精神科職能治療活動操作表現評量工具的發展與標準化

行政院國家科學委員會補助專題研究計畫成果報告

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精神科職能治療活動操作表現評量工具的發展與標準化

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The development and standardization of a task performance scale

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used in psychiatric occupational therapy

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計畫類別：□個別型計畫　　□整合型計畫

計畫編號：NSC89－2314－B002－098－

執行期間：88 年 08 月 01 日至 89 年 07 月 31 日

計畫主持人：潘璦琬

共同主持人：呂淑貞

本成果報告包括以下應繳交之附件：

□赴國外出差或研習心得報告一份

□赴大陸地區出差或研習心得報告一份

□出席國際學術會議心得報告及發表之論文各一份

□國際合作研究計畫國外研究報告書一份

執行單位：國立台灣大學

中　華　民　國 89 年 10 月 31 日

計畫編號：NSC 89-2314-B-002-098

執行期限：88 年 8 月 1 日至 89 年 8 月 31 日

主持人：潘璦琬，國立台灣大學職能治療學系

(aywoan@ha.mc.ntu.edu.tw)

共同主持人：呂淑貞，八里療養院職能治療科

計畫參與人員：鍾麗英，元智大學會計科

1、Chinese abstract 職能治療的介入重點為重建或恢復 病人的職能功能，因此如何評量病患的職 能功能表現程度，以及治療的進展，是職 能治療師首要考慮的。在評估病患的職能 功能表現上，客觀的觀察加上病人主觀的 描述，有助於澄清問題所在，並確認治療 的方向。因此職能治療師所採用的評估工 具應能有效地結合這兩種取向，以便獲取 合宜的、符合現實情境的資訊，作為臨床 介入的基礎。本研究即是翻譯並驗證加拿 大職能表現測驗（Canadian

Occupational Performance Measure, COPM），應用於台灣臨床精神病患之研 究，用以探討此測驗於台灣個案的適用 性。本研究共收集 141 位來自於療養院以 及醫學中心精神部的精神病患。治療師均 接受施測前的訓練，共有 13 位治療師參 與資料的收集。本研究結果顯示，每位病 人平均確認了 3.3 個職能表現的問題。 其中自我照顧類的問題佔 37％，工作/就 學類的問題佔 25％，休閒類的職能表現 問題佔 20％。治療師的評價中，一半對 使用以個案為中心導向之評估工具，持正 面看法。然而，使用上，治療師仍覺得有 若干困難度。未來在使用此類工具時，應 著重於概念的介紹，以及其提供的優點， 作為施測者的參考。 關鍵詞：職能治療評估、個案中心、職能 表現 2、English Abstract

The purpose of occupational therapy is to restore or establish the occupational performance capabilities of the clients. In order to achieve the goals of treatment, the need to utilize an appropriate assessment

tool to evaluate the clients are important. The purpose of the study is to develop such a scale for use in mental health occupational therapy. The Canadian Occupational Performance Measure, COPM, was translated and tested on a group of Taiwanese clients with psychiatric disorders. The total numbers of tested clients are 141. The results of the study showed that COPM could be applied to the clients reliably and validly. The test retest reliability is excellent. By using the COPM, the therapists can identify all kinds of occupational performacne problems (37 % as self-care tasks; 25 % as work related tasks; 20 % as leisure activities). Therapists’ feedback on the use of COPM was described and discussed. Further researches of the use of COPM in Taiwan were suggested.

Keywords: Occupational Therapy

Assessment, Client-center, Occupational Performance

2、Introduction

One of occupational therapy’s traditions, the use of occupation or purposeful activity as a therapeutic agent, has been a unique aspect of our profession

(1,2)

. During the observation of activity performance of the client, occupational therapists attain significant information about a patient’s ability to perform an occupation and the skill deficits that could influence the task performance (3,4)

. Occupational therapists thus focus on skill training to increase client’s occupational functioning. From this perspective, an instrument to evaluate clients’ performance objectively and effectively is necessary. The purpose of the study is to develop such

an instrument and validate its use in clients with psychiatric disorders in Taiwan.

Literature suggests that individuals with psychiatric disorders typically present with pervasive functional deficits Deficits in occupational performance components include sensori-motor, cognitive, psychosocial integration, low energy levels, decreased strength, decreased endurance, short attention span, limited abilities to initiate activities and the inability to solve problem encountered in performance(5-7)

. The impact of the deficits on occupational performance deserves special attention from occupational therapists. Since occupational performance (self-care, work, and leisure tasks) is unique focus of our profession(8,9). The current study will focus on developing an instrument for measuring occupational performance of the clients.

An extensive literature review and national survey were conducted in order to identify theoretical and clinical perspectives upon the use of an assessment instrument The stress of the easiness, flexibility, and evidence-based as well as client-centeredness focus of the assessment tools were identified as universal concerns in occupational therapy literature and clinical application (10-12). The easiness and flexibility of the test pertain to the clinical utility of the test, while the evidence-based character refers to the immediate need of the profession to demonstrate the effectiveness of the intervention. The client-centeredness approach, which can be traced back to the professional tradition, focuses on the collaboration of the clients, respect of the clients’ perspectives on his or her own problems and empowering the clients to be able to change (13)

. Thus, Canadian Occupational Performance Measure (COPM) (14), which matched the requirements of the clinical assessment, was chosen as the tool to be developed for use in Taiwan.

The research questions of the study are:

(1) Does COPM can be effectively applied to Taiwanese clients?

(2) What are the occupational performance problems identified by clients with

psychiatric disorders? Is it valid to identify related occupational performance issues?

(3) Is COPM reliable?

3、Methods

One hundred and forty one subjects with psychiatric disorders were recruited to participate in the study. They were from a psychiatric institute and a university-affiliated hospital in northern part of Taiwan. The subjects came from a variety of treatment units of acute, sub-acute, chronic, rehabilitation and psychosomatic wards. Fifty-eight percent of the subjects are male. The mean age of the subjects is 35.6 (SD=9.3), with the youngest as 17 years old and the oldest as 62 years old. Ninety-four percent of the subjects were diagnosed as Schizophrenia; the other 6 percent of the subjects were classified as other diagnoses.

These subjects were tested by their occupational therapist on the COPM and retest with two weeks or one month apart depending on the type of setting they were reside. Before the administration of the COPM, each therapist attended a three-hour administration training and discussion.

3、Results

The results of the study can be separately examined to answer three research questions of the study:

（1） Does COPM can be effectively applied to Taiwanese clients?

This is examined through descriptive data provided from the therapists who attended the study. Thirteen therapists completed the user survey. The mean age of the therapists is 26.7 (SD=5.8); the mean year of working as an occupational therapist is 3.15 (SD=4.6); 77 % of them had bachelor degree and 23 % of them had postgraduate degree. The average length of administration of COPM is 23.6 (SD=6) minutes. It is 13.4 (SD=4.61) minutes for the re-test. The level of easiness of administering the COPM was investigated by use of a 7 point rating scale that 1 represents hard and 7 means easy. The average level of easiness to identify COPM problems is 3.8. The level of easiness in

rating the importance of the COPM problems is 4.6, the level of easiness in rating the performance of the COPM problems is 3.9 and 3.9 for the level of easiness in satisfaction with the performance. When therapists were asked of their opinions about the client-center approach, 50 % of the therapists accepted, another 50 % of the therapists held doubtful attitude toward the approach. Finally, their willingness to apply COPM in clinical setting showed that 50 % of the respondents are willing to apply it and another 50 % of the respondents felt that they would consider it. In addition to quantitative data, therapists raised several issues about the COPM

(i) Patients with psychiatric disorders may have cognitive deficits, impeding their abilities to make appropriate ratings.

(ii) Some of the identified problems were unclassified based on the occupational performance scheme. For example, to be able to make decisions. It may fit into any category depending on the problems to be solved.

(iii) The perceived problems of the clients differed from those identified by the therapists. The therapists worried that the clients may make inaccurate judgements due to poor reality testing.

(iv) Some of the problems raised by the clients were not solvable. For example, change another staff or change ward. (v) The occupational performance

components were not identified by COPM.

(vi) COPM enabled therapists to recognize occupational performance problems that could not be discovered otherwise.

(vii) Therapists felt that by conducting COPM, the clients were motivated to participate in his or her own treatment planning.

(2) What are the occupational performance problems identified by clients with psychiatric disorders? Is it valid to identify related occupational

performance issues?

According to the results of the study, the average number of identified COPM problems from is 3.3, with the minimal number as 1 and the maximal number as 6. From the identified COPM problems, the researcher classified them into five groups of occupational performance: self-care, work, leisure, social, and other activities. The results showed that 37 % of the identified problems belong to self-care type, 25 % of the problems are work-related type, 20 % of the problems are leisure type activities, 12 % of the problems are related to social encounter and the remaining 5 % of the problems are other type. The results did suggest that COPM can validly identify all types of occupational performance problems of the clients.

(3) Is COPM reliable?

This was examined through the test and re-test of 86 clients with psychiatric disorders. These clients were tested and retested within one month. During which time, their functional performance should remain stable. The Pearson Product Moment Correlation Coefficients of the two scores, representing test re-test reliability is excellent (r =0.86, p < .0001) for both performance and satisfaction measure.

4、Discussions

The results of the study support the clinical utility, validity and reliability of COPM applying to Taiwanese subjects. Although the therapists expressed some concerns about the usage of COPM in clients with psychiatric disorders, these issues can be solved by adequately address the problems through multiple resources. It might be necessary to disseminate the client-centeredness to the therapists and the clients before the use of COPM. As mentioned in the COPM manual (14), whenever therapists make judgements about the clients, they need to be very careful not to impose certain value system to the clients. In case of conflicts, the therapists should bring up the issue and discuss it with the clients. Sometimes the therapists found that the identified problems

of the clients may not be solved in the clinical setting. In this case, the therapists should inform the clients about the limitations of the setting. The therapists may need to refer the case to another profession to deal with the issue.

In summary, the COPM can be an effective way to identify clients' self-perceived occupational performance problems. Involving the clients in the treatment process also provides incentives for the clients to engage in the treatment actively. There were also certain obstacles in using the COPM. Certain educations and training about the client center approach and the use of COPM need to be implemented. Further researches are necessary to ensure that the COPM is valid and reliable in Taiwanese population.

5、References

1. Neistadt, M. E., & Crepeau, E. B. (1998). Willard & Spackman's Occupational Therapy (9th Ed.). Philadelphia, PA: Lippincott-Raven Publishers.

2. Kielhofner, G. (1992) Conceptual Foundations of Occupational Therapy. Philadelphia, PA: F. A. Davis Co.

3. Cottrell, R. P. F. (1996). Perspectives on Purposeful Activity: Foundation & Future of Occupational Therapy. Bethesda, MD: AOTA, Inc.

4. Zemke, R. & Clark, F. (1996). Occupational Science: The Evolving Discipline. Philadelphia, PA: F. A. Davis, Co.

5. Margolis, R. L. etc. (1996). Occupational therapy task observation scale (OTTOS): A rapid method for rating task group function of psychiatric patients. The American Journal of Occupational Therapy, 50, 380-385. 6. Kannenberg, K. R. (1997).

Occupational Therapy Practice Guidelines for Adults With Schizophrenia. Bethesda, MD: The American Occupational therapy Association, Inc.

7. Bonder, B. R. (1995). Psychopathology & Function (2nd Ed.). Thorofare, NJ: SLACK Inc.

8. Fisher, A. G. (1997). AMPS: Assessment of motor and process skills. Fort Collins, CO: Three Star Press.

9. Fisher, A. G. (1998). Uniting Practice

and Theory in an Occupational Framework. The American Journal of Occupational Therapy, 52, 509-521. 10. Asher, I. E. (1996). Occupational

Therapy Assessment Tools: An Annotated Index (2nd Ed.). Bethesda, MD: The American Occupational Therapy Association, Inc.

11. Eakin, P. (1989). Assessments of

activities of daily living :A critical review. British Journal of Occupational Therapy, 52, 11-15.

12. Early, M.B. (1996). Mental Health

Concepts and Techniques for the occupational therapy assistant. (2nd Ed.). Philadelphia, Pennsylvania: Lippincott-Raven Publishers.

13. Hemphill-Pearson, B. J. (1999). Assessments in occupational therapy mental health: An integrative approach. Thorofare, NJ: SLACK Inc.

14. 潘璦琬（民 89）加拿大職能表現測驗