1. The Occupational Therapy Practice framework: Domain & Process

2. The Occupational Therapy Practice framework
an evolution of Uniform Terminology III
a broader document
Describes the profession's DOMAlN
Describes the PROCESS used to deliver services
This revision came out of UT III but is a different kind of document—broader. Addresses process as well as domain—to help therapists and assistants wee how domain can be applied

3. Background—history of UT
three editions (79, '89, '94)
Each evolved—purpose shifted
UT III reviewed in 1999 to determine need for revision
To understand where this document came from it is helpful to briefly look at how Uniform Terminology evolved. UT revised three times— each time adding to and clarifying the professions domain
The purpose of UT shifted with each edition
UT I—govt mandated each discipline establish common reporting system for services—necessitating development of common terminiology
Under Carter administration. Never implemented. AOTA went forward anyway feeling that common terminology would be useful to the profession
UTII—dropped the product output reporting part and focused on delineating pert areas and pert comp that OT addressed
UT III—expanded to reflect current thinking and practice. Purpose to provide a generic outline of domain of concern and provide common terminology
UT III is an official document (voted on and approved by RA). COP has a policy that all official documents are reviewed every 5 years to determine if they need to be continued, revised or rescinded. UT III was reviewed in 1999

4. What we found out... Knowledge has evolved—Practice has changed
Our language was unclear to external audiences—and sometimes to ourselves
UT does not describe our focus on occupation—the core of our profession
Consensus—it's time to change
Knowledge has evolved—know more about occupation (occupational science). We understand more about our core constructs
Practice has changed. The service delivery process has changed—less time with clients. Therapists finding it difficult to evaluate in the same way because of time constraints. Began to have a better understanding of the relationship between pert. Comp and pert areas. Learning pert components did not dictate successful performance
Language—what is a pert area? A pert component? Other disciplines, funding agencies did not understand these terms—they were our own professional jargon. Because not language used by others often our literature was not referenced in data basis—we were using different key terms i.e no one knew we did IADL because we talked about "productive" activities reather than IADL
There was lack of consistency in our own terminology lists—i.e. roles, strength, fine coord
Some terms missing—spirituality, occupation, psychosocial and cognitive area terms incomplete or inaccurate
Occupation—the core of our practice—not mentioned or defined in UT III New language ICF—widely understood and getting disseminated
Was a need to provide links among all practice areas. A need to provide consistency across practice areas and specialties so it was clear what OT is about—makes us more understandable
Conclusion: UT not meant to direct practice but yet it was being used that way because it structured our thinking. Pert comp list was being used as a list of everything that had to be evaluated. The list became OT...
UT III although never meant to direct how practice was performed was in fact doing that—people leaning about pert components and feeling had to evaluate all of them
The list of words developed a life of their own—the list became OT— The list began to direct the process of practice as well as the content. List was misused

5. Purpose of the Framework
More clearly articulate OT's unique focus on daily life activities and interventions that promote engagement in occupations to support participation in context—
Describe our
Give practitioners a way to think about, talk about and apply occupation across the OT process-Outline an occupation based OT
1) Need both purposes—tells what we focus on and how we apply
2) Our hope—to position OT place in the provision of health services
3) Provide a tool to help practitioners describe what they do (DOMAIN) and how they do it (PROCESS)—to LINK the two
4) Both domain and process or linked to occupation.
Wanted to orient and remind people of the profession's focus and strength.
5) Called a framework—because is a structure on which a variety of ideas, theories, and approaches could be placed
6) Next we ill talk about the major sections of the document and highlight content of each

6. Relationship of the domain and the process
Domain outlines the area in which we provide services--
Process describes the structural pieces (i.e. evaluation, intervention outcomes) we use when delivering services
They are interdependent
The domain defines the area in which services delivery occurs.
The domain serves as our foundation
Defines the focus and the factors that will be addressed during the process
The process is "built" on the domain
Domain and process are interrelated: If therapist is unclear about the domain may shift practice to the domain of a related profession. Lack of clarity tempts therapist to adopt a "technique" practice or use techniques and approaches that are currently popular.
Causes confusion about what is OT
Why needed to address both—people were unclear how to apply the constructs from the UT III domain into the Process. Result—intervention became focused on the long list of perf comp. Felt needed to more clearly explicate or point out how the process needed to be grounded in an understanding of the person's issues, needs and concerns related to engaging in occupations. Also how to use occupations in interventions—how process is focused on achieving outcomes related to engaging in occupations
The domain and process are interdependent—must understand your domain to know the area in which you apply the process

7. Our domain...
The area of human experience in which we offer assistance to others....
We help others to engage in everyday life activities...or....
What is a domain?—the area of human experience in which we offer assistnace to others (taken from Mosey—see framework for reference)
What is our domain?—OCCUPATION—we help people engage in everyday life

8. Occupation Defined as:
Activities., of everyday life, named, organized, and given value and meaning by individual and a culture. Occupation is everything people do to occupy themselves, including looking after themselves,...enjoying life,...and contributing to the social and economic fabric of their communities...(Law, Polatajko, Baptiste, & Townsend, 1997, p. 32)
How we defined occupation...
Note: occupations are activities with certain qualities—they are valued by the person and meaningful. They have meaning for the culture also
OTs often use the terms activity and occupation interchangeably but the framework reflects current thinking that these two ideas are somewhat different (read the document and references cited)

9. Domain of Occupational Therapy
Engagement in Occupation to Support Participation in Context
Performance in areas of occupation
Performance skills
Performance patterns
Figure provides an overview of our domain—all areas of the domain are important. No one is more important than another. All are features of our domain that we consider when we work with people Next—look at each aspects in more depth Will look at each section in more depth....
Client Factors
Context
Activity Demands

10. Engagement in Occupation to Support Participation in Context
The overarching phrase that describes the domain
Why was this phrase was chosen – look at each term in more depth to understand its intent and meaning

11. Why was this phrase chosen?
Engagement—recognizes choice, personal meaning, psychological/emotional and physical aspects of performance
• Participation—an aspect of health in the ICF model, OTs contribution to health is in linking activities and participation through engaging in occupations
• Context—supports and mediates engagement
Engagement—commitment to performance that occurs because of self-choice, motivation and meaning.
Holistic understanding of performance—emotional/psychological as well as physical—subjective and objective
Engaging leads to desired participation in a variety of life situations. Participation is an aspect of health (activities and participation) defined by ICF.
Link our interest in and focus on helping people carry out important life occupations to an aspect of health. Makes OT contribution and role in health restoration, maintenance and promotion clearer
Help therapists recognize that their interventions focus on more than task performance—interventions are ultimately directed at facilitating the person's ability to participate in meaningful roles and routines.

12. Other aspects Of domain i. e
Other aspects Of domain i.e. performance in areas of occupation, performance skills, performance patterns, context, activity demands, client factors
No one aspect more important than another
Ail aspects influence engagement in occupations
OTs and OTAs consider all aspects during evaluation and intervention process

13. Performance in Areas of Occupation
Categories of occupation in which people engage
Called performance areas in UTIII
Resorted and expanded from UTIII
To understand how clients are engaging in occupation we need a way of categorizing them
We sort occupation in different areas—these areas are broad categories of human performance
-they are artificial—because only the person can define an occupation and its meaning to him or her.
By providing a list of categories it helps to ensure that we look at all aspects of engagement nd of participation in meaningful life activities
-these categories have been resorted and expanded from the UT III performance areas

14. Performance Skills—NEW
Some Performance Components In
UT III were Performance Skills
Describes observed actions...lifts, chooses, asks
3 kinds of skills
-Motor skills
-Process skills
- Communication /Interaction skills
A new term in Framework—In UT III old perfcomp list actually included a mixture of perf. Skill, body functions, body structures and perf. Patterns.
By sorting out perf skills hope to clarify our language and thinking
OTs use these terms when describing what they see a client do when carrying out an activity or occupation as opposed to what the underlying body functions is that may be contributing to the skill performance problem
Can use these terms in verbal and written communication.
Inclusion of this newer language and expanded terms should help therapists more accurately and discretely describe performance—and differentiate the performance that is observed from the underlying body function that may be causing the skill deficit.
Skills occur or are observed as a result of the transaction that occurs between the performer's body functions/structures, the demands of the activity and the context in which performance occurs.
Offers more precise language for understanding and describing performance. Clarify thinking about what observing
Helps, hopefully, therapists to understand that body functions and skills are different—and than because an person has a body functions does not directly translate into their ability to perform a skill

15. Performance in Areas of Occupation
Activities of Daily Living (ADL)
Instrumental Activities of Daily Living (IADL)
Education
Work
Play
Leisure
Social Participation* (new)
Use of more universal terms (ADL, IADL)
Separated education and work (was productive activity)—these are more self explanatory tersm
Separated Play from Leisure—again more understandable—recognizes different meaningsmay related to difference in ages
Added area of social participation—in community, family, with peers/friends. Defined as "activities asociated with orgaized patterns of behavior that re characteristic and expected of an individual or an individual interacting with others within a given social system (adapted from Mosey)

16. Performance Patterns—NEW
Habits
Routines
Roles
Performance patterns are recurring behaviors related to daily routines
Including this aspect recognizes performance patterns as a legitimate aspect of engaging in occupations that OTs address and consider

17. Performance Skills...
Performance skill terms differentiate skilled action from underlying body functions
Skills occur as transactions between the performer's body function/structure, the demands of the activity, and the context in which performance occurs
Effective skill performance is not ensured by adequate underlying body functions or structures

18. Context Cultural (retained) Physical (retained) Social (retained)
Personal (resorted from UT III Temporal context—refers to age, gender, educational & socio-economic status)
Spiritual (new)
Temporal (resorted from UT HI Temporal context—refers to time of day, year, stage of life etc.)
Virtual (new)
OTs always consider how context influences performance, skills and ultimately engagement
Context -interrelated conditions within and surrounding the client. Context seem as existing both external to the client and internal to the client
This area was expanded and revised from UT Added
Personal (age, gender, education, socio economic) Spiritual—fundamental orientation -meaning
Virtual—communication without physical contact—recognizes the increasing presence of this context in our life
Revised temporal context from old UT so that meaning is different— now refers to time ie. Time of day, year, stage of life

19. Activity Demands—NEW! Objects used and their properties Space Demands
Social Demands
Sequencing and Timing
Required actions
Required body functions
Required body structures
Not a new construct to OT but has been a part of our professions thinking and applications since our early years. Supports our skill in and use of activity analysis as an important aspect of understanding and providing interventions to support performance in occupations. This is the first time we have explicated activity demands as a construct that we consider in our domain of practice.
Making OTs use of activity analysis explicit

20. Activity Demands Relate to a specific activity
Different than physical context and social context
Note that some of the demands listed i.e. space demand and social demands may remind one of context terms i.e. physical context, social context. Activity demands are not the same as context. The demands of an activity are small—they relate to the specific requirements or demands of a specific activity. Context is a much broader term. The demands of a specific activity occur within a larger context. For example the social demands of playing volleyball include sharing space with other team members, interacting verbally and physically with others. The social context in which volleyball might occur might be non existent if the game were being played for practice in a gym after school and no observers were present. It would be much different if the game were played in competition with team supporters for both sides present and cheering both teams on.
Comment on how activity demands are different from context
Note that some of the demands listed i.e. space demand and social demands may remind one of context terms i.e. physical context, social context. Activity demands are not the same as context. The demands of an activity are small—they relate to the specific requirements or demands of a specific activity. Context is a much broader term. The demands of a specific activity occur within a larger context. For example the social demands of playing volleyball include sharing space with other team members, interacting verbally and physically with others. The social context in which volleyball might occur might be non existent if the game were being played for practice in a gym after school and no observers were present. It would be much different if the game were played in competition with team supporters for both sides present and cheering both teams on. .

21. Client Factors—body functions & body structures
Underlying physiological abilities or structures that reside in the person
includes mental (affective, cognitive, perceptual), sensory, physical and physiological abilities
Used classification from ICF— aligned with body systems
Many included in UT as performance components
Body systems: mental functions; sensory and pain functions; neuromusculoskeletal and movement functions, cardiovascular hematological, immunological and respiratory system functions.
Examples: mental body functions—emotional stability, motivation, memory, temperament, perception
Sensory function: discriminating touch,
Neuromsuculaoskeletal and movement functions: ROM strength eye-hand coordination.
Body structures—anatomical parts of body
Listing is not complete. Faculty may need to look at this
Why chose ICF classification? Wide distribution. Understood by others. Because familiar others would get it. A broad classification that provides examples but avoids definitive lists provides more flexibility -allows updated examples to be added
Differentiate body functions from perf skills—language for each. Help to clarify thinking—understanding what body function contribute to what skills.—part of clinical reasoning process.

22. OT practice framework process
Occupational profile
Intervention Review
Outcomes
Engagement in occupations to support participation
Analysis of Occupational Performance
Intervention Implementation
Three main sections outlined in the process (note color changes!!) Evaluation Intervention Outcome
Understanding of and application of occupation is embedded throughout the process.
Note that this process, by itself is not unique to OT..
Note: It's important that process begins with the occupational profile— who and what the person is as an occupational being. Serves to focus our evaluation and. intervention on our domain (occupation) from the very start
Will talk about each box in more depth highlighting what happens and over all ideas
Intervention Plan

23. What makes this process unique to OT?
What is evaluated: occupational needs, problems, risks and concerns
How the problem is framed: occupational performance—risks or difficulties with daily life tasks
Type of intervention: use of selected therapeutic activities and occupations to facilitate engagement in occupation
Outcome: directed toward facilitating engagement in occupation to support participation
What makes it OT is its connection with the domain—and the integration of occupation into this process
What is evaluated—look at person's problems, needs, risks and concerns. Note phrasing—aimed at evaluating not just people with performance problems but also looking at people with potential problems—moves OT in prevention and wellness arenas
How the problem is framed—its OT when we define/describe the problems/issues for which we will provide intervention in terms of occupational performance—note ROM, Sensory integration etc
Type of intervention—its OT because we use therapeutic activity and occupations in our intervention to facilitate performance and engagement in occupatons
Outcome: its OT because it is clear throughout the process that we are working toward the outcome of helping people engage in everyday life activities that are meaningful and important to them i.e. occupations
What makes process unique? The focus on occupation and the use of occupation. Occupation as ends and means

24. Key points about the process
Client-centered
Clients may be individuals, groups of populations
Dynamic and interactive
Broad & inclusive of all practice areas
Context an embedded influence on the process of service delivery
Grounded in occupation
Clients may be individuals, groups or populations. Individuals may be persons with identified needs or individuals who are involved in supporting or caring for the person i.e. spouse, teacher, caregiver, employer parent. Understanding clients in this way broadens who OTs can serve

25. The Occupational Profile... the initial step
Describes client's occupational history, patterns of living, interests, values, and needs
Identify client's priorities. What are client's needs, wants and concerns re: engaging in occupations
Frame client concerns and issues within the domain of occupational therapy
Get to know the person—their background re engaging in occupation and participation, and their perspective
Note: the evaluation process begins with a profile of the person—not a PROBLEM.
Focuses the process within the domain (occupations) and allows therapists and client to focus on assets as well as liabilities
Know what is important to them-priorities
Describes their problems from occupational perspective
This step firmly ground the process in a client centered approach
Begin collecting data about the profile at the start of evaluation but throughout process pick up more information to add to the profile

26. Analysis of Occupational Performance
More specifically identify underlying factors which support and hinder performance
-observe performance
-perform selected specific assessments if needed
-consider context, activity demands and client factors
-identify client strengths & weaknesses
Identify facilitators and barriers to performance Suggesting a top down approach
Understood that this process occurs by using a clinical reasoning process and it guided and directed by OT theory and specific frames of reference that the therapist has selected as appropriate to this client problems and issues. Knowledge of evidence will also inform the therapists decisions and actions in this phase of the evaluation.
Performa selected assessments. Perform only those assessment that will give you additional info you need—do not do every test!
Based on additional info gathered you interpret the data
In this part of evaluation you develop and refine your hypothesis about client's strengths and weaknesses regarding occupational performance
Confirm the outcome you are headed toward

27. Intervention Plan Develop plan in collaboration with client
Base plan on:
--Selected theory and/or practice framework
--Evidence
Select intervention approach: create/promote, establish/restore, maintain, modify, prevent
Target desired outcomes
Development of plan is client centered...
Plan will be influenced by theory and or practice framework you use
Plan should be ground in evidence—what works best
Conscious selection of interventions approach is made. Therapist needs to realize that we have many more approaches to intervention other that the "fix the person" or establish restore approach valued in the medical model. Framework outlines these (like the Guide to Practice also does).
In the plane desired targeted outcomes are also stated—usually in a goal format—and these outcomes or goals are stated in occupation terms—what will the client be able to do, perform, engage in. Should be related to his/her priorities
OTPF has a table which define, describes various intervention approaches. OTs may use one or more during intervention
Outcomes targeted related to end outcome of engaging in occupation
Plan is client centered—work with client to develop plan and understand his needs and priorities

28. Intervention • Action to influence and support performance
• Types of interventions
-Therapeutic use of self
-Therapeutic use of occupations/activities Occupation-based activity, purposeful activity, preparatory methods
-Consultation process
-Education process
During intervention actions are taken to influence and support performance—actions may be directed as one or more of the aspects of the domain that influence performance i.e. context, client factors, activity demands, perf. Skills, perf, patterns.
Types of interventions outlined in Table 8. Briefly discuss what is occupation based activity, purposeful activity, and preparatory methods

29. Intervention Plan Review plan, process and progress towards outcomes
Modify plan if needed
Determine futire action
Collaborate with client during this review

30. Outcomes— Engagement in occupation to support participation
Describes the broad outcome of the OT intervention process
Links the outcome to the domain
Outcomes is the last stage of the process—it is the end result of the process. However the action involved in outcome determination, measurement and achievement are woven throughout the process
Note the term used to describe the broad outcome of OT intervention— Engagement in occupation to support participation. Same as term which describes our domain. Use of same or similar term serves to link the domain and the process—the area of human activity in which we provide service also describes what the outcome of our services are

31. Outcomes— Engagement in occupation to support participation
Types of outcomes
-Occupational performance
-Client satisfaction
-Role competence
-Adaptation
-Health and wellness —Prevention of performance problems
-Quality of life
Engagement in occupation to support participation is the broad dimension of health that occupational therapy targets
The types of outcomes provide an idea of the many dimensions of health that can be directed to or lead to engagement in occupation

32. New terms.............Old terms Framework UT III
Areas of occupation
Performance skills
Performance patterns
Context
Activity demands
Client Factors—body functions, body structures
Outcomes
Performance areas
Performance components
Not addressed
Performance context
Provides a brief comparison of new term and old terms. Table 1 in the background section of the framework provides even more information

33. In Summary The Occupational Therapy Practice Framework: Domain & Process
Affirms the profession's focus on engagement in occupation to support participation as:
- an important aspect of health
- the broad outcome targeted by OT intervention
Describes and links the profession's domain and process
Emphasizes the profession's expertise in addressing performance issues related to engaging in every day life occupations and activities. :
incorporates terms more commonly used by other disciplines
Adds constructs to the domain & updates terms throughout to reflect current knowledge and thinking

34. How the Framework can be used...
Examine own practice in light of new ideas
Consider application to new settings and areas
Explain occupational therapy to others— communicate our contribution to health
To teach about occupation centered practice