed in Box 7-2.
Summary
Occupational therapists teach activities for a variety of reasons. They reteach familiar activities, teach alternate or compensatory strategies of performing valued activities, teach new performance skills to support role performance, teach therapeutic challenges to improve performance skills to support occupational participation, and teach caregivers and/or family members to facilitate client independence and safety in the home environment.
Occupational therapists use a variety of teaching strategies to promote skill acquisition, skill retention, and transfer of learning. Procedural and declarative learning represent unconscious and conscious learning processes, respectively.
Occupational therapists maximize the learning process by (1) identifying activities that have meaning or value to the client/family, (2) providing instruction tailored to the needs of the individual and the task, (3) structuring the environment to facilitate learning, (4) providing reinforcement and grading of activities to establish intrinsic motivation, (5) structuring feedback and practice to facilitate acquisition, retention, and transfer of learning, and (6) helping clients develop self-awareness and self-monitoring skills.
1. What is the difference between acquisition, retention, and transfer of learning? Apply these terms to describe the learning stages in a client you have observed.
2. When are declarative learning and procedural learning processes used? How will teaching methods differ when declarative or procedural processes are required?
3. What are the reasons why therapists teach activities? Give an example of desired teaching outcomes for each of the reasons presented in the chapter.
4. In which situations is extrinsic feedback valuable to the therapeutic process? What are some advantages and disadvantages of providing extrinsic feedback to clients?
5. Why does contextual interference contribute to transfer of learning? Think of an example of how contextual interference can be incorporated into an OT session.
6. Differentiate between random and blocked practice schedules. In which situations would each of these practice schedules be chosen?
7. Provide examples of how a therapist might structure whole practice versus part practice. In which situations might each of these types of practice be appropriate?
8. In which ways can occupational therapists enhance the variability of practice contexts? Give practical examples of how occupational therapists working in inpatient settings can provide treatment in natural contexts.
9. How can occupational therapists help clients develop metacognitive skills? Why are these skills important in the learning process?
References
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