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Occupational Therapy Practice Framework: Domain and Process
Fourth Edition
Preface
The fourth edition of theOccupational Therapy Practice Framework: Domain
and Process (hereinafter referred to as theOTPF–4), is an official document of
the American Occupational Therapy Association (AOTA). Intended for
occupational therapy practitioners and students, other health care
professionals, educators, researchers, payers, policymakers, and consumers,
the OTPF–4 presents a summary of interrelated constructs that describe
occupational therapy practice.
Definitions Within theOTPF–4, occupational therapy is defined as the therapeutic use of
everyday life occupations with persons, groups, or populations (i.e., the client)
for the purpose of enhancing or enabling participation. Occupational therapy
practitioners use their knowledge of the transactional relationship among the
client, the client’s engagement in valuable occupations, and the context to
design occupation-based intervention plans. Occupational therapy services
are provided for habilitation, rehabilitation, and promotion of health and
wellness for clients with disability- and non–disability-related needs. These
services include acquisition and preservation of occupational identity for
clients who have or are at risk for developing an illness, injury, disease,
disorder, condition, impairment, disability, activity limitation, or participation
restriction (AOTA, 2011; see the glossary in Appendix A for additional
definitions).
When the term occupational therapy practitioners is used in this
document, it refers to both occupational therapists and occupational therapy
assistants (AOTA, 2015b). Occupational therapists are responsible for all
aspects of occupational therapy service delivery and are accountable for the
safety and effectiveness of the occupational therapy service delivery process.
Contents
Preface .....................................................................1
Definitions ..........................................................1
Evolution of This Document ..............................2
Vision for This Work ..........................................4
Introduction ..............................................................4
Occupation and Occupational Science ...........4
OTPF Organization .......................................4
Cornerstones of Occupational Therapy
Practice ......................................................6
Domain .....................................................................6
Occupations .......................................................7
Contexts ............................................................9
Performance Patterns .....................................12
Performance Skills ..........................................13
Client Factors ..................................................15
Process ..................................................................17
Overview of the Occupational Therapy
Process ....................................................17
Evaluation ........................................................21
Intervention ......................................................24
Outcomes ........................................................26
Conclusion .............................................................28
Tables ....................................................................29
References .............................................................68
Table 1. Examples of Clients: Persons, Groups,
and Populations ............................................29
Table 2. Occupations ......................................30
Table 3. Examples of Occupations for Persons,
Groups, and Populations ..............................35
Table 4. Context: Environmental Factors .......36
Table 5. Context: Personal Factors ................40
Table 6. Performance Patterns .......................41
Table 7. Performance Skills for Persons .......43
Table 8. Performance Skills for Groups .........50
Table 9. Client Factors ....................................51
Table 10. Occupational Therapy Process for
Persons, Groups, and Populations .............55
Table 11. Occupation and Activity
Demands ......................................................57
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Occupational therapy assistants deliver occupational therapy services under
the supervision of and in partnership with an occupational therapist (AOTA,
2020a).
The clients of occupational therapy are typically classified as persons
(including those involved in care of a client), groups (collections of individuals
having shared characteristics or a common or shared purpose; e.g., family
members, workers, students, people with similar interests or occupational
challenges), and populations (aggregates of people with common attributes
such as contexts, characteristics, or concerns, including health risks; Scaffa
& Reitz, 2014). People may also consider themselves as part of a community,
such as the Deaf community or the disability community; a community is a
collection of populations that is changeable and diverse and includes various
people, groups, networks, and organizations (Scaffa, 2019; World Federation
of Occupational Therapists [WFOT], 2019). It is important to consider the
community or communities with which a client identifies throughout the
occupational therapy process.
Whether the client is a person, group, or population, information about the
client’s wants, needs, strengths, contexts, limitations, and occupational risks is
gathered, synthesized, and framed fromanoccupational perspective. Throughout
the OTPF–4, the term client is used broadly to refer to persons, groups, and
populationsunlessotherwise specified. In theOTPF–4, “group”asa client is distinct
from “group” as an intervention approach. For examples of clients, see Table 1 (all
tables are placed together at the end of this document). The glossary in Appendix
A provides definitions of other terms used in this document.
Evolution of This Document The Occupational Therapy Practice Framework was originally developed to
articulate occupational therapy’s distinct perspective and contribution to
promoting the health and participation of persons, groups, and populations
through engagement in occupation. The first edition of the OTPF emerged
from an examination of documents related to the Occupational Therapy Product
Output Reporting System and Uniform Terminology for Reporting Occupational
TherapyServices (AOTA, 1979).Originally a document that responded to a federal
requirement to develop a uniform reporting system, this text gradually shifted to
describing and outlining the domains of concern of occupational therapy.
The second edition of Uniform Terminology for Occupational Therapy
(AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and
published in 1989. The document focused on delineating and defining only
the occupational performance areas and occupational performance components
that are addressed in occupational therapy direct services. The third and final
edition ofUniform Terminology for Occupational Therapy (UT–III; AOTA, 1994)
was adopted by the RA in 1994 and was “expanded to reflect current practice
and to incorporate contextual aspects of performance” (p. 1047). Each revision
Table 12. Types of Occupational Therapy
Interventions ................................................59
Table 13. Approaches to Intervention ............63
Table 14. Outcomes ........................................65
Exhibit 1. Aspects of the Occupational Therapy
Domain ...........................................................7
Exhibit 2. Operationalizing the Occupational
Therapy Process .........................................16
Figure 1. Occupational Therapy Domain and
Process ..........................................................5
Authors ............................................................72
Acknowledgments ...........................................73
Appendix A. Glossary .....................................74
Index ................................................................85
Copyright © 2020 by the American Occupational Therapy Association.
Citation: American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi. org/10.5014/ajot.2020.74S2001
ISBN: 978-1-56900-488-3
For permissions inquiries, visit https://www. copyright.com.
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reflected changes in practice and provided consistent
terminology for use by the profession.
In fall 1998, the AOTA Commission on Practice (COP)
embarked on the journey that culminated in the
Occupational Therapy Practice Framework: Domain
and Process (AOTA, 2002a). At that time, AOTA also
published The Guide to Occupational Therapy Practice
(Moyers, 1999), which outlined contemporary practice
for the profession. Using this document and the feedback
received during the review process for theUT–III, the COP
proceeded to develop a document that more fully
articulated occupational therapy.
The OTPF is an ever-evolving document. As an
official AOTA document, it is reviewed on a 5-year
cycle for usefulness and the potential need for further
refinements or changes. During the review period, the COP
collects feedback from AOTA members, scholars, authors,
practitioners, AOTA volunteer leadership and staff, and
other stakeholders. The revision process ensures that the
OTPFmaintains its integrity while responding to internal and
external influences that should be reflected in emerging
concepts and advances in occupational therapy.
The OTPF was first revised and approved by the RA in
2008. Changes to the document included refinement of the
writing and the addition of emerging concepts and changes
in occupational therapy. The rationale for specific changes
can be found in Table 11 of the OTPF–2 (AOTA, 2008,
pp. 665–667).
In 2012, the process of review and revision of the
OTPF was initiated again, and several changes were
made. The rationale for specific changes can be found
on page S2 of the OTPF–3 (AOTA, 2014).
In 2018, the process to revise the OTPF began again.
After member review and feedback, several modifications
were made and are reflected in this document:
n The focus on group and population clients is
increased, and examples are provided for both. n Cornerstones of occupational therapy practice are
identified and described as foundational to the
success of occupational therapy practitioners. n Occupational science is more explicitly described
and defined.
n The terms occupation and activity are more clearly
defined. n For occupations, the definition of sexual activity as an
activity of daily living is revised, health management is
added as a general occupation category, and intimate
partner is added in the social participation category
(see Table 2). n The contexts and environments aspect of the
occupational therapy domain is changed to context on
the basis of theWorld Health Organization (WHO; 2008)
taxonomy from the International Classification of
Functioning, Disability and Health (ICF) in an effort
to adopt standard, well-accepted definitions (see
Table 4). n For the client factors category of body functions,
gender identity is now included under “experience of
self and time,” the definition of psychosocial is
expanded to match the ICF description, and
interoception is added under sensory functions. n For types of intervention, “preparatory methods and
tasks” has been changed to “interventions to support
occupations” (see Table 12). n For outcomes, transitions and discontinuation are
discussed as conclusions to occupational therapy
services, and patient-reported outcomes are
addressed (see Table 14). n Five new tables are added to expand on and clarify
concepts: + Table 1. Examples of Clients: Persons, Groups,
and Populations + Table 3. Examples of Occupations for Persons,
Groups, and Populations + Table 7. Performance Skills for Persons (includes
examples of effective and ineffective
performance skills) + Table 8. Performance Skills for Groups
(includes examples of the impact of ineffective
individual performance skills on group
collective outcome) + Table 10. Occupational Therapy Process for
Persons, Groups, and Populations.
n Throughout, the use of OTPF rather than Framework
acknowledges the current requirements for a unique
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identifier to maximize digital discoverability and to
promote brevity in social media communications. It
also reflects the longstanding use of the acronym in
academic teaching and clinical practice. n Figure 1 has been revised to provide a simplified
visual depiction of the domain and process of
occupational therapy.
Vision for This Work Although this edition of the OTPF represents the latest in
the profession’s efforts to clearly articulate the
occupational therapy domain and process, it builds on a
set of values that the profession has held since its
founding in 1917. The original vision had at its center a
profound belief in the value of therapeutic occupations as
a way to remediate illness and maintain health (Slagle,
1924). The founders emphasized the importance of
establishing a therapeutic relationship with each client
and designing a treatment plan based on knowledge
about the client’s environment, values, goals, and desires
(Meyer, 1922). They advocated for scientific practice
based on systematic observation and treatment (Dunton,
1934). Paraphrased using today’s lexicon, the founders
proposed a vision that was occupation based, client
centered, contextual, and evidence based—the vision
articulated in the OTPF–4.
Introduction
The purpose of a framework is to provide a structure or
base on which to build a system or a concept
(“Framework,” 2020). The OTPF describes the central
concepts that ground occupational therapy practice and
builds a common understanding of the basic tenets and
vision of the profession. TheOTPF–4 does not serve as a
taxonomy, theory, or model of occupational therapy. By
design, the OTPF–4 must be used to guide occupational
therapy practice in conjunction with the knowledge and
evidence relevant to occupation and occupational
therapy within the identified areas of practice and with the
appropriate clients. In addition, the OTPF–4 is intended
to be a valuable tool in the academic preparation of
students, communication with the public and
policymakers, and provision of language that can shape
and be shaped by research.
Occupation and Occupational Science Embedded in this document is the occupational therapy
profession’s core belief in the positive relationship
between occupation and health and its view of people as
occupational beings. Occupational therapy practice
emphasizes the occupational nature of humans and the
importance of occupational identity (Unruh, 2004) to
healthful, productive, and satisfying living. As Hooper and
Wood (2019) stated,
A core philosophical assumption of the profession, therefore, is that by virtue of our biological endowment, people of all ages and abilities require occupation to grow and thrive; in pursuing occupation, humans express the totality of their being, a mind–body–spirit union. Because human existence could not otherwise be, humankind is, in essence, occupational by nature. (p. 46)
Occupational science is important to the practice of
occupational therapy and “provides a way of thinking that
enables an understanding of occupation, the occupational
nature of humans, the relationship between occupation,
health and well-being, and the influences that shape
occupation” (WFOT, 2012b, p. 2). Many of its concepts are
emphasized throughout the OTPF–4, including
occupational justice and injustice, identity, time use,
satisfaction, engagement, and performance.
OTPF Organization The OTPF–4 is divided into two major sections: (1) the
domain, which outlines the profession’s purview and the
areas in which its members have an established body
of knowledge and expertise, and (2) the process,
which describes the actions practitioners take when
providing services that are client centered and
focused on engagement in occupations. The
profession’s understanding of the domain and process
of occupational therapy guides practitioners as they
seek to support clients’ participation in daily living,
which results from the dynamic intersection of clients,
their desired engagements, and their contexts
(including environmental and personal factors;
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Christiansen & Baum, 1997; Christiansen et al., 2005;
Law et al., 2005).
“Achieving health, well-being, and participation in life
through engagement in occupation” is the overarching
statement that describes the domain and process of
occupational therapy in its fullest sense. This statement
acknowledges the profession’s belief that active
engagement in occupation promotes, facilitates,
supports, and maintains health and participation. These
interrelated concepts include
n Health—“a state of complete physical, mental,
and social well-being, and not merely the
absence of disease or infirmity” (WHO, 2006,
p. 1).
n Well-being—“a general term encompassing the total
universe of human life domains, including physical,
mental, and social aspects, that make up what can be
called a ‘good life’” (WHO, 2006, p. 211). n Participation—“involvement in a life situation” (WHO,
2008, p. 10). Participation occurs naturally when clients
are actively involved in carrying out occupations or daily
life activities they find purposeful and meaningful. More
specific outcomes of occupational therapy intervention
are multidimensional and support the end result of
participation. n Engagement in occupation—performance of
occupations as the result of choice, motivation, and
meaning within a supportive context (including
Figure 1. Occupational Therapy Domain and Process
Achieving health, well-being, and
participation in life through engagement
in occupation.
PROCESS
DOMAIN Cl
ie nt
Fa ct
or s
Occupations Contexts
Perform
ance Skills Perform ance
Pa tt
er n
s
Intervention Outcom
esEv al
ua tio
n
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environmental and personal factors). Engagement
includes objective and subjective aspects of clients’
experiences and involves the transactional interaction
of the mind, body, and spirit. Occupational therapy
intervention focuses on creating or facilitating
opportunities to engage in occupations that lead to
participation in desired life situations (AOTA, 2008).
Although the domain and process are described
separately, in actuality they are linked inextricably in a
transactional relationship. The aspects that constitute
the domain and those that constitute the process exist in
constant interaction with one another during the delivery of
occupational therapy services. Figure 1 represents
aspects of the domain and process and the overarching
goal of the profession as achieving health, well-being, and
participation in life through engagement in occupation.
Although the figure illustrates these two elements in
distinct spaces, in reality the domain and process interact
in complex and dynamic ways as described throughout
this document. The nature of the interactions is
impossible to capture in a static one-dimensional image.
Cornerstones of Occupational Therapy Practice The transactional relationship between the domain and
process is facilitated by the occupational therapy
practitioner. Occupational therapy practitioners have
distinct knowledge, skills, and qualities that contribute to the
success of the occupational therapy process, described in
this document as “cornerstones.” A cornerstone can be
defined as something of great importance on which
everything else depends (“Cornerstone,” n.d.), and the
following cornerstones of occupational therapy help
distinguish it from other professions:
n Core values and beliefs rooted in occupation (Cohn,
2019; Hinojosa et al., 2017) n Knowledge of and expertise in the therapeutic use of
occupation (Gillen, 2013; Gillen et al., 2019) n Professional behaviors and dispositions (AOTA
2015a, 2015c) n Therapeutic use of self (AOTA, 2015c; Taylor, 2020).
These cornerstones are not hierarchical; instead, each
concept influences the others.
Occupational therapy cornerstones provide a
fundamental foundation for practitioners from which to
view clients and their occupations and facilitate the
occupational therapy process. Practitioners develop the
cornerstones over time through education, mentorship,
and experience. In addition, the cornerstones are ever
evolving, reflecting developments in occupational therapy
practice and occupational science.
Many contributors influence each cornerstone. Like
the cornerstones, the contributors are complementary
and interact to provide a foundation for practitioners.
The contributors include, but are not limited to, the
following:
n Client-centered practice n Clinical and professional reasoning n Competencies for practice n Cultural humility n Ethics n Evidence-informed practice n Inter- and intraprofessional collaborations n Leadership n Lifelong learning n Micro and macro systems knowledge n Occupation-based practice n Professionalism n Professional advocacy n Self-advocacy n Self-reflection n Theory-based practice.
Domain
Exhibit 1 identifies the aspects of the occupational
therapy domain: occupations, contexts, performance
patterns, performance skills, and client factors. All
aspects of the domain have a dynamic interrelatedness.
All aspects are of equal value and together interact to
affect occupational identity, health, well-being, and
participation in life.
Occupational therapists are skilled in evaluating all
aspects of the domain, the interrelationships among the
aspects, and the client within context. Occupational
therapy practitioners recognize the importance and
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impact of the mind–body–spirit connection on
engagement and participation in daily life. Knowledge of
the transactional relationship and the significance of
meaningful and productive occupations forms the basis for
the use of occupations as both the means and the ends
of interventions (Trombly, 1995). This knowledge sets
occupational therapy apart as a distinct and valuable
service (Hildenbrand & Lamb, 2013) for which a focus on
the whole is considered stronger than a focus on isolated
aspects of human functioning.
The discussion that follows provides a brief
explanation of each aspect of the domain. Tables included
at the end of the document provide additional
descriptions and definitions of terms.
Occupations Occupations are central to a client’s (person’s, group’s, or
population’s) health, identity, and sense of competence
and have particular meaning and value to that client. “In
occupational therapy, occupations refer to the everyday
activities that people do as individuals, in families, and with
communities to occupy time and bring meaning and
purpose to life. Occupations include things people
need to, want to and are expected to do” (WFOT, 2012a,
para. 2).
In the OTPF–4, the term occupation denotes
personalized and meaningful engagement in daily life
events by a specific client. Conversely, the term activity
denotes a form of action that is objective and not related
to a specific client’s engagement or context (Schell et al.,
2019) and, therefore, can be selected and designed to
enhance occupational engagement by supporting the
development of performance skills and performance
patterns. Both occupations and activities are used as
interventions by practitioners. For example, a practitioner
may use the activity of chopping vegetables during an
intervention to address fine motor skills with the ultimate
goal of improving motor skills for the occupation of
preparing a favorite meal. Participation in occupations is
considered both the means and the end in the
occupational therapy process.
Occupations occur in contexts and are influenced by
the interplay among performance patterns, performance
skills, and client factors. Occupations occur over time;
have purpose, meaning, and perceived utility to the client;
and can be observed by others (e.g., preparing a meal) or
be known only to the person involved (e.g., learning
through reading a textbook). Occupations can involve the
execution of multiple activities for completion and can
result in various outcomes.
The OTPF–4 identifies a broad range of occupations
categorized as activities of daily living (ADLs), instrumental
activities of daily living (IADLs), health management, rest
and sleep, education, work, play, leisure, and social
participation (Table 2). Within each of these nine broad
categories of occupation aremany specific occupations. For
example, the broad category of IADLs has specific
Exhibit 1. Aspects of the Occupational Therapy Domain All aspects of the occupational therapy domain transact to support engagement, participation, and health. This exhibit does not imply a hierarchy.
Occupations Contexts Performance Patterns
Performance Skills Client Factors
Activities of daily living (ADLs) Instrumental activities of daily
living (IADLs) Health management Rest and sleep Education Work Play Leisure Social participation
Environmental factors
Personal factors
Habits Routines Roles Rituals
Motor skills Process skills Social interaction skills
Values, beliefs, and spirituality
Body functions Body structures
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occupations that include grocery shopping and money
management.
When occupational therapy practitioners work with
clients, they identify the types of occupations clients
engage in individually or with others. Differences among
clients and the occupations they engage in are complex
and multidimensional. The client’s perspective on how an
occupation is categorized varies depending on that
client’s needs, interests, and contexts. Moreover, values
attached to occupations are dependent on cultural and
sociopolitical determinants (Wilcock & Townsend, 2019).
For example, one person may perceive gardening as
leisure, whereas another person, who relies on the food
produced from that garden to feed their family or
community, may perceive it as work. Additional examples
of occupations for persons, groups, and populations can
be found in Table 3.
The ways in which clients prioritize engagement in
selected occupations may vary at different times. For
example, clients in a community psychiatric rehabilitation
setting may prioritize registering to vote during an election
season and food preparation during holidays. The unique
features of occupations are noted and analyzed by
occupational therapy practitioners, who consider all
components of the engagement and use them effectively
as both a therapeutic tool and a way to achieve the
targeted outcomes of intervention.
The extent to which a client is engaged in a particular
occupation is also important. Occupational therapy
practitioners assess the client’s ability to engage in
occupational performance, defined as the
accomplishment of the selected occupation resulting from
the dynamic transaction among the client, their contexts,
and the occupation. Occupations can contribute to a well-
balanced and fully functional lifestyle or to a lifestyle that is
out of balance and characterized by occupational
dysfunction. For example, excessive work without
sufficient regard for other aspects of life, such as sleep or
relationships, places clients at risk for health problems.
External factors, including war, natural disasters, or
extreme poverty, may hinder a client’s ability to create
balance or engage in certain occupations (AOTA, 2017b;
McElroy et al., 2012).
Because occupational performance does not exist in a
vacuum, context must always be considered. For example,
for a client who lives in food desert, lack of access to a
grocery store may limit their ability to have balance in their
performance of IADLs such as cooking and grocery
shopping or to follow medical advice from health care
professionals on health management and preparation of
nutritiousmeals. For this client, the limitation is not caused by
impaired client factors or performance skills but rather is
shaped by the context in which the client functions. This
context may include policies that resulted in the decline of
commercial properties in the area, a socioeconomic status
that does not enable the client to live in an area with access
to a grocery store, and a social environment in which lack of
access to fresh food is weighed as less important than the
social supports the community provides.
Occupational therapy practitioners recognize that
health is supported and maintained when clients are able
to engage in home, school, workplace, and community
life. Thus, practitioners are concerned not only with
occupations but also with the variety of factors that disrupt
or empower those occupations and influence clients’
engagement and participation in positive health-
promoting occupations (Wilcock & Townsend, 2019).
Although engagement in occupations is generally
considered a positive outcome of the occupational therapy
process, it is important to consider that a client’s history
might include negative, traumatic, or unhealthy
occupational participation (Robinson Johnson & Dickie,
2019). For example, a person who has experienced a
traumatic sexual encounter might negatively perceive and
react to engagement in sexual intimacy. A person with an
eating disorder might engage in eating in a maladaptive
way, deterring health management and physical health.
In addition, some occupations that are meaningful to a
client might also hinder performance in other occupations
or negatively affect health. For example, a person who
spends a disproportionate amount of time playing video
games may develop a repetitive stress injury and may
have less balance in their time spent on IADLs and other
forms of social participation. A client engaging in the
recreational use of prescription pain medications may
experience barriers to participation in previously
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important occupations such as work or spending time with
family.
Occupations have the capacity to support or promote
other occupations. For example, children engage in play
to develop the performance skills that later facilitate
engagement in leisure and work. Adults may engage in
social participation and leisure with an intimate partner
that may improve satisfaction with sexual activity. The
goal of engagement in sleep and health management
includes maintaining or improving performance of work,
leisure, social participation, and other occupations.
Occupations are often shared and done with others.
Those that implicitly involve two or more individuals are
termed co-occupations (Zemke & Clark, 1996). Co-
occupations are the most interactive of all social
occupations. Central to the concept of co-occupation is that
two or more individuals share a high level of physicality,
emotionality, and intentionality (Pickens & Pizur-Barnekow,
2009). In addition, co-occupations can be parallel (different
occupations in close proximity to others; e.g., reading while
others listen to music when relaxing at home) and shared
(same occupation but different activities; e.g., preparing
different dishes for a meal; Zemke & Clark, 1996).
Caregiving is a co-occupation that requires active
participation by both the caregiver and the recipient of
care. For the co-occupations required during parenting,
the socially interactive routines of eating, feeding, and
comforting may involve the parent, a partner, the child,
and significant others (Olson, 2004). The specific
occupations inherent in this social interaction are
reciprocal, interactive, and nested (Dunlea, 1996; Esdaile
& Olson, 2004). Consideration of co-occupations by
practitioners supports an integrated view of the client’s
engagement in the context of relationship to significant
others.
Occupational participation can be considered
independent whether it occurs individually or with others. It
is important to acknowledge that clients can be
independent in living regardless of the amount of
assistance they receive while completing occupations.
Clients may be considered independent even when they
direct others (e.g., caregivers) in performing the actions
necessary to participate, regardless of the amount or kind
of assistance required, if clients are satisfied with their
performance. In contrast to definitions of independence
that imply direct physical interaction with the environment
or objects within the environment, occupational therapy
practitioners consider clients to be independent whether
they perform the specific occupations by themselves, in an
adapted or modified environment, with the use of various
devices or alternative strategies, or while overseeing
activity completion by others (AOTA, 2002b). For
example, a person with spinal cord injury who directs a
personal care assistant to assist them with ADLs is
demonstrating independence in this essential aspect of
their life.
It is also important to acknowledge that not all clients
view success as independence. Interdependence, or
co-occupational performance, can also be an indicator
of personal success. How a client views success may
be influenced by their client factors, including their
culture.
Contexts Context is a broad construct defined as the environmental
and personal factors specific to each client (person, group,
population) that influence engagement and participation
in occupations. Context affects clients’ access to
occupations and the quality of and satisfaction with
performance (WHO, 2008). Practitioners recognize that
for people to truly achieve full participation, meaning, and
purpose, they must not only function but also engage
comfortably within their own distinct combination of
contexts.
In the literature, the terms environment and context
often are used interchangeably, but this may result in
confusion when describing aspects of situations in which
occupational engagement takes place. Understanding the
contexts in which occupations can and do occur provides
practitionerswith insights into the overarching, underlying,
and embedded influences of environmental factors and
personal factors on engagement in occupations.
Environmental Factors
Environmental factors are aspects of the physical, social,
and attitudinal surroundings in which people live and
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conduct their lives (Table 4). Environmental factors
influence functioning and disability and have positive
aspects (facilitators) or negative aspects (barriers or
hindrances; WHO, 2008). Environmental factors include
n Natural environment and human-made changes to
the environment: Animate and inanimate elements of
the natural or physical environment and
components of that environment that have been
modified by people, as well as characteristics of
human populations within that environment.
Engagement in human occupation influences the
sustainability of the natural environment, and
changes to human behavior can have a positive
impact on the environment (Dennis et al., 2015). n Products and technology: Natural or human-made
products or systems of products, equipment, and
technology that are gathered, created, produced, or
manufactured. n Support and relationships: People or animals that
provide practical physical or emotional support,
nurturing, protection, assistance, and connections to
other persons in the home, workplace, or school or at
play or in other aspects of daily occupations. n Attitudes: Observable evidence of customs,
practices, ideologies, values, norms, factual beliefs,
and religious beliefs held by people other than the
client. n Services, systems, and policies: Benefits,
structured programs, and regulations for operations
provided by institutions in various sectors of society
designed to meet the needs of persons, groups, and
populations.
When people interact with the world around them,
environmental factors can either enable or restrict
participation in meaningful occupations and can present
barriers to or supports and resources for service delivery.
Examples of environmental barriers that restrict
participation include the following:
n For persons, doorway widths that do not allow for
wheelchair passage
n For groups, absence of healthy social opportunities
for those abstaining from alcohol use n For populations, businesses that are not welcoming
to people who identify as LGBTQ+. (Note: In this
document, LGBTQ+ is used to represent the large
and diverse communities and individuals with
nonmajority sexual orientations and gender
identities.)
Addressing these barriers, such as by widening a doorway
to allow access, results in environmental supports that
enable participation. A client who has difficulty performing
effectively in one context may be successful when the
natural environment has human-mademodifications or if the
client uses applicable products and technology. In addition,
occupational therapy practitioners must be aware of norms
related to, for example, eating or deference to medical
professionalswhenworkingwith someone froma culture or
socioeconomic status that differs from their own.
Personal Factors
Personal factors are the unique features of a person that
are not part of a health condition or health state and that
constitute the particular background of the person’s life
and living (Table 5). Personal factors are internal
influences affecting functioning and disability and are not
considered positive or negative but rather reflect the
essence of the person—“who they are.” When clients
provide demographic information, they are typically
describing personal factors. Personal factors also
include customs, beliefs, activity patterns, behavioral
standards, and expectations accepted by the society or
cultural group of which a person is a member.
Personal factors are generally considered to be
enduring, stable attributes of the person, although some
personal factors change over time. They include, but are
not limited to, the following:
n Chronological age n Sexual orientation (sexual preference, sexual
identity) n Gender identity n Race and ethnicity n Cultural identification and attitudes
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n Social background, social status, and socioeconomic
status n Upbringing and life experiences n Habits and past and current behavioral patterns n Psychological assets, temperament, unique
character traits, and coping styles n Education n Profession and professional identity n Lifestyle n Health conditions and fitness status (that may affect
the person’s occupations but are not the primary
concern of the occupational therapy encounter).
For example, siblings share personal factors of race
and age, yet for those separated at birth, environmental
differences may result in divergent personal factors in
terms of cultural identification, upbringing, and life
experiences, producing different contexts for their
individual occupational engagement.Whether separated
or raised together, as siblings move through life, they may
develop differences in sexual orientation, life experience,
habits, education, profession, and lifestyle.
Groups and populations are often formed or identified
on the basis of shared or similar personal factors that make
possible occupational therapy assessment and
intervention. Of course, individual members of a group or
population differ in other personal factors. For example, a
group of fifth graders in a community public school are
likely to share age and, perhaps, socioeconomic status.
Yet race, fitness, habits, and coping styles make each
group member unlike the others. Similarly, a population of
older adults living in an urban low-income housing
communitymay have few personal factors in commonother
than age and current socioeconomic status.
Application of Context to Occupational Justice
Interwoven throughout the concept of context is that of
occupational justice, defined as “a justice that
recognizes occupational rights to inclusive participation
in everyday occupations for all persons in society,
regardless of age, ability, gender, social class, or other
differences” (Nilsson & Townsend, 2010, p. 58).
Occupational therapy’s focus on engagement in
occupations and occupational justice complements
WHO’s (2008) perspective on health. To broaden the
understanding of the effects of disease and disability on
health,WHOemphasized that health can be affected by the
inability to carry out occupations and activities and
participate in life situations caused by contextual barriers
and by problems that exist in body structures and body
functions. The OTPF–4 identifies occupational justice as
both an aspect of contexts and an outcome of intervention.
Occupational justice involves the concern that
occupational therapy practitioners have with respect,
fairness, and impartiality and equitable opportunities
when considering the contexts of persons, groups, and
populations (AOTA, 2015a). As part of the occupational
therapy domain, practitioners consider how these
aspects can affect the implementation of occupational
therapy and the target outcome of participation.
Practitioners recognize that for individuals to truly
achieve full participation, meaning, and purpose, they
must not only function but also engage comfortably within
their own distinct combination of contexts (both
environmental factors and personal factors).
Examples of contexts that can present occupational
justice issues include the following: n An alternative school placement for children with
mental health and behavioral disabilities that
provides academic support and counseling but
limited opportunities for participation in sports,
music programs, and organized social activities n A residential facility for older adults that offers safety
and medical support but provides little opportunity for
engagement in the role-related occupations that were
once a source of meaning n A community that lacks accessible and inclusive
physical environments and provides limited services
and supports, making participation difficult or even
dangerous for people who have disabilities (e.g.,
lack of screening facilities and services resulting in
higher rates of breast cancer among community
members)
n A community that lacks financial and other necessary
resources, resulting in an adverse and
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disproportionate impact of natural disasters and
severe weather events on vulnerable populations.
Occupational therapy practitioners recognize areas of
occupational injustice and work to support policies,
actions, and laws that allow people to engage in
occupations that provide purpose and meaning in their
lives. By understanding and addressing the specific
justice issues in contexts such as an individual’s home, a
group’s shared job site, or a population’s community
center, practitioners promote occupational therapy
outcomes that address empowerment and self-
advocacy.
Performance Patterns Performance patterns are the acquired habits, routines,
roles, and rituals used in the process of engaging
consistently in occupations and can support or hinder
occupational performance (Table 6). Performance
patterns help establish lifestyles (Uyeshiro Simon &
Collins, 2017) and occupational balance (e.g., proportion
of time spent in productive, restorative, and leisure
occupations; Eklund et al., 2017; Wagman et al., 2015)
and are shaped, in part, by context (e.g., consistency,
work hours, social calendars) and cultural norms (Eklund
et al., 2017; Larson & Zemke, 2003).
Time provides an organizational structure or rhythm for
performance patterns (Larson & Zemke, 2003); for
example, an adult goes to work every morning, a child
completes homework every day after school, or an
organization hosts a fundraiser every spring. The manner
in which people think about and use time is influenced by
biological rhythms (e.g., sleep–wake cycles), family of
origin (e.g., amount of time a person is socialized to
believe should be spent in productive occupations), work
and social schedules (e.g., religious services held on the
same day each week), and cyclic cultural patterns (e.g.,
birthday celebration with cake every year, annual cultural
festival; Larson & Zemke, 2003). Other temporal factors
influencing performance patterns are timemanagement and
time use. Time management is the manner in which a
person, group, or population organizes, schedules, and
prioritizes certain activities (Uyeshiro Simon&Collins, 2017).
Time use is the manner in which a person manages their
activity levels; adapts to changes in routines; and organizes
their days, weeks, and years (Edgelow & Krupa, 2011).
Habits are specific, automatic adaptive or maladaptive
behaviors. Habits may be healthy or unhealthy (e.g.,
exercising on a daily basis vs. smoking during every
lunch break), efficient or inefficient (e.g., completing
homework after school vs. in the few minutes before the
school bus arrives), and supportive or harmful (e.g.,
setting an alarm clock before going to bed vs. not doing
so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019).
Routines are established sequences of occupations or
activities that provide a structure for daily life; they can also
promote or damage health (Fiese, 2007; Koome et al.,
2012; Segal, 2004). Shared routines involve two or more
people and take place in a similar manner regardless of
the individuals involved (e.g., routines shared by parents
to promote the health of their children; routines shared by
coworkers to sort the mail; Primeau, 2000). Shared
routines can be nested in co-occupations. For example,
a young child’s occupation of completing oral hygiene
with the assistance of an adult is a part of the child’s daily
routine, and the adult who provides the assistance may
also view helping the young child with oral hygiene as a
part of the adult’s own daily routine.
Roles have historically been defined as sets of
behaviors expected by society and shaped by culture and
context; they may be further conceptualized and defined
by a person, group, or population (Kielhofner, 2008;
Taylor, 2017). Roles are an aspect of occupational
identity—that is, they help define who a person, group, or
population believes themselves to be on the basis of their
occupational history and desires for the future. Certain
roles are often associated with specific activities and
occupations; for example, the role of parent is associated
with feeding children (Kielhofner, 2008; Taylor, 2017).
When exploring roles, occupational therapy practitioners
consider the complexity of identity and the limitations
associated with assigning stereotypical occupations to
specific roles (e.g., on the basis of gender). Practitioners
also consider how clients construct their occupations and
establish efficient and supportive habits and routines to
achieve health outcomes, fulfill their perceived roles and
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identity, and determine whether their roles reinforce their
values and beliefs.
Rituals are symbolic actions with spiritual, cultural, or
social meaning. Rituals contribute to a client’s identity and
reinforce the client’s values and beliefs (Fiese, 2007; Segal,
2004). Some rituals (e.g., those associated with certain
holidays) are associated with different seasons or times of
the year (e.g., New Year’s Eve, Independence Day),
whereas others are associated with times of the day or days
of the week (e.g., daily prayers, weekly family dinners).
Performance patterns are influenced by all other
aspects of the occupational therapy domain and develop
over time. Occupational therapy practitioners who
consider clients’ past and present behavioral and
performance patterns are better able to understand the
frequency and manner in which performance skills and
healthy and unhealthy occupations are, or have been,
integrated into clients’ lives. Although clients may have the
ability to engage in skilled performance, if they do not
embed essential skills in a productive set of engagement
patterns, their health, well-being, and participation may be
negatively affected. For example, a person may have
skills associated with proficient health literacy but not
embed them into consistent routines (e.g., a dietitian who
consistently chooses to eat fast food rather than prepare
a healthy meal) or struggle with modifying daily
performance patterns to access health systems effectively
(e.g., a nurse who struggles to modify work hours to get a
routine mammogram).
Performance Skills Performance skills are observable, goal-directed actions
and consist of motor skills, process skills, and social
interaction skills (Fisher & Griswold, 2019; Table 7). The
occupational therapist evaluates and analyzes
performance skills during actual performance to
understand a client’s ability to perform an activity (i.e.,
smaller aspect of the larger occupation) in natural
contexts (Fisher & Marterella, 2019). This evaluation
requires analysis of the quality of the individual actions
(performance skills) during actual performance.
Regardless of the client population, the performance skills
defined in this document are universal and provide the
foundation for understanding performance (Fisher &
Marterella, 2019).
Performance skills can be analyzed for all occupations
with clients of any age and level of ability, regardless of the
setting in which occupational therapy services are
provided (Fisher & Marterella, 2019). Motor and process
skills are seen during performance of an activity that
involves the use of tangible objects, and social
interaction skills are seen in any situation in which a
person is interacting with others: n Motor skills refer to how effectively a person moves
self or interacts with objects, including positioning the
body, obtaining and holding objects, moving self and
objects, and sustaining performance. n Process skills refer to how effectively a person
organizes objects, time, and space, including
sustaining performance, applying knowledge,
organizing timing, organizing space and objects, and
adapting performance. n Social interaction skills refer to how effectively a
person uses both verbal and nonverbal skills to
communicate, including initiating and terminating,
producing, physically supporting, shaping content of,
maintaining flow of, verbally supporting, and adapting
social interaction.
For example, when a client catches a ball, the
practitioner can analyze how effectively they bend and
reach for and then grasp the ball (motor skills). When a
client cooks a meal, the practitioner can analyze how
effectively they initiate and sequence the steps to
complete the recipe in a logical order to prepare the meal
in a timely and well-organized manner (process skills). Or
when a client interacts with a friend at work, the
practitioner can analyze the manner in which the client
smiles, gestures, turns toward the friend, and responds to
questions (social interaction skills). In these examples,
many other motor skills, process skills, and social
interaction skills are also used by the client.
By analyzing the client’s performance within an
occupation at the level of performance skills, the
occupational therapist identifies effective and ineffective
use of skills (Fisher & Marterella, 2019). The result of this
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analysis indicates not only whether the person is able to
complete an activity safely and independently but also
the amount of physical effort and efficiency the client
demonstrates in activities.
After the quality of occupational performance skills has
been analyzed, the practitioner speculates about the
reasons for decreased quality of occupational
performance and determines the need to evaluate
potential underlying causes (e.g., occupational demands,
environmental factors, client factors; Fisher & Griswold,
2019). Performance skills are different from client factors
(see the “Client Factors” section that follows), which
include values, beliefs, and spirituality and body
structures and functions (e.g., memory, strength) that
reside within the person. Occupational therapy
practitioners analyze performance skills as a client
performs an activity, whereas client factors cannot be
directly viewed during the performance of occupations.
For example, the occupational therapy practitioner
cannot directly view the client factors of cognitive ability or
memory when a client is engaged in cooking but rather
notes ineffective use of performance skills when the
person hesitates to start a step or performs steps in an
illogical order. The practitioner may then infer that a
possible reason for the client’s hesitation may be
diminished memory and elect to further assess the client
factor of cognition.
Similarly, context influences the quality of a client’s
occupational performance. After analyzing the client’s
performance skills while completing an activity, the
practitioner can hypothesize how the client factors and
context might have influenced the client’s performance.
Thus, client factors and contexts converge and may
support or limit a person’s quality of occupational
performance.
Application of Performance Skills With Persons
When completing the analysis of occupational
performance (described in the “Evaluation” section later in
this document), the practitioner analyzes the client’s
challenges in performance and generates a hypothesis
about gaps between current performance and effective
performance and the need for occupational therapy
services. To plan appropriate interventions, the
practitioner considers the underlying reasons for the gaps,
which may involve performance skills, performance
patterns, and client factors. The hypothesis is generated
on the basis of what the practitioner analyzes when the
client is actually performing occupations.
Regardless of the client population, the universal
performance skills defined in this section provide the
foundations for understanding performance (Fisher &
Marterella, 2019). The following example crosses many
client populations. The practitioner observes as a client
rushes through the steps of an activity toward completion.
On the basis of what the client does, the practitioner may
interpret this rushing as resulting from a lack of impulse
control. This limitation may be seen in clients living with
anxiety, attention deficit hyperactivity disorder, dementia,
traumatic brain injury, and other clinical conditions. The
behavior of rushing may be captured in motor performance
skills of manipulates, coordinates, or calibrates; in process
performance skills of paces, initiates, continues, or
organizes; or in social interaction performance skills of
takes turn, transitions, times response, or times duration.
Understanding the client’s specific occupational challenges
enables the practitioner to determine the suitable
intervention to address impulsivity to facilitate greater
occupational performance. Clinical interventions then
address the skills required for the client’s specific
occupational demands on the basis of their alignment with
the universal performance skills (Fisher & Marterella, 2019).
Thus, the application of universal performance skills guides
practitioners in developing the intervention plan for specific
clients to address the specific concerns occurring in the
specific practice setting.
Application of Performance Skills With Groups
Analysis of performance skills is always focused on
individuals (Fisher & Marterella, 2019). Thus, when
analyzing performance skills with a group client, the
occupational therapist always focuses on one individual
at a time (Table 8). The therapist may choose to analyze
some or all members of the group engaging in relevant
group occupations over time as the group members
contribute to the collective actions of the group.
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If all members demonstrate effective performance
skills, then the group client may achieve its collective
outcomes. If one or more group members demonstrate
ineffective performance skills, the collective outcomes
may be diminished. Only in cases in which group
members demonstrate ongoing limitations in
performance skills that hinder the collective outcomes of
the group would the practitioner recommend interventions
for individual group members. Interventions would then
be directed at those members demonstrating diminished
performance skills to facilitate their contributions to the
collective group outcomes.
Application of Performance Skills With Populations
Using an occupation-based approach to population
health, occupational therapy addresses the needs of
populations by enhancing occupational performance
and participation for communities of people (see “Service
Delivery” in the “Process” section). Service delivery to
populations focuses on aggregates of people rather than
on intervention for persons or groups; thus, it is not
relevant to analyze performance skills at the person level
in service delivery to populations.
Client Factors Client factors are specific capacities, characteristics, or
beliefs that reside within the person, group, or population
and influence performance in occupations (Table 9).
Client factors are affected by the presence or absence of
illness, disease, deprivation, and disability, as well as by
life stages and experiences. These factors can affect
performance skills (e.g., a client may have weakness in
the right arm [a client factor], affecting their ability to
manipulate a button [a motor and process skill] to button
a shirt; a child in a classroommay be nearsighted [a client
factor], affecting their ability to copy from a chalkboard [a
motor and process skill]).
In addition, client factors are affected by occupations,
contexts, performance patterns, and performance skills.
For example, a client in a controlled and calm
environment might be able to problem solve to complete an
occupation or activity, but when they are in a louder, more
chaotic environment, their ability to process and plan may
be adversely affected. It is through this interactive
relationship that occupations and interventions to support
occupations can be used to address client factors and vice
versa.
Values, beliefs, and spirituality influence clients’
motivation to engage in occupations and give their life or
existence meaning. Values are principles, standards, or
qualities considered worthwhile by the client who holds
them. A belief is “something that is accepted, considered
to be true, or held as an opinion” (“Belief,” 2020).
Spirituality is “a deep experience of meaning brought
about by engaging in occupations that involve the
enacting of personal values and beliefs, reflection, and
intention within a supportive contextual environment”
(Billock, 2005, p. 887). It is important to recognize
spirituality “as dynamic and often evolving” (Humbert,
2016, p. 12).
Body functions and body structures refer to the
“physiological function of body systems (including
psychological functions) and anatomical parts of the
body such as organs, limbs, and their components,”
respectively (WHO, 2008, p. 10). Examples of body
functions include sensory, musculoskeletal, mental
(affective, cognitive, perceptual), cardiovascular,
respiratory, and endocrine functions. Examples of body
structures include the heart and blood vessels that
support cardiovascular function. Body structures and
body functions are interrelated, and occupational therapy
practitioners consider them when seeking to promote
clients’ ability to engage in desired occupations.
Occupational therapy practitioners understand that the
presence, absence, or limitation of specific body functions
and body structures does not necessarily determine a
client’s success or difficulty with daily life occupations.
Occupational performance and client factors may benefit
from supports in the physical, social, or attitudinal
contexts that enhance or allow participation. It is through
the process of assessing clients as they engage in
occupations that practitioners are able to determine the
transaction between client factors and performance skills;
to create adaptations, modifications, and remediation; and
to select occupation-based interventions that best
promote enhanced participation.
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Exhibit 2. Operationalizing the Occupational Therapy Process Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the occupational therapy process.
Evaluation Occupational Profile • Identify the following:
◦ Why is the client seeking services, and what are the client’s current concerns relative to engaging in occupations and in daily life activities?
◦ In what occupations does the client feel successful, and what barriers are affecting their success in desired occupations? ◦ What is the client’s occupational history (i.e., life experiences)? ◦ What are the client’s values and interests? ◦ What aspects of their contexts (environmental and personal factors) does the client see as supporting engagement in desired occupations, and what aspects are inhibiting engagement?
◦ How are the client’s performance patterns supporting or limiting occupational performance and engagement? ◦ What are the client’s patterns of engagement in occupations, and how have they changed over time? ◦ What client factors does the client see as supporting engagement in desired occupations, and what aspects are inhibiting engagement (e.g., pain, active symptoms)?
◦ What are the client’s priorities and desired targeted outcomes related to occupational performance, prevention, health and wellness, quality of life, participation, role competence, well-being, and occupational justice?
Analysis of Occupational Performance • The analysis of occupational performance involves one or more of the following:
◦ Synthesizing information from the occupational profile to determine specific occupations and contexts that need to be addressed
◦ Completing an occupational or activity analysis to identify the demands of occupations and activities on the client ◦ Selecting and using specific assessments to measure the quality of the client’s performance or performance deficits while completing occupations or activities relevant to desired occupations, noting the effectiveness of performance skills and performance patterns
◦ Selecting and using specific assessments to measure client factors that influence performance skills and performance patterns ◦ Selecting and administering assessments to identify and measure more specifically the client’s contexts and their impact on occupational performance.
Synthesis of Evaluation Process • This synthesis may include the following:
◦ Determining the client’s values and priorities for occupational participation ◦ Interpreting the assessment data to identify supports and hindrances to occupational performance ◦ Developing and refining hypotheses about the client’s occupational performance strengths and deficits ◦ Considering existing support systems and contexts and their ability to support the intervention process ◦ Determining desired outcomes of the intervention ◦ Creating goals in collaboration with the client that address the desired outcomes ◦ Selecting outcome measures and determining procedures to measure progress toward the goals of intervention, which may include repeating assessments used in the evaluation process.
Intervention
Intervention Plan • Develop the plan, which involves selecting
◦ Objective and measurable occupation-based goals and related time frames; ◦ Occupational therapy intervention approach or approaches, such as create or promote, establish or restore, maintain, modify, or prevent; and
◦ Methods for service delivery, including what types of intervention will be provided, who will provide the interventions, and which service delivery approaches will be used.
• Consider potential discharge needs and plans. • Make recommendations or referrals to other professionals as needed.
(Continued)
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Client factors can also be understood as pertaining to
group and population clients and may be used to help
define the group or population. Although client factors
may be described differently when applied to a group or
population, the underlying principles do not change
substantively. Client factors of a group or population are
explored by performing needs assessments, and
interventions might include program development and
strategic planning to help the members engage in
occupations.
Process
This section operationalizes the process undertaken by
occupational therapy practitioners when providing
services to clients. Exhibit 2 summarizes the aspects of
the occupational therapy process.
The occupational therapy process is the client-
centered delivery of occupational therapy services. The
three-part process includes (1) evaluation and (2)
intervention to achieve (3) targeted outcomes and occurs
within the purview of the occupational therapy domain
(Table 10). The process is facilitated by the distinct
perspective of occupational therapy practitioners
engaging in professional reasoning, analyzing
occupations and activities, and collaborating with clients.
The cornerstones of occupational therapy practice
underpin the process of service delivery.
Overview of the Occupational Therapy Process Many professions use a similar process of evaluating,
intervening, and targeting outcomes. However, only
occupational therapy practitioners focus on the
therapeutic use of occupations to promote health, well-
Exhibit 2. Operationalizing the Occupational Therapy Process (cont’d)
Intervention Implementation • Select and carry out the intervention or interventions, which may include the following:
◦ Therapeutic use of occupations and activities ◦ Interventions to support occupations ◦ Education ◦ Training ◦ Advocacy ◦ Self-advocacy ◦ Group intervention ◦ Virtual interventions.
• Monitor the client’s response through ongoing evaluation and reevaluation.
Intervention Review • Reevaluate the plan and how it is implemented relative to achieving outcomes. • Modify the plan as needed. • Determine the need for continuation or discontinuation of services and for referral to other services.
Outcomes
Outcomes • Select outcome measures early in the occupational therapy process (see the “Evaluation” section of this table) on the basis of their
properties: ◦ Valid, reliable, and appropriately sensitive to change in clients’ occupational performance ◦ Consistent with targeted outcomes ◦ Congruent with the client’s goals ◦ Able to predict future outcomes.
• Use outcome measures to measure progress and adjust goals and interventions by ◦ Comparing progress toward goal achievement with outcomes throughout the intervention process and ◦ Assessing outcome use and results to make decisions about the future direction of intervention (e.g., continue, modify, transition, discontinue, provide follow-up, refer for other service).
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being, and participation in life. Practitioners use
professional reasoning to select occupations as primary
methods of intervention throughout the process. To help
clients achieve desired outcomes, practitioners facilitate
interactions among the clients, their contexts, and the
occupations in which they engage. This perspective is
based on the theories, knowledge, and skills generated
and used by the profession and informed by available
evidence.
Analyzing occupational performance requires an
understanding of the complex and dynamic interaction
among the demands of the occupation and the client’s
contexts, performance patterns, performance skills,
and client factors. Occupational therapy practitioners
fully consider each aspect of the domain and gauge the
influence of each on the others, individually and
collectively. By understanding how these aspects
influence one another, practitioners can better
evaluate how each aspect contributes to clients’
participation and performance-related concerns and
potentially to interventions that support occupational
performance and participation.
The occupational therapy process is fluid and
dynamic, allowing practitioners and clients to maintain
their focus on the identified outcomes while continually
reflecting on and changing the overall plan to
accommodate new developments and insights along the
way, including information gained from inter- and
intraprofessional collaborations. The process may be
influenced by the context of service delivery (e.g., setting,
payer requirements); however, the primary focus is
always on occupation.
Service Delivery Approaches
Various service delivery approaches are used when
providing skilled occupational therapy services, of
which intra- and interprofessional collaborations are a
key component. It is imperative to communicate with all
relevant providers and stakeholders to ensure a
collaborative approach to the occupational therapy
process. These providers and stakeholders can be
within the profession (e.g., occupational therapist and
occupational therapy assistant collaborating to work
with a student in a school, a group of practitioners
collaborating to develop community-based mental
health programming in their region) or outside the
profession (e.g., a team of rehabilitation and medical
professionals on an inpatient hospital unit; a group of
employees, human resources staff, and health and
safety professionals in a large organization working
with an occupational therapy practitioner on workplace
wellness initiatives).
Regardless of the service delivery approach, the
individual client may not be the exclusive focus of the
occupational therapy process. For example, the needs of
an at-risk infant may be the initial impetus for intervention,
but the concerns and priorities of the parents, extended
family, and funding agencies are also considered.
Occupational therapy practitioners understand and focus
intervention to include the issues and concerns
surrounding the complex dynamics among the client,
caregiver, family, and community. Similarly, services
addressing independent living skills for adults coping
with serious mental illness or chronic health conditions
may also address the needs and expectations of
state and local service agencies and of potential
employers. Direct Services. Services are provided directly to
clients using a collaborative approach in settings such as
hospitals, clinics, industry, schools, homes, and
communities. Direct services include interventions
completed when in direct contact with the client through
various mechanisms such as meeting in person, leading a
group session, and interacting with clients and families
through telehealth systems (AOTA, 2018c).
Examples of person-level direct service delivery
include working with an adult on an inpatient rehabilitation
unit, working with a child in the classroom while
collaborating with the teacher to address identified goals,
and working with an adolescent in an outpatient setting.
Direct group interventions include working with a cooking
group in a skilled nursing facility, working with an
outpatient feeding group, and working with a handwriting
group in a school. Examples of population-level direct
services include implementing a large-scale healthy
lifestyle or safe driver initiative in the community and
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delivering a training program for brain injury treatment
facilities regarding safely accessing public transportation.
An occupational therapy approach to population health
focuses on aggregates or communities of people and the
many factors that influence their health and well-being:
“Occupational therapy practitioners develop and
implement occupation-based health approaches to
enhance occupational performance and participation,
[quality of life], and occupational justice for populations”
(AOTA, 2020b, p. 3). Indirect Services. When providing services to clients
indirectly on their behalf, occupational therapy
practitioners provide consultation to entities such as
teachers, multidisciplinary teams, and community
planning agencies. For example, a practitioner may
consult with a group of elementary school teachers and
administrators about opportunities for play during
recess to promote health and well-being. A practitioner
may also provide consultation on inclusive design to a
park district or civic organization to address how the
built and natural environments can support occupa-
tional performance and engagement. In addition, a
practitioner may consult with a business regarding the
work environment, ergonomic modifications, and
compliance with the Americans With Disabilities Act of
1990 (Pub. L. 101-336).
Occupational therapy practitioners can advocate
indirectly on behalf of their clients at the person, group,
and population levels to ensure their occupational
needs are met. For example, an occupational therapy
practitioner may advocate for funding to support the
costs of training a service animal for an individual
client. A practitioner working with a group client may
advocate for meeting space in the community for a peer
support group of transgender youth. Examples of
population-level advocacy include talking with
legislators about improving transportation for older
adults, developing services for people with disabilities
to support their living and working in the community of
their choice, establishing meaningful civic engagement
opportunities for underserved youth, and assisting in
the development of policies that address inequities in
access to health care.
Additional Approaches. Occupational therapy
practitioners use additional approaches that may also be
classified as direct or indirect for persons, groups, and
populations. Examples include, but are not limited to,
case management (AOTA, 2018b), telehealth (AOTA,
2018c), episodic care (Centers for Medicare & Medicaid
Services, 2019), and family-centered care approaches
(Hanna & Rodger, 2002).
Practice Within Organizations and Systems
Organization- or systems-level practice is a valid and
important part of occupational therapy for several reasons.
First, organizations serve as amechanism through which
occupational therapy practitioners provide interventions
to support participation of people who are members of or
served by the organization (e.g., falls prevention
programming in a skilled nursing facility, ergonomic
changes to an assembly line to reduce musculoskeletal
disorders). Second, organizations support occupational
therapy practice and practitioners as stakeholders in
carrying out the mission of the organization. Practitioners
have the responsibility to ensure that services provided
to organizational stakeholders (e.g., third-party payers,
employers) are of high quality and delivered in an ethical,
efficient, and efficacious manner.
Finally, organizations employ occupational therapy
practitioners in roles in which they use their knowledge of
occupation and the profession of occupational therapy
indirectly. For example, practitioners can serve in
positions such as dean, administrator, and corporate
leader (e.g., CEO, business owner). In these positions,
practitioners support and enhance the organization but
do not provide occupational therapy services in the
traditional sense. Occupational therapy practitioners can
also serve organizations in roles such as client advocate,
program coordinator, transition manager, service or care
coordinator, health and wellness coach, and community
integration specialist.
Occupational and Activity Analysis
Occupational therapy practitioners are skilled in the
analysis of occupations and activities and apply this
important skill throughout the occupational therapy
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process. Occupational analysis is performed with an
understanding of “the specific situation of the client and
therefore . . . the specific occupations the client wants or
needs to do in the actual context in which these
occupations are performed” (Schell et al., 2019, p. 322). In
contrast, activity analysis is generic and
decontextualized in its purpose and serves to develop an
understanding of typical activity demands within a given
culture. Many professions use activity analysis, whereas
occupational analysis requires the understanding of
occupation as distinct from activity and brings an
occupational therapy perspective to the analysis process
(Schell et al., 2019).
Occupational therapy practitioners analyze the
demands of an occupation or activity to understand the
performance patterns, performance skills, and client
factors that are required to perform it (Table 11).
Depending on the purpose of the analysis, the meaning
ascribed to and the contexts for performance of and
engagement in the occupation or activity are considered
either from a client-specific subjective perspective
(occupational analysis) or a general perspective within a
given culture (activity analysis).
Therapeutic Use of Self
An integral part of the occupational therapy process is
therapeutic use of self, in which occupational therapy
practitioners develop and manage their therapeutic
relationship with clients by using professional
reasoning, empathy, and a client-centered, collaborative
approach to service delivery (Taylor & Van
Puymbrouck, 2013). Occupational therapy practitioners
use professional reasoning to help clients make sense of
the information they are receiving in the intervention
process, discover meaning, and build hope (Taylor,
2019; Taylor & Van Puymbrouck, 2013). Empathy is the
emotional exchange between occupational therapy
practitioners and clients that allows more open
communication, ensuring that practitioners connect with
clients at an emotional level to assist them with their
current life situation.
Practitioners develop a collaborative relationship with
clients to understand their experiences and desires for
intervention. The collaborative approach used
throughout the process honors the contributions of
clients along with practitioners. Through the use of
interpersonal communication skills, practitioners shift
the power of the relationship to allow clients more
control in decision making and problem solving, which is
essential to effective intervention. Clients have
identified the therapeutic relationship as critical to the
outcome of occupational therapy intervention (Cole &
McLean, 2003).
Clients bring to the occupational therapy process
their knowledge about their life experiences and their
hopes and dreams for the future. They identify and
share their needs and priorities. Occupational therapy
practitioners must create an inclusive, supportive
environment to enable clients to feel safe in expressing
themselves authentically. To build an inclusive
environment, practitioners can take actions such as
pursuing education on gender-affirming care,
acknowledging systemic issues affecting
underrepresented groups, and using a lens of cultural
humility throughout the occupational therapy process
(AOTA, 2020c; Hammell, 2013).
Occupational therapy practitioners bring to the
therapeutic relationship their knowledge about how
engagement in occupation affects health, well-being,
and participation; they use this information, coupled
with theoretical perspectives and professional
reasoning, to critically evaluate, analyze, describe,
and interpret human performance. Practitioners and
clients, together with caregivers, family members,
community members, and other stakeholders (as
appropriate), identify and prioritize the focus of the
intervention plan.
Clinical and Professional Reasoning
Throughout the occupational therapy process,
practitioners are continually engaged in clinical and
professional reasoning about a client’s occupational
performance. The term professional reasoning is used
throughout this document as a broad term to encompass
reasoning that occurs in all settings (Schell, 2019).
Professional reasoning enables practitioners to
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n Identify the multiple demands, required skills, and
potential meanings of the activities and occupations
and n Gain a deeper understanding of the interrelationships
among aspects of the domain that affect performance
and that support client-centered interventions and
outcomes.
Occupational therapy practitioners use theoretical
principles and models, knowledge about the effects of
conditions on participation, and available evidence on
the effectiveness of interventions to guide their reasoning.
Professional reasoning ensures the accurate selection
and application of client-centered evaluation methods,
interventions, and outcome measures. Practitioners also
apply their knowledge and skills to enhance clients’
participation in occupations and promote their health and
well-being regardless of the effects of disease, disability,
and occupational disruption or deprivation.
Evaluation The evaluation process is focused on finding out what
the client wants and needs to do; determining what the
client can do and has done; and identifying supports and
barriers to health, well-being, and participation. Evaluation
occurs during the initial and all subsequent interactions
with a client. The type and focus of the evaluation differ
depending on the practice setting; however, all evaluations
should assess the complex and multifaceted needs of each
client.
The evaluation consists of the occupational profile and
the analysis of occupational performance, which are
synthesized to inform the intervention plan (Hinojosa
et al., 2014). Although it is the responsibility of the
occupational therapist to initiate the evaluation process,
both occupational therapists and occupational therapy
assistants may contribute to the evaluation, following
which the occupational therapist completes the analysis
and synthesis of information for the development of the
intervention plan (AOTA, 2020a). The occupational
profile includes information about the client’s needs,
problems, and concerns about performance in
occupations. The analysis of occupational performance
focuses on collecting and interpreting information
specifically to identify supports and barriers related to
occupational performance and establish targeted
outcomes.
Although theOTPF–4 describes the components of the
evaluation process separately and sequentially, the exact
manner in which occupational therapy practitioners
collect client information is influenced by client needs,
practice settings, and frames of reference or practice
models. The evaluation process for groups and
populations mirrors that for individual clients.
In some settings, the occupational therapist first
completes a screening or consultation to determine the
appropriateness of a full occupational therapy evaluation
(Hinojosa et al., 2014). This process may include
n Review of client history (e.g., medical, health, social,
or academic records), n Consultation with an interprofessional or referring
team, and n Use of standardized or structured screening
instruments.
The screening or consultation process may result in
the development of a brief occupational profile and
recommendations for full occupational therapy
evaluation and intervention (Hinojosa et al., 2014).
Occupational Profile
The occupational profile is a summary of a client’s
(person’s, group’s, or population’s) occupational history
and experiences, patterns of daily living, interests,
values, needs, and relevant contexts (AOTA, 2017a).
Developing the occupational profile provides the
occupational therapy practitioner with an understanding
of the client’s perspective and background.
Using a client-centered approach, the occupational
therapy practitioner gathers information to understand what
is currently important andmeaningful to the client (i.e., what
the client wants and needs to do) and to identify past
experiences and interests that may assist in the
understanding of current issues and problems. During the
process of collecting this information, the client, with the
assistance of the practitioner, identifies priorities and desired
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targeted outcomes that will lead to the client’s engagement
in occupations that support participation in daily life. Only
clients can identify the occupations that givemeaning to their
lives and select the goals and priorities that are important to
them. By valuing and respecting clients’ input, practitioners
help foster their involvement and can more effectively guide
interventions.
Occupational therapy practitioners collect information
for the occupational profile at the beginning of contact with
clients to establish client-centered outcomes. Over time,
practitioners collect additional information, refine the
profile, and ensure that the additional information is
reflected in changes subsequently made to targeted
outcomes. The process of completing and refining the
occupational profile varies by setting and client and may
occur continuously throughout the occupational therapy
process.
Information gathering for the occupational profile may
be completed in one session or over a longer period while
working with the client. For clients who are unable to
participate in this process, their profile may be compiled
through interaction with family members or other significant
people in their lives. Information for the occupational
profile may also be gathered from available and relevant
records.
Obtaining information for the occupational profile
through both formal and informal interview techniques and
conversation is a way to establish a therapeutic
relationship with clients and their support network.
Techniques used should be appropriate and reflective of
clients’ preferred method and style of communication
(e.g., use of a communication board, translation
services). Practitioners may use AOTA’s Occupational
Profile Template as a guide to completing the
occupational profile (AOTA, 2017a). The information
obtained through the occupational profile contributes to an
individualized approach in the evaluation, intervention
planning, and intervention implementation stages.
Information is collected in the following areas:
n Why is the client seeking services, and what are the
client’s current concerns relative to engaging in
occupations and in daily life activities?
n In what occupations does the client feel successful,
and what barriers are affecting their success in
desired occupations? n What is the client’s occupational history (i.e., life
experiences)? n What are the client’s values and interests? n What aspects of their contexts (environmental and
personal factors) does the client see as supporting
engagement in desired occupations, and what
aspects are inhibiting engagement? n How are the client’s performance patterns supporting
or limiting occupational performance and
engagement? n What are the client’s patterns of engagement in
occupations, and how have they changed over time? n What client factors does the client see as supporting
engagement in desired occupations, andwhat aspects
are inhibiting engagement (e.g., pain, active
symptoms)? n What are the client’s priorities and desired targeted
outcomes related to occupational performance,
prevention, health and wellness, quality of life,
participation, role competence, well-being, and
occupational justice?
After the practitioner collects profile data, the
occupational therapist views the information and develops
a working hypothesis regarding possible reasons for the
identified problems and concerns. Reasons could include
impairments in performance skills, performance patterns,
or client factors or barriers within relevant contexts. In
addition, the therapist notes the client’s strengths and
supports in all areas because these can inform the
intervention plan and affect targeted outcomes.
Analysis of Occupational Performance
Occupational performance is the accomplishment of the
selected occupation resulting from the dynamic transaction
among the client, their contexts, and the occupation. In the
analysis of occupational performance, the practitioner
identifies the client’s ability to effectively complete desired
occupations. The client’s assets and limitations or potential
problems are more specifically determined through
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assessment tools designed to analyze, measure, and inquire
about factors that support or hinder occupational
performance.
Multiple methods often are used during the evaluation
process to assess the client, contexts, occupations, and
occupational performance. Methods may include
observation and analysis of the client’s performance of
specific occupations and assessment of specific aspects
of the client or their performance. The approach to the
analysis of occupational performance is determined by
the information gathered through the occupational profile
and influenced by models of practice and frames of
reference appropriate to the client and setting. The
analysis of occupational performance involves one or
more of the following:
n Synthesizing information from the occupational
profile to determine specific occupations and
contexts that need to be addressed n Completing an occupational or activity analysis to
identify the demands of occupations and activities on
the client n Selecting and using specific assessments to
measure the quality of the client’s performance or
performance deficits while completing occupations or
activities relevant to desired occupations, noting the
effectiveness of performance skills and performance
patterns n Selecting and using specific assessments to
measure client factors that influence performance
skills and performance patterns n Selecting and administering assessments to identify and measure more specifically the client’s contexts
and their impact on occupational performance.
Occupational performance may be measured through
standardized, formal, and structured assessment tools, and
when necessary informal approaches may also be used
(Asher, 2014). Standardized assessments are preferred,
when available, to provide objective data about various
aspects of the domain influencing engagement and
performance. The use of valid and reliable assessments
for obtaining trustworthy information can also help support
and justify the need for occupational therapy services
(Doucet & Gutman, 2013; Hinojosa & Kramer, 2014). In
addition, the use of standardized outcome performance
measures and outcome tools assists in establishing a
baseline of occupational performance to allow for objective
measurement of progress after intervention.
Synthesis of the Evaluation Process
The occupational therapist synthesizes the information
gathered through the occupational profile and analysis of
occupational performance. This process may include the
following:
n Determining the client’s values and priorities for
occupational participation n Interpreting the assessment data to identify supports
and hindrances to occupational performance n Developing and refining hypotheses about the
client’s occupational performance strengths and
deficits n Considering existing support systems and contexts
and their ability to support the intervention process n Determining desired outcomes of the intervention n Creating goals in collaboration with the client that
address the desired outcomes n Selecting outcome measures and determining
procedures to measure progress toward the goals of
intervention, which may include repeating
assessments used in the evaluation process.
Any outcome assessment used by occupational
therapy practitioners must be consistent with clients’
belief systems and underlying assumptions regarding
their desired occupational performance. Occupational
therapy practitioners select outcome assessments
pertinent to clients’ needs and goals, congruent with
the practitioner’s theoretical model of practice.
Assessment selection is also based on the practitioner’s
knowledge of and available evidence for the
psychometric properties of standardized measures or the
rationale and protocols for nonstandardized structured
measures. In addition, clients’ perception of success in
engaging in desired occupations is a vital part of outcome
assessment (Bandura, 1986). The occupational therapist
uses the synthesis and summary of information from the
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evaluation and established targeted outcomes to guide the
intervention process.
Intervention The intervention process consists of services provided by
occupational therapy practitioners in collaboration with
clients to facilitate engagement in occupation related to
health, well-being, and achievement of established goals
consistent with the various service delivery models.
Practitioners use the information about clients gathered
during the evaluation and theoretical principles to select
and provide occupation-based interventions to assist
clients in achieving physical, mental, and social well-
being; identifying and realizing aspirations; satisfying
needs; and changing or coping with contextual factors.
Types of occupational therapy interventions are
categorized as occupations and activities, interventions to
support occupations, education and training, advocacy,
group interventions, and virtual interventions (Table 12).
Approaches to intervention include create or promote,
establish or restore, maintain, modify, and prevent
(Table 13). Across all types of and approaches to
interventions, it is imperative that occupational therapy
practitioners maintain an understanding of the
Occupational Therapy Code of Ethics (AOTA, 2015a)
and the Standards of Practice for Occupational Therapy
(AOTA, 2015c).
Intervention is intended to promote health, well-being,
and participation. Health promotion is “the process of
enabling people to increase control over, and to improve,
their health” (WHO, 1986). Wilcock (2006) stated,
Following an occupation-based health promotion approach to well-being embraces a belief that the potential range of what people can do, be, and strive to become is the primary concern, and that health is a by-product. A varied and full occupational lifestyle will coincidentally maintain and improve health and well-being if it enables people to be creative and adventurous physically, mentally, and socially. (p. 315)
Interventions vary depending on the client—person,
group, or population—and the context of service delivery.
The actual term used for clients or groups of clients
receiving occupational therapy varies among practice
settings and delivery models. For example, when
working in a hospital, the person or group might be
referred to as a patient or patients, and in a school, the
clients might be students. Early intervention requires
practitioners to work with the family system as their
clients. When practitioners provide consultation to an
organization, clients may be called consumers or
members. Terms used for others who may help or be
served indirectly include, but are not limited to,
caregiver, teacher, parent, employer, or spouse.
Intervention can also be in the form of collective
services to groups and populations. Such intervention
can occur as direct service provision or consultation.
When consulting with an organization, occupational
therapy practitioners may use strategic planning, change
agent plans, and other program development
approaches. Practitioners addressing the needs of a
population direct their interventions toward current or
potential diseases or conditions with the goal of
enhancing the health, well-being, and participation of all
members collectively. With groups and populations, the
intervention focus is often on health promotion,
prevention, and screening. Interventions may include
(but are not limited to) self-management training,
educational services, and environmental modification. For
instance, occupational therapy practitioners may provide
education on falls prevention and the impact of fear of
falling to residents in an assisted living center or training to
people facing a mental health challenge in use of the
internet to identify and coordinate community resources
that meet their needs.
Occupational therapy practitioners work with a
wide variety of populations experiencing difficulty in
accessing and engaging in healthy occupations because
of factors such as poverty, homelessness, displacement,
and discrimination. For example, practitioners can
work with organizations providing services to
refugees and asylum seekers to identify opportunities to
reestablish occupational roles and enhance well-being and
quality of life.
The intervention process is divided into three
components: (1) intervention plan, (2) intervention
implementation, and (3) intervention review. During the
intervention process, the occupational therapy practitioner
integrates information from the evaluation with theory,
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practice models, frames of reference, and research
evidence on interventions, including those that support
occupations. This information guides the practitioner’s
professional reasoning in intervention planning,
implementation, and review. Because evaluation is
ongoing, revision may occur at any point during the
intervention process.
Intervention Plan
The intervention plan, which directs the actions of
occupational therapy practitioners, describes the
occupational therapy approaches and types of
interventions selected for use in reaching clients’ targeted
outcomes. The intervention plan is developed
collaboratively with clients or their proxies and is directed
by
n Client goals, values, beliefs, and occupational needs
and n Client health and well-being,
as well as by the practitioners’ evaluation of
n Client occupational performance needs; n Collective influence of the contexts, occupational or
activity demands, and client factors on the client; n Client performance skills and performance
patterns; n Context of service delivery in which the intervention is
provided; and n Best available evidence.
The occupational therapist designs the intervention
plan on the basis of established treatment goals,
addressing the client’s current and potential situation
related to engagement in occupations or activities. The
intervention plan should reflect the priorities of the client,
information on occupational performance gathered
through the evaluation process, and targeted outcomes
of the intervention. Intervention planning includes the
following steps:
1. Developing the plan, which involves selecting
+ Objective and measurable occupation-based goals
and related time frames;
+ Occupational therapy intervention approach or
approaches; and
+ Methods for service delivery, including what types of
interventions will be provided, who will provide the
interventions, and which service delivery
approaches will be used;
2. Considering potential discharge needs and plans; and
3. Making recommendations or referrals to other
professionals as needed.
Steps 2 and 3 are discussed in the Outcomes section.
Intervention Implementation
Intervention implementation is the process of putting
the intervention plan into action and occurs after the
initial evaluation process and development of the
intervention plan. Interventions may focus on a single
aspect of the occupational therapy domain, such as a
specific occupation, or on several aspects of the
domain, such as contexts, performance patterns, and
performance skills, as components of one or more
occupations. Intervention implementation must always
reflect the occupational therapy scope of practice;
occupational practitioners should not perform
interventions that do not use purposeful and
occupation-based approaches (Gillen et al., 2019).
Intervention implementation includes the following
steps (see Table 12):
n Select and carry out the intervention or
interventions, which may include the following:
+ Therapeutic use of occupations and activities
+ Interventions to support occupations
+ Education
+ Training
+ Advocacy
+ Self-advocacy
+ Group intervention
+ Virtual interventions. n Monitor the client’s response through ongoing
evaluation and reevaluation.
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Given that aspects of the domain are interrelated and
influence one another in a continuous, dynamic process,
occupational therapy practitioners expect that a client’s
ability to adapt, change, and develop in one area will
affect other areas. Because of this dynamic
interrelationship, evaluation, including analysis of
occupational performance, and intervention planning
continue throughout the implementation process. In
addition, intervention implementation includes
monitoring of the client’s response to specific
interventions and progress toward goals.
Intervention Review
Intervention review is the continuous process of
reevaluating and reviewing the intervention plan, the
effectiveness of its delivery, and progress toward
outcomes. As during intervention planning, this
process includes collaboration with the client to identify
progress toward goals and outcomes. Reevaluation
and review may lead to change in the intervention plan.
Practitioners should review best practices for using process
indicators and, as appropriate, modify the intervention plan
and monitor progress using outcome performance
measures and outcome tools. Intervention review includes
the following steps:
1. Reevaluating the plan and how it is implemented
relative to achieving outcomes
2. Modifying the plan as needed
3. Determining the need for continuation or
discontinuation of occupational therapy services and
for referral to other services.
Outcomes Outcomes emerge from the occupational therapy
process and describe the results clients can achieve
through occupational therapy intervention (Table 14).
The outcomes of occupational therapy are
multifaceted and may occur in all aspects of the domain
of concern. Outcomes should be measured with the
same methods used at evaluation and determined
through comparison of the client’s status at evaluation
with the client’s status at discharge or transition.
Results of occupational therapy services are
established using outcome performance measures and
outcome tools.
Outcomes are directly related to the interventions
provided and to the targeted occupations, performance
patterns, performance skills, client factors, and
contexts. Outcomes may be traced to improvement in
areas of the domain, such as performance skills and
client factors, but should ultimately be reflected in
clients’ ability to engage in their desired occupations.
Outcomes targeted in occupational therapy can be
summarized as
n Occupational performance, n Prevention, n Health and wellness, n Quality of life, n Participation, n Role competence, n Well-being, and n Occupational justice.
Occupational adaptation, or the client’s effective and
efficient response to occupational and contextual
demands (Grajo, 2019), is interwoven through all of
these outcomes.
The impact of outcomes and the way they are defined
are specific to clients (persons, groups, or populations)
and to other stakeholders such as payers and regulators.
Outcomes and their documentation vary by practice
setting and are influenced by the stakeholders in each
setting (AOTA, 2018a).
The focus on outcomes is woven throughout the
process of occupational therapy. During evaluation,
occupational therapy practitioners and clients (and often
others, such as parents and caregivers) collaborate to
identify targeted outcomes related to engagement in valued
occupations or daily life activities. These outcomes are the
basis for development of the intervention plan. During
intervention implementation and review, clients and
practitioners may modify targeted outcomes to
accommodate changing needs, contexts, and
performance abilities. Ultimately, the intervention process
should result in the achievement of outcomes related to
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health, well-being, and participation in life through
engagement in occupation.
Outcome Measurement
Objective outcomes are measurable and tangible
aspects of improved performance. Outcome
measurement is sometimes derived from standardized
assessments, with results reflected in numerical data
following specific scoring instructions. These data quantify
a client’s response to intervention in a way that can be
used by all relevant stakeholders. Objective outcome
measures are selected early in the occupational therapy
process on the basis of properties showing that they are
n Valid, reliable, and appropriately sensitive to change
in the client’s occupational performance, n Consistent with targeted outcomes, n Congruent with the client’s goals, and n Able to predict future outcomes.
Practitioners use objective outcome measures to
measure progress and adjust goals and interventions by
n Comparing progress toward goal achievement with
outcomes throughout the intervention process and n Measuring and assessing results to make decisions
about the future direction of intervention (e.g.,
continue, modify, transition, discontinue, provide
follow-up, refer for other service).
In some settings, the focus is on patient-reported
outcomes (PROs), which have been defined as “any
report of the status of a patient’s health condition that
comes directly from the patient, without interpretation of
the patient’s response by a clinician or anyone else”
(National Quality Forum, n.d., para. 1). PROs can be
used as subjective measures of improved outlook,
confidence, hope, playfulness, self-efficacy, sustainability
of valued occupations, pain reduction, resilience, and
perceived well-being. An example of a PRO is parents’
greater perceived efficacy in parenting through a new
understanding of their child’s behavior (Cohn, 2001;
Cohn et al., 2000; Graham et al., 2013). Another example
is a report by an outpatient client with a hand injury of a
reduction in pain during the IADL of doing laundry. “PRO
tools measure what patients are able to do and how they
feel by asking questions. These tools enable assessment
of patient-reported health status for physical, mental, and
social well-being” (National Quality Forum, n.d., para. 1).
Outcomes can also be designed for caregivers—for
example, improved quality of life for both care recipient
and caregiver. Studies of caregivers of people with
dementia who received a home environmental
intervention found fewer declines in occupational
performance, enhanced mastery and skill, improved
sense of self-efficacy and well-being, and less need for
help with care recipients (Gitlin & Corcoran, 2005; Gitlin
et al., 2001, 2003, 2008; Graff et al., 2007; Piersol et al.,
2017).
Outcomes for groups that receive an educational
intervention may include improved social interaction,
increased self-awareness through peer support, a larger
social network, or improved employee health and
productivity. For example, education interventions for
groups of employees on safety and workplace wellness
have been shown to decrease work injuries and increase
workplace productivity and satisfaction (Snodgrass &Amini,
2017).
Outcomes for populations may address health
promotion, occupational justice and self-advocacy, health
literacy, community integration, community living, and
access to services. As with other occupational therapy
clients, outcomes for populations are focused on
occupational performance, engagement, and participation.
For example, outcomes at the population level as a result of
advocacy interventions include construction of accessible
playground facilities, improved accessibility for polling
places, and reconstruction of a school after a natural
disaster.
Transition and Discontinuation
Transition is movement from one life role or experience to
another. Transitions in services, like all life transitions,
may require preparation, new knowledge, and time to
accommodate to the new situation (Orentlicher et al.,
2015). Transition planning may be needed, for example,
when a client moves from one setting to another along
the care continuum (e.g., acute hospital to skilled nursing
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facility) or ages out of one program and into a new one
(e.g., early intervention to elementary school).
Collaboration among practitioners is necessary to ensure
safety, well-being, and optimal outcomes for clients (Joint
Commission, 2012, 2013).
Transition planning may include a referral to a provider
within occupational therapy with advanced knowledge
and skill (e.g., vestibular rehabilitation, driver evaluation,
hand therapy) or outside the profession (e.g.,
psychologist, optometrist). Transition planning for groups
and populations may be needed for a transition from one
stage to another (e.g., middle school students in a life
skills program who transition to high school) or from one
set of needs to another (e.g., older adults in a community
falls prevention program who transition to a community
exercise program).
Planning for discontinuation of occupational
therapy services begins at initial evaluation.
Discontinuation of care occurs when the client ends
services after meeting short- and long-term goals or
chooses to discontinue receiving services (consistent
with client-centered care). Safe and effective
discharge planning for a person may include
education on the use of new equipment, adaptation of
an occupation, caregiver training, environmental
modification, or determination of the appropriate
setting for transition of care. A key goal of discharge
planning for individual clients is prevention of
readmission (Rogers et al., 2017). Discontinuation of
services for groups and populations occurs when goals
are met and sustainability plans are implemented for
long-term success.
Conclusion
The OTPF–4 describes the central concepts that ground
occupational therapy practice and builds a common
understanding of the basic tenets and distinct
contribution of the profession. The occupational therapy
domain and process are linked inextricably in a
transactional relationship. An understanding of this
relationship supports and guides the complex decision
making required in the daily practice of occupational
therapy and enhances practitioners’ ability to
define the reasons for and justify the provision of
services when communicating with clients, family
members, team members, employers, payers, and
policymakers.
This edition of the OTPF provides a broader view than
previous editions of occupational therapy as related to
groups and populations and current and future
occupational needs of clients. It also presents and
describes the cornerstones of occupational therapy practice,
which are discrete and critical qualities of occupational
therapy practitioners that provide them with a foundation for
success in the occupational therapy process. The OTPF–4
highlights the distinct value of occupation and occupational
therapy in contributing to health, well-being, and participation
in life for persons, groups, and populations. This document
can be used to advocate for the importance of occupational
therapy in meeting society’s current and future needs,
ultimately advancing the profession to ensure a sustainable
future.
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Table 1. Examples of Clients: Persons, Groups, and Populations
Person Group Population
Health Management
Middle-school student with diabetes in- terested in developing self-management skills to test blood sugar levels
Group of students with diabetes interested in problem solving the school setting’s support for management of their condition
All students in the school provided with access to food choices to meet varying dietary needs and desires
Feeding
Family of an infant with a history of pre- maturity and difficulty accepting nutrition orally
Families with infants experiencing feeding challenges advocating for the local hos- pital’s rehabilitation services to develop infant feeding classes
Families of infants advocating for re- search and development of alternative nipple and bottle designs to address feeding challenges
Community Mobility
Person with stroke who wants to return to driving
Stroke support group talking with elected leaders about developing community mobility resources
Stroke survivors advocating for increased access to community mobility options for all persons living with mobility limitations
Social Participation
Young adult with IDD interested in in- creasing social participation
Young adults with IDD in a transition program sponsoring leisure activities in which all may participate in valued social relationships
Young adults with IDD educating their community about their need for inclusion in community-based social and leisure activities
Home Establishment and Management
Person living with SMI interested in de- veloping skills for independent living
Support group for people living with SMI developing resources to foster indepen- dent living
People living with SMI in the same region advocating for increased housing options for independent living
Work Participation
Older worker with difficulty performing some work tasks
Group of older workers in a factory ad- vocating for modification of equipment to address discomfort when operating the same set of machines
Older workers in a national corporation advocating for company-wide wellness support programs
Note. IDD = intellectual and developmental disabilities; SMI = serious mental illness.
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Table 2. Occupations Occupations are “the everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do” (World Federation of Occupational Therapists, 2012a, para. 2). Occupations are categorized as activities of daily living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation.
Occupation Description
Activities of Daily Living (ADLs)—Activities oriented toward taking care of one’s own body and completed on a routine basis (adapted from Rogers & Holm, 1994).
Bathing, showering Obtaining and using supplies; soaping, rinsing, and drying body parts; maintaining bathing position; transferring to and from bathing positions
Toileting and toilet hygiene Obtaining and using toileting supplies, managing clothing, maintaining toileting position, transferring to and from toileting position, cleaning body, caring for menstrual and continence needs (including catheter, colostomy, and suppository man- agement), maintaining intentional control of bowel movements and urination and, if necessary, using equipment or agents for bladder control (Uniform Data System for Medical Rehabilitation, 1996, pp. III-20, III-24)
Dressing Selecting clothing and accessories with consideration of time of day, weather, and desired presentation; obtaining clothing from storage area; dressing and undressing in a sequential fashion; fastening and adjusting clothing and shoes; applying and re- moving personal devices, prosthetic devices, or splints
Eating and swallowing Keeping and manipulating food or fluid in the mouth, swal- lowing it (i.e., moving it from the mouth to the stomach)
Feeding Setting up, arranging, and bringing food or fluid from the vessel to the mouth (includes self-feeding and feeding others)
Functional mobility Moving from one position or place to another (during perfor- mance of everyday activities), such as in-bed mobility, wheel- chair mobility, and transfers (e.g., wheelchair, bed, car, shower, tub, toilet, chair, floor); includes functional ambulation and transportation of objects
Personal hygiene and grooming Obtaining and using supplies; removing body hair (e.g., using a razor or tweezers); applying and removing cosmetics; washing, drying, combing, styling, brushing, and trimming hair; caring for nails (hands and feet); caring for skin, ears, eyes, and nose; applying deodorant; cleaning mouth; brushing and flossing teeth; removing, cleaning, and reinserting dental orthotics and prosthetics
Sexual activity Engaging in the broad possibilities for sexual expression and experiences with self or others (e.g., hugging, kissing, foreplay, masturbation, oral sex, intercourse)
Instrumental Activities of Daily Living (IADLs)—Activities to support daily life within the home and community.
Care of others (including selection and supervision of caregivers) Providing care for others, arranging or supervising formal care (by paid caregivers) or informal care (by family or friends) for others
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Table 2. Occupations (cont’d)
Occupation Description Care of pets and animals Providing care for pets and service animals, arranging or su-
pervising care for pets and service animals
Child rearing Providing care and supervision to support the developmental and physiological needs of a child
Communication management Sending, receiving, and interpreting information using systems and equipment such as writing tools, telephones (including smartphones), keyboards, audiovisual recorders, computers or tablets, communication boards, call lights, emergency systems, Braille writers, telecommunication devices for deaf people, augmentative communication systems, and personal digital assistants
Driving and community mobility Planning and moving around in the community using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, ride shares, or other transportation systems
Financial management Using fiscal resources, including financial transaction methods (e.g., credit card, digital banking); planning and using finances with long-term and short-term goals
Home establishment and management Obtaining and maintaining personal and household possessions and environments (e.g., home, yard, garden, houseplants, appliances, vehicles), including maintaining and repairing personal possessions (e.g., clothing, household items) and knowing how to seek help or whom to contact
Meal preparation and cleanup Planning, preparing, and serving meals and cleaning up food and tools (e.g., utensils, pots, plates) after meals
Religious and spiritual expression Engaging in religious or spiritual activities, organizations, and practices for self-fulfillment; finding meaning or religious or spiritual value; establishing connection with a divine power, such as is involved in attending a church, temple, mosque, or synagogue; praying or chanting for a religious purpose; en- gaging in spiritual contemplation (World Health Organization, 2008); may also include giving back to others, contributing to society or a cause, and contributing to a greater purpose
Safety and emergency maintenance Evaluating situations in advance for potential safety risks; recognizing sudden, unexpected hazardous situations and ini- tiating emergency action; reducing potential threats to health and safety, including ensuring safety when entering and exiting the home, identifying emergency contact numbers, and replacing items such as batteries in smoke alarms and light bulbs
Shopping Preparing shopping lists (grocery and other); selecting, pur- chasing, and transporting items; selecting method of payment and completing payment transactions; managing internet shopping and related use of electronic devices such as com- puters, cell phones, and tablets
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Table 2. Occupations (cont’d)
Occupation Description
Health Management—Activities related to developing, managing, and maintaining health and wellness routines, including self-management, with the goal of improving or maintaining health to support participation in other occupations.
Social and emotional health promotion and maintenance Identifying personal strengths and assets, managing emotions, expressing needs effectively, seeking occupations and social engagement to support health and wellness, developing self- identity, making choices to improve quality of life in participation
Symptom and condition management Managing physical and mental health needs, including using coping strategies for illness, trauma history, or societal stigma; managing pain; managing chronic disease; recognizing symptom changes and fluctuations; developing and using strategies for managing and regulating emotions; planning time and establishing behavioral patterns for restorative activities (e.g., meditation); using community and social supports; navigating and accessing the health care system
Communication with the health care system Expressing and receiving verbal, written, and digital commu- nication with health care and insurance providers, including understanding and advocating for self or others
Medication management Communicating with the physician about prescriptions, filling prescriptions at the pharmacy, interpreting medication in- structions, taking medications on a routine basis, refilling prescriptions in a timely manner (American Occupational Therapy Association, 2017c; Schwartz & Smith, 2017)
Physical activity Completing cardiovascular exercise, strength training, and balance training to improve or maintain health and decrease risk of health episodes, such as by incorporating walks into daily routine
Nutrition management Implementing and adhering to nutrition and hydration recom- mendations from the medical team, preparing meals to support health goals, participating in health-promoting diet routines
Personal care device management Procuring, using, cleaning, and maintaining personal care de- vices, including hearing aids, contact lenses, glasses, orthotics, prosthetics, adaptive equipment, pessaries, glucometers, and contraceptive and sexual devices
Rest and Sleep—Activities related to obtaining restorative rest and sleep to support healthy, active engagement in other occupations.
Rest Identifying the need to relax and engaging in quiet and effortless actions that interrupt physical and mental activity (Nurit & Michal, 2003, p. 227); reducing involvement in taxing physical, mental, or social activities, resulting in a relaxed state; engaging in relaxation or other endeavors that restore energy and calm and renew interest in engagement
Sleep preparation Engaging in routines that prepare the self for a comfortable rest, such as grooming and undressing, reading or listening to music, saying goodnight to others, and engaging in meditation or prayers; determining the time of day and length of time
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Table 2. Occupations (cont’d)
Occupation Description desired for sleeping and the time needed to wake; establishing sleep patterns that support growth and health (patterns are often personally and culturally determined); preparing the physical environment for periods of sleep, such as making the bed or space on which to sleep, ensuring warmth or coolness and protection, setting an alarm clock, securing the home (e.g., by locking doors or closing windows or curtains), setting up sleep- supporting equipment (e.g., CPAP machine), and turning off electronics and lights
Sleep participation Taking care of personal needs for sleep, such as ceasing ac- tivities to ensure onset of sleep, napping, and dreaming; sus- taining a sleep state without disruption; meeting nighttime toileting and hydration needs, including negotiating the needs of and interacting with others (e.g., children, partner) within the social environment, such as providing nighttime caregiving (e.g., breastfeeding) and monitoring comfort and safety of others who are sleeping
Education—Activities needed for learning and participating in the educational environment.
Formal educational participation Participating in academic (e.g., math, reading, degree course- work), nonacademic (e.g., recess, lunchroom, hallway), extracurricular (e.g., sports, band, cheerleading, dances), technological (e.g., online assignment completion, distance learning), and vocational (including prevocational) educational activities
Informal personal educational needs or interests exploration (beyond formal education)
Identifying topics and methods for obtaining topic-related in- formation or skills
Informal educational participation Participating in classes, programs, and activities that provide instruction or training outside of a structured curriculum in identified areas of interest
Work—Labor or exertion related to the development, production, delivery, or management of objects or services; benefits may be financial or nonfinancial (e.g., social connectedness, contributions to society, structure and routine to daily life; Christiansen & Townsend, 2010; Dorsey et al., 2019).
Employment interests and pursuits Identifying and selecting work opportunities consistent with personal assets, limitations, goals, and interests (adapted from Mosey, 1996, p. 342)
Employment seeking and acquisition Advocating for oneself; completing, submitting, and reviewing application materials; preparing for interviews; participating in interviews and following up afterward; discussing job benefits; finalizing negotiations
Job performance and maintenance Creating, producing, and distributing products and services; maintaining required work skills and patterns; managing time use; managing relationships with coworkers, managers, and customers; following and providing leadership and supervision; initiating, sustaining, and completing work; complying with work norms and procedures; seeking and responding to feedback on performance
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Table 2. Occupations (cont’d)
Occupation Description Retirement preparation and adjustment Determining aptitudes, developing interests and skills, selecting
vocational pursuits, securing required resources, adjusting lifestyle in the absence of the worker role
Volunteer exploration Identifying and learning about community causes, organiza- tions, and opportunities for unpaid work consistent with per- sonal skills, interests, location, and time available
Volunteer participation Performing unpaid work activities for the benefit of selected people, causes, or organizations
Play—Activities that are intrinsically motivated, internally controlled, and freely chosen and that may include suspension of reality (e.g., fantasy; Skard & Bundy, 2008), exploration, humor, risk taking, contests, and celebrations (Eberle, 2014; Sutton-Smith, 2009). Play is a complex and multidimensional phenomenon that is shaped by sociocultural factors (Lynch et al., 2016).
Play exploration Identifying play activities, including exploration play, practice play, pretend play, games with rules, constructive play, and symbolic play (adapted from Bergen, 1988, pp. 64–65)
Play participation Participating in play; maintaining a balance of play with other occupations; obtaining, using, and maintaining toys, equip- ment, and supplies
Leisure—“Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, p. 250).
Leisure exploration Identifying interests, skills, opportunities, and leisure activities
Leisure participation Planning and participating in leisure activities; maintaining a balance of leisure activities with other occupations; obtaining, using, and maintaining equipment and supplies
Social Participation—Activities that involve social interaction with others, including family, friends, peers, and community members, and that support social interdependence (Bedell, 2012; Khetani & Coster, 2019; Magasi & Hammel, 2004).
Community participation Engaging in activities that result in successful interaction at the community level (e.g., neighborhood, organization, workplace, school, digital social network, religious or spiritual group)
Family participation Engaging in activities that result in “interaction in specific re- quired and/or desired familial roles” (Mosey, 1996, p. 340)
Friendships Engaging in activities that support “a relationship between two people based on mutual liking in which partners provide support to each other in times of need" (Hall, 2017, para. 2)
Intimate partner relationships Engaging in activities to initiate and maintain a close relation- ship, including giving and receiving affection and interacting in desired roles; intimate partners may or may not engage in sexual activity
Peer group participation Engaging in activities with others who have similar interests, age, background, or social status
Note. CPAP = continuous positive airway pressure.
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Table 3. Examples of Occupations for Persons, Groups, and Populations Persons engage in occupations, and groups engage in shared occupations; populations as a whole do not engage in shared occupations, which happen at the person or group level. Occupational therapy practitioners provide interventions for persons, groups, and populations.
Occupation Category Client Type Example
Activities of daily living Person Older adult completing bathing with assistance from an adult child
Group Students eating lunch during a lunch break
Instrumental activities of daily living Person Parent using a phone app to pay a babysitter electronically
Group Club members using public transportation to arrive at a musical performance
Health management Person Patient scheduling an appointment with a spe- cialist after referral by the primary care doctor
Group Parent association sharing preparation of healthy foods to serve at a school-sponsored festival
Rest and sleep Person Person turning off lights and adjusting the room temperature to 68° before sleep
Group Children engaging in nap time at a day care center
Education Person College student taking an African-American his- tory class online
Group Students working on a collaborative science project on robotics
Work Person Electrician turning off power before working on a power line
Group Peers volunteering for a day of action at an animal shelter
Play Person Child playing superhero dress up
Group Class playing freeze tag during recess
Leisure Person Family member knitting a sweater for a new baby
Group Friends meeting for a craft circle
Social participation Person New mother going to lunch with friends
Group Older adults gathering at a community center to wrap holiday presents for charity distribution
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Table 4. Context: Environmental Factors Context is the broad construct that encompasses environmental factors and personal factors. Environmental factors are aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives.
Environmental Factor Components Examples Natural environment and human-made changes to the environment: Animate and inanimate elements of the natural or physical environment and components of that environment that have been modified by people, as well as characteristics of human populations within the environment
Physical geography • Raised flower beds in a backyard • Local stream cleanup by Boy Scouts during a community service day project
• Highway expansion cutting through an established neighborhood
Population: Groups of people living in a given environment who share the same pattern of environmental adaptation
• Universal access playground where children with mobility impairment can play
• Hearing loop installed in a synagogue for congregation members with hearing aids
• Tree-shaded, solid-surface walking path enjoyed by older adults in a senior living community
Flora (plants) and fauna (animals) • Nonshedding service dog • Family-owned herd of cattle • Community garden
Climate: Meteorological features and events, such as weather
• Sunny day requiring use of sunglasses • Rain shower prompting a crew of road workers to don rain gear
• Unusually high temperatures turning a community ice skating pond to slush
Natural events: Regular or irregular geo- graphic and atmospheric changes that cause disruption in the physical environment
• Barometric pressure causing a headache
• Flood of a local creek damaging neighborhood homes
• Hurricane devastating a low-lying region
Human-caused events: Alterations or dis- turbances in the natural environment caused by humans that result in the dis- ruption of day-to-day life
• High air pollution forcing a person with lung disease to stay indoors
• Accessible dock at a local river park demolished to make way for a new bridge construction project
• Derailment of a train loaded with highly combustible chemicals leading to the emergency total evacuation of a small town
Light: Light intensity and quality • Darkness requiring use of a reading lamp • Office with ample natural light • Street lamps
Time-related changes: Natural, regularly occurring, or predictable change; rhythm and duration of activity; time of day, week, month, season, or year; day–night cycles; lunar cycles
• Jet lag • Quitting time at the end of a work shift • Summer solstice
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Table 4. Context: Environmental Factors (cont’d)
Environmental Factor Components Examples Sound and vibration: Heard or felt phe- nomena that may provide useful or dis- tracting information about the world
• Vibration of a cell phone indicating a text message
• Bell signaling the start of the school day • Outdoor emergency warning system on a college campus
Air quality: Characteristics of the atmo- sphere (outside buildings) or enclosed areas of air (inside buildings)
• Heavy perfume use by a family member causing an asthmatic reaction
• Smoking area outside an office building • High incidence of respiratory diseases near an industrial district
Products and technology: Natural or human-made products or systems of products, equipment, and technology that are gathered, created, produced, or manufactured
Food, drugs, and other products or sub- stances for personal consumption
• Preferred snack • Injectable hormones for a transgender man
• Grade-school cafeteria lunch
General products and technology for personal use in daily living (including assistive technology and products)
• Toothbrush • Household refrigerator • Shower in a fitness or exercise facility
Personal indoor and outdoor mobility and transportation equipment used by people in activities requiring movement inside and outside of buildings
• Four-wheeled walker • Family car • Elevator in a multistory apartment building
Communication: Activities involving sending and receiving information
• Hearing aid • Text chain via personal cell phones • Use of emergency response system to warn region of impending dangerous storms
Education: Processes and methods for acquiring knowledge, expertise, or skill
• Textbook • Online course • Curriculum for workplace sexual ha- rassment program
Employment: Paid work activities • Home office for remote work • Assembly factory • Internet connection for health care workers to access electronic medical records
Cultural, recreational, and sporting activities
• Gaming console • Instruments for a university marching band
• Soccer stadium
Practice of religion and spirituality • Prayer rug • Temple • Sunday church service television broadcast
Indoor and outdoor human-made envi- ronments that are planned, designed, and constructed for public and private use
• Home bathroom with grab bars and raised toilet seat
• Accessible playground at a city park • Zero-grade entry to a shopping mall
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Table 4. Context: Environmental Factors (cont’d)
Environmental Factor Components Examples Assets for economic exchange, such as money, goods, property, and other valu- ables that an individual owns or has rights to use
• Pocket change • Household budget • Condominium association tax bill
Virtual environments occurring in simu- lated, real-time, and near-time situations, absent of physical contact
• Personal cell phone • Synchronous video meeting of co- workers in distant locations
• Open-source video gaming community
Support and relationships: People or ani- mals that provide practical physical or emotional support, nurturing, protection, assistance, and relationships to other persons in the home, workplace, or school or at play or in other aspects of their daily activities
Immediate and extended family • Spouses, partners, parents, siblings, foster parents, and adoptive grandparents
• Biological families and found or con- structed families
Friends, acquaintances, peers, colleagues, neighbors, and community members
• Trusted best friend • Coworkers • Helpful next-door neighbor • Substance abuse recovery support group sponsor
People in positions of authority and those in subordinate positions
• Teacher who offers extra tutoring • Legal guardian for a parentless minor • Female religious reporting to a sister superior
• New employee being oriented to the job tasks by an assigned mentor
Personal care providers and personal as- sistants providing support to individuals
Health care professionals and other professionals serving a community
Domesticated animals • Therapy dog program in a senior living community
• Horse kept to draw a buggy for an Amish family’s transportation
Attitudes: Observable evidence of cus- toms, practices, ideologies, values, norms, factual beliefs, and religious beliefs held by people other than the client
Individual attitudes of immediate and ex- tended family, friends and acquaintances, peers and colleagues, neighbors and community members, people in positions of authority and subordinate positions, personal care providers and personal as- sistants, strangers, and health care and other professionals
• Shared grief over the untimely death of a sibling
• Automatic trust from a patient who knows one’s father
• Reliance among members of a faith community
Societal attitudes, including discriminatory practices
• Failure to acknowledge a young person who wants to vote for the first time
• Racial discrimination in job hiring processes
Social norms, practices, and ideologies that marginalize specific populations
No time off work allowed to observe a religion’s holy day
Services, systems, and policies: Benefits, structured programs, and regulations for operations, provided by institutions in
Services designed to meet the needs of persons, groups, and populations
• Economic services, including Social Security income and public assistance
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Table 4. Context: Environmental Factors (cont’d)
Environmental Factor Components Examples various sectors of society, designed to meet the needs of persons, groups, and populations
• Health services for preventing and treating health problems, providing medical rehabilitation, and promoting healthy lifestyles
Systems established by governments at the local, regional, national, and interna- tional levels or by other recognized authorities
• Public utilities (e.g., water, electricity, sanitation)
• Communications (transmission and exchange of information)
• Transportation systems • Political systems related to voting, elections, and governance
Policies constituted by rules, regulations, conventions, and standards established by governments at the local, regional, na- tional, and international levels or by other recognized authorities
• Architecture, construction, open space use, and housing policies
• Civil protection and legal services • Labor and employment policies related to finding suitable work, looking for different work, or seeking promotion
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Table 5. Context: Personal Factors Context is the broad construct that encompasses environmental factors and personal factors. Personal factors are the particular background of a person’s life and living and consist of the unique features of the person that are not part of a health condition or health state.
Personal Factor Person A Person B Age (chronological) • 48 years old • 14 years old
Sexual orientation • Attracted to men • Attracted to all genders
Gender identity • Female • Male
Race and ethnicity • Black French Caribbean • Southeast Asian Hmong
Cultural identification and cultural attitudes • Urban Black • Feminist • Caribbean island identification
• Traditional clan structure • Elders who are decision makers for community
Social background, social status, and so- cioeconomic status
• Urban, upscale neighborhood • Friends in the professional workforce • Income that allows for luxury
• Family owns small home • Father with a stable job in light manufacturing
• Mother who is a child care provider for neighborhood children
Upbringing and life experiences • No siblings • Raised in household with grandmother as caregiver
• Moved from California to Boston while an adolescent
• Traditional • Born in a refugee camp before parents emigrated
• Youngest of five siblings • Lives in a small city in the Upper Midwest
Habits and past and current behavioral patterns
• Coffee before anything else • Meticulous about dress
• Organized and attentive to family • Never misses a family meal
Individual psychological assets, including temperament, character traits, and coping styles, for handling responsibilities, stress, crises, and other psychological demands (e.g., extroversion, agreeableness, con- scientiousness, psychic stability, open- ness to experience, optimism, confidence)
• Anxious when not working • Extroverted • High level of confidence • Readily adapts approach to and inter- actions with those who are culturally different
• Known for being calm • Not outgoing but friendly to all • Does not speak up or complain at school during conflict
Education • Master’s degree in political science • Law degree
• High school freshman • Advanced skills in the sciences
Profession and professional identity • Public interest lawyer • Public high school student
Lifestyle • High-rise apartment • Likes urban nightlife and casual dating • Works long hours
• Engaged in clan and community • Four older siblings who live nearby
Other health conditions and fitness • Treated for anorexia nervosa while an adolescent
• Occasional runner
• Wears eyeglasses for astigmatism • Sedentary at home except for assigned chores
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Table 6. Performance Patterns Performance patterns are the habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process of engaging in occupations or activities. These patterns are influenced by context and time use and can support or hinder occupational performance.
Category Description Examples
Person
Habits “Specific, automatic behaviors performed repeat- edly, relatively automatically, and with little varia- tion” (Matuska & Barrett, 2019, p. 214). Habits can be healthy or unhealthy, efficient or inefficient, and supportive or harmful (Dunn, 2000).
• Automatically puts car keys in the same place • Spontaneously looks both ways before crossing the street
• Always turns off the stove burner before re- moving a cooking pot
• Activates the alarm system before leaving the home
• Always checks smartphone for emails or text messages on waking
• Snacks when watching television
Routines Patterns of behavior that are observable, regular, and repetitive and that provide structure for daily life. They can be satisfying, promoting, or dam- aging. Routines require delimited time commit- ment and are embedded in cultural and ecological contexts (Fiese, 2007; Segal, 2004).
• Follows a morning sequence to complete toi- leting, bathing, hygiene, and dressing
• Follows the sequence of steps involved in meal preparation
• Manages morning routine to drop children off at school and arrive at work on time
Roles Aspects of identity shaped by culture and context that may be further conceptualized and defined by the client and the activities and occupations one engages in.
• Sibling in a family with three children • Retired military personnel • Volunteer at a local park district • Mother of an adolescent with developmental disabilities
• Student with a learning disability studying computer technology
• Corporate executive returning to part-time work after a stroke
Rituals Symbolic actions with spiritual, cultural, or social meaning contributing to the client’s identity and reinforcing values and beliefs. Rituals have a strong affective component and consist of a collection of events (Fiese, 2007; Fiese et al., 2002; Segal, 2004).
• Shares a highlight from the day during evening meals with family
• Kisses a sacred book before opening the pages to read
• Recites the Pledge of Allegiance before the start of the school day
Group and Population
Routines Patterns of behavior that are observable, regular, and repetitive and that provide structure for daily life. They can be satisfying, promoting, or dam- aging. Time provides an organizational structure or rhythm for routines (Larson & Zemke, 2003). Routines are embedded in cultural and ecological contexts (Segal, 2004).
Group • Workers attending weekly staff meetings • Students turning in homework assignments as they enter the classroom
• Exercise class attendees setting up their mats and towels before class
Population • Parents of young children following health practices such as yearly checkups and sched- uled immunizations
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Table 6. Performance Patterns (cont’d)
Category Description Examples
• Corporations following business practices such as providing services for disadvantaged pop- ulations (e.g., loans to underrepresented groups)
• School districts following legislative procedures such as those associated with the Individuals With Disabilities Education Improvement Act of 2004 (Pub. L. 108-446) or Medicare
Roles Sets of behaviors by the group or population ex- pected by society and shaped by culture and context that may be further conceptualized and defined by the group or population.
Group • Nonprofit civic group providing housing for people living with mental illness
• Humanitarian group distributing food and clothing donations to refugees
• Student organization in a university educating elementary school children about preventing bullying
Population • Parents providing care for children until they become adults
• Grandparents or older community members being consulted before decisions are made
Rituals Shared social actions with traditional, emotional, purposive, and technological meaning contributing to values and beliefs within the group or population.
Group • Employees of a company attending an annual holiday celebration
• Members of a community agency hosting a fundraiser every spring
Population • Citizens of a country suspending work activities in observance of a national holiday
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Table 7. Performance Skills for Persons Performance skills are observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are supported by the context in which the performance occurs, including environmental and client factors (Fisher & Marterella, 2019). Effective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of social interaction performance skills is demonstrated when the client completes interactions in a manner that matches the demands of the social situation. Ineffective use of performance skills is demonstrated when the client routinely requires assistance or support to perform activities or engage in social interactions.
The examples in this table are limited to descriptions of the client’s ability to use each performance skill in an effective or ineffective manner. A client who demonstrates ineffective use of performance skills may be able to successfully complete the entire occupation with the use of occupational or environmental adaptations. Successful occupational performance by the client may be achieved when such adaptions are used.
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Motor Skills—“Motor skills are the group of performance skills that represent small, observable actions related to moving oneself or moving and interacting with tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life) in the context of performing a personally and ecologically relevant daily life task” (Fisher & Marterella, 2019, p. 331).
Positioning the body Washing dishes at the kitchen sink
Stabilizes—Moves through task environ- ment and interacts with task objects without momentary propping or loss of balance
Person moves through the kitchen without propping or loss of balance.
Person momentarily props on the counter to stabilize body while standing at the sink and washing dishes.
Aligns—Interacts with task objects with- out evidence of persistent propping or leaning
Person washes dishes without using the counter for support.
Person persistently leans on the counter, resulting in ineffective performance when washing dishes.
Positions—Positions self an effective distance from task objects and without evidence of awkward arm or body positions
Person places body or wheelchair at an effective distance for washing dishes.
Person positions body or wheelchair too far from the sink, resulting in difficulty reaching for dishes in the sink.
Obtaining and holding objects Acquiring a game from a cabinet in preparation for a family activity
Reaches—Effectively extends arm and, when appropriate, bends trunk to ef- fectively grasp or place task objects that are out of reach
Person reaches without effort for the game box.
Person reaches with excessive physical effort for the game box.
Bends—Flexes or rotates trunk as ap- propriate when sitting down or when bending to grasp or place task objects that are out of reach
Person bends without effort when reach- ing for the game box.
Person demonstrates excessive stiffness when bending to reach for the game box.
Grips—Effectively pinches or grasps task objects such that the objects do not slip (e.g., from between fingers, from be- tween teeth, from between hand and supporting surface)
Person grips the game box and game pieces, and they do not slip from the hand.
Person grips the game box ineffectively, and the box slips from the hand so that game pieces spill.
Manipulates—Uses dexterous finger movements, without evidence of fum- bling, when manipulating task objects
Person readily manipulates the game pieces with fingers while setting up and playing the game.
Person fumbles the game pieces so that some pieces fall off the game board.
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Motor Skills (cont’d)
Moving self and objects Completing janitorial tasks at a factory site
Coordinates—Uses two or more body parts together to manipulate and hold task objects without evidence of fumbling or task objects slipping from the grasp
Person uses both hands to shuffle the game cards without fumbling them, and the cards do not slip from the hands.
Person uses both hands to shuffle the cards but fumbles the deck, and the cards slip out of the hands.
Moves—Effectively pushes or pulls task objects along a supporting surface, pulls to open or pushes to close doors and drawers, or pushes on wheels to propel a wheelchair
Person moves the broom easily, pushing and pulling it across the floor.
Person demonstrates excessive effort to move the broom across the floor when sweeping.
Lifts—Effectively raises or lifts task objects without evidence of excessive physical effort
Person easily lifts cleaning supplies out of the cart.
Person needs to use both hands to lift small lightweight containers of cleaning supplies out of the cart.
Walks—During task performance, ambu- lates on level surfaces without shuffling feet, becoming unstable, propping, or using assistive devices
Person walks steadily through the factory. Person demonstrates unstable walking while performing janitorial duties or walks while supporting self on the cart.
Transports—Carries task objects from one place to another while walking or moving in a wheelchair
Person carries cleaning supplies from one factory location to another, either by walking or using a wheelchair, without effort.
Person is unstable when transporting cleaning supplies throughout the factory.
Calibrates—Uses movements of appro- priate force, speed, or extent when interacting with task objects (e.g., does not crush task objects, pushes a door with enough force to close it without a bang)
Person uses an appropriate amount of force to squeeze liquid soap onto a cleaning cloth.
Person applies too little force to squeeze soap out of the container onto the cleaning cloth.
Flows—Uses smooth and fluid arm and wrist movements when interacting with task objects
Person demonstrates fluid arm and wrist movements when wiping tables.
Person demonstrates stiff and jerky arm and wrist movements when wiping tables.
Sustaining performance Bathing an older parent as caregiver
Endures—Persists and completes the task without demonstrating physical fatigue, pausing to rest, or stopping to catch breath
Person completes bathing of parent without evidence of physical fatigue.
Person stops to rest, interrupting the task of bathing the parent.
Paces—Maintains a consistent and ef- fective rate or tempo of performance throughout the entire task performance
Person uses an appropriate tempo when bathing the parent.
Person sometimes rushes or delays ac- tions when bathing the parent.
Process Skills—“Process skills are the group of performance skills that represent small, observable actions related to selecting, interacting with, and using tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life); carrying out individual actions and steps; and preventing problems of occupational performance from occurring or reoccurring in the context of performing a personally and ecologically relevant daily life task” (Fisher & Marterella, 2019, pp. 336–337).
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Process Skills (cont’d)
Sustaining performance Writing sentences for a school assignment
Paces—Maintains a consistent and ef- fective rate or tempo of performance throughout the entire task performance
Person uses a consistent and even tempo when writing sentences.
Person rushes writing sentences, resulting in incorrectly formed letters or misspelled words.
Attends—Does not look away from task performance, maintaining the ongoing task progression
Person maintains gaze on the assignment and continues writing sentences without pause.
Person looks toward another student and pauses when writing sentences.
Heeds—Carries out and completes the task originally agreed on or specified by another person
Person completes the assignment, writing the number of sentences required.
Person writes fewer sentences than re- quired, not completing the assignment.
Applying knowledge Taking prescribed medications
Chooses—Selects necessary and appro- priate type and number of objects for the task, including the task objects that one chooses or is directed to use (e.g., by a teacher)
Person chooses specified medicine bottles appropriate for the specific timed dose.
Person chooses an incorrect medicine bottle for the specific timed dose.
Uses—Applies task objects as they are intended (e.g., using a pencil sharpener to sharpen a pencil but not a crayon) and in a hygienic fashion
Person uses a medicine spoon to take a dose of liquid medicine.
Person uses a tablespoon to take a 1- teaspoon dose of liquid medicine.
Handles—Supports or stabilizes task ob- jects appropriately, protecting them from being damaged, slipping, moving, or falling
Person supports the medicine bottle, keeping it upright without the bottle tip- ping or falling.
Person allows the medicine bottle to tip, and pills spill from the bottle.
Inquires—(1) Seeks needed verbal or written information by asking questions or reading directions or labels and (2) does not ask for information when fully oriented to the task and environment and recently aware of the answer
Person reads the label on the medicine bottle before taking the medication.
Person asks the care provider what dose to take having already read the dose on the label.
Organizing timing Using an ATM to get cash to pay a babysitter
Initiates—Starts or begins the next task action or task step without any hesitation
Person begins each step of ATM use without hesitation.
Person pauses before entering the PIN into the ATM.
Continues—Performs single actions or steps without any interruptions so that once an action or task step is initiated, performance continues without pauses or delays until the action or step is completed
Person completes each step of ATM use without delays.
Person starts to enter the PIN, pauses, and then continues entering the PIN.
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Process Skills (cont’d)
Sequences—Performs steps in an effec- tive or logical order and with an absence of randomness in the ordering or in- appropriate repetition of steps
Person completes each step of ATM use in logical order.
Person attempts to enter the PIN before inserting the bank card into the card reader.
Terminates—Brings to completion single actions or single steps without inappro- priate persistence or premature cessation
Person completes each step of ATM use in the appropriate length of time.
Person persists in entering numbers after completing the four-digit PIN.
Organizing space and objects Managing clerical duties for a large company
Searches/locates—Looks for and locates task objects in a logical manner
Person readily locates needed office sup- plies from shelves and drawers.
Person searches a shelf a second time to locate needed clerical supplies.
Gathers—Collects related task objects into the same work space and regathers task objects that have spilled, fallen, or been misplaced
Person gathers required clerical tools and supplies in the assigned work space.
Person places required paper and pen in different work spaces and then must move them to the same work space.
Organizes—Logically positions or spatially arranges task objects in an orderly fashion within a single work space or between multiple appropriate work spaces such that the work space is not too spread out or too crowded
Person organizes required clerical tools and supplies within the work space so all are within reach.
Person places books on top of papers, resulting in a crowded work space.
Restores—Puts away task objects in ap- propriate places and ensures that the immediate work space is restored to its original condition
Person returns clerical tools and supplies to their original storage location.
Person puts pens and extra paper in a different storage closet from where originally found.
Navigates—Moves body or wheelchair without bumping into obstacles when moving through the task environment or interacting with task objects
Person moves through the office space without bumping into office furniture or machines.
Person bumps hand into the edge of the desk when reaching for a pen from the pen holder.
Adapting performance Preparing a green salad for a family meal
Notices/responds—Responds appropri- ately to (1) nonverbal task-related cues (e.g., heat, movement), (2) the spatial arrangement and alignment of task objects to one another, and (3) cup- board doors or drawers that have been left open during task performance
Person notices the carrot rolling off the cutting board and catches it before it rolls onto the floor.
Person delays noticing a rolling carrot, and it rolls off the cutting board onto the floor.
Adjusts—Overcomes problems with on- going task performance effectively by (1) going to a new workspace; (2) moving task objects out of the current workspace; or (3) adjusting knobs, di- als, switches, or water taps
Person readily adjusts the flow of water from the tap when washing vegetables.
Person delays turning off the water tap after washing the vegetables.
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Process Skills (cont’d)
Accommodates—Prevents ineffective performance of all other motor and process skills and asks for assistance only when appropriate or needed
Person prevents problems from occurring during the salad preparation.
Person does not prevent problems from occurring, such as carrots rolling off the cutting board and onto the floor.
Benefits—Prevents ineffective perfor- mance of all other motor and process skills from recurring or persisting
Person prevents problems from continu- ing or reoccurring during the salad preparation.
Person retrieves the carrot from the floor and puts it back on the cutting board, and the carrot rolls off the board again.
Social Interaction Skills—“Social interaction skills are the group of performance skills that represent small, observable actions related to communicating and interacting with others in the context of engaging in a personally and ecologically relevant daily life task performance that involves social interaction with others” (Fisher & Marterella, 2019, p. 342).
Initiating and terminating social interaction Participating in a community support group
Approaches/starts—Approaches or initi- ates interaction with the social partner in a manner that is socially appropriate
Person politely begins interactions with support group members.
Person begins interactions with support group members by yelling at them from across the room.
Concludes/disengages—Effectively termi- nates the conversation or social inter- action, brings to closure the topic under discussion, and disengages or says goodbye
Person politely ends a conversation with a support group member.
Person abruptly ends interaction with the support group by walking out of the room.
Producing social interaction Child playing in the sandbox with others to build roads for cars and trucks
Produces speech—Produces spoken, signed, or augmentative (i.e., com- puter-generated) messages that are audible and clearly articulated
Person produces clear verbal, signed, or augmentative messages to communicate with other children playing in the sandbox.
Person mumbles when interacting with other children playing in the sandbox, and the other children do not understand the message.
Gesticulates—Uses socially appropriate gestures to communicate or support a message
Person gestures by waving or pointing while communicating with other children playing in the sandbox.
Person uses aggressive gestures when interacting with other children playing in the sandbox.
Speaks fluently—Speaks in a fluent and continuous manner, with an even pace (not too fast, not too slow) and without pauses or delays, while sending a message
Person speaks, without pausing, stutter- ing, or hesitating, when engaging with other children playing in the sandbox.
Person hesitates or pauses when talking with other children playing in the sandbox.
Physically supporting social interaction Older adult in a senior residence talking with other residents
during a shared mealtime
Turns toward—Actively positions or turns body and face toward the social partner or the person who is speaking
Person turns body and face toward other residents while interacting during the meal.
Person turns face away from other resi- dents while interacting during the meal.
Looks—Makes eye contact with the social partner
Person makes eye contact with other residents while interacting during the meal.
Person looks down at own plate while interacting during the meal.
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Social Interaction Skills (cont’d)
Places self—Positions self at an appro- priate distance from the social partner
Person sits an appropriate distance from other residents at the table.
Person sits too far from other residents, interfering with interactions.
Touches—Responds to and uses touch or bodily contact with the social partner in a socially appropriate manner
Person touches other residents appropri- ately during the meal.
Person reaches out, grasps another resident’s shirt, and abruptly pulls on it during the meal.
Regulates—Does not demonstrate irrele- vant, repetitive, or impulsive behaviors during social interaction
Person avoids demonstrating irrelevant, repetitive, or impulsive behaviors while interacting during the meal.
Person repeatedly taps the fork on the plate while interacting during the meal.
Shaping content of social interaction Serving ice cream to customers in an ice cream shop
Questions—Requests relevant facts and information and asks questions that support the intended purpose of the social interaction
Person asks customers for their choice of ice cream flavor.
Person asks customers for their choice of ice cream flavor and then repeats the question after they respond.
Replies—Keeps conversation going by replying appropriately to suggestions, opinions, questions, and comments
Person readily replies with relevant an- swers to customers’ questions about ice cream products.
Person delays in replying to customers’ questions or provides irrelevant information.
Discloses—Reveals opinions, feelings, and private information about self or others in a socially appropriate manner
Person discloses no personal information about self or others to customers.
Person reveals socially inappropriate details about own family.
Expresses emotions—Displays affect and emotions in a socially appropriate manner
Person displays socially appropriate emotions when sending messages to customers.
Person uses a sarcastic tone of voice when describing ice cream flavor options.
Disagrees—Expresses differences of opinion in a socially appropriate manner
Person expresses a difference of opinion about ice cream products in a polite way.
Person becomes argumentative when a customer requests a flavor that is not available.
Thanks—Uses appropriate words and gestures to acknowledge receipt of services, gifts, or compliments
Person thanks the customers for pur- chasing ice cream.
Person fails to say thank you after cus- tomers purchase ice cream.
Maintaining flow of social interaction Sharing suggestions with others in a support group for persons experiencing
mental health challenges
Transitions—Handles transitions in the conversation or changes the topic without disrupting the ongoing conversation
Person offers comments or suggestions that relate to the topic of mental health challenges, smoothly moving the topic in a relevant direction.
Person abruptly changes the topic of conversation to planning social activities during a discussion of mental health challenges.
Times response—Replies to social mes- sages without delay or hesitation and without interrupting the social partner
Person replies to another group member’s question about community supports for mental health challenges after briefly considering how best to respond.
Person replies to another group mem- ber’s question about community sup- ports for mental health challenges before the other person finishes asking the question.
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Table 7. Performance Skills for Persons (cont’d)
Specific Skill Definitions
Examples
Effective Performancea Ineffective Performanceb
Performance Skills: Social Interaction Skills (cont’d)
Times duration—Speaks for a reasonable length of time given the complexity of the message
Person sends messages about mental health challenges of an appropriate length.
Person sends prolonged messages con- taining extraneous details.
Takes turns—Speaks in turn and gives the social partner the freedom to take their turn
Person engages in back-and-forth con- versation with others in the group.
Person does not respond to comments from others during the group discussion.
Verbally supporting social interaction Visiting a Social Security office to obtain information relative to potential benefits
Matches language—Uses a tone of voice, dialect, and level of language that are so- cially appropriate and matched to the social partner’s abilities and level of understanding
Person uses a tone of voice and vocabulary that match those of the Social Security agent.
Person uses a loud voice and slang when interacting with the Social Security agent.
Clarifies—Responds to gestures or verbal messages from the social partner sig- naling that the social partner does not comprehend or understand a message and ensures that the social partner is following the conversation
Person rephrases the initial question when the Social Security agent requests clarification.
Person asks an unrelated question when the Social Security agent requests clari- fication of the initial question.
Acknowledges and encourages— Acknowledges receipt of messages, encourages the social partner to con- tinue the social interaction, and en- courages all social partners to participate in the interaction
Person nods to indicate understanding of the information shared by the Social Se- curity agent.
Person does not nod or use words to acknowledge receipt of messages sent by the Social Security agent.
Empathizes—Expresses a supportive at- titude toward the social partner by agreeing with, empathizing with, or expressing understanding of the social partner’s feelings and experiences
Person shows empathy when the Social Security agent expresses frustration with the slow computer system.
Person shows impatience when the So- cial Security agent expresses frustration with the slow computer system.
Adapting social interaction Deciding which restaurant to go to with a group of friends
Heeds—Uses goal-directed social inter- actions focused on carrying out and completing the intended purpose of the social interaction
Person maintains focus on deciding which restaurant to go to.
Person makes comments unrelated to choosing a restaurant, disrupting the group decision making.
Accommodates—Prevents ineffective or socially inappropriate social interaction
Person avoids making ineffective re- sponses to others about restaurant choice.
Person asks a question that is irrelevant to choosing a restaurant.
Benefits—Prevents problems with inef- fective or socially inappropriate social interaction from recurring or persisting
Person avoids making reoccurring inef- fective comments during the decision making.
Person persists in asking questions ir- relevant to choosing a restaurant.
Note. ATM = automated teller machine; PIN = personal identification number. aEffective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of social interaction performance skills is demonstrated when the client completes interactions in a manner that matches the demands of the social situation. bIneffective performance skills are demonstrated when the client routinely requires assistance or support to perform activities or engage in social interaction. Ineffective use of social interaction performance skills is demonstrated when the client engages in social interactions in a manner that does not appropriately meet the demands of the social situation. Source. From Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
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Table 8. Performance Skills for Groups To address performance skills for a group client, occupational therapy practitioners analyze the motor, process, and social interaction skills of individual group members to identify whether ineffective performance skills may limit the group’s collective outcome. Italicized words in the middle column are specific performance skills defined in Table 7.
Performance Skill Category Ineffective Performance by an Individual Group Member
Impact on Group Collective Outcome
Group collective outcome: Religious organization committee furnishing spaces for a preschool for member families
Motor—Obtaining and holding objects • Member reaches with excessive effort for chairs stored in closet.
• Member bends with stiffness or exces- sive effort when reaching for the chairs.
• Member fumbles when gripping writing materials in preparation for recording committee decisions for planning.
• Member demonstrates limited finger dexterity to manipulate tools for as- sembling storage units for toys.
• Member is unable to coordinate one hand and trunk to stabilize self while gripping and loading toys onto shelves.
Other members may need to take re- sponsibility for obtaining and holding objects to accommodate the member’s ineffective motor performance skills during the process of furnishing pre- school spaces.
Process—Organizing space and objects • Member repeatedly asks for help when searching for needed furniture or lo- cating play equipment that is organized logically in near and distant places within the building.
• Member does not effectively gather re- quired play activity materials in the designated play spaces.
• Member has difficulty organizing toys or play equipment within the various play spaces in a logical and orderly fashion.
• Member does not restore toys or play equipment to storage spaces to return the preschool space to an effective order.
• Member bumps into play furniture when navigating spaces to set up furniture to meet the needs of families or groups.
The group may need to accommodate the member’s limitations in effectively orga- nizing space and objects by adjusting the timing of the outcome to allow greater time to complete furnishing the preschool spaces.
Social interaction—Producing social interaction
• Member communicates in whispers when producing speech to communicate with other members about decisions for placing play equipment.
• Member delays in gesticulating so other members do not receive effective mes- sages while arranging toys and play equipment.
• Member speaks fluently but too quickly when communicating to friends, resulting in challenges for other members in deci- sion making for furnishing the preschool.
The group decision-making process may be hindered by the member’s difficulty in producing social interactions. Limited communication during the tasks of placing furniture in preschool spaces may cause confusion among group members.
Source. Performance skill categories are from Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
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Table 9. Client Factors Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures. Client factors reside within the client and influence the client’s performance in occupations.
Category Examples Relevant to Occupational Therapy Practice
Values, Beliefs, and Spirituality—Client’s (person’s, group’s, or population’s) perceptions, motivations, and related meaning that influence or are influenced by engagement in occupations.
Values—Acquired beliefs and commitments, derived from culture, about what is good, right, and important to do (Kielhofner, 2008)
Person • Honesty with self and others • Commitment to family
Group • Obligation to provide a service • Fairness • Inclusion
Population • Freedom of speech • Equal opportunities for all • Tolerance toward others
Beliefs—“Something that is accepted, considered to be true, or held as an opinion” (“Belief,” 2020).
Person • One is powerless to influence others. • Hard work pays off.
Group • Teaching others how to garden decreases their reliance on grocery stores.
•Writing letters as part of a neighborhood group can support the creation of a community park.
Population • Some personal rights are worth fighting for. • A new health care policy, as yet untried, will positively affect society.
Spirituality—“A deep experience of meaning brought about by engaging in occupations that involve the enacting of personal values and beliefs, reflection, and intention within a supportive contextual environment” (Billock, 2005, p. 887). It is important to recognize spirituality “as dynamic and often evolving” (Humbert, 2016, p. 12).
Person • Personal search for purpose and meaning in life • Guidance of actions by a sense of value beyond the acquisition of wealth or fame
Group • Study of religious texts together • Attendance at a religious service
Population • Common search for purpose and meaning in life • Guidance of actions by values agreed on by the collective
Body Functions—“The physiological functions of body systems (including psychological functions)” (WHO, 2001, p. 10). This section of the table is organized according to the classifications of the ICF; for fuller descriptions and definitions, refer to WHO (2001). This list is not all inclusive.
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Table 9. Client Factors (cont’d)
Category Examples Relevant to Occupational Therapy Practice
Body Functions (cont'd)
Mental functions
Specific mental functions
Higher level cognitive Judgment, concept formation, metacognition, executive func- tions, praxis, cognitive flexibility, insight
Attention Sustained shifting and divided attention, concentration, distractibility
Memory Short-term, long-term, and working memory Perception Discrimination of sensations (e.g., auditory, tactile, visual, ol-
factory, gustatory, vestibular, proprioceptive) Thought Control and content of thought, awareness of reality vs. delu-
sions, logical and coherent thought Mental functions of sequencing complex movement Mental functions that regulate the speed, response, quality, and
time of motor production, such as restlessness, toe tapping, or hand wringing, in response to inner tension
Emotional Regulation and range of emotions; appropriateness of emotions, including anger, love, tension, and anxiety; lability of emotions
Experience of self and time Awareness of one’s identity (including gender identity), body, and position in the reality of one’s environment and of time
Global mental functions
Consciousness State of awareness and alertness, including the clarity and continuity of the wakeful state
Orientation Orientation to person, place, time, self, and others Psychosocial General mental functions, as they develop over the life span,
required to understand and constructively integrate the mental functions that lead to the formation of the personal and inter- personal skills needed to establish reciprocal social interactions, in terms of both meaning and purpose
Temperament and personality Extroversion, introversion, agreeableness, conscientiousness, emotional stability, openness to experience, self-control, self- expression, confidence, motivation, impulse control, appetite
Energy Energy level, motivation, appetite, craving, impulse Sleep Physiological process, quality of sleep
Sensory functions
Visual functions Quality of vision, visual acuity, visual stability, and visual field functions to promote visual awareness of environment at var- ious distances for functioning
Hearing functions Sound detection and discrimination; awareness of location and distance of sounds
Vestibular functions Sensation related to position, balance, and secure movement against gravity
Taste functions Association of taste qualities of bitterness, sweetness, sourness, and saltiness
Smell functions Sensing of odors and smells
Proprioceptive functions Awareness of body position and space (Continued)
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Table 9. Client Factors (cont’d)
Category Examples Relevant to Occupational Therapy Practice
Body Functions (cont'd) Touch functions Feeling of being touched by others or touching various textures,
such as those of food; presence of numbness, paresthesia, hyperesthesia
Interoception Internal detection of changes in one’s internal organs through specific sensory receptors (e.g., awareness of hunger, thirst, digestion, state of alertness)
Pain Unpleasant feeling indicating potential or actual damage to some body structure; sensations of generalized or localized pain (e.g., diffuse, dull, sharp, phantom)
Sensitivity to temperature and pressure Thermal awareness (hot and cold), sense of force applied to skin (thermoreception)
Neuromusculoskeletal and movement-related functions
Functions of joints and bones
Joint mobility Joint range of motion Joint stability Maintenance of structural integrity of joints throughout the
body; physiological stability of joints related to structural integrity
Muscle functions
Muscle power Strength Muscle tone Degree of muscle tension (e.g., flaccidity, spasticity, fluctuation) Muscle endurance Sustainability of muscle contraction
Movement functions
Motor reflexes Involuntary contraction of muscles automatically induced by specific stimuli (e.g., stretch, asymmetrical tonic neck, sym- metrical tonic neck)
Involuntary movement reactions Postural reactions, body adjustment reactions, supporting reactions
Control of voluntary movement Eye–hand and eye–foot coordination, bilateral integration, crossing of the midline, fine and gross motor control, oculo- motor function (e.g., saccades, pursuits, accommodation, binocularity)
Gait patterns Gait and mobility in relation to engagement in daily life activities (e.g., walking patterns and impairments, asymmetric gait, stiff gait)
Cardiovascular, hematological, immune, and respiratory system functions (Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the interaction that occurs among these functions to support health, well-being, and participation in life through engagement in occupation.)
Cardiovascular system functions Maintenance of blood pressure functions (hypertension, hy- potension, postural hypotension), heart rate and rhythm
Hematological and immune system functions Protection against foreign substances, including infection, al- lergic reactions
Respiratory system functions Rate, rhythm, and depth of respiration Additional functions and sensations of the cardiovascular and respiratory systems
Physical endurance, aerobic capacity, stamina, fatigability
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Table 9. Client Factors (cont’d)
Category Examples Relevant to Occupational Therapy Practice Voice and speech functions; digestive, metabolic, and endocrine system functions; genitourinary and reproductive functions (Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the interaction that occurs among these functions to support health, well-being, and participation in life through engagement in occupation.)
Voice and speech functions Fluency and rhythm, alternative vocalization functions
Digestive, metabolic, and endocrine system functions Digestive system functions, metabolic system, and endocrine system functions
Genitourinary and reproductive functions Genitourinary and reproductive functions
Skin and related structure functions (Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the interaction that occurs among these functions to support health, well-being, and participation in life through engagement in occupation.)
Skin functions Hair and nail functions
Protection (presence or absence of wounds, cuts, or abrasions), repair (wound healing)
Body Structures—“Anatomical parts of the body, such as organs, limbs, and their components” that support body function (WHO, 2001, p. 10). This section of the table is organized according to the ICF classifications; for fuller descriptions and definitions, refer to WHO (2001).
Structure of the nervous system Structures related to the eyes and ears Structures involved in voice and speech Structures of the cardiovascular, immunological, and respiratory
systems Structures related to the digestive, metabolic, and endocrine
systems Structures related to the genitourinary and reproductive
systems Structures related to movement
Occupational therapy practitioners have knowledge of body structures and understand broadly the interaction that occurs between these structures to support health, well-being, and participation in life through engagement in occupation.
Note. The categorization of body functions and body structures is based on the ICF (WHO, 2001). The classification was selected because it has received wide exposure and presents a language that is understood by external audiences. ICF = International Classification of Function, Disability and Health;WHO = World Health Organization.
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Table 10. Occupational Therapy Process for Persons, Groups, and Populations The occupational therapy process applies to work with persons, groups, and populations. The process for groups and populations mirrors that for persons. The process for populations includes public health approaches, and the process for groups may include both person and population methods to address occupational performance (Scaffa & Reitz, 2014).
Process Component
Process Step
Person Group Population Evaluation Consultation and screening:
• Review client history • Consult with interprofessional team • Administer standardized screening tools
Consultation and screening, envi- ronmental scan: • Identify collective need on the basis of available data
• For each individual in the group, + Review history + Administer standardized
screening tools + Consult with interprofessional
team
Environmental scan, trend analysis, preplanning: • Collect data to inform design of intervention program by identify- ing information needs
• Identify health trends in targeted population and potential positive and negative impacts on occupa- tional performance
Occupational profile: • Interview client and caregiver
Occupational profile or community profile: • Interview persons who make up the group
• Engage with persons in the group to determine their interests, needs, and priorities
Needs assessment, community profile: • Engage with persons within the population to determine their in- terests and needs and opportuni- ties for collaboration
• Identify priorities through + Surveys + Interviews + Group discussions or forums
Analysis of occupational performance: • Assess occupational performance • Conduct occupational and activity analysis
• Assess contexts • Assess performance skills and patterns
• Assess client factors
Analysis of occupational performance: • Conduct occupational and activity analysis
• Assess group context • Assess the following for individual group members: + Occupational performance + Performance skills and patterns + Client factors
• Analyze impact of individual per- formance on the group
Needs assessment, review of sec- ondary data: • Evaluate existing quantitative data, which may include + Public health records + Prevalence of disease or
disability + Demographic data + Economic data
Synthesis of evaluation process: • Review and consolidate information to select occupational outcomes and determine impact of perfor- mance patterns and client factors on occupation
Synthesis of evaluation process: • Review and consolidate information to select collective occupational outcomes
• Review and consolidate information regarding each member’s perfor- mance and its impact on the group and the group’s occupational per- formance as a whole
Data analysis and interpretation: • Review and consolidate informa- tion to support need for the pro- gram and identify any missing data
Intervention Development of the intervention plan: • Identify client goals • Identify intervention outcomes • Select outcome measures
Development of the intervention plan or program: • Identify collective group goals
Program planning: • Identify short-term program objectives
• Identify long-term program goals
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Table 10. Occupational Therapy Process for Persons, Groups, and Populations (cont’d)
Process Component
Process Step
Person Group Population • Select methods for service delivery, including theoretical framework
• Identify intervention outcomes for the group
• Select outcome measures • Select methods for service delivery, including theoretical framework
• Select outcome measures to be used in program evaluation
• Select strategies for service deliv- ery, including theoretical framework
Intervention implementation: • Carry out occupational therapy in- tervention to address specific oc- cupations, contexts, and performance patterns and skills af- fecting performance
Intervention or program implementation: • Carry out occupational therapy in- tervention or program to address the group’s specific occupations, contexts, and performance patterns and skills affecting group performance
Program implementation: • Carry out program or advocacy action to address identified occu- pational needs
Intervention review: • Reevaluate and review client’s re- sponse to intervention
• Review progress toward goals and outcomes
• Modify plan as needed
Intervention review or program evaluation: • Reevaluate and review individual members’ and the group’s response to intervention
• Review progress toward goals and outcomes
• Modify plan as needed • Evaluate efficiency of program • Evaluate achievement of determined objectives
Program evaluation: • Gather information on program implementation
•Measure the impact of the program • Evaluate efficiency of program • Evaluate achievement of deter- mined objectives
Outcomes Outcomes: • Use measures to assess progress toward outcomes
• Identify change in occupational participation
Outcomes: • Use measures to assess progress toward outcomes
• Identify change in occupational performance of individual members and the group as a whole
Outcomes: • Use measures to assess progress toward long-term program goals
• Identify change in occupational performance of targeted population
Transition: • Facilitate client’s move from one life role or experience to another, such as + Moving to a new level of care + Transitioning between providers + Moving into a new setting or
program
Transition: • Facilitate group members’ move from one life role or experience to another, such as + Moving to a new level of care + Transitioning between providers + Moving into a new setting or
program
Sustainability plan: • Develop action plan to maintain program
• Identify sources of funding • Build community capacity and support relationships to continue program
Discontinuation: • Discontinue care after short- and long-term goals have been achieved or client chooses to no longer participate
• Implement discharge plan to sup- port performance after discontinu- ation of services
Discontinuation: • Discontinue care after the group’s short- and long-term goals have been achieved
• Implement discharge plan to sup- port performance after discontinu- ation of services
Dissemination plan: • Share results with participants, stakeholders, and community members
• Implement sustainability plan
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Table 11. Occupation and Activity Demands Occupation and activity demands are the components of occupations and activities that occupational therapy practitioners consider in their professional and clinical reasoning process. Activity demands are what is typically required to carry out the activity regardless of client and context. Occupation demands are what is required by the specific client (person, group, or population) to carry out an occupation. Depending on the context and needs of the client, occupation and activity demands can act as barriers to or supports for participation. Specific knowledge about activity demands assists practitioners in selecting occupations for therapeutic purposes.
Type of Demand Activity Demands: Typically Required
to Carry Out the Activity
Occupational Demands: Required by the Client (Person, Group,
or Population) to Carry Out the Occupation
Relevance and importance General meaning of the activity within the given culture
Meaning the client derives from the oc- cupation, which may be subjective and personally constructed; symbolic, un- conscious, and metaphorical; and aligned with the client’s goals, values, beliefs, and needs and perceived utility
Person: Knitting clothing items for personal use, for income from sale, or as a leisure activity
Person: Knitting as a way to practice mindfulness strategies for coping with anxiety
Group: Cooking to provide nutrition, fulfill a family role, or engage in a leisure activity
Group: Preparation of a holiday meal with family to connect members to each other and to their culture and traditions
Population: Presence of accessible restrooms in public spaces in compliance with federal law
Population: Creation of new accessible and all-gender restrooms to symbolize a community’s commitment to safety and inclusion of members with disabilities and LGBTQ+ members
Objects used and their properties: Tools (e.g., scissors, dishes, shoes, volleyball), supplies (e.g., paints, milk, lipstick), equipment (e.g., workbench, stove, bas- ketball hoop), and resources (e.g., money, transportation) required in the process of carrying out the activity or occupation and their inherent properties (e.g., heavy, rough, sharp, colorful, loud, bitter tasting)
Person: Computer workstation that includes a computer, keyboard, mouse, desk, and chair
Group: Financial and transportation resources for a group of friends to attend a concert
Population: Tools, supplies, and equipment for flood relief efforts to ensure safety of people with disabilities
Space demands: Physical environment requirements of the occupation or activity (e.g., size, arrangement, surface, lighting, temperature, noise, humidity, ventilation)
Person: Desk arrangement in an elementary school classroom
Group: Accessible meeting space to run a fall prevention workshop
Population: Noise, lighting, arrangement, and temperature controls for a sensory- friendly museum
Social demands: Elements of the social and attitudinal environments required for the occupation or activity
Person: Rules of engagement for a child at recess
Group: Expectations of travelers in an airport (e.g., waiting in line, following cues from staff and others, asking questions when needed)
Population: Understanding of the social and political climate of the geographic region
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Table 11. Occupation and Activity Demands (cont’d)
Type of Demand Activity Demands: Typically Required
to Carry Out the Activity
Occupational Demands: Required by the Client (Person, Group,
or Population) to Carry Out the Occupation
Sequencing and timing demands: Tem- poral process required to carry out the activity or occupation (e.g., specific steps, sequence of steps, timing requirements)
Person: Preferred sequence and timing of a client’s morning routine to affirm social, cultural, and gender identity
Group: Steps a class of students takes in preparation to start the school day
Population: Public train schedules
Required actions and performance skills: Actions and performance skills (motor, process, and social interaction) that are an inherent part of the activity or occupation
Person: Body movements required to drive a car
Group and population: See “Performance Skills” section for discussion related to groups and population
Required body functions: “Physiological functions of body systems (including psychological functions)” (WHO, 2001, p. 10) required to support the actions used to perform the activity or occupation
Person: Cognitive level required for a child to play a game
Group and population: See “Client Factors” section for discussion of required body functions related to groups and populations
Required body structures: “Anatomical parts of the body such as organs, limbs, and their components” that support body functions (WHO, 2001, p. 10) and are required to perform the activity or occupation
Person: Presence of upper limbs to play catch
Group and population: See “Client Factors” section for discussion of required body structures related to groups and populations
Note. WHO = World Health Organization.
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Table 12. Types of Occupational Therapy Interventions Occupational therapy intervention types include occupations and activities, interventions to support occupations, education and training, advocacy, group interventions, and virtual interventions. Occupational therapy interventions facilitate engagement in occupation to enable persons, groups, and populations to achieve health, well-being, and participation in life. The examples provided illustrate the types of interventions that clients engage in (denoted as “client”) and that occupational therapy practitioners provide (denoted as “practitioner”) and are not intended to be all-inclusive.
Intervention Type Description Examples
Occupations and Activities—Occupations and activities selected as interventions for specific clients are designed to meet therapeutic goals and address the underlying needs of the client’s mind, body, and spirit. To use occupations and activities therapeutically, the practitioner considers activity demands and client factors in relation to the client’s therapeutic goals and contexts.
Occupations Broad and specific daily life events that are personalized and meaningful to the client
Person Client completes morning dressing and hy- giene using adaptive devices.
Group Client plays a group game of tag on the playground to improve social participation.
Population Practitioner creates an app to improve access for people with autism spectrum disorder using metropolitan paratransit systems.
Activities Components of occupations that are objective and separate from the client’s engagement or contexts. Activities as interventions are selected and designed to support the development of perfor- mance skills and performance patterns to enhance occupational engagement.
Person Client selects clothing and manipulates clothing fasteners in advance of dressing.
Group Group members separate into two teams for a game of tag.
Population Client establishes parent volunteer commit- tees at their children’s school.
Interventions to Support Occupations—Methods and tasks that prepare the client for occupational performance are used as part of a treatment session in preparation for or concurrently with occupations and activities or provided to a client as a home-based engagement to support daily occupational performance.
PAMs and mechanical modalities Modalities, devices, and techniques to prepare the client for occupational performance. Such approaches should be part of a broader plan and not used exclusively.
Person Practitioner administers PAMs to decrease pain, assist with wound healing or edema control, or prepare muscles for movement to enhance occupational performance.
Group Practitioner develops a reference manual on postmastectomy manual lymphatic drainage techniques for implementation at an outpa- tient facility.
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Table 12. Types of Occupational Therapy Interventions (cont’d)
Intervention Type Description Examples Orthotics and prosthetics Construction of devices to mobilize,
immobilize, or support body structures to enhance participation in occupations
Person Practitioner fabricates and issues a wrist orthosis to facilitate movement and enhance participation in household activities.
Group Group members participate in a basketball game with veterans using prosthetics after amputation.
Assistive technology and environ- mental modifications
Assessment, selection, provision, and education and training in use of high- and low-tech assistive technology; ap- plication of universal design principles; and recommendations for changes to the environment or activity to support the client’s ability to engage in occupations
Person Practitioner recommends using a visual support (e.g., social story) to guide behavior.
Group Practitioner uses a smart board with speaker system during a social skills group session to improve participants’ attention.
Population Practitioner recommends that a large health care organization paint exits in their facilities to resemble bookshelves to deter patients with dementia from eloping.
Wheeled mobility Products and technologies that facilitate a client’s ability to maneuver through space, including seating and position- ing; improve mobility to enhance par- ticipation in desired daily occupations; and reduce risk for complications such as skin breakdown or limb contractures
Person Practitioner recommends, in conjunction with the wheelchair team, a sip-and-puff switch to allow the client to maneuver the power wheelchair independently and interface with an environmental control unit in the home.
Group Group of wheelchair users in the same town host an educational peer support event.
Self-regulation Actions the client performs to target specific client factors or performance skills. Intervention approaches may address sensory processing to promote emotional stability in preparation for social participation or work or leisure activities or executive functioning to support engagement in occupation and meaningful activities. Such approaches involve active participation of the client and sometimes use of materials to simulate components of occupations.
Person Client participates in a fabricated sensory environment (e.g., through movement, tactile sensations, scents) to promote alertness before engaging in a school-based activity.
Group Practitioner instructs a classroom teacher to implement mindfulness techniques, visual imagery, and rhythmic breathing after recess to enhance students’ success in classroom activities.
Population Practitioner consults with businesses and community sites to establish sensory-friendly environments for people with sensory pro- cessing deficits.
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Table 12. Types of Occupational Therapy Interventions (cont’d)
Intervention Type Description Examples
Education and Training
Education Imparting of knowledge and information about occupation, health, well-being, and participation to enable the client to acquire helpful behaviors, habits, and routines
Person Practitioner provides education regarding home and activity modifications to the spouse or family member of a person with dementia to support maximum independence.
Group Practitioner participates in a team care planning meeting to educate the family and team members on a patient’s condition and level of function and establish a plan of care.
Population Practitioner educates town officials about the value of and strategies for constructing walking and biking paths accessible to people who use mobility devices.
Training Facilitation of the acquisition of concrete skills for meeting specific goals in a real- life, applied situation. In this case, skills refers to measurable components of function that enable mastery. Training is differentiated from education by its goal of enhanced performance as opposed to enhanced understanding, although these goals often go hand in hand (Collins & O’Brien, 2003).
Person Practitioner instructs the client in the use of coping skills such as deep breathing to ad- dress anxiety symptoms before engaging in social interaction.
Group Practitioner provides an in-service on ap- plying new reimbursement and practice standards adopted by a facility.
Population Practitioner develops a training program to support practice guidelines addressing oc- cupational deprivation and cultural compe- tence for practitioners working with refugees.
Advocacy—Efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to support health, well-being, and occupational participation.
Advocacy Advocacy efforts undertaken by the practitioner
Person Practitioner collaborates with a client to procure reasonable accommodations at a work site.
Group Practitioner collaborates with and educates teachers in an elementary school about in- clusive classroom design.
Population Practitioner serves on the policy board of an organization to procure supportive housing accommodations for people with disabilities.
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Table 12. Types of Occupational Therapy Interventions (cont’d)
Intervention Type Description Examples Self-advocacy Advocacy efforts undertaken by the
client with support by the practitioner Person Client requests reasonable accommodations, such as audio textbooks, to support their learning disability.
Group Client participates in an employee meeting to request and procure adjustable chairs to improve comfort at computer workstations.
Population Client participates on a student committee partnering with school administration to develop cyberbullying prevention programs in their district.
Group Interventions—Use of distinct knowledge of the dynamics of group and social interaction and leadership techniques to facilitate learning and skill acquisition across the lifespan. Groups are used as a method of service delivery.
Functional groups, activity groups, task groups, social groups, and other groups
Groups used in health care settings, within the community, or within orga- nizations that allow clients to explore and develop skills for participation, in- cluding basic social interaction skills and tools for self-regulation, goal set- ting, and positive choice making
Person Client participates in a group for adults with traumatic brain injury focused on individual goals for reentering the community after inpatient treatment.
Group Group of older adults participates in volunteer days to maintain participation in the com- munity through shared goals.
Population Practitioner works with middle school teachers in a district on approaches to ad- dress issues of self-efficacy and self-esteem as the basis for creating resiliency in children at risk for being bullied.
Virtual Interventions—Use of simulated, real-time, and near-time technologies for service delivery absent of physical contact, such as telehealth or mHealth.
Telehealth (telecommunication and information technology) and mHealth (mobile telephone application technology)
Use of technology such as video con- ferencing, teleconferencing, or mobile telephone application technology to plan, implement, and evaluate occupa- tional therapy intervention, education, and consultation
Person Practitioner performs a telehealth therapy session with a client living in a rural area.
Group Client participates in an initial online support group session to establish group protocols, procedures, and roles.
Population Practitioner develops methods and standards for mHealth in community occupational therapy practice.
Note. mHealth = mobile health; PAMs = physical agent modalities.
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Table 13. Approaches to Intervention Approaches to intervention are specific strategies selected to direct the evaluation and intervention processes on the basis of the client’s desired outcomes, evaluation data, and research evidence. Approaches inform the selection of practice models, frames of references, and treatment theories.
Approach Description Examples Create, promote (health promotion) An intervention approach that does not
assume a disability is present or that any aspect would interfere with performance. This approach is designed to provide enriched contextual and activity experi- ences that will enhance performance for all people in the natural contexts of life (adapted from Dunn et al., 1998, p. 534).
Person Develop a fatigue management program for a client recently diagnosed with multiple sclerosis
Group Create a resource list of developmentally appropriate toys to be distributed by staff at a day care program
Population Develop a falls prevention curriculum for older adults for trainings at senior centers and day centers
Establish, restore (remediation, restoration)
Approach designed to change client vari- ables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired (adapted from Dunn et al., 1998, p. 533)
Person Restore a client’s upper extremity movement to enable transfer of dishes from the dishwasher into the upper kitchen cabinets
Collaborate with a client to help establish morning routines needed to arrive at school or work on time
Group Educate staff of a group home for clients with serious mental illness to develop a structured schedule, chunking tasks to decrease residents’ risk of being over- whelmed by the many responsibilities of daily life roles
Population Restore access ramps to a church en- trance after a hurricane
Maintain Approach designed to provide supports that will allow clients to preserve the performance capabilities that they have regained and that continue to meet their occupational needs. The assumption is that without continued maintenance in- tervention, performance would decrease and occupational needs would not be met, thereby affecting health, well-being, and quality of life.
Person Provide ongoing intervention for a client with amyotrophic lateral sclerosis to ad- dress participation in desired occupations through provision of assistive technology
Group Maintain environmental modifications at a group home for young adults with physical disabilities for continued safety and engagement with housemates
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Table 13. Approaches to Intervention (cont’d)
Approach Description Examples Population Maintain safe and independent access for people with low vision by increasing hallway lighting in a community center
Modify (compensation, adaptation) Approach directed at “finding ways to revise the current context or activity de- mands to support performance in the natural setting, [including] compensatory techniques . . . [such as] enhancing some features to provide cues or reducing other features to reduce distractibility” (Dunn et al., 1998, p. 533)
Person Simplify task sequence to help a person with cognitive impairments complete a morning self-care routine
Group Modify a college campus housing build- ing to accommodate a group of students with mobility impairments
Population Consult with architects and builders to design homes that will support aging in place and use universal design principles
Prevent (disability prevention) Approach designed to address the needs of clients with or without a disability who are at risk for occupational performance problems. This approach is designed to prevent the occurrence or evolution of barriers to performance in context. Inter- ventions may be directed at client, context, or activity variables (adapted from Dunn et al., 1998, p. 534).
Person Aid in the prevention of illicit substance use by introducing self-initiated routine strategies that support drug-free behavior
Group Prevent social isolation of employees by promoting participation in after-work group activities
Population Consult with a hotel chain to provide an ergonomics educational program designed to prevent back injuries in housekeeping staff
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Table 14. Outcomes Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through occupational therapy intervention. Some outcomes are measurable and are used for intervention planning and review and discharge planning. These outcomes reflect the attainment of treatment goals that relate to engagement in occupation. Other outcomes are experienced by clients when they have realized the effects of engagement in occupation and are able to return to desired habits, routines, roles, and rituals.
Adaptation is embedded in all categories of outcomes. The examples listed specify how the broad outcome of health and participation in life may be operationalized.
Outcome Category Description Examples Occupational performance Act of doing and accomplishing a selected
action (performance skill), activity, or oc- cupation (Fisher, 2009; Fisher & Griswold, 2019; Kielhofner, 2008) that results from the dynamic transaction among the client, the context, and the activity. Improving or enhancing skills and patterns in occupa- tional performance leads to engagement in occupations or activities (adapted in part from Law et al., 1996, p. 16).
Person A patient with hip precautions showers safely with modified independence using a tub transfer bench and a long-handled sponge.
Group A group of older adults cooks a holiday meal during their stay in a skilled nursing facility with minimal assistance from staff.
Population A community welcomes children with spina bifida in public settings after a news story featuring occupational therapy practitioners.
Improvement Increased occupational performance through adaptation when a performance limitation is present
Person A child with autism plays interactively with a peer. An older adult returns home from a skilled nursing facility as desired.
Group Back strain in nursing personnel decreases as a result of an in-service education program on body mechanics for job duties that require bending and lifting.
Population Accessible playground facilities for all children are constructed in city parks.
Enhancement Development of performance skills and performance patterns that augment exist- ing performance of life occupations when a performance limitation is not present
Person A teenagemother experiences increased confidence and competence in parenting as a result of struc- tured social groups and child development classes.
Group Membership in the local senior citizen center increases as a result of expanded social wellness and exercise programs. School staff have increased ability to address and manage school-age youth violence as a result of conflict resolution training to address bullying.
Population Older adults have increased opportunities to participate in community activities through ride- share programs.
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Table 14. Outcomes (cont’d)
Outcome Category Description Examples Prevention Education or health promotion efforts
designed to identify, reduce, or stop the onset and reduce the incidence of un- healthy conditions, risk factors, diseases, or injuries. Occupational therapy promotes a healthy lifestyle at the individual, group, population (societal), and government or policy level (adapted from AOTA, 2020b).
Person A child with orthopedic impairments is provided with appropriate seating and a play area.
Group A program of leisure and educational activities is implemented at a drop-in center for adults with serious mental illness.
Population Access to occupational therapy services is pro- vided in underserved areas where residents typically receive other services.
Health and wellness Health: State of physical, mental, and social well-being, as well as a positive concept emphasizing social and personal resources and physical capacities (WHO, 1986). Health for groups and populations also includes social responsibility of members to the group or population as a whole.
Wellness: “Active process through which individuals [or groups or populations] become aware of and make choices toward a more successful existence” (Hettler, 1984, p. 1117). Wellness is more than a lack of disease symptoms; it is a state of mental and physical balance and fitness (adapted from “Wellness,” 1997, p. 2110)
Person A person with a mental health challenge partici- pates in an empowerment and advocacy group to improve services in the community. A person with attention deficit hyperactivity dis- order demonstrates self-management through the ability to manage the various aspects of their life.
Group A company-wide program for employees is implemented to identify problems and solutions regarding the balance among work, leisure, and family life.
Population The incidence of childhood obesity decreases.
Quality of life Dynamic appraisal of the client’s life sat- isfaction (perceptions of progress toward goals), hope (real or perceived belief that one can move toward a goal through se- lected pathways), self-concept (composite of beliefs and feelings about oneself), health and functioning (e.g., health status, self-care capabilities), and socioeconomic factors (e.g., vocation, education, income; adapted from Radomski, 1995)
Person A deaf child from a hearing family participates fully and actively during a recreational activity.
Group A facility experiences increased participation of residents during outings and independent travel as a result of independent living skills training for care providers.
Population A lobby is formed to support opportunities for social networking, advocacy activities, and sharing of scientific information for stroke sur- vivors and their families.
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Table 14. Outcomes (cont’d)
Outcome Category Description Examples Participation Engagement in desired occupations in
ways that are personally satisfying and congruent with expectations within the culture
Person A person recovers the ability to perform the es- sential duties of his or her job after a flexor tendon laceration.
Group A family enjoys a vacation spent traveling cross- country in their adapted van.
Population All children within a state have access to school sports programs.
Role competence Ability to effectively meet the demands of the roles in which one engages
Person A person with cerebral palsy is able to take notes and type papers to meet the demands of the student role.
Group A factory implements job rotation to allow sharing of higher demand tasks so employees can meet the demands of the worker role.
Population Accessibility of polling places is improved, enabling all people with disabilities in the community to meet the demands of the citizen role.
Well-being Contentment with one’s health, self-es- teem, sense of belonging, security, and opportunities for self-determination, meaning, roles, and helping others (Hammell, 2009). Well-being is “a general term encompassing the total universe of human life domains, including physical, mental, and social aspects, that make up what can be called a ‘good life’” (WHO, 2006, p. 211).
Person A person with amyotrophic lateral sclerosis achieves contentment with their ability to find meaning in fulfilling the role of parent through compensatory strategies and environmental modifications.
Group Members of an outpatient depression and anxiety support group feel secure in their sense of group belonging and ability to help other members.
Population Residents of a town celebrate the groundbreaking for a school being reconstructed after a natural disaster.
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Table 14. Outcomes (cont’d)
Outcome Category Description Examples Occupational justice Access to and participation in the full range
of meaningful and enriching occupations afforded to others, including opportunities for social inclusion and resources to par- ticipate in occupations to satisfy personal, health, and societal needs (adapted from Townsend & Wilcock, 2004)
Person An individual with intellectual and developmental disabilities serves on an advisory board to es- tablish programs to be offered by a community recreation center.
Group Workers have enough break time to eat lunch with their young children in the day care center.
Group and Population People with persistent mental illness experience an increased sense of empowerment and self- advocacy skills, enabling them to develop an antistigma campaign promoting engagement in the civic arena (group) and alternative adapted housing options for older adults to age in place (population).
Note. AOTA = American Occupational Therapy Association; WHO = World Health Organization.
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Authors
Cheryl Boop, MS, OTR/L
Susan M. Cahill, PhD, OTR/L, FAOTA
Charlotte Davis, MS, OTR/L
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA
Varleisha Gibbs, PhD, OTD, OTR/L
Brian Herr, MOT, OTR/L
Kimberly Kearney, COTA/L
Elizabeth “Liz” Griffin Lannigan, PhD, OTR/L, FAOTA
Lizabeth Metzger, MS, OTR/L
Julie Miller, MOT, OTR/L, SWC
Amy Owens, OTR
Krysta Rives, MBA, COTA/L, CKTP
Caitlin Synovec, OTD, OTR/L, BCMH
Wayne L. Winistorfer, MPA, OTR, FAOTA
Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison
for
The Commission on Practice
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson
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Acknowledgments
In addition to those named below, the COP thanks everyone who has contributed to the dialogue, feedback, and
concepts presented in the document. Sincerest appreciation is extended to AOTA Staff members Chris Davis,
Jennifer Folden, Caroline Polk, and Debbie Shelton for all their support. Further appreciation and thanks are
extended to AnneG. Fisher, ScD, OT, FAOTA; Lou AnnGriswold, PhD, OTR/L, FAOTA; and AbbeyMarterella, PhD,
OTR/L.
The COP wishes to acknowledge the authors of the third edition of this document: Deborah Ann Amini, EdD, OTR/L,
CHT, FAOTA, Chairperson, 2011–2014; Kathy Kannenberg, MA, OTR/L, CCM, Chairperson-Elect, 2013–2014;
Stefanie Bodison, OTD, OTR/L; Pei-Fen Chang, PhD, OTR/L; Donna Colaianni, PhD, OTR/L, CHT; Beth Goodrich,
OTR, ATP, PhD; Lisa Mahaffey, MS, OTR/L, FAOTA; Mashelle Painter, MEd, COTA/L; Michael Urban, MS, OTR/L,
CEAS, MBA, CWCE; Dottie Handley-More, MS, OTR/L, SIS Liaison; Kiel Cooluris, MOT, OTR/L, ASD Liaison;
Andrea McElroy, MS, OTR/L, Immediate-Past ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA
Headquarters Liaison.
The COPwishes to acknowledge the authors of the second edition of this document: Susanne Smith Roley, MS, OTR/L,
FAOTA, Chairperson, 2005–2008; Janet V. DeLany, DEd, OTR/L, FAOTA; Cynthia J. Barrows, MS, OTR/L; Susan
Brownrigg, OTR/L; DeLana Honaker, PhD, OTR/L, BCP; Deanna Iris Sava, MS, OTR/L; Vibeke Talley, OTR/L; Kristi
Voelkerding, BS, COTA/L, ATP; Deborah Ann Amini, MEd, OTR/L, CHT, FAOTA, SIS Liaison; Emily Smith, MOT, ASD
Liaison; Pamela Toto, MS, OTR/L, BCG, FAOTA, Immediate-Past SIS Liaison; Sarah King, MOT, OTR, Immediate-Past
ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison; with contributions from
M. Carolyn Baum, PhD, OTR/L, FAOTA; Ellen S. Cohn, ScD, OTR/L, FAOTA; Penelope A. Moyers Cleveland, EdD,
OTR/L, BCMH, FAOTA; and Mary Jane Youngstrom, MS, OTR, FAOTA.
TheCOPalsowishes to acknowledge the authors of the first edition of this document: Mary Jane Youngstrom,MS,OTR,
FAOTA, Chairperson (1998–2002); Sara Jane Brayman, PhD, OTR, FAOTA, Chairperson-Elect (2001–2002); Paige
Anthony, COTA; Mary Brinson, MS, OTR/L, FAOTA; Susan Brownrigg, OTR/L; Gloria Frolek Clark, MS, OTR/L,
FAOTA; Susanne Smith Roley, MS, OTR; James Sellers, OTR/L; Nancy L. Van Slyke, EdD, OTR; Stacy M. Desmarais,
MS,OTR/L, ASD Liaison; Jane Oldham, MOTS, Immediate-Past ASCOTA Liaison; Mary Vining Radomski, MA, OTR,
FAOTA, SIS Liaison; Sarah D. Hertfelder, MEd, MOT, OTR, FAOTA, National Office Liaison.
Revised by the Commission on Practice, 2020
Adopted by the Representative Assembly May, 2020
Note. This document replaces the 2014 Occupational Therapy Practice Framework: Domain and Process (3rd ed.). Published in the American
Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://dx.doi.org/10.5014/ajot.2020.74S2001
Copyright © 2020 by the American Occupational Therapy Association.
Citation:AmericanOccupational TherapyAssociation. (2020). Occupational therapy practice framework: Domain and process (4th ed.).American
Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
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Appendix A. Glossary
A
Activities Actions designed and selected to support the development of performance skills and performance patterns to enhance
occupational engagement.
Activities of daily living (ADLs) Activities that are oriented toward taking care of one’s own body (adapted from Rogers & Holm, 1994) and are
completed on a daily basis. These activities are “fundamental to living in a social world; they enable basic survival and
well-being” (Christiansen & Hammecker, 2001, p. 156; see Table 2).
Activity analysis Generic and decontextualized analysis that seeks to develop an understanding of typical activity demands within a
given culture.
Activity demands Aspects of an activity needed to carry it out, including relevance and importance to the client, objects used and their
properties, space demands, social demands, sequencing and timing, required actions and performance skills, and
required underlying body functions and body structures (see Table 11).
Adaptation Effective and efficient response by the client to occupational and contextual demands (Grajo, 2019).
Advocacy Efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to fully
participate in their daily life occupations. Efforts undertaken by the practitioner are considered advocacy, and those
undertaken by the client are considered self-advocacy and can be promoted and supported by the practitioner (see
Table 12).
Analysis of occupational performance The step in the evaluation process in which the client’s assets and limitations or potential problems are more specifically
determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder
occupational performance (see Exhibit 2).
Assessment “A specific tool, instrument, or systematic interaction . . . used to understand a client’s occupational profile, client factors,
performance skills, performance patterns, and contextual and environmental factors, as well as activity demands that
influence occupational performance” (Hinojosa et al., 2014, pp. 3–4).
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B
Belief Something that is accepted, considered to be true, or held as an opinion (“Belief,” 2020).
Body functions “Physiological functions of body systems (including psychological functions)” (World Health Organization, 2001, p. 10;
see Table 9).
Body structures “Anatomical parts of the body, such as organs, limbs, and their components” that support body functions (World Health
Organization, 2001, p. 10; see Table 9).
C
Client Person (including one involved in the care of a client), group (collection of individuals having shared characteristics or
common or shared purpose, e.g., family members, workers, students, and those with similar interests or occupational
challenges), or population (aggregate of people with common attributes such as contexts, characteristics, or concerns,
including health risks; Scaffa & Reitz, 2014).
Client-centered care (client-centered practice) Approach to service that incorporates respect for and partnership with clients as active participants in the therapy
process. This approach emphasizes clients’ knowledge and experience, strengths, capacity for choice, and overall
autonomy (Schell & Gillen, 2019, p. 1194).
Client factors Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occu-
pations. Client factors include values, beliefs, and spirituality; body functions; and body structures (see Table 9).
Clinical reasoning See Professional reasoning
Collaboration “The complex interpretative acts in which the practitioners must understand the meanings of the interventions, the
meanings of illness or disability in a person and family’s life, and the feelings that accompany these experiences”
(Lawlor & Mattingly, 2019, p. 201).
Community Collection of populations that is changeable and diverse and includes various people, groups, networks, and orga-
nizations (Scaffa, 2019; World Federation of Occupational Therapists, 2019).
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Context Construct that constitutes the complete makeup of a person’s life as well as the common and divergent factors
that characterize groups and populations. Context includes environmental factors and personal factors (see Tables 4
and 5).
Co-occupation Occupation that implicitly involves two or more individuals (Schell & Gillen, 2019, p. 1195) and includes aspects of
physicality, emotionality, and intentionality (Pickens & Pizur-Barnekow, 2009).
Cornerstone Something of significance on which everything else depends.
D
Domain Profession’s purview and areas in which its members have an established body of knowledge and expertise.
E
Education As an occupation: Activities involved in learning and participating in the educational environment (see Table 2).
As an environmental factor of context: Processes and methods for acquisition of knowledge, expertise, or skills (see
Table 4).
As an intervention: Activities that impart knowledge and information about occupation, health, well-being, and par-
ticipation, resulting in acquisition by the client of helpful behaviors, habits, and routines that may or may not require
application at the time of the intervention session (see Table 12).
Empathy Emotional exchange between occupational therapy practitioners and clients that allows more open communication,
ensuring that practitioners connect with clients at an emotional level to assist them with their current life situation.
Engagement in occupation Performance of occupations as the result of choice, motivation, and meaning within a supportive context.
Environmental factors Aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives.
Evaluation “The comprehensive process of obtaining and interpreting the data necessary to understand the person, system, or
situation. . . . Evaluation requires synthesis of all data obtained, analytic interpretation of that data, reflective
clinical reasoning, and consideration of occupational performance and contextual factors” (Hinojosa et al., 2014,
p. 3).
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G
Goal Measurable and meaningful, occupation-based, long-term or short-term aim directly related to the client’s ability and
need to engage in desired occupations (AOTA, 2018a, p. 4).
Group Collection of individuals having shared characteristics or a common or shared purpose (e.g., family members, workers,
students, others with similar occupational interests or occupational challenges).
Group intervention Use of distinct knowledge and leadership techniques to facilitate learning and skill acquisition across the lifespan
through the dynamics of group and social interaction. Groups may be used as a method of service delivery (see
Table 12).
H
Habilitation Health care services that help a person keep, learn, or improve skills and functioning for daily living (e.g., therapy for a
child who does not walk or talk at the expected age). These services may include physical and occupational therapy,
speech-language pathology, and other services for people with disabilities in a variety of inpatient and outpatient
settings (“Provision of EHB,” 2015).
Habits “Specific, automatic behaviors performed repeatedly, relatively automatically, and with little variation” (Matuska &
Barrett, 2019, p. 214). Habits can be healthy or unhealthy, efficient or inefficient, and supportive or harmful (Dunn, 2000).
Health “State of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (World
Health Organization, 2006, p. 1).
Health management Occupation focused on developing, managing, and maintaining routines for health and wellness by engaging in self-
care with the goal of improving or maintaining health, including self-management, to allow for participation in other
occupations (see Table 2).
Health promotion “Process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical,
mental, and social well-being, an individual or group must be able to identify and realize aspirations, to satisfy needs,
and to change or cope with the environment” (World Health Organization, 1986).
Hope Real or perceived belief that one can move toward a goal through selected pathways.
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I
Independence “Self-directed state of being characterized by an individual’s ability to participate in necessary and preferred occupations
in a satisfying manner irrespective of the amount or kind of external assistance desired or required” (AOTA, 2002a, p.
660).
Instrumental activities of daily living (IADLs) Activities that support daily life within the home and community and that often require more complex interactions than
those used in ADLs (see Table 2).
Interdependence “Reliance that people have on one another as a natural consequence of group living” (Christiansen & Townsend, 2010,
p. 419). “Interdependence engenders a spirit of social inclusion, mutual aid, and a moral commitment and responsibility
to recognize and support difference” (Christiansen & Townsend, 2010, p. 187).
Interests “What one finds enjoyable or satisfying to do” (Kielhofner, 2008, p. 42).
Intervention “Process and skilled actions taken by occupational therapy practitioners in collaboration with the client to facilitate
engagement in occupation related to health and participation. The intervention process includes the plan, imple-
mentation, and review” (AOTA, 2015c, p. 2).
Intervention approaches Specific strategies selected to direct the process of interventions on the basis of the client’s desired outcomes,
evaluation data, and evidence (see Table 13).
Interventions to support occupations Methods and tasks that prepare the client for occupational performance, used as part of a treatment session in
preparation for or concurrently with occupations and activities or provided to a client as a home-based engagement to
support daily occupational performance (see Table 12).
L
Leisure “Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time
not committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, p. 250; see
Table 2).
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M
Motor skills The “group of performance skills that represent small, observable actions related to moving oneself or moving and
interacting with tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life) in the
context of performing a personally and ecologically relevant daily life task. They are commonly named in terms of type of
task being performed (e.g., [activity of daily living] motor skills, school motor skills, work motor skills)” (Fisher &
Marterella, 2019, p. 331; see Table 7).
O
Occupation Everyday personalized activities that people do as individuals, in families, and with communities to occupy time and
bring meaning and purpose to life. Occupations can involve the execution of multiple activities for completion and can
result in various outcomes. The broad range of occupations is categorized as activities of daily living, instrumental
activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation (see
Table 2).
Occupation-based Characteristic of the best practice method used in occupational therapy, in which the practitioner uses an evaluation
process and types of interventions that actively engage the client in occupation (Fisher & Marterella, 2019).
Occupational analysis Analysis that is performed with an understanding of “the specific situation of the client and therefore [of] the specific
occupations the client wants or needs to do in the actual context in which these occupations are performed” (Schell
et al., 2019, p. 322).
Occupational demands Aspects of an activity needed to carry it out, including relevance and importance to the client, objects used and their
properties, space demands, social demands, sequencing and timing, required actions and performance skills, and
required underlying body functions and body structures (see Table 10).
Occupational identity “Composite sense of who one is and wishes to become as an occupational being generated from one’s history of
occupational participation” (Schell & Gillen, 2019, p. 1205).
Occupational justice “A justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society,
regardless of age, ability, gender, social class, or other differences” (Nilsson & Townsend, 2010, p. 58). Occupational
justice includes access to and participation in the full range of meaningful and enriching occupations afforded to others,
including opportunities for social inclusion and the resources to participate in occupations to satisfy personal, health,
and societal needs (adapted from Townsend & Wilcock, 2004).
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Occupational performance Accomplishment of the selected occupation resulting from the dynamic transaction among the client, their context, and
the occupation.
Occupational profile Summary of the client’s occupational history and experiences, patterns of daily living, interests, values, needs, and
relevant contexts (see Exhibit 2).
Occupational science “Way of thinking that enables an understanding of occupation, the occupational nature of humans, the relationship
between occupation, health and wellbeing, and the influences that shape occupation” (World Federation of
Occupational Therapists, 2012b, p. 2).
Occupational therapy Therapeutic use of everyday life occupations with persons, groups, or populations (i.e., clients) for the purpose of
enhancing or enabling participation. Occupational therapy practitioners use their knowledge of the transactional re-
lationship among the person, their engagement in valued occupations, and the context to design occupation-based
intervention plans. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health
and wellness for clients with disability- and non-disability-related needs. Services promote acquisition and preservation
of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition,
impairment, disability, activity limitation, or participation restriction (adapted from American Occupational Therapy
Association, 2011).
Organization Entity composed of individuals with a common purpose or enterprise, such as a business, industry, or agency.
Outcome Result clients can achieve through the occupational therapy process (see Table 14).
P
Participation “Involvement in a life situation” (World Health Organization, 2001, p. 10).
Performance patterns Habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process of engaging in
occupations or activities. These patterns are influenced by context and time and can support or hinder occupational
performance (see Table 6).
Performance skills Observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are supported
by the context in which the performance occurred and by underlying client factors (Fisher & Marterella, 2019).
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Person Individual, including family member, caregiver, teacher, employee, or relevant other.
Personal factors Unique features of the person reflecting the particular background of their life and living that are not part of a health
condition or health state. Personal factors are generally considered to be enduring, stable attributes of the person,
although some personal factors may change over time (see Table 5).
Play Active engagement in an activity that is intrinsically motivated, internally controlled, and freely chosen and that may
include the suspension of reality (Skard & Bundy, 2008). Play includes participation in a broad range of experiences
including but not limited to exploration, humor, fantasy, risk, contest, and celebrations (Eberle, 2014; Sutton-Smith,
2009). Play is a complex and multidimensional phenomenon that is shaped by sociocultural factors (Lynch et al., 2016;
see Table 2).
Population Aggregate of people with common attributes such as contexts, characteristics, or concerns, including health risks.
Prevention Education or health promotion efforts designed to identify, reduce, or prevent the onset and decrease the incidence of
unhealthy conditions, risk factors, diseases, or injuries (American Occupational Therapy Association, 2020a).
Process Series of steps occupational therapy practitioners use to operationalize their expertise in providing services to clients.
The occupational therapy process includes evaluation, intervention, and outcomes; occurs within the purview of the
occupational therapy domain; and involves collaboration among the occupational therapist, occupational therapy
assistant, and client.
Process skills The “group of performance skills that represent small, observable actions related to selecting, interacting with, and using
tangible task objects (e.g., tools, utensils, clothing, food or other supplies, digital devices, plant life); carrying out
individual actions and steps; and preventing problems of occupational performance from occurring or reoccurring in the
context of performing a personally and ecologically relevant daily life task. They are commonly named in terms of type of
task being performed (e.g., [activity of daily living] process skills, school process skills, work process skills)” (Fisher &
Marterella, 2019, pp. 336–337; see Table 7).
Professional reasoning “Process that practitioners use to plan, direct, perform, and reflect on client care” (Schell, 2019, p. 482).
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Q
Quality of life Dynamic appraisal of life satisfaction (perception of progress toward identifying goals), self-concept (beliefs and feelings
about oneself), health and functioning (e.g., health status, self-care capabilities), and socioeconomic factors (e.g.,
vocation, education, income; adapted from Radomski, 1995).
R
Reevaluation Reappraisal of the client’s performance and goals to determine the type and amount of change that has taken
place.
Rehabilitation Services provided to persons experiencing deficits in key areas of physical and other types of function or limitations in
participation in daily life activities. Interventions are designed to enable the achievement and maintenance of optimal
physical, sensory, intellectual, psychological, and social functional levels. Rehabilitation services provide tools and
techniques clients need to attain desired levels of independence and self-determination.
Rituals For persons: Sets of symbolic actions with spiritual, cultural, or social meaning contributing to the client’s identity and
reinforcing values and beliefs. Rituals have a strong affective component (Fiese, 2007; Fiese et al., 2002; Segal, 2004;
see Table 6).
For groups and populations: Shared social actions with traditional, emotional, purposive, and technological meaning
contributing to values and beliefs within the group or population (see Table 6).
Roles For persons: Sets of behaviors expected by society and shaped by culture and context that may be further con-
ceptualized and defined by the client (see Table 6).
For groups and populations: Sets of behaviors by the group or population expected by society and shaped
by culture and context that may be further conceptualized and defined by the group or population
(see Table 6).
Routines For persons, groups, and populations: Patterns of behavior that are observable, regular, and repetitive and
that provide structure for daily life. They can be satisfying and promoting or damaging. Routines require
momentary time commitment and are embedded in cultural and ecological contexts (Fiese et al., 2002; Segal, 2004;
see Table 6).
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S
Screening “Process of reviewing available data, observing a client, or administering screening instruments to identify a person’s (or
a population’s) potential strengths and limitations and the need for further assessment” (Hinojosa et al., 2014, p. 3).
Self-advocacy Advocacy for oneself, including making one’s own decisions about life, learning how to obtain information to gain an
understanding about issues of personal interest or importance, developing a network of support, knowing one’s rights
and responsibilities, reaching out to others when in need of assistance, and learning about self-determination.
Service delivery Set of approaches and methods for providing services to or on behalf of clients.
Skilled services To be covered as skilled therapy, services must require the skills of a qualified occupational therapy practitioner and
must be reasonable and necessary for the treatment of the patient’s condition, illness, or injury. Skilled therapy services
may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or
slow further deterioration of the patient’s condition. Practitioners should check their payer policies to ensure they meet
payer definitions and comply with payer requirements.
Social interaction skills The “group of performance skills that represent small, observable actions related to communicating and interacting with
others in the context of engaging in a personally and ecologically relevant daily life task performance that involves social
interaction with others” (Fisher & Marterella, 2019, p. 342).
Social participation “Interweaving of occupations to support desired engagement in community and family activities as well as those
involving peers and friends” (Schell & Gillen, 2019, p. 711) involvement in a subset of activities that incorporate social
situations with others (Bedell, 2012) and that support social interdependence (Magasi & Hammel, 2004; see Table 2).
Spirituality “Deep experience of meaning brought about by engaging in occupations that involve the enacting of personal values
and beliefs, reflection, and intention within a supportive contextual environment” (Billock, 2005, p. 887). It is important to
recognize spirituality “as dynamic and often evolving” (Humbert, 2016, p. 12).
T
Time management Manner in which a person, group, or population organizes, schedules, and prioritizes certain activities.
Transaction Process that involves two or more individuals or elements that reciprocally and continually influence and affect one
another through the ongoing relationship (Dickie et al., 2006).
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V
Values Acquired beliefs and commitments, derived from culture, about what is good, right, and important to do (Kielhofner,
2008).
W
Well-being “General term encompassing the total universe of human life domains, including physical, mental, and social aspects,
that make up what can be called a ‘good life’” (World Health Organization, 2006, p. 211).
Wellness “The individual’s perception of and responsibility for psychological and physical well-being as these contribute to overall
satisfaction with one’s life situation” (Schell & Gillen, 2019, p. 1215).
Work Labor or exertion related to the development, production, delivery, or management of objects or services; benefits may
be financial or nonfinancial (e.g., social connectedness, contributions to society, adding structure and routine to daily
life; Christiansen & Townsend, 2010; Dorsey et al., 2019).
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Index
Note: Page numbers in italic refer to exhibits, figures, and tables.
activities
defined, 74
interventions for, 59
activities of daily living (ADLs)
overview, 30, 74
examples, 35
activity analysis, 19–20, 74
activity demands, 57–58, 74
adaptation, 74
advocacy, 61–62, 74
American Occupational Therapy
Association (AOTA)
Commission on Practice
(COP), 3
Representative Assembly
(RA), 2–3
analysis of occupational perfor-
mance, 74
animals, 31
assessment, 74
assistive technology (AT), 60
bathing, 30
beliefs
defined, 15, 75
occupational performance and,
51
body functions and body
structures
overview, 15, 75
occupational performance and,
51–54
cardiovascular system functions, 53
care of others, 30
care of pets and animals, 31
case management, 19
child rearing, 31
client factors
beliefs, 51
body functions and body
structures, 51–54
defined, 75
domain and, 15
spirituality, 51
values, 51
client-centered care (client-centered
practice), 75
clients
defined, 75
examples, 29
terminology, 2, 24
clinical reasoning, 20, 75
Commission on Practice (COP), 3
communication management, 31
communication with the health
care system, 32
community, 2, 75
community mobility, 29, 31
community participation, 34
consumers, 24
context
defined, 76
environmental factors, 36–39
personal factors, 40
co-occupations, 76
cornerstones of occupational
therapy practice, 6, 76
direct services, 18
discontinuation, 27
domain
aspects of, 5, 6
client factors, 15
defined, 76
environmental factors, 9–10
occupational justice, 11–12
occupations and, 6–9
performance patterns, 12–13
performance skills, 12–15
personal factors, 10–11
dressing, 30
driving, 31
eating and swallowing, 30
education
overview, 33, 76
examples, 35
interventions for, 61
empathy, 76
employment, 33–34. see also
work
engagement in occupation, 5–6,
76
enhancement, 65–66
environmental factors, 9–10,
36–39, 76
environmental modifications, 60
episodic care, 19
evaluation
overview, 23, 76
process, 16, 55
synthesis of, 23
family participation, 34
family-centered care approaches,
19
feeding, 29, 30
financial management, 31
friendships, 34
functional mobility, 30
goals, 77
group interventions, 62, 77
groups
defined, 2, 77
examples, 29
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performance patterns, 41–42
performance skills and, 14, 50
process, 55–56
The Guide to Occupational
Therapy Practice (Moyers), 3
habilitation, 77
habits, 12, 41, 77
health and wellness, 5, 66, 77
health management
overview, 32
defined, 77
examples, 29, 35
health promotion, 24, 77
hematological and immune
system functions, 53
home establishment and
management, 29, 31
hope, 77
immune system functions, 53
improvement, 65
independence, 78
indirect services, 18–19
instrumental activities of daily
living (IADLs)
overview, 30–31, 78
examples, 35
interdependence, 78
interests, 78
intervention
approaches to, 63–64, 78
defined, 78
for education, 61
group interventions, 62
intervention implementation, 25
intervention plan, 24–25
intervention review, 25
process, 16–17, 23–26, 55–56
supporting occupations, 78
for training, 61
types of, 59–62
virtual interventions, 62
intimate partner relationships, 34
job performance and
maintenance, 33. see also work
leisure
overview, 34, 78
examples, 35
meal preparation and cleanup, 31
medication management, 32
members, 24
mental functions, 52
motor skills, 13, 43–44, 50, 79
movement-related functions, 53
neuromusculoskeletal functions, 53
nutrition management, 32
occupational adaptation, 26
occupational analysis, 19–20, 79
occupational demands, 79
occupational identity, 79
occupational justice, 11–12,
67–68, 79
occupational performance
analysis, 16, 23
client factors, 51–54
defined, 80
outcomes, 65
occupational profile, 16, 21–22, 80
occupational science, 80
occupational therapy, 1, 4, 80
Occupational Therapy Code of
Ethics, 24
occupational therapy practice
cornerstones, 6
occupational therapy
practitioners, 1
Occupational Therapy Product
Output Reporting System and
Uniform Terminology for
Reporting Occupational
Therapy Services, 2
occupation-based practice, 79
occupations
activities of daily living (ADLs), 30, 35
defined, 79
domain and, 6–9
education, 33, 35
health management, 32, 35
instrumental activities of daily living
(IADLs), 30–31, 35
interventions for, 59
leisure, 34, 35
play, 34, 35
rest and sleep, 32–33, 35
social participation, 34, 35
work, 33–34, 35
organization, 80
organization-level practice, 19
orthotics and prosthetics, 60
outcomes
overview, 26–27, 80
descriptions and examples, 65–68
process, 17, 56
PAMs and mechanical modalities, 59
participation, 5, 67, 80
patient-reported outcomes
(PROs), 27. see also outcomes
patients, 24
peer group participation, 34
performance patterns, 12–13,
41–42, 80
performance skills
defined, 81
domain and, 12–15
motor skills, 13, 43–44, 50
process skills, 13, 44–47, 50
social interaction skills, 13, 47–49
personal care device management, 32
personal factors, 10–11, 40, 81
personal hygiene and grooming, 30
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persons
defined, 2, 81
examples, 29
performance patterns, 41
performance skills and, 14, 43–49
process, 55–56
pets and animals, 31
physical activity, 32
play
overview, 34, 81
examples, 35
populations
defined, 2, 81
examples, 29
performance patterns, 41–42
performance skills and, 15
process, 55–56
prevention, 66, 81
process
overview, 15–19
activity analysis, 19–20
aspects of, 5
case management, 19
clinical reasoning, 20
defined, 81
direct services, 18
episodic care, 19
evaluation, 16, 23
family-centered care approaches, 19
groups, 55–56
indirect services, 18–19
intervention, 16–17, 23–26
occupational analysis, 19–20
occupational performance, 16
occupational profile, 16
organization-level practice, 19
outcomes, 17
persons, 55–56
populations, 55–56
professional reasoning, 20
service delivery approaches, 18–19
systems-level practice, 19
telehealth, 19
therapeutic use of self, 20
process skills
overview, 13, 81
performance skills, 44–47, 50
professional reasoning, 20, 81
prosthetics, 60
quality of life, 66, 82
reevaluation, 82
rehabilitation, 82
religious and spiritual
expression, 31
Representative Assembly (RA), 2–3
respiratory system functions, 53
rest and sleep, 32–33, 35
retirement preparation and
adjustment, 34
revisions, 3–4
rituals, 12, 41–42, 82
role competence, 67
roles, 12, 41–42, 82
routines, 12, 41, 82
safety and emergency
maintenance, 31
screening, 83
self-advocacy, 62, 83
self-regulation, 60
sensory functions, 52–53
service delivery, 18–19, 83
sexual activity, 30
shopping, 31
showering, 30
skilled services, 83
skin and related structure functions, 54
sleep, 33. see also rest and sleep
social and emotional health
promotion and maintenance, 32
social interaction skills, 13,
47–49, 83
social participation
overview, 34, 83
examples, 29, 35
speech functions, 54
spiritual expression, 31
spirituality
defined, 15, 83
occupational performance and, 51
Standards of Practice for
Occupational Therapy, 24
students, 24
swallowing, 30
symptom and condition
management, 32
systems-level practice, 19
telehealth, 19, 62
therapeutic use of self, 20
time, time management and time
use, 12, 83
toileting and toilet hygiene, 30
training interventions, 61
transaction, 83
transition, 27
Uniform Terminology for Oc-
cupational Therapy, 2
values
defined, 15, 84
occupational performance and, 51
virtual interventions, 62
voice and speech functions, 54
volunteer exploration and
participation, 34
well-being, 5, 67, 84
wellness, 84
wheeled mobility, 60
work
overview, 33–34, 84
examples, 35
work participation, examples, 29
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- Occupational Therapy Practice Framework: Domain and Process
- Definitions
- Contents
- Evolution of This Document
- Vision for This Work
- Introduction
- Occupation and Occupational Science
- OTPF Organization
- Cornerstones of Occupational Therapy Practice
- Domain
- Occupations
- Contexts
- Environmental Factors
- Personal Factors
- Application of Context to Occupational Justice
- Performance Patterns
- Performance Skills
- Application of Performance Skills With Persons
- Application of Performance Skills With Groups
- Application of Performance Skills With Populations
- Client Factors
- Process
- Overview of the Occupational Therapy Process
- Service Delivery Approaches
- Direct Services.
- Indirect Services.
- Additional Approaches.
- Practice Within Organizations and Systems
- Occupational and Activity Analysis
- Therapeutic Use of Self
- Clinical and Professional Reasoning
- Evaluation
- Occupational Profile
- Analysis of Occupational Performance
- Synthesis of the Evaluation Process
- Intervention
- Intervention Plan
- Intervention Implementation
- Intervention Review
- Outcomes
- Outcome Measurement
- Transition and Discontinuation
- Conclusion
- References
- References
- Index
