Abstract
Introduction
Rehabilitation is a repetitive, educational, problem-solving and client-centered process undertaken in a complex environment where goal setting, shared decision-making, collaboration, partnership, and empowerment are central [1, 2]. Literature has shown that client-centered principles applied to goal setting and intervention increase client performance, self-efficacy, and satisfaction; they also contribute to a better understanding of contextual issues, create new opportunities and improve work-related outcomes [3–7].
Disadvantaged groups, such as those with a disability, should be supported in returning to work or entering the labor market [8]. Participation in work with a disability is a complex experience, influenced by a diversity of factors [9], which can be captured and addressed though a biopsychosocial approach to assessment and rehabilitation [9, 10]. In health and social services there is an increased focus on instruments that provide assessments at the level of participation, as defined by the International Classification of Functioning, Disability and Health (ICF) [11, 12]. Outcomes on the level of participation are most relevant to people with disabilities, their relatives and society [11, 12]. In a recent review of existing literature, Désiron et al. [13] confirmed the positive contribution of occupational therapy interventions in successful vocational rehabilitation, particularly those taking place in a real working environment. A client-centered approach to practice may be one method of enhancing client participation in the rehabilitation process [13]. In occupational therapy, the Canadian Occupational Performance Measure (COPM) is proposed as an instrument that enables describing and measuring activity limitations and the participation restrictions perceived by the client [14]. The COPM supports determining the client’s occupational performance issues and facilitates a goal setting process in a client-centeredapproach [14].
In 2000 the Slovenian version of the COPM was introduced (Table 1); occupational therapists need to follow a two-day standardized workshop, consisting of theoretical and practical part, including application of the COPM with clients. Since that time, it has been used in practice [15], research [16] and has been proposed as a standard of practice for occupational therapists working in vocational rehabilitation [17]. Using this standard, an inter-professional vocational rehabilitation and client-centered approach are integrated [17].
Literature review
A literature search was performed in PubMed, OT Seeker and Google Scholar using the following keywords: The Canadian Occupational Performance Measure, work, vocational rehabilitation, return to work, occupational therapy. Some studies were also identified through a review of references in relevant articles.
The COPM is a valid, reliable, and clinically useful outcome measure of self-perceived occupational performance and participation across a wide variety of clients, settings, purposes and programs [18, 19]. Through a semi-structured interview, clients and occupational therapists jointly identify the most important occupational performance problems. For each of the problems clients rate performance and satisfaction with performance [18]. Reviews and studies of the clinical utility and application of the COPM support its central role in reinforcing a client-centered and partnership approach, defining problems in occupational performance, planning interventions and monitoring change in the context of occupational therapy, as well as in the broader context of inter-professional teamwork [13, 18– 23]. A recent study by Colquhoun et al. [20] showed that the administration of the COPM could significantly improve occupational therapy treatment.
The COPM can be used to establish programs that identify and measure occupational performance and outcomes in different contexts [13, 18– 22]. However, few studies [24, 25] on the application of the COPM in vocational rehabilitation could be found. In the reviewed studies the COPM was used as part of a client-centered approach to identifying problems and measuring change in occupational performance and it was found to be useful in goal setting, intervention planning and outcome measurement in vocational rehabilitation [24, 25]. Furthermore Macedo et al. [4] and Dielacher and Höss [26] showed that occupational therapy intervention based on the COPM, brought significantly higher improvements in clients’ work-related outcomes and better opportunities for return to work.
Although the Slovenian version of the COPM exists and is used in practice, no research on its clinical utility has been carried out. The present study was, therefore, aimed at exploring how Slovenian occupational therapists working in vocational rehabilitation perceived and described the usefulness of the COPM in their everyday practice.
Methods
Theoretical framework
A social constructivist perspective has been used to reach an understanding of the meaning that occupational therapists attributed to their experience and perception of the use of the COPM in their daily practice in vocational rehabilitation [27]. Social constructivism is a framework in which people seek to understand their world and develop their own meanings based on their experience and in interaction with others [27]. Because this perspective focuses on the formation of meaning through active participation in a socially mediated context, it enabled the researchers to access a variety of personal views and contextual dimensions of participants’ experience[27].
Research design
A qualitative inquiry using a focus group discussion was chosen to elicit dialogue and rich information as well as to facilitate the expression and exchange of different viewpoints in a social context [27–29]. In order to facilitate open and encouraging discussion, the participants were selected strategically to ensure homogeneity in profession and working area. Thirty invitation letters, including a detailed description of the study, were sent electronically through the Slovenian Association of Occupational Therapists to all the occupational therapists that were members of the vocational rehabilitation section. Potential participants of this study were employed in 8 different Slovenian organizations, providing vocational rehabilitation services to various client groups. This means that one third (N = 10) of the occupational therapists working in the area of vocational rehabilitation in Slovenia agreed to participate in the focus groups. They gave their written consent for using data gathered in the present study.
Data collection
Data was collected through two focus group discussions. One group consisted of six, and the other of four occupational therapists. The first author (AŠ) facilitated the discussions using a semi-structured interview guide [29]. The questions covered the following main topics: Experiences when using the COPM in everyday practice, perceptions of the instrument, opinion on the training elements for the use of the COPM, and reflections about the usefulness of the results (Table 2). The guiding questions were formulated neutrally and the same interview guide was used in both focus groups. Possible bias in conducting the focus groups was also minimized by using the same moderator, opening statements and order of topics [29]. The moderator ensured that all topics were discussed in both focus groups but tried to be as open as possible to emerging participants’ perspectives. A research assistant took field notes. The first focus group lasted for an hour and a half and the second for one hour. Both focus groups were audio taped and transcribed verbatim. The authors assured the participants of the confidentiality and anonymity of the information that theyshared.
Participants
The participants were selected strategically on the basis of the following inclusion criteria: They had to have attended a COPM training workshop and had to have worked as occupational therapists in vocational rehabilitation for at least two years. Ten participating occupational therapists came from five different rehabilitation centers. These participants worked with the following client groups: Physical disabilities (four), mental health problems (three), intellectual disabilities (one) and mixed disabilities (two). The two day COPM training workshops, designed in cooperation with CanChild Research Center, are provided by a group of Slovenian occupational therapists and researchers. Workshops are organized by the Slovenian Association of Occupational Therapists on a regular basis. They are lead by the second author (BP), who is also one of the authors of the Slovenian translation of the COPM [17]. During two days the participants learn about the COPM, its theoretical background and evidence [14– 15, 18– 23] and have opportunity to apply the COPM with actual clients.
Data analysis
Data analysis followed the meaning condensation method [28]. In the first stage of the analysis the researchers read through both focus group transcripts several times to obtain a complete sense of each focus group discussion. The data were then compiled and divided into natural meaning units. From these meaning units, the dominating themes were extracted based on the expressions of the participants’ viewpoints. The meaning units were then related to the specific aims of the study. Finally, essential themes were linked into descriptive statements and illustrated by the most suitable citations [29].
Trustworthiness
The researchers strived to ensure credibility of the study by using several strategies. In the first place they chose the focus group approach to collecting data, which is a well established method for getting rich and diverse experience about the topic from participants coming from similar backgrounds [28]. The familiarity of the moderator (the first author) with the topic and the participants facilitated a comfortable and non-threatening atmosphere for the discussion. At the beginning of each focus group the participants were informed that they could withdraw from participation at any time and that the confidentiality of their identity or information was ensured. With the aim of setting aside their own assumptions as far as possible, the researchers also adopted a reflexive approach to the research process [30]. Whilst analyzing data from focus groups and writing up the findings, they reflected upon and used memos of possible biases, influencing the understanding and interpretation of the data. These biases could arise predominantly from direct daily involvement of the first author (AŠ) in vocational rehabilitation. The second author (BP) who has experience in research and is not working in vocational rehabilitation, gave constant reflective feedback on the analysis process, challenging the ideas and interpretations developed by the first author (AŠ). This helped to recognize and reflect on any possible biases and preferences of the first author that may have arisen due to her being so close to the research topic.
The focus groups were held in Slovenian language. In order to stay close to the meaning, the analysis of data was also performed in Slovenian [31]. The article was afterwards written up in English by both authors, who have studied and published in English before. To minimize possible meaning losses by translation, the most meaningful parts of the text, especially findings and quotes of the participants, were together with the original Slovenian text, discussed with and edited by a professional translator [31].
Findings
The analysis of the data resulted in five major themes: (1) the COPM facilitates collaboration with clients; (2) the COPM is a source of evidence and empowerment for occupational therapists; (3) the challenges that arise when using the COPM; (4) the use of COPM requires training; and (5) using the COPM results and understanding their meaning. These themes are additionally explained by occupational therapists’ perceptions as shown in the Table 3.
The COPM facilitates collaboration with clients
Participants perceived the COPM as a powerful tool for identifying a broad range of occupational performance issues including work related issues, as well as seeing it as a tool that supports a goal setting process. The participants described the COPM as a way for clients to discover what is really meaningful to them. They said that by using the COPM, meaningful occupational performance issues and priorities could be identified more easily. One participant gave the following example:
In mental health, we are striving to be client-centered... He or she (the client) has to agree, has to see the meaning, and we need to set goals together... and, it is great that the COPM is just supporting that.
The COPM gave the participants the potential to identify a broad scope of occupational performance priorities and issues, not only those related to work. One participant mentioned that she believed that successfully entering or returning to work needed to be planned and carried out whilst considering all other important daily occupations and roles. According to her, providing an occupational therapy intervention which does not focus only on work-related issues, helped clients to go through the occupational transition to work in a more enabling way:
By also addressing other occupational areas (besides work) you can support your client to overcome the problems in entering the work environment. If, for example, a person expresses problems in leisure activities, you can start working there ... with the final goal of supporting inclusion into society.
The participants also described how using the COPM helped them in a goal setting process and in focusing interventions towards the most relevant occupational performance issues in a time-efficient way. Its contribution to problem identification was understood as one of the major strengths of the instrument:
It (the COPM) gives you a quick insight into the most relevant occupational issues. The client identifies the problems, the therapist identifies them, and this is a good guideline for planning the intervention together.
The COPM is a source of evidence and empowerment for occupational therapists
The participants described how the COPM contributed to their professional empowerment and appreciation in the inter-professional team by gathering unique information about clients’ functioning and by following changes in occupational performance over time. They found that the information about the clients’ occupational performance issues, gathered with the COPM, was crucial and could not be obtained by any other professional:
The psychiatrist himself told me that he could not get such information about clients from his interview and that it was essential and beneficial for further assessment and therapy.
Several participants described how the results of the COPM helped with planning, goal setting and the coordination of treatment for the whole team. As one participant explained:
The priorities that emerge – these occupational performance issues – are a sort of indicator for the whole (vocational rehabilitation) team about how and what to do with a client. We are aware that we cannot do everything in the allocated time, but we can together start solving some of the problems, seek and connect the client to a social network, and counsel the client on where to go for further treatment, etc.
Several participants used the COPM as an outcome measure to track changes in thclients’ performance issues that were addressed during vocational rehabilitation. Measuring change in occupational performance was important for the occupational therapist in order to discuss the follow-up with the individual client and to provide evidence for the effectiveness of occupational therapy treatment with the vocational rehabilitation team. One of them explained:
I had a great experience of treating a male client over one year. I performed the COPM four times during the therapeutic process, and it really showed change. In fact, if I did not have this instrument, I could not show that this man’s performance improved considerably.
Challenges that arise when using the COPM
Participants described several challenges in the use of the COPM. Some of them were related to the decisive role of clients, acknowledging their perceptions, and to the level of insight of certain client groups. Others were related to the more organizational issues of conducting the COPM interview and assessment. Although the client-centered approach was preferred by the participants during occupational therapy intervention, some of them revealed doubts in sharing control with their clients or had issues with appreciating the validity of the clients’ individual perceptions about their occupational performance:
This is a subjective assessment and what I missed is also an objective one. I missed the possibility for the therapist to get insight into the client’s actual situation because we know that clients sometimes experience a problem as a terrible one when there is none, or they minimize others when they are much bigger. The therapist can only compare the client’sassessment.
Therapists who have worked with clients that have a learning disability, brain injury or mental health issues frequently faced problems when conducting the COPM. These problems were mostly related to their clients’ limited ability to gain an insight into their own occupational performance abilities and limitations. For example, one of the participants said:
Exceptions are clients with poor insight. I meet a lot of them, not only among clients with learning disabilities or traumatic brain injury, but also among those having problems with mental health. This lack of insight can really be a problem. Sometimes (performing the COPM) is really difficult.
The participants felt that the COPM cannot be used to its full potential and meaning in short interventions such as vocational assessment. The short duration of intervention was experienced as a challenge when applying the COPM because the therapists could not address the issues in therapy or use the COPM to track changes in clients’ occupational performance or satisfaction:
I felt awful after connecting with a client. After talking in depth with this client, there was no opportunity to follow up with issues which were identified further on in the treatment sessions. Because clients really open up about so many things, I am at a loss... what should the treatment focus on if there are only two weeks available?
Some of the participants’ felt that they would use the COPM more regularly if its use was somehow regulated inside the treatment process. They all experienced substantial pressure of time and organizational frameworks on their work. Defining the role of the COPM within these frameworks would, in their opinion, enable them to use it more freely. One of the participants expressed this by saying:
When the clinical pathways are set and when you know exactly how much time you have for a certain client and how to conduct the intervention, then this is also paid for and you can afford it. If the COPM was regulated in such a way all occupational therapists could do it. Since it is not, we have little time and have to decide ...
Some of the participants felt that the rating scale from 1 to 10 was too broad and because of that it was sometimes difficult to use it in the Slovenian context. They suggested reducing it to a rating from 1 to 5. This would enable clients to relate the meaning of the grades to the 1– 5 grading system that is used in primary and secondary schools.
The use of COPM requires training
The participants saw training as a necessary step for the introduction of the COPM into occupational therapy practice because it not only provided learning on the use of the instrument itself but also on the philosophy and rationale behind it. All the participants attended a COPM training workshop before they started using it. They believed that this training contributed significantly to its use in their daily practice. What they found very beneficial were the practical exercises in conducting the COPM. The participants felt that conducting the COPM required specific communication, partnership and leadership skills. As one of them said:
This is not an interview where you can follow the questions and tick the answers. This is an interview in which you need to know how to formulate questions to stimulate clients to express their issues.
The theory behind the COPM and the Canadian Models presented in the workshop extended participants’ knowledge and built up their confidence in using the client-centered approach in their practice. As one participant described it, the theoretical part of the training was crucial for understanding the philosophy and meaning of the COPM:
The Canadian model and the process model that supports the COPM were presented in a concise and illustrative way. From this you could see how to lead the process further on.
The participants also talked about their first experiences when using the COPM with their clients. They described questions that arose from the interaction with clients:
At the beginning, after the workshop, everything seems to be clear. But, when you are alone with a client, then you realize that you still have a million questions.
Some of the participants emphasized how participating in the training workshop helped them in overcoming problems they had encountered when performing the COPM with clients. They all expressed the need for new knowledge and continued support in using the instrument:
It is important to refresh your knowledge. There could be workshops or meetings like this, or at least an internet forum or something like that.
Using the COPM results and understanding their meaning
Participants described how the COPM results offered a valuable basis for further collaboration with clients in the occupational therapy process, enabled an insight into clients’ current life priorities, and shed light on societal influences on the meaning of work and employment for their clients. The participants described how, at first, the COPM results enabled them to discuss with clients the planning, follow-up, and adaptation of the occupational therapy intervention to the client’s needs. One of the participants described this by saying:
Actually, I talked to them. We discussed different assessments, and planned interventions. If the client wanted to continue like this, we made an agreement and set new goals.
When discussing the COPM results, the participants agreed that from their experience work was the most important preoccupation for their clients. However, they also pointed out that clients’ answers might, to some degree, be influenced by their expectations in the treatment context, namely the vocational rehabilitation team, because the COPM was conducted as part of the vocational rehabilitation program:
Participating in the vocational rehabilitation program could be the reason that they emphasize productivity because we expect them to.
Further discussion found that in the participants’ experience, for many of their clients’ unpaid work, such as voluntary, household or social inclusion activities, was more important than paid employment. This was especially true for clients with traumatic brain injury or mental health problems. One of the participants described her observations by saying:
I can see a tendency that if clients decide to pursue an occupation, then they prefer the unpaid over the paid ones. This is because they (the unpaid occupations) are less demanding; you do not need to come in on time or do things exactly the way the employer says. And you still get acknowledged, belong to a group, and have a good time. This seems to be sufficient for them.
Participants described many experiences of conducting the COPM with clients who were not sure whether entering or returning to paid work (employment) was something that had meaning for them or was something that they desired in their current life circumstances. This enabled occupational therapists to obtain a unique insight into clients’ actual life and occupational priorities. In the participants’ opinion, this ambivalence regarding the value and meaning of employment for their clients was influenced very much by societal factors, especially the relationship between personal income from welfare and paid work. As one of the participants said:
I think that the policy of the society is contributing a lot to these perceptions. Clients often say to me: “Why would I go to work – leave home, pay for transportation, pay for clothes, the hairdresser, and buy shoes – if I get less money than when I am unemployed?” The difference between the minimal wage and welfare money should be much bigger.
For the participating occupational therapists this insight was important because it gave them a broader perspective on clients’ perceptions and also guided them to focus their intervention beyond the immediate client– therapist interaction and towards the societal level:
For the intervention – now you know what to address. Build up motivation. And maybe – report further (to policy makers), so that they will see where the problem is and act accordingly...
Discussion
This study has tried to reach an understanding of how Slovenian occupational therapists working in vocational rehabilitation, perceived the usefulness of the COPM in their everyday practice. Several of the findings contribute to existing knowledge; some, however, bring new insights and perspectives on using the COPM and its results in vocational rehabilitation. The participants of this study confirmed, as in other contexts [13, 33], and also in vocational rehabilitation, the use of the COPM enhances client-centered occupational therapy practice. Facilitating the collaboration with clients through addressing relevant occupational issues, supporting transition to work, and enabling comprehensiveness of the COPM, were the main characteristics of theirperceptions.
Furthermore, participants in this study described how the use of the COPM increased their professional identity and empowerment not only in relation to clients but also in the vocational rehabilitation inter-professional team. Evidence of the empowering potential of occupational therapy, generated through the use of standardized instruments, was previously found by Clark [34].
Additionally, the challenges that the participants described in using the COPM have already been discussed in previous studies. Some were related to allowing clients a decisive role and acknowledging their perceptions. Although participants in this study unanimously agreed on the importance of applying a client-centered approach and enabling the active participation of clients in their programs, they also expressed doubts and described problems in actually sharing control and responsibility for the vocational rehabilitation process with their clients. Shaw et al. [35] also showed a tendency by service providers to superimpose their own goals upon the clients’ goals and to take control of the rehabilitation process. Discrepancies in the perception and the enacting of the client-centered approach between occupational therapists and their clients were also reflected by other authors [1]. In a qualitative study that involved service providers and clients, Shaw et al. [5] developed a conceptual model that explains that creating a client-centered environment requires conscious attention and effort by both providers andclients.
The participants in this study described some organizational aspects, such as time constraints and organizational policies that were barriers to fully using the COPM; this also supports existing knowledge [36, 37]. Other challenges described by the participants, such as the poor insight of the clients or difficulties with understanding the scale, have also been reported in previous studies [1, 38]. Participants in this study confirmed the findings of McColl et al. [19] who emphasized that using the COPM to its full potential with different clients and in various settings required flexibility and adaptability.
Additionally, the findings of this study highlight participants’ views of the importance of training in how to use the COPM. As reported in previous research [38] they also perceived training as a necessary step to properly applying the COPM in their occupational therapy practice. The workshop not only provided skills for performing the assessment but also gave them a rationale, knowledge and understanding for using the information gathered. The participants in this study also emphasized that continuous peer support (e.g., via an internet forum) could have been helpful in implementing the client-centered approach and in using the whole potential of the COPM in daily practice. Wilding et al. [39] have also shown that supportive communities of practicing occupational therapists can contribute to their professional development, confidence and work satisfaction.
New insights and perspectives about the usefulness of the COPM, provided by the findings of this study, are related to participants’ perceptions of the COPM results in relation to the contextual factors of vocational rehabilitation. Discussing occupational performance issues – identified by the COPM – with their clients enabled them to attain an insight into the meaning of paid or unpaid work and into the social context that influenced both. Participants shared the experience that the meaning of work in the form of employment was, for their clients, very much related to the economic aspects of their environment, especially to financial compensation during absence from work or during periods of unemployment. Hestbaek et al. [40] also noted the negative effects of financial compensation for absence from work on vocational rehabilitation and its outcomes. The meaning of work as reflected in the COPM occupational performance issues of the vocational rehabilitation clients can also be discussed through the perspective of occupational justice – which refers to the rights, responsibilities and liberties that enable people to experience health and quality of life through engagement in meaningful occupations and in their economic, political, cultural and other environments [41]. From this point of view, the socio-economic context of engagement in work, as described by vocational rehabilitation clients and occupational therapists in Slovenia, may be associated with certain types of occupational injustice, especially occupational alienation and imbalance. During the COPM interview, participants’ clients explained that because of low pay, returning to work or entering employment in their current situation did not result in an improvement to their quality of life. This is a situation, where employment fails to meet the needs of potential workers and may actually lead to occupational imbalance instead of to health and well-being [41]. These injustices cannot be resolved at the individual level or by enabling opportunities for work, but rather by taking action at the level of society, as proposed by Hansen [42]. This was a view also recognized by the participants of this study. As discussed by Wolf et al. [43], the application of the occupational justice framework to occupational therapy practice may guide occupational therapists to identify and address the environmental and system barriers in a way that leads to more occupationally just solutions. Since participation in work is, in any context, crucially defined by environmental determinants, adopting an occupational justice framework to the understanding COPM results can help occupational therapists to support their clients beyond the individual interaction and immediate workplace intervention.
In this broader view, occupational therapy interventions in vocational rehabilitation become less focused on the direct engagement with clients and include more activity related to enabling and removing obstacles for occupation in the social and physical environment. This may require occupational therapists to adopt additional roles in relation to clients and the inter-professional team, for example, case management, team coordination or providing advocacy for clients. The participants in this study recognized the potential of the COPM to inform the inter-professional vocational rehabilitation team not only about the most relevant occupations that clients experience as important but also about barriers that are present in the environment.
Study limitations
A possible limitation that may have influenced the results of this study is that the focus group moderator knew all the participants and that the participants also knew each other. The moderator was also one of the trainers in the COPM workshop. This could have caused bias by eliciting preferable answers. This familiarity has on the other hand facilitated a sincere and open discussion,
For this study, the focus group approach to collecting data was chosen. The group interaction, however, did not allow for a deeper exploration of participants’ individual perceptions of the benefits and challenges of the use of the COPM in their everyday practice. Therefore, the individual interview method might allow for richer and more in-depth data to be collected.
The present study looked into the therapists’ perspective of the use of the COPM. Research into the clients’ perspective of the role of the COPM in the client-centered approach to occupational therapy and vocational rehabilitation could also provide valuable insights that may further support its benefits and help to address any persisting challenges inits use.
Conclusion
The findings of the study support the clinical utility of the COPM in the vocational rehabilitation context. The majority of the findings of this study show that when using the COPM in the context of vocational rehabilitation, the experiences of some Slovenian occupational therapists support the existing knowledge of the strengths and barriers to using the COPM in other contexts. The participants agreed that by enabling client-centeredness and focusing treatment on relevant occupations, the use of the COPM empowered their clients and themselves in the process of vocational rehabilitation. New insights from this study are related to using the COPM results for planning and implementing interventions, especially in relation to the contextual factors that influence the meaning and importance of work for vocational rehabilitation clients. In this respect, as already proposed by other authors [40, 42], the findings support the need for occupational therapists to broaden their conceptualization of the environment. Taking account of the contextual influences on the importance of work, as assigned through the COPM ratings, can be crucial for understanding the meaning of work for individual clients in their individual circumstances. This specific insight could facilitate the setting of achievable and realistic goals not only for occupational therapy, but also for the vocational rehabilitation program as a whole. Adopting an occupational justice framework to identifying the barriers to their clients’ participation in work can provide a new perspective on the potential for addressing them. However, further research is needed to explore the contextual influences on the interpretation and implementation of the COPM results.
Conflict of interest
None to declare.
Footnotes
Acknowledgments
Thanks are extended to the occupational therapists working in different vocational rehabilitation programmes in Slovenia for their willing participation in this study. Furthermore, the authors would like to thank Mrs. Meghan Norton and Mrs. Mateja Vovk for their contribution to this manuscript.