Stroke survivors’ occupational performance and cognitive strategy use: A pilot exploration of strengths and difficulties using the Perceive Recall Plan Perform System of Task Analysis

Abstract

Introduction

The Perceive Recall Plan Perform System of Task Analysis is an ecological assessment of occupational performance and cognitive strategy application. This study aimed to describe occupational performance and cognitive strategies of stroke survivors in an early supported discharge service, compare the assessment with global measures of function and evaluate the feasibility of implementing the assessment in the early supported discharge setting.

Method

This study was a pilot study design and used consecutive sampling. Participants were assessed with the Perceive Recall Plan Perform System of Task Analysis and two global measures: the Functional Independence Measure and the Australian Modified Lawton’s Instrumental Activities of Daily Living Scale. Scores from the Perceive Recall Plan Perform System of Task Analysis were analysed by task mastery, sub-quadrants and quadrants, and correlations between the assessment and global measures were examined.

Findings

In this cohort (n = 10), the Perceive Recall Plan Perform System of Task Analysis assessment required 47 minutes per task and identified reduced task mastery (mean = 55%, SD = 10%) with common difficulties in the perceive and plan domains. High to moderate correlations were identified between the plan quadrant and global measures (p < 0.05).

Conclusion

Perceive Recall Plan Perform System of Task Analysis assessment can be successfully implemented by occupational therapists with stroke survivors receiving early supported discharge to measure occupational performance and identify strengths and difficulties in cognitive strategy application.

Keywords

Information processing early supported discharge task performance and analysis executive function feasibility studies activities of daily living

Introduction

Cognitive impairment is a common and significant sequela post stroke, adversely affecting independence in activities of daily living (ADL), instrumental activities of daily living (IADL) (Intercollegiate Stroke Working Party (ISWP), 2016: 53) and quality of life (McDonald et al., 2019). It is essential that stroke survivors receive screening for post-stroke cognitive impairment with standardised tools and, when indicated, a thorough cognitive assessment to guide intervention (ISWP, 2016: 59). Traditional cognitive testing is commonly evaluated on psychometrically standardised tools, conducted in a quiet clinical environment, to measure discrete cognitive constructs, such as attention and memory (Chapparo and Ranka, 2012; Nott and Chapparo, 2012). This approach does not evaluate the multiple information processing demands or the cognitive strategies that are applied during goal-directed performance in real-world conditions (Burns and Neville, 2016). Conversely, ecological, occupation-based tools such as the Perceive Recall Plan Perform System of Task Analysis (PRPP) examine information processing during completion of naturalistic or real-world activities (Burns and Neville, 2016; Sansonetti and Hoffman, 2013), enabling context-specific assessment and intervention (Ranka and Chapparo, 2010).

The PRPP assessment is a standardised, ecological, criterion-referenced measure of the effectiveness of cognitive strategy use during occupational performance (Nott et al., 2009). There are several other ecological measures that have established use with stroke survivors, including the Multiple Errands Test and the Assessment of Motor and Process Skills (Poulin et al., 2013). However, only the PRPP can be applied to an infinite number of tasks and environments, thereby maximising ecological validity (Morrison et al., 2015; Steultjens et al., 2012). The PRPP does not require written or verbal output (Chapparo and Ranka, 2012), is highly individualised (Van Keulen-Rouweler et al., 2017) and can be applied to activities of varying complexity and familiarity, as determined by the assessment aim (Nott and Chapparo, 2012). As stroke survivors receiving early supported discharge (ESD) services have diversity of cognitive presentations, rehabilitation goals and environments, the flexibility of the PRPP may support its application in this setting. The PRPP has demonstrably measured task mastery and cognitive strategy application in populations with neurocognitive dysfunction (Lewis et al., 2016; Nott and Chapparo, 2012; Steultjens et al., 2012); however, there is negligible published evidence regarding how stroke survivors apply their cognitive strategies during everyday activities whilst receiving ESD (Chouliara et al., 2014).

Literature recommends further research of post-stroke cognition and standardised ecological-based assessments of cognition (McDonald et al., 2019; Pilegaard et al., 2014; Sansonetti and Hoffman, 2013) such as the PRPP. In Australia, ESD is commonly a transitional service and, for benchmarking, this particular service routinely collected global measures of occupational performance using the Functional Independence Measure (FIM) to assess ADL and the Australian modified Lawton’s Instrumental Activities of Daily Living scale (Lawton’s) to measure IADL (Australian Rehabilitation Outcomes Centre, 2018; Harper et al., 2019). Whilst effective ADL and IADL performance is associated with cognition (Pilegaard et al., 2014), these tools alone do not evaluate the interplay between cognitive strategy application, occupational performance and the environment, nor do they support individualised intervention to optimise occupational performance. The relationship between contextualised occupational performance, cognitive strategy application and global ADL and IADL performance of stroke survivors in the community has not been examined; neither has the implementation of ecological cognitive assessments in ESD practice. This study aimed to describe stroke survivors’ occupational performance, explore the strengths and difficulties that they may experience in cognitive strategy application, compare these areas to other measures of occupational performance and evaluate the feasibility of implementing the PRPP in ESD practice.

Background

Cognitive screens and assessments are integral to recognising and addressing post-stroke cognitive impairment, yet the implementation of standardised cognitive assessments by occupational therapists in community settings is inconsistent (Burns and Neville, 2016; Stigen et al., 2019). Occupation-based assessments have been reported as the most common assessment method occupational therapists use to examine cognition; however, the use of standardised occupation-based measures have been documented as a gap in occupational therapy practice (Pilegaard et al., 2014; Sansonetti and Hoffman, 2013). It is increasingly recognised that ecologically valid cognitive assessment methods can concurrently evaluate occupational performance and information processing (Nott and Chapparo, 2012), executive skills and real-world performance (Poulin et al., 2013).

After the protection and structure of the hospital environment, the transition home can be a challenging period for the stroke survivor and their family (van der Wijst et al., 2014; Winstein et al., 2016) due to the dynamic home environment and subsequent increased demands on cognitive strategy application (Burns and Neville, 2016; Stigen et al., 2019). Whilst identifying advantages of ESD and the home environment (Lou et al., 2017), stroke survivors have also reported challenges with transition home due to incongruency between anticipated and real level of occupational performance and cognition (Connolly and Mahoney, 2018; Lou et al., 2017). This cognitive challenge may be magnified by shorter inpatient length of stays (Chouliara et al., 2014), stroke survivors not receiving standardised cognitive assessment during their inpatient admission and hospital-based assessments being a poor predictor of real-world performance (Morrison et al., 2015; Pilegaard et al., 2014). Upon transition home, assessment of ADL, IADL (Winstein et al., 2016) and a cognitive assessment may be indicated to measure participation in daily life (van der Wijst et al., 2014). Contextual assessment of occupational performance and cognition offers a unique perspective on the interaction between cognition, task demands and the environment (van der Wijst et al., 2014), which may not have been evaluated prior to discharge. The implementation of an ecological tool like the PRPP has potential to benefit both stroke survivors and clinicians as it facilitates client engagement through the assessment and utilisation of meaningful activities (Pilegaard et al., 2014; Poulin et al., 2013; Steultjens et al., 2012; Winstein et al., 2016).

Occupational therapists’ selection of cognitive assessments is influenced by factors including clinical guidelines, participants’ occupational performance, health service context, training in standardised assessments and time (Burns and Neville, 2016; Kristensen et al., 2012; Pilegaard et al., 2014). Utilisation of the PRPP assessment in ESD may decrease the amount of client and therapist time required to complete assessments by providing a standardised, concurrent occupational performance and cognitive strategy application evaluation (Ranka and Chapparo, 2010) at a logical juncture in the rehabilitation journey (Morrison et al., 2015). Internationally, occupational therapists value standardised occupation-based assessment; however, the feasibility of their use in practice has been questioned (Burns and Neville, 2016; Sansonetti and Hoffman, 2013; Stigen et al., 2019). Whilst the PRPP is considered to have high clinical utility due to its breadth of applicability, psychometric properties and ability to fulfil clinical guidelines for assessment post stroke (IWSP, 2016: 59–64), it is unknown how practicable implementation of the PRPP is in a clinical setting in terms of time resources.

The PRPP: overview

The PRPP is a two-staged tool for exclusive use by occupational therapists to assess task mastery and cognitive strategy application (Nott et al., 2009; Ranka and Chapparo, 2010). Cognitive strategies are defined as internal mental techniques used to process and respond to information in the ‘here and now’ (Chapparo and Ranka, 2012). Efficient cognitive strategy use is reflected through proficient occupational performance, indicated by higher test scores. The PRPP is a criterion-referenced assessment, measuring efficacy of task performance against specified criteria of what the individual is expected to do, in their, environment now and in the future (Chapparo and Ranka, 2012). This differs from norm-referenced testing, which measures an individual’s behaviour in comparison to a normally distributed group. Criteria for task mastery is established through client–therapist negotiation and clinical reasoning, reflecting an appropriate challenge and rehabilitation goal (Steultjens et al., 2012; Van Keulen-Rouweler et al., 2017). When establishing the criteria, the occupational therapist considers how much of the task the individual must independently perform without error, with scores of 85% or greater indicating effective performance (Aubin et al., 2009b; Ranka and Chapparo, 2010).

Procedural task analysis methodology is used in stage one to analyse the key steps of the task. Performance is scored against the presence of four error types: accuracy, omission, repetition and/or timing (Nott et al., 2009). An overall task mastery score is then calculated by dividing the sum of the error-free steps by the total number of steps (Steultjens et al., 2012) and converting this to a percentage. This score is then compared to the expected performance criteria of the task. Cognitive task analysis is used in stage two to evaluate cognitive strategy application (Ranka and Chapparo, 2010). Strategies are assessed against 35 cognitive behavioural items, termed ‘descriptors’, measured on a three-point scale, with three indicating effective performance, two inconsistent and one ineffective. The descriptors are further classified into 12 sub-quadrants and four overarching quadrants: perceive, recall, plan and perform (Nott and Chapparo, 2012). The quadrants address sensory registration, perception and attention (perceive); memory (recall); planning and evaluating (plan) and performance monitoring (perform). Effective task performance requires the interplay between the four quadrants and flexible, spontaneous use of the descriptor behaviours (Chapparo and Ranka, 2012).

The PRPP assessment has demonstrated construct validity (Nott and Chapparo, 2012), high test procedure reliability, moderate interrater reliability (Nott et al., 2009), good interrater validity at stage one, moderate interrater reliability for quadrant scores and good interrater reliability as a composite measure (Aubin et al., 2009a). It has been found to be reliable for use by multiple occupational therapists on a broad range of tasks in the community with multiple diagnostic groups, including dementia (Steultjens et al., 2012), schizophrenia (Aubin et al., 2009b), HIV-neurocognitive disorder (Ranka and Chapparo, 2010) and Parkinson’s disease (Van Keulen-Rouweler et al., 2017). The PRPP assessment has also been successfully utilised to measure information processing and structure intervention with people after traumatic brain injury (TBI) (Nott and Chapparo, 2012; Nott et al., 2008). There are common areas of cognitive impairment between people with TBI and stroke; however, published evidence regarding PRPP in stroke is lacking. The primary aim of this study was to describe stroke survivors’ occupational performance and cognitive strategy application during everyday activities whilst receiving ESD. Secondary aims were to compare the PRPP with global measures of ADL and IADL and to evaluate the feasibility of implementing the PRPP in the ESD setting.

Method

Study design

This exploratory pilot study used a prospective, descriptive study design. Ethical approval was received from the health service ethics committee and informed written consent was obtained from all participants.

Participants

From August 2016 to March 2017, consecutive potential participants meeting the study criteria were invited to participate by their treating occupational therapist. Inclusion criteria were aged over 18 years, less than 6 months post stroke with post-stroke cognitive impairment previously identified on a standardised cognitive screen, able to communicate in English and able to consent. Exclusion criteria were determined through consultation with the ESD and were presence of a premorbid cognitive impairment, readmission to hospital prior to the completion of the study outcome measures and not receiving occupational therapy through the ESD. People with aphasia were included in this study.

Measurement

The PRPP requires postgraduate training (Nott and Chapparo, 2012), and was hence administered and scored by three PRPP-trained occupational therapists, who were also the treating occupational therapists for nine of the participants. The treating occupational therapist clinically reasoned assessment tasks of appropriate complexity by considering the participant’s goals, occupational performance needs and difficulties, and then guided the participant to select two assessment tasks. Assessments occurred at home or in the community on tasks such as dressing, grocery shopping and internet use. The assessing occupational therapist recorded if the assessed task was novel or familiar to the participant, the duration of assessment and scoring time. To evaluate tasks of appropriate complexity and challenge executive skills, novel tasks were included (Poulin et al., 2013). Given that participants needed to be able to perform these tasks effectively in familiar environments, the performance criterion was set at 85%.

In addition to the PRPP, two global measures of ADL and IADL were used to evaluate the participant’s occupational performance. These were:

The Functional Independence Measure: a widely used measure of independence in ADL (Morrison et al., 2015; Silva et al., 2020). It includes items evaluating self-care, mobility and cognition. Each item is rated on a seven-point scale, with 1 being complete dependence and 7 complete independence.

Australian modified Lawton’s Instrumental Activities of Daily Living scale: this scale assesses occupational performance in community living across eight IADL activities (telephone use, shopping, food preparation, housekeeping, laundry, transport, medication management and financial management). Each activity is rated on an ordinal scale of what the individual could do, to a maximum score of 30, with higher scores representing greater independence (Harper et al., 2019).

As per standard practice for the service, the FIM and Lawton’s were administered through observation or interview by the treating occupational therapist or another treating allied health professional from the ESD service. To maximise reliability, clinicians followed standardised scoring guidelines for each assessment (Nott et al., 2009) and assessments were completed within the first five occupational therapy home visits. Demographic information was sourced from the participant’s medical record.

Data analysis

SPSS version 22 (IBM Corp, released 2013, IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) and Microsoft Excel 2016 were used for data analysis. Participants’ individual PRPP task results were averaged from the two tasks, and these averages were used in all calculations. The PRPP data was analysed by stage one scores, with a focus on the cognitive strategies detailed through sub-quadrants and quadrants. Descriptive statistics and percentages were used to explore PRPP sub-quadrants and quadrants. Spearman’s rho correlations were performed with PRPP quadrant scores, FIM total score, Lawton’s total score and time since stroke. Significance was set at p < 0.05. Correlation relationships of less than 0.3 were deemed to be weak, 0.3 to 0.7 as moderate and over 0.7 as high (Polgar and Thomas, 2000).

Findings

The cohort (n = 10) had mean age of 63 years (SD = 9.7) and were a mean of 43 (SD = 22.3) days post stroke (range 18–81). Most participants required minimal assistance with ADL (FIM mean = 104.2, SD = 10.51), and required assistance with IADL (Lawton’s mean = 16.5, SD = 3.69). Further details of participants’ scores can be found in Table 1. The average PRPP stage one task mastery score was 55% (SD = 10%, range 44%–73%), indicating ineffective performance. On average, each participant made two accuracy errors, one error in omission and one error in timing. Few repetition errors were recorded. On average, tasks took 28 minutes to administer (range: 10–90 minutes, SD = 20.4) and 5–40 minutes to score (mean = 19 minutes, SD = 13.0). One quarter of assessed tasks were classified as novel.

Table 1.

Participant information and assessment scores.

Participant	Age	Stroke type	FIM/126	Lawton’s/30	Stage one PRPP mastery score
1	65	Left MCA infarct	100	18	59%
2	44	Left ACA and MCA infarct	111	23	50%
3	54	Right frontoparietal infarct	86	13	45%
4	77	Right parietal infarct	110	16	72%
5	56	Left thalamic haemorrhage	114	17	50%
6	59	Bilateral PCA infarct	113	18	47%
7	63	Right basal ganglia haemorrhage	103	11	52%
8	65	Right frontal infarct	108	14	44%
9	65	Left basal ganglia haemorrhage	111	21	73%
10	78	Left MCA infarct	86	14	58%

FIM: Functional Independence Measure; Lawton’s: Lawton’s Instrumental Activities of Daily Living scale; PRPP: Perceive Recall Plan Perform System of Task Analysis. MCA: Middle Cerebral Artery, ACA: Anterior Cerebral Artery, PCA: Posterior Cerebral Artery.

Overall, participants in this study demonstrated ineffective cognitive strategy application at both the quadrant and sub-quadrant levels of perceive and plan, achieving less than 85% in these quadrants. Plan had the lowest scores, with an average of 18.35 (SD = 2.57), from a possible score of 27. The lowest mean sub-quadrant scores were in sensing (mean = 5.30, SD = 1.65), mapping (mean = 6.00, SD = 0.94) and evaluating (mean = 5.45, SD = 1.99). Most participants demonstrated effective skills throughout the perform quadrant, and at a sub-quadrant level scored well in discriminating (mean = 8.40, SD = 1.07), recalling facts (mean = 8.15, SD = 1.20) and initiating (mean = 5.60, SD = 0.97). Further quadrant and sub-quadrant results are detailed in Table 2 and Figure 1.

Table 2.

PRPP quadrant ranges, means and associations with FIM and Lawton’s scores.

Quadrant	Minimum	Maximum	Mean (SD)	FIM Scores	Lawton’s Scores
Perceive	15.0	24.0	20.55 (2.48)	0.57	0.91**
Recall	19.5	27.0	23.05 (2.63)	−0.27	−0.46
Plan	15.0	23.0	18.35 (2.57)	0.64*	0.66*
Perform^a	19.0	24.0	21.70 (1.96)	0.17	−0.07

PRPP: Perceive Recall Plan Perform System of Task Analysis; FIM: Functional Independence Measure; Lawton’s: Lawton’s Instrumental Activities of Daily Living scale.

^aAll quadrants have a possible score range of 9 to 27, bar perform which is 8-24.

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

Figure 1.

Cohort sub-quadrants means and ranges.

Spearman’s rank-order correlations revealed several significant relationships between the PRPP quadrants and general standardised measures of ADL and IADL performance. A strong, positive association was evident between the perceive quadrant and Lawton’s total score (r = 0.91, p < 0.01) and there were moderate strength relationships between the plan quadrant and the FIM (r = 0.64, p = 0.046) and the Lawton’s (r = 0.66, p = 0.037). In addition, a moderate strength relationship was evident between perceive quadrant scores and the FIM that approached significance (r = 0.57, p = 0.08). No association was found between time post stroke and any of the measures. Correlation results are detailed in Table 2.

Discussion and implications

In this exploratory study of 10 stroke survivors receiving ESD occupational therapy, task mastery and cognitive strategy application were concurrently evaluated using the PRPP. The PRPP stage one task mastery scores demonstrated that all participants lacked efficiency in task performance, despite assessment occurring in familiar environments, on tasks that reflected their everyday pre-stroke and current occupational performance goals activities. Stage two results detailed preliminary trends in cognitive strategy weaknesses in the sub-quadrants within perceive and plan and some general areas of strengths, particularly in the perform quadrant. Results also indicated that whilst PRPP scores were associated with performance of ADL and IADL on the FIM and Lawton’s, the PRPP assessment provided a more thorough analysis of stroke survivors’ occupational performance and information processing. Furthermore, the implementation of the PRRP appeared advantageous to ESD practice through its inherently ecological approach (Chouliara et al., 2014), which facilitated a comprehensive evaluation of occupational performance and cognitive strategy application in under 2 hours.

Early supported discharge is provided to optimise stroke survivors’ occupational performance through the provision of timely, intensive, individualised rehabilitation, supporting skill acquisition in the familiarity of the home setting (Chouliara et al., 2014; ISWP, 2016: 20). None of the participants in this study demonstrated mastery of their assessed tasks, despite the PRPP being assessed an average of 9 days post hospital discharge in a familiar environment. In this cohort, it is likely that post-stroke cognitive impairment, new physical disability and the recent transition home contributed to these reduced scores. This finding supports the need for ongoing intensive home-based rehabilitation post stroke during periods of challenge and adaptation (Connolly and Mahoney, 2018; Winstein et al., 2016). The high proportion of accuracy errors compared to the other error types indicated that participants were able to perform the key steps of the task but had difficulty applying cognitive strategies to do so effectively. The relative frequency of accuracy errors in this study may also indicate that whilst participants were assessed on everyday tasks in a familiar environment, the processing demands were greater than pre-stroke.

Executive dysfunction negatively impacts stroke survivors’ occupational performance (Poulin et al., 2013) as demonstrated by the participants’ scores in task mastery and plan. These results were supported by hierarchical analysis of the PRPP, which reported descriptors in mapping and evaluating as the most cognitively demanding (Nott and Chapparo, 2012). The low plan scores demonstrated that the participants had difficulty applying cognitive strategies efficiently to optimise their performance, without the structures imposed by an inpatient context or the automaticity of simplistic tasks. Many of the participants were also observed to have difficulty with searching and locating during task performance, leading to the low results in sensing and in the perceive quadrant. It appears that the PRRP was able to identify challenges in the perceive quadrant with this cohort, which is clinically relevant as these foundation skills can greatly affect occupational performance (van der Wijst et al., 2014) and are not commonly evaluated during occupational performance-based testing.

Conversely, participants in this sample scored well in the recall and perform quadrants, indicating that they were adept in applying several cognitive strategies during ADL and IADL tasks, such as recognising and categorising objects and using their existing knowledge to support their performance. The highest average sub-quadrant scores were in discriminating, recalling facts and initiating. These strengths may have been evident as participants primarily performed familiar tasks in an environment that they knew, reducing some of the cognitive demands in these areas. As in standard occupational therapy practice, most participants were assessed on familiar tasks (van der Wijst et al., 2014), which was a contributing factor for the high average score in recalling facts. Overall, cognitive strategy application strength and challenges experienced by this cohort were in keeping with the hierarchy of the PRPP descriptors in the acquired brain injury population (Nott and Chapparo, 2012).

In comparison to community-dwelling adults with conditions other than stroke, this cohort had areas of similarity to other populations with neurocognitive impairment. Accuracy errors were also the most prevalent error type made by people living in the community with schizophrenia when completing IADL tasks. Meanwhile, both cohorts demonstrated strengths in the perform quadrant, indicating that they were able to use strategies to support task execution (Aubin et al., 2009b). Participants in this study had comparatively lower scores in each quadrant than community-dwelling people with Parkinson’s disease who were also assessed on real-world tasks in familiar settings (Van Keulen-Rouweler et al., 2017), which may be due to the diverse impacts of stroke on cognition. Whilst participants in this study achieved similar recall quadrant scores to community-dwelling adults with schizophrenia (Aubin et al., 2014), the stroke cohort displayed lower total PRPP scores, suggesting greater difficulty in the perceive and plan quadrants. In both this study and that of Lewis et al. (2016), at least one participant scored 100% in 11 of the 12 sub-quadrants and both groups scored over 90% for ‘recalls facts’, indicating a diverse range of strengths and efficient use of pre-existing knowledge. However, the participants in this current study experienced greater difficulties in mapping and evaluating, which may be attributed to specific difficulties that stroke survivors experience in attention and perception (ISWP, 2016: 59–64).

Occupational therapists commonly employ a broad range of assessment tools with stroke survivors; however, multiple tools are usually employed to evaluate cognition, perception and occupational performance (Stigen et al., 2019). Although the FIM is regularly used in stroke rehabilitation, it is not an adequate indicator of occupational performance (Morrison et al., 2015). This study supports the use of the PRPP to evaluate occupational performance and cognitive strategy application, including executive skills (Aubin et al., 2009b; Morrison et al., 2015), and indicates that measurement of occupational performance and cognition in ESD practice requires assessment beyond the domain of self-care. Positive associations were found between the perceive and plan quadrants and global measures of ADL, indicating that a higher plan score was associated with greater independence, highlighting the importance of effective cognitive strategy application, particularly in perceive (attention and visuospatial skills) and plan (executive skills), to occupational performance post stroke. Scores on both the FIM and Lawton’s were positively correlated with plan quadrant scores. The plan quadrant encompasses executive functions including knows goals, chooses and analyses, all of which are cognitive strategies that contribute to efficient and independent performance (Nott and Chapparo, 2008). The PRPP was more strongly associated with the Lawton’s than the FIM, supporting the contention that IADL tasks are more cognitively demanding than ADL tasks (Aubin et al., 2009a; Pilegaard et al., 2014). In addition, the strong correlation between perceive quadrant scores and Lawton’s scores highlighted the attention and perception required for efficient IADL occupational performance, such as managing medications and shopping, which are included in the Lawton’s and were assessed on the PRPP.

Similar to earlier PRPP research, this study did not evaluate uniform tasks (Nott and Chapparo, 2012; Van Keulen-Rouweler et al., 2017); rather, the functional tasks to be assessed were negotiated with the stroke survivor. In total, 20 tasks were assessed, from domains including ADL, IADL and productivity. This differed to the procedures adopted by Steultjens et al. (2012), who allowed community-dwelling participants to choose two tasks from a task bank, and those of Van Keulen-Rouweler et al. (2017), where the participant selected any task that they perceived to be problematic, without clinician input. As the depth of information processing relates to the complexity of the task (Aubin et al., 2009a; Van Keulen-Rouweler et al., 2017), clinical reasoning was used in this study to determine which activities would be evaluated on the PRPP. This discretion ensured that participants were included in their service planning (Kristensen et al., 2012) and were assessed on activities that were relevant to daily life and at an appropriate degree of complexity (van der Wijst et al., 2014).

This research demonstrated how the PRPP can be applied to a broad range of tasks and performed by stroke survivors receiving ESD without increasing the assessment load on patients or therapists. It is imperative that assessments are easily implemented in multiple settings, valid for a broad client base and examine executive function (McDonald et al., 2019). In this study, each tool was scored in full, suggesting that these tools have clinical utility in ESD. Occupational therapists strive to deliver assessment of and intervention in occupational performance in an ecological manner whilst working within the constraints of systems, logistics and time. The range of time requirements was most likely due to the varying levels of participants’ impairments and resultant task difficulty (Chapparo and Ranka, 2012), with participants who had experienced a greater recovery completing more complex tasks, such as grocery shopping, compared to the simpler tasks that participants with less subtle impairments performed. The time required to administer (28 minutes) and score (19 minutes) each PRPP task was comparable to many other occupation-based assessments, such as the Executive Performance Function Test at 30–45 minutes (Poulin et al., 2013) and the Assessment of Motor and Process Skills (AMPS) at 30–40 minutes. However, it is not documented if these time estimates include both administration and scoring, and for the AMPS if it applies to one or two tasks. By allowing standardised evaluation of any activity, the PRPP may also reduce overall occupational therapy assessment time, compared to the use of non-standardised activity analysis combined with standardised traditional cognitive testing.

Literature indicates that training and resourcing increases the implementation of standardised ecological assessments (Burns and Neville, 2016; Sansonetti and Hoffman, 2013). Whilst the PRPP differs significantly to the AMPS in its theoretical basis, focus on cognition, clinical utility (Stigen et al., 2019) and its combined approach to occupational performance, real-world congitive strategy application and individidualised intervention (Chapparo and Ranka, 2012; Sansonetti and Hoffman, 2013), the PRPP and AMPS are the most common standardised ecological assessments used by occupational therapists (Sansonetti and Hoffman, 2013) and both require training in their use (Harper et al., 2019; Sansonetti and Hoffman, 2013). Further studies should investigate the application of the AMPS in ESD and compare PRPP to AMPS, alongside other measures. The results of this study support the ongoing training of occupational therapists on the PRPP to enable client-centred, ecological assessment. The findings of the PRPP assessment can be used to inform the systematic intervention of cognitive strategy use within real-world occupations (Nott et al., 2008). The clinical application of the PRPP in this study supports recommendations that occupational therapists provide intervention that maintains and optimises occupational performance with stroke survivors (Gillen et al., 2014).

There are numerous limitations inherent within this study design. The small sample from one service restricts generalisability of the results. Potential sources of bias included the treating occupational therapist usually completing the three assessments, which may have influenced task selection and scoring, impacting correlation analyses. Although PRPP assessment and scoring was conducted by senior occupational therapists who were experienced in occupational performance and cognitive assessment in early supported discharge, it is possible that scoring differences between raters occurred due to varying familiarity with the PRPP. Scoring consistency may be improved by providing PRPP refresher training. Some participants scored higher than anticipated on the PRPP, which may have been due to tasks lacking complexity (Van Keulen-Rouweler et al., 2017). However, it was determined that restricting the choice of assessable tasks was not in keeping with the premise of the PRPP or with current clinical practice. Correlations were tested without correcting for multiple testing and further statistical analysis was limited by the descriptive design.

Conclusion

This exploratory study described the strengths and weaknesses in cognitive strategy application used by stroke survivors during real-world occupations. This cohort demonstrated reduced task mastery, with difficulties in the perceive and plan quadrants, despite performing everyday occupations in familiar environments. The PRPP provided more detailed data on occupational performance than the FIM or the Lawton’s and took under 2 hours to evaluate occupational performance and cognitive strategy application. These results indicate that the PRPP is a feasible tool to ecologically evaluate occupational performance and cognitive skills in ESD. Further investigation of the PRPP should examine its reliability and validity as an outcome measure and ability to systematically develop individualised metacognitive strategy training in stroke rehabilitation (Gillen et al., 2014; Sansonetti and Hoffman, 2013).

Key findings

The PRPP assessment with stroke survivors identified impaired cognitive strategy application in under 2 hours.

Efficient cognitive strategy application is related to independence in ADL and IADL.

What the study has added

The PRPP assessment can be successfully implemented by occupational therapists with stroke survivors receiving ESD to measure occupational performance and identify strengths and difficulties in cognitive strategy application.

Footnotes

Acknowledgements

We would like to thank the staff from Rehabilitation in the Home, Perth, Western Australia for their assistance with data collection, and the South Metropolitan Health Service library staff for their support.

Research ethics

Ethical approval was provided by East Metropolitan Health Service Research Ethics and Governance, 2016. Australian/New Zealand Clinical Trials Registry number: ACTRN12616000684426.

Consent

Informed written consent was obtained from all participants.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Contributorship

Jocelyn White initiated and managed the research project, and wrote the article. The research design and methodology was supported by Chris Barr and Stacey George. Chris Barr provided data analysis, and contributed to the study design. Melissa Nott and Chris Chapparo provided input regarding data interpretation. All authors reviewed and edited the manuscript, and approved the final version.

ORCID iD

Jocelyn White

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