Canadian Practice Process Framework
Noémi Cantin; Martine Brousseau
Abstract
The Canadian Practice Process Framework (CPPF) (Polatajko, Craik, Davis, & Townsend, 2007a) is introduced as a tool designed to guide occupational therapists as they enable the individual, group, community or population to engage in and perform occupations, placing these people at the centre of the occupational therapy process. The CPPF represents the progression of a partnership between an occupational therapist and the people receiving occupational therapy services that enables the move from an occupational challenge to successful occupational performance, within a given societal and practice context. In this chapter, the practice stories of three individuals are used to guide occupational therapy students, as well as novice and experienced occupational therapists, as they reflect on the practical use of the CPPF.
▪ The Canadian Practice Process Framework (Polatajko et al., 2007a) is a generic framework that ensures occupational therapists position an individual, group, community or population at the centre of the occupational therapy process.
▪ The CPPF graphically represents the occupational therapy practice process through eight action points.
▪ The eight action points are contained within the frame(s) of reference element of the CPPF to illustrate that theories, models of occupational therapy practice and interdisciplinary frames of reference influence everything that an occupational therapist does.
▪ The CPPF represents the occupational therapy process across the different contexts within which occupational therapy can take place, while also highlighting the influence of the societal context.
▪ The CPPF emphasises the necessity for occupational therapists to become expert reflective practitioners throughout the practice process.
Introduction
Exemplary occupational therapy is based on the fundamental concepts of the profession, focuses on enabling an individual, group, community or population to engage in and perform occupations, places these people at the centre of the process, is research informed, and is congruent with the services offered within the practice context. In this chapter, the Canadian Practice Process Framework (CPPF) (Polatajko et al., 2007a) is introduced as a tool designed to guide occupational therapists as they carry out such practice. First, the elements of CPPF are briefly introduced. Then, each of the action points of the process framework are described and illustrated using practice stories.
The canadian practice process framework
In general, occupational therapy practice models graphically depict beliefs regarding the interaction of concepts critical to the production of occupational performance or engagement. The CPPF (Polatajko et al., 2007a) belongs to a different category of models. The CPPF is a generic framework that graphically represents the occupational therapy practice process. It represents this process across the different contexts within which occupational therapy can take place when working with an individual, group, community or population (Craik, Davis, & Polatajko, 2013). The CPPF represents the progression of a partnership between an occupational therapist and an individual, group, community or population receiving occupational therapy services that enables the move from an occupational challenge to successful occupational performance within a given societal and practice context.
Four specific elements are illustrated in the CPPF (Fig. 8.1): the societal context (outer box), the practice context (inner box), the frames of reference (large circle) and the action points (small circles) (Craik et al., 2013). Each element will be briefly described here and illustrated in the practice stories.
Societal Context
The societal context is included in the framework to highlight the influence of cultural, institutional, physical and social elements of the environment on all occupational therapy practice processes. Occupational therapists from around the world can use the CPPF to frame their actions and reflect on how their particular societal context influences what they do. Examples of influential elements could be health care funding policies, cultural expectations or societal values.
Practice Context
The practice context is embedded within this societal context, which is why the line separating the two in Figure 8.1 is dotted. It also includes cultural, institutional, physical and social elements of the environment, but this time it is specific to an occupational therapist’s practice environment. This might include physical characteristics of the spaces where interventions are carried out, the presence of other team members, an institution’s culture, or the prevailing model of service delivery. The practice context also includes personal elements related to the therapist and the client’s “knowledge, abilities, skills, habits, values, beliefs and attitudes” (Craik et al., 2013, p. 236). As illustrated by the graded shading in Figure 8.1, the practice context is where the therapeutic relationship between the occupational therapist and the individual, group, community or population begins.
Frames of Reference
The circle representing frames of reference is embedded within the practice context. The frames of reference hold the eight action points in the practice process. This illustrates that theories, models of occupational therapy practice and interdisciplinary frames of reference influence everything that an occupational therapist does (Craik et al., 2013). In occupational therapy, a frame of reference is understood to be based on a set of theories and assumptions that influence and constrain an occupational therapist’s perception and understanding of occupational challenges, ultimately guiding professional reasoning during the occupational therapy process (Mosey, 1986; Townsend & Polatajko, 2013). In the CPFF, this element is defined broadly to include paradigms, theories, occupational therapy practice models and specific interdisciplinary frames of reference (Craik et al., 2013).
Despite numerous studies proposing that using theory intentionally and explicitly throughout the occupational therapy process is important, this remains a challenge for many therapists (Boniface et al., 2008; Leclair et al., 2013; Melton, Forsyth, & Freeth, 2010; Wimpenny, Forsyth, Jones, Matheson, & Colley, 2010). Indeed, the integration of theory into practice requires considerable commitment. When models of practice and frames of reference are mastered, their application results in solid professional reasoning. However, when understanding is superficial, or when the use of theory in practice is not valued, professional reasoning is weak and application of a theory’s tools is haphazard and often ineffective (Boniface et al., 2008; Leclair et al., 2013). The CPPF highlights the importance of frames of reference and theories by depicting that the action points for intervention are based within these frames of reference that guide professional reasoning.
Action Points
The eight action points represent actions to be completed by occupational therapists to ensure their practice is centred on the individual, group, community or population, research informed, and occupation based. As such, the CPPF does not depict professional reasoning itself. Instead, it depicts the key action points where professional reasoning and reflection occur. The shading of the circles represents that both the individual, group, community or population and the therapist are actively engaged in each action step. Recognising that therapists work within varied societal and practice contexts, the process is meant to be flexible, allowing therapists to skip or repeat an action while still ensuring that they are following best practices. The dotted arrows in Figure 8.1 illustrate this flexible practice process. Furthermore, although each action point is represented separately, it is important to note that, sometimes, certain action points can be carried out simultaneously. For the purposes of illustrating the action points, the practice stories of three individuals will be used; it should be noted that these same action points can be used when working with groups, communities and populations.
Enter, Initiate
Victoria is a 40 year-old sole parent of two teenagers. She works at a local automobile manufacturing plant. She was referred to an outpatient chronic pain programme because of chronic back, shoulder and neck pain. Today, during the weekly team meeting, her file was presented by the nurse responsible for admissions. Victoria’s pain was described in terms of its location, duration, frequency and intensity, and the nurse expressed her concerns about Victoria’s mental health. As was typical in this programme, an appointment was scheduled for a psychologist to conduct an initial assessment and provide an introduction to cognitive behavioural therapy. Victoria’s initial meeting with the occupational therapist was scheduled for 2 weeks after the MDT meeting.
In this practice story, the occupational therapist’s first point of contact with Victoria occurs when her file is presented during a weekly team meeting. This meeting marks the beginning of the occupational therapy process. At this action point, it is important to develop a clear understanding of the reason for referral. Such an understanding is essential to assess whether conflicts of interest could impede the therapist’s ability to work with Victoria. Knowing the reason for referral helps the therapist evaluate whether the issue falls within the therapist’s scope of practice and expertise. In a perfect world, referral sources would always understand that the goal of occupational therapy is to enable people to perform and engage in occupations that are important and meaningful to them (Polatajko, Davis, Cantin, Dubouloz, & Trentham, 2013b). However, in some practice contexts, occupational therapists report that they have to reframe the reason for referral so that it reflects what they actually do (Brousseau, 2004; Ordre des Ergothérapeutes du Québec (OEQ), 2010). In such cases, occupational therapists may need to educate and advocate to ensure that referral sources understand their expertise and scope of practice.
Even though Victoria was not physically present at the Enter/Initiate stage, this first action point forms the foundation of the therapeutic process. By identifying this as the initial action point, the CPPF highlights the importance of placing Victoria at the centre of the process and ensuring that occupations are the starting point of the interaction. To this end, before meeting Victoria, the therapist should read her file. During this reading, the therapist reviews information from the referral source and begins to form an image of Victoria. At the same time, the therapist reflects on her own thoughts, feelings and first impressions of Victoria, and reflects on the possible influence of previous experiences on the upcoming interaction with Victoria.
Reid (2009) proposes that occupational therapists can enhance their practice by intentionally setting the expectation that they will practice mindfully throughout the therapeutic process. Mindfulness has been discussed by many authors and disciplines. Reid chooses to define it as ‘a means of paying attention in a particular way, on purpose, in the present moment, and in a nonjudgemental way’ (Kabat-Zinn, 1994, p. 4)
The occupational therapist sat in her office, going over Victoria’s file and reading the psychologist’s report in preparation for her initial meeting with Victoria. She allowed herself to critically reflect on her typical practice, hoping to interrupt her usual ways of thinking and acting so that she could approach Victoria with an open mind, with creativity and an appreciation for Victoria’s unique occupational experiences.
The therapist noted that the information currently in Victoria’s file offered a very biomedical perspective of her pain. The occupational therapist really wanted to know Victoria as an occupational being, to learn more about her occupational roles, routines and habits and understand her perspective on her current occupational performance and engagement. The occupational therapist reflected on what she learnt and reflected on this through the lens of the occupational therapy practice model used to frame her practice. The therapist’s knowledge of the research and previous experience with people with chronic pain suggested to her that Victoria’s pain was likely to have an impact on her occupational roles and identity. The therapist expected that, to a certain extent, Victoria had adapted to her condition, had developed coping strategies, and had probably discovered that being engaged in some occupations helped distract her momentarily from the pain.
The occupational therapist met Victoria in the waiting room and invited her into the assessment room for their initial meeting.
Setting the Stage
It is during the Setting the Stage action point that the strengths and resources of people referred for occupational therapy are identified, as well as the occupational challenges that will be the focus of the occupational therapy process. At this action point the reason for referral might need to be reframed with, and centred on, the individual, group, community or population to ensure that the stage is set for a therapeutic process focused on significant occupations (Brousseau, 2004; Cup, Scholte Op Reimer, Thijssen, & Van Kuyk-Minis, 2003, OEQ, 2010). Indeed, since the importance and meaning of occupations is unique to each individual performing them, these can only be understood and explained by the people engaged in their performance (Polatajko et al., 2013a). Accordingly, the person receiving the occupational therapy services must be the ones who identify their occupational challenges.
The practice context will have a certain influence on an occupational therapist’s scope of practice and the occupational challenges that can be addressed throughout the therapeutic process. The influence of the practice context on the therapeutic process should be discussed with the individual, group, community or population. It is nevertheless important for occupational therapists to remember that, despite their practice context, their scope of practice is occupational enablement and, accordingly, therapists should strive to enable people to not only see ‘what is’ but also consider ‘what could be’ (Townsend et al., 2013, p. 121) with regards to their occupational performance and engagement. Here again, the occupational therapist may need to educate and advocate to ensure managers and third party payers understand the health-promoting benefits of engagement in a broad range of occupations.
Engaging people in sharing their occupational narratives – that is, offering them the opportunity to tell their stories by organising past events, perceptions and experiences into meaningful wholes (Bonsall, 2012) – enables them to share the meanings they ascribe to their occupational performance and engagement, occupational roles and identities (Bonsall, 2012; Goldstein, Kielhofner, & Paul-Ward, 2004). The use of narratives early in the practice process also motivates them to be invested in their rehabilitation as it positions occupational therapy within the context of their life stories (Cup et al., 2003; Mattingly, 1998). Furthermore, narratives allow therapists to gain a greater understanding of the cultural meaning of occupations, which is critical to a culturally sensitive occupational therapy practice (Awaad, 2003).
The overarching occupational model of practice used by a therapist should have an influence on the structure of this initial therapeutic encounter and the information sought. For example, a therapist who ascribes to the Canadian Model of Occupational Performance and Engagement (CMOP-E) (Polatajko, Townsend, & Craik, 2007b) might consider using the Canadian Measure of Occupational Performance (Law et al., 2014) to guide the narratives of the individual, group, community or population and prioritise occupational challenges needing to be addressed. As therapists move on to the next action point, they would be interested in understanding how the dynamic interaction between factors related to people, their environments and occupations results in the current occupational performance and engagement issues.
Assess, Evaluate
Matthew’s practice story will be used to illustrate the next two action points of the CPPF.
Matthew is a 36-year-old high school teacher. He had a spinal cord injury 4 years ago when he was involved in a motor vehicle accident. He was quite frustrated with his current wheelchair and asked to be seen at the seating clinic where an occupational therapist responsible for wheelchairs and adaptive seating systems procurement works.
During the initial meeting, the occupational therapist inquired about Matthew’s current occupational engagement and performance to identify the occupational challenges that would be the focus of assessment. He explained that he felt quite limited by his current wheelchair. To him, it looked too medical, it seemed very slow and he felt that it limited the upper body movements he needed for many of the tasks and activities he had to do at work. Furthermore, his current wheelchair was not adequate for him to participate in most recreational activities he wished to engage in. Before his accident, Matthew was involved in many activities with his friends such as floor hockey, ultimate Frisbee and soccer. He wanted to get involved in adapted sports. The occupational challenges he identified were: (1) performing work activities requiring upper body mobility, and (2) engaging in adapted sports.
After gathering this information, the occupational therapist was ready to proceed with her evaluation to better understand why Matthew was experiencing these occupational challenges.
It is important to highlight here the many influences on this action point. Receiving a referral for occupational therapy does not always imply the need to perform an in-depth assessment of an individual, group, community or population’s overall occupational performance. Sometimes, professional reasoning might suggest that only a screening assessment is needed; at other times the in-depth assessment of a single occupation might be most appropriate. The societal and practice contexts, and identified occupational challenges, as well as the chosen model of practice and relevant frames of reference will all contribute important elements to the professional reasoning leading to this decision.
Recognising the influence of the societal and practice contexts on this action point is essential. Sometimes, the practice context might determine the assessment tools that are available, the ones that must be routinely performed for reimbursement purposes or the ones for which the therapist has expertise to perform.
As well, given occupational therapists’ understanding that occupational performance is the result of a dynamic interplay between a person, the person’s environment and the occupation being performed, this action point is ideally carried out in the environment where occupational challenges are experienced. When the practice context prevents this from happening, the expertise of the individual, group, community or population should be relied upon for additional information. Reflecting on the likely influence of the environment on an individual, group, community or population's occupational challenges involves placing them at the centre of the assessment process and evaluating in the environments where these activities actually take place. Again, the therapist is called on to educate and advocate when managers or funders have difficulty supporting best practices in occupational therapy evaluation.
The occupational therapy model of practice guiding the therapeutic process will also influence the assessment process by drawing the focus of evaluation to specific elements of the model. Indeed, although each occupational therapy model has similarities, each model also uniquely presents its assertions with regards to the dynamic interaction of components of the person, the environment or the occupation that lead to occupational performance (Polatajko et al., 2013b). In an attempt to explore plausible explanations for the occupational challenges identified by an individual, group, community or population, frames of reference and related theories guide a therapist to explore specific components of the person, the environment or the occupation. Research-informed best practices and professional experiences will also come into play.
The occupational therapist commenced her evaluation of Matthew’s occupational challenges. She explained her assessment plan and obtained his consent to proceed. She wanted to start her assessment by observing Matthew at his workplace; however, her current practice context limited her ability to leave the seating clinic. Accordingly, she attempted to reproduce similar environmental conditions in the clinic and choose to rely on Matthew’s assessment of his own work environment to explore the role it could play in explaining his current occupational challenges. Then, drawing from a biomechanical frame of reference, the occupational therapist proceeded to assess the fit of the chair and Matthew’s postural alignment. Biomechanical theories further guided her professional reasoning and her decision about which measures to focus on. Finally, because of her practice experience, she decided to perform muscle testing to compare it with Matthew’s previous assessment on file, wondering whether his current occupational challenge at work was related to a decrease in his strength.
Matthew had researched the different adapted sports available to him and had decided that he would like to join a local wheelchair hockey team. The occupational therapist had ordered adapted wheelchairs for that sport before and proceeded to take the necessary measurements.
Once the assessment is completed, this action point ends by putting all of the information gathered together to elaborate an analysis of an individual, group, community or population’s current occupational challenges. This analysis represents an occupational therapist’s interpretation of assessment findings and professional reasoning as to why an individual, group, community or population is experiencing such challenges (OEQ, 2010). This analysis provides the transition point between the assessment and evaluation of occupational challenges, the elaboration of occupational objectives, and a related intervention plan. This analysis is discussed with the individual, group, community or population before moving on to the next action point.
Matthew’s satisfaction and performance of significant occupations was moderately altered. Specifically, his performance of tasks and activities related to his teaching had been affected by mobility restrictions secondary to the wheelchair’s high back. Related reduced efficiency had also resulted in deconditioning of his postural muscles. His wheelchair offered too much postural support. Furthermore, his actual wheelchair was inadequate for playing wheelchair hockey.
The occupational therapist was ready to discuss potential objectives and develop an intervention plan with Matthew to enable him to resolve his occupational challenges.
Agree on Objectives and Plan
The specifics of an occupational therapist’s practice context will influence the therapist’s professional decision making while collaborating with an individual, group, community or population to establish objectives and plan the occupational therapy intervention. Available resources will vary by culture, values and beliefs, such as the value placed on universal accessibility to activities. Each practice context comes with its own set of factors that will influence a therapist’s professional decision making at this action point, and it is important to actively consider if such factors will be facilitators to be exploited or obstacles to be overcome while forming objectives and the intervention plan.
At this action point, situating people at the centre of the process requires that they be actively engaged in setting the objectives and elaborating the intervention plan. Engaging them signifies more than simply asking for agreement with the objectives established by the therapist; it involves enabling them to see what is possible, to express their wants and needs, and to make informed choices (Ripat & Colatruglio, 2016). In a study exploring the wheelchair procurement process from the perspectives of therapists and people who use wheelchairs, Mortenson and Miller (2008) discovered that not all people who used wheelchairs were actively engaged in the process of setting objectives or elaborating the intervention plan. Some authors have suggested that this lack of involvement could explain the high levels of wheelchair abandonment reported in the literature (Kittel, Di, & Stewart, 2002). In fact, when the wants and needs of an individual who uses a wheelchair are not at the centre of the process, a wheelchair, which is supposed to offer great benefits such as improved comfort, increased autonomy in mobility and community participation (Mortenson & Miller, 2008), can lead to disability by, for example, limiting the individual’s mobility or engagement in recreational activities (Kittel et al., 2002; Ripat, Brown, & Ethans, 2015).
After identifying the objectives, the occupational therapist developed a detailed intervention plan comprised of enabling skills, actions, and strategies in collaboration with Matthew that could be implemented to assist him to reach those specific objectives. The plan included answers to the what, when, where, who and how of the intervention. As the therapist elaborated the intervention plan, Matthew’s unique experiences and expertise, as well as the therapist’s previous professional experiences, research evidence from the literature, selected occupational model of practice, specific frames of reference and related theories, guided the therapist’s professional reasoning.
Implement the Plan
Mrs Chin’s practice story will be used to illustrate the remaining CPPF action points.
Mrs Chin was a 61-year-old widow, mother of four grown children and grandmother of two grandchildren. She experienced a stroke and was transferred to the inpatient rehabilitation unit. More than anything, Mrs Chin wanted to return home. Living alone and without access to support services, Mrs Chin felt she had to regain her autonomy in self-care occupations if she was to feel at ease at home. The occupational challenges she identified and prioritised when completing the Canadian Occupational Performance Measure (COPM) (Law et al., 2014) during her initial meeting with an occupational therapist were showering, getting dressed and preparing a nutritious meal.
With these priorities in mind, at the next session her occupational therapist began an initial assessment of Mrs Chin’s performance of those occupations. Once the evaluation was complete, the occupational therapist’s analysis suggested that Mrs Chin was not able to complete these tasks as problems with bilateral coordination and dexterity, limited mobility of her right upper extremity, and mild attention deficits affected her function.
The occupational therapist determined that a cognitive-based approach to intervention, the Cognitive Orientation to daily Occupational Performance Approach (CO-OPApproach™) (Polatajko & Mandich, 2004), was likely to help Mrs Chin return to her chosen occupations. The occupational therapist’s decision to use CO-OPApproach™ was research informed and based on her positive practice experience with the approach.
In collaboration with Mrs Chin, the occupational therapist proceeded to set the following specific occupational therapy objectives: Mrs Chin (1) will shower herself independently within 3 weeks, (2) will dress herself independently within 3 weeks, and (3) will prepare a nutritious lunch independently within 4 weeks. The occupational therapist developed an intervention plan with Mrs Chin, framed within the CO-OPApproach™. Mrs Chin agreed that this approach fitted with her general objective of regaining her autonomy before returning home.
When implementing the intervention plan elaborated with Mrs Chin, the specifics of the societal context and context of practice come into play. For example, stroke rehabilitation programs vary between regions and countries. Understandably, elements of the societal context will ultimately influence which intervention plans can be implemented. For example, for Mrs Chin, health care funding mechanisms and available health and social services resources within her community could have an impact on the type of intervention plan that would be possible.
Similarly, the context of practice on inpatient rehabilitation units also varies greatly. Some occupational therapists work within interprofessional teams where multiple professionals collaborate to achieve person-driven goals; others work on occupational therapy units where the scope of practice of each health care professional is dictated by their programme director or prescriptive treatment pathways. With Mrs Chin, the context of practice would likely influence the frequency and length of occupational therapy sessions and the duration of her stay on the rehabilitation unit. Once again, the therapist is called on to educate and advocate when managers or funders are not yet supporting best practices for occupational therapy intervention.
The occupational model of practice and frames of reference selected at the previous action point will guide the implementation of the intervention plan. For example, in this practice story, the protocol for the CO-OPApproach™ suggests that the first session be focused on establishing baseline performance of the chosen occupations and on teaching the global cognitive strategy. The CO-OPApproach™ protocol, adapted for adults who have experienced stroke, proposes that the approach be implemented over approximately 10 sessions, on a weekly basis or twice a week (McEwen, Polatajko, Huijbregts, & Ryan, 2009). However, it is important to note here that this protocol was initially tested with community-dwelling participants experiencing a more chronic phase of stroke. Professional reasoning may lead a therapist to increase the frequency of sessions to three times a week or daily for Mrs Chin. Evidence-based practice integrates research evidence, person expertise and professional expertise to inform professional reasoning and decision making (Kristensen, Person, Nygren, Boll, & Matzen, 2011; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). In this case, when developing the intervention plan, the occupational therapist considered the fit between her previous experience using the approach on the rehabilitation unit, the research evidence and Mrs Chin's current condition.
Additionally, when implementing an intervention plan, occupational therapists must be acutely aware of the intervention burden imposed on people and ensure that it is minimised (Gallacher et al., 2013). Positioning people at the centre of the therapeutic process and weaving interventions within their daily lives is one of the ways in which the burden of an intervention plan can be reduced (Gallacher et al., 2013; Shippee et al., 2012). This begins with open dialogue between the therapist and the individual, group, community or population to identify potential issues and strategies to resolve them. It also requires a constant dialogue with the rest of the health care team to ensure coordination of everyone’s efforts.
As the occupational therapist implemented the plan, she closely monitored Mrs Chin’s progress toward her occupational goals to ensure that the intervention plan was helping her move towards her objectives.
Monitor and Modify
Positioning people at the centre of the therapeutic process also ensures that interventions are not futile, that they make sense to those receiving the interventions and that they lead to positive outcomes. However, to ensure that positive outcomes are reached, progress towards occupational objectives must be monitored and intervention plans must be modified and adapted to respond to the changing needs of people. Sometimes, this may even involve going back to ‘assess/evaluate’ and redrafting occupational objectives and developing a new intervention plan.
To be flexible and open to modifying an intervention plan, a therapist must necessarily be engaged in critical self-reflection throughout the therapeutic process; this reflection must necessarily involve the individual, group, community or population. By definition, the word reflection suggests thinking back about something that has happened (Yanow & Tsoukas, 2009), reflective practice being ‘the practice of stepping back to ponder the meaning [of] what has recently transpired’ (Raelin, 2001, p. 11). The term reflection-on-action describes reflection that takes place after the event has happened, whereas the term reflection-in-action has been coined to describe reflection that takes place in the moment, while the event is happening (Schön, 1987; Yanow & Tsoukas, 2009).
At the simplest level, therapists monitor progress to ensure that the intervention plan is truly helping people move towards their goals. As well, it is important to monitor whether progress appears to be sufficiently rapid that people’s goals are likely to be met before discharge. If not, the intervention plan should be modified or a plan should be put in place to ensure people receiving occupational therapy services will be able to continue working towards these goals after discharge.
On a somewhat more abstract level, it is important that occupational therapists periodically review the plan to ensure that their understanding of the individual, group, community or population’s goals aligns with their understanding. For example, if autonomy is a goal, is the occupational therapist’s definition of autonomy consistent with the individual, group, community or population’s definition? It is important to recognise that how autonomy is defined and what it means for different people, within a particular societal context, will be highly variable. Positioning people, with their wants, needs and specific contexts, at the centre of the therapeutic process will ensure that the occupational therapist is working in collaboration with them to reach the same goal.
Evaluate Outcome
Mrs Chin worked towards her occupational objectives for 3 weeks. As was determined when the objectives were set, it was time to evaluate the outcome of the intervention plan implemented. To gain Mrs Chin’s perspective on her current performance in showering, dressing and preparing lunch, the occupational therapist readministered the COPM. Mrs Chin rated her performance and her satisfaction with her performance as significantly improved for all three objectives. The occupational therapist observed her performing the occupations and noted that the original breakdowns in performance have all been resolved. However, despite her progress, Mrs Chin was still anxious at the idea of being discharged back to her home. She felt that there was much to do to maintain her home and was unsure that she would be able to manage it all.
The focus of the summative evaluation was to determine the outcome of the implemented intervention plan in relation to the occupational challenges identified at the outset of the therapeutic process, the occupational objectives agreed upon after the initial evaluation, and the model of practice and frames of reference selected to guide the intervention. When people are positioned at the centre of the therapeutic process, outcome evaluation necessarily relies on their perceptions of goal attainment, as well as their satisfaction. What is most important is that, once an intervention plan has been implemented, people receiving occupational therapy services can perform and engage in the occupations they need and want to do, to their satisfaction. Sometimes, when the context of practice permits, outcome evaluation marks the transition to the identification of new occupational goals and beginning of a new therapeutic process. Other times, outcome evaluation marks the transition to concluding the occupational therapy process.
Beyond the importance of outcome evaluation for the individual, group, community or population, this action point is an important part of an occupational therapist’s reflective practice. Professional expertise was mentioned earlier when briefly discussing evidence-based practice. Professional expertise can be thought of as the judgement and competencies that therapists acquire through experience and practice (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). It is often this expertise that guides a therapist’s professional reasoning when deciding how to integrate research-based evidence in an intervention plan. To build expertise, therapists must critically evaluate the outcome of each intervention plan implemented. Evaluating outcomes allows occupational therapists to accumulate a repertoire of personal practice stories, documenting on a very small scale the efficiency of their interventions. However, studies have demonstrated that with increased experience, professional decisions sometimes become intuitive and based on habitual patterns of practice (Boudrieu, 1990; Jarvis, 1999). Occupational therapists should be careful not to fall into this trap; instead, they must continuously question usual ways of doing through self-reflection while remaining open to the integration of research evidence into practice.
Conclude/Exit
The occupational therapist agreed that, although Mrs Chin had reached her occupational goals, further important occupational issues remained. However, unit policy required that Mrs Chin be discharged. In preparation for her imminent discharge from the unit, the occupational therapist engaged Mrs Chin in a discussion of her hopes with regards to her future occupational engagement and identified new occupational challenges. With Mrs Chin and the rest of the team, the occupational therapist arranged for follow-up services to help Mrs Chin meet these new occupational goals.
At the end of the therapeutic process, once intervention objectives have been met, the last action point remaining is to conclude the therapeutic relationship. Sometimes, and for many different reasons, the individual, group, community or population and therapist might decide to end the therapeutic relationship earlier in the process. Regardless, it is important that this action point be planned as carefully as the others. For example, for Mrs Chin, recognising that stroke recovery is a long-term and complex process, concluding the therapeutic relationship would necessarily involve coordinating with the community-based occupational therapist and other community agencies and services to ensure continuity of care beyond the inpatient rehabilitation unit.
It is important to remember that, although the conclusion of the therapeutic process does represent an end in itself, it also represents an important transition for people. Indeed, while on the rehabilitation unit, people like Mrs Chin are actively engaged in creating new meanings and order in their lives while attempting to keep a certain continuity in their sense of self (Dubouloz 2014; Mezirow, 2000; Purves & Suto, 2004). It could be said that they are in a transitional process between their previous selves and their future selves. In this sense, the conclusion of the therapeutic relationship would actually mark the continuation of this transitional process, with new challenges to face and new contexts to adapt to. When people are positioned at the centre of the therapeutic process, they are included in planning the conclusion.
Conclusion
In this chapter, the Canadian Practice Process Framework (Polatajko, 2007) was introduced and each element of the model was presented. The impact of societal and practice contexts on the occupational therapy practice process was highlighted throughout the chapter. The eight action points of the framework were depicted using three practice stories to offer varied exemplars of how the CPPF can be used to frame an occupational therapist’s practice process and professional reasoning, keeping the individual, group, community or population and their occupations at the centre of the process. Finally, the influence and importance of models of practice and frames of reference in professional reasoning and practice was emphasised.
In many ways, although the CPFF may at first appear to represent a simple process to be followed, there is a complexity to this process, which clearly emphasises the necessity for occupational therapists to keep abreast of advances within the profession and their area of practice, integrate research evidence within their professional reasoning and strive to become expert reflective practitioners.
