Leisure Assessment in Occupational Therapy: An Exploratory Study
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Heather Turner, BS, OTS Sandra Chapman, BS, OTS Alyce McSherry, BS, OTS Sheama Krishnagiri, PhD, OTR/L Janet Watts, PhD, OTR/L
ABSTRACT. Occupational therapy asserts that leisure, along with self-care and work, is a primary occupation of individuals and essential to occupational functioning. The purpose of this study was to explore the leisure assessment practices of occupational therapists in a variety of settings. A telephone survey, developed by the researchers, was administered to 105 occupational therapists in North Carolina, Pennsylvania, and Virginia. In addition, face to face interviews were conducted with 15 occupational therapists using the telephone survey as a guide. The results indicated that therapists report assessing leisure primarily through informal methods, especially through interview/discussion with their clients. The frequency with which they assessed leisure was significantly correlated with how much they valued leisure in their practice of occupational therapy. Lastly, therapists practicing in psychosocial areas valued leisure significantly more than those practicing in physical disabilities. [Article copies available for a fee from The Haworth Document DeliveryService:1-800-342-9678.E-mailaddress:[email protected] ]
KEYWORDS. Occupational therapy, leisure, assessment
Heather Turner, Sandra Chapman, and Alyce McSherry are graduate students at Virginia Commonwealth University. Sheama Krishnagiri and Janet Watts are faculty of the Department of Occupational Therapy, School of Allied Health Professions, Medical College of Virginia Campus, Virginia Commonwealth University in Richmond, VA. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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INTRODUCTION
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Occupational therapy’s holistic principles assert that play/leisure skills and interests, as part of a balanced lifestyle, are vital to an individual’s well-being and long-term health (Primeau, 1996; Taylor & McGruder, 1996). Accordingly, the occupational therapist assists clients in exploring leisure interests, in performing leisure occupations, and in balancing leisure with work and self-care. This role in maintaining occupational balance warrants occupational therapy assessment of leisure in the clinical setting.
LITERATURE REVIEW Despite the theoretical foundation of the profession that leisure is a primary occupation of human beings and essential to occupational functioning, the profession has contributed little to the theoretical and practical knowledge of leisure in the clinical setting. A review of the literature shows that occupational therapists have researched leisure activity patterns and how they are affected by disability, with an emphasis on the personal meaning attached to such activities. These studies, however, have been limited to patients with specific diagnoses, such as stroke (Drummond & Walker, 1996; Jongbloed & Morgan, 1991). Leisure activities have also been evaluated by occupational therapists as a form of coping and for their effect on self-concept and life satisfaction (Parker, 1996; Reynolds, 1997). Leisure, as a concept, has been defined in the literature by various disciplines, such as sociology, psychology, and recreation. Some definitions include leisure as free time away from work, as specific types of activities that produce pleasure and relaxation, and as a state of mind which is the subjective state of the individual during leisure participation (Csikszentmihalyi, 1975; Howe, 1985; Neulinger, 1976). The profession of occupational therapy defines leisure as ‘‘skill and performance in choosing, performing, and engaging in activities for amusement, relaxation, spontaneous enjoyment, and/or self-expression’’ (Hopkins & Smith, 1993, p.911). This definition seems to encompass the many ways leisure has been defined by other disciplines. Leisure assessments range from formal, standardized assessments to more informal assessments. These assessments may be categorized
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Turner et al.
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into one of the following types: interest checklists, history taking, activity patterns, and subjective assessments of leisure attitudes (DiLorenzo, Prue, & Scott, 1987; Matsutsuyu, 1967). A critical problem currently facing many disciplines, including occupational therapy, is the lack of functional and standardized assessments of leisure (Fisher & Short-DeGraff, 1993; Mann & Talty, 1991; Soderback & Hammarlund, 1993). For an instrument to be standardized it should have a clearly written administration protocol and established reliability and validity. Those assessments within the field of occupational therapy that are standardized have often been fragmented into smaller parts and then used in an adapted, non-standardized fashion (Smith, 1992). In the area of leisure, further research is needed regarding assessment procedures in clinical settings, if and how leisure is being used in treatment, and continued examination of the effectiveness of such treatment. More specifically, with respect to leisure assessment procedures, it is also important to explore how occupational therapists define leisure, methods commonly used to assess leisure, and whether this assessment is used to plan treatment activities. In order to provide a basis for future efficacy studies regarding occupational therapy treatment in the leisure performance area, we must first gain information regarding their assessment and intervention practices in clinical settings (Wallen & Walker, 1995). There is a paucity of information in the literature about leisure assessment practices, but there are studies that have investigated practice patterns within the profession (Hemphill, 1980). All have involved some type of descriptive research, most often using survey methods such as questionnaires and telephone interviews (Lawlor, 1994). The foundation of the profession rests on the inclusion of leisure in treatment, and this process begins with assessment.
PURPOSE OF THE STUDY The intent of this research study is to explore the leisure assessment practices of occupational therapists across various practice settings. It is important to generate such research to examine the validity of the theoretical foundation and the occupational therapy principles that govern the profession. The need to ascertain if and how leisure assessments are included in the evaluation procedure is important in order to
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contribute to theoretical knowledge and practical treatment interventions in the clinic. METHODS
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Sample The names of 230 occupational therapists were systematically selected from the North Carolina, Pennsylvania, and Virginia professional organizations’ membership directories. Criteria for participation included: currently practicing as a registered occupational therapist and serving clients ages 13 and older. Registered occupational therapists were the focus because they are trained to administer evaluations, and since leisure is considered an occupation of adolescents and adults, participants must be working with clients ages 13 and older (Hopkins & Smith, 1993). Instrumentation A 10 to 20 minute telephone survey was used to gather data followed by interviews with a sub-sample. The survey included demographics and close-ended as well as open-ended questions. Questions addressed were frequency of evaluation of self-care, work, and leisure; type of leisure assessment (formal and informal); use of leisure to plan treatment activities; and definitions of leisure. The face to face interviews were conducted using the telephone instrument as a guide along with established probes. Pilot Study Two pilot studies were conducted to evaluate the instrument and the procedures. The telephone survey was administered to 10 occupational therapy graduate students and 5 registered occupational therapists in the Richmond area. Respondents were asked at the end of the survey to comment on the overall clarity of the instrument. The pilot test with the graduate students indicated that the administration time adhered to the 20 minute limit. Also, the probing techniques used for each question were adequate, and no difficulties were
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reported with the survey questions. Pilot administration of the survey with occupational therapists resulted in several changes to ensure accuracy of responses and clarity of the instrument.
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Procedures Invitations to participate in the study were sent two weeks prior to the telephone survey. Telephone calls were then made to the selected therapists in afternoons and early evenings. If the therapists were not available, a systematic method was followed for making call backs. Therapists who reported using formal assessments, either specific to their facility or published, were asked to send copies of them to the researchers. Face to face interviews were later conducted with 15 occupational therapists in the Richmond area to increase the validity of the findings. Field notes were taken during the interviews to record any additional information offered by the therapists after they had answered the established questions. To establish interrater reliability of the recording of therapists’ responses to open-ended questions, 22 randomly selected surveys were completed by two interviewers simultaneously. An independent party compared the interviewers’ written responses to each question and rated their similarity on a scale of 1 to 10. For each question, the exact agreement between interviewers as judged by the independent party ranged from 80% to 100%. Data Management and Analysis Preliminary categories were established by the researchers for each of the five open-ended questions. These categories were confirmed by an independent rater. The researchers then independently coded the answers to those questions according to the categories and then met to compare and determine final coding for data analysis. The frequency of responses for each category was calculated. Summary statistics were calculated. Multiple t-tests were used to determine if significant differences existed between practice settings with respect to frequency of leisure assessment and valuing of leisure. Since many therapists reported working in more than one setting, it was necessary to compare therapists in each individual setting with all of the remaining respondents. In addition, t-tests were used to deter-
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mine if frequency of leisure assessment varied based on other demographic information, such as method of reimbursement. The correlation between frequency of assessment and value of leisure was also calculated. RESULTS
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Demographics The final sample size of 105 yielded an overall response rate of 61%. Table 1 reports descriptive statistics. Eighty-seven percent of the respondents reported their primary area of practice as physical disabilities and 13% reported it as psychosocial. Frequency of Leisure Assessment The first research questions asked: ‘‘Are occupational therapists assessing leisure as part of the evaluation process and, if so, how frequently?’’ and ‘‘Do occupational therapists value leisure within their practice of occupational therapy?’’ One hundred and three of the 105 subjects reported assessing leisure. Therapists were asked to rate how often they gather information about leisure, self-care, and work (see Table 2). The percentage of therapists who almost always or always gathered information about leisure was 67.7%, about self-care was 89.5%, and about work was 72.4%. Therapists in psychosocial TABLE 1. Demographics of Sample (n = 105) n
%
M (SD)
range
Gender Female Male
92 13
87.6% 12.4%
-------
-------
State North Carolina Pennsylvania Virginia
25 46 34
23.8% 43.8% 32.4%
----------
---------1-52
Years work experience
105
----
13.1 (9.2)
Hours worked/week
105
----
36.6 (10.8)
Percent time in direct care
105
----
68.5% (24.9)
3-60 10%-100%
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TABLE 2. Frequency of Leisure Assessment and the Valuing of Leisure Across Practice Settings (n = 105)
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
n
Frequency of Leisure Assessment
Valuing of Leisure
M (SD)
M (SD)
By primary practice area Psychosocial Disabilities Physical Disabilities
14 91
4.39 (0.79) 3.97 (1.12)
* 4.29 (0.91) 3.66 (1.02)
By setting Acute Care Inpatient Rehabilitation Outpatient Rehabilitation Home Health LongTerm Care Hand Therapy
24 24 20 14 29 17
3.62 (1.11)* 4.50 (1.02) 4.10 (0.97) 4.29 (0.99) 4.07 (1.03) 3.82 (1.07)
3.44 (1.05) 3.94 (1.18) 3.68 (0.77) 4.07 (0.92) 3.74 (1.18) 3.32 (0.81)
Note. Therapists rated how frequently they assessed leisure on a scale of 1 to 5, with 1 meaning never and 5 meaning always, and how much they valued leisure on a scale of 1 to 5, with 1 meaning not at all and 5 meaing a great deal. Some therapists reported working in multiple settings. *p < .05
settings reported assessing leisure more frequently than those working in physical disabilities, although this difference was not significant, t(105) = 1.35, p = .18. Frequency of leisure assessment was significantly correlated with how much the therapists valued leisure within their practice of occupational therapy, r = .5064, t(105) = 5.961, p < .05. In addition, therapists working in the area of psychosocial disabilities reported valuing leisure significantly more than those working in physical disabilities, t(105) = 2.16, p < .05. Leisure Assessment When asked what types of leisure assessments (informal, formal) are used most frequently, 5% reported using formal assessments only, 83% used informal assessment methods only, and 12% used both formal and informal. Of the occupational therapists who used some type of formal assessments, 79% reported using one specific to their facility and 21% used assessments that were published. Information regarding the types of formal and informal assessment methods used by therapists was gathered (see Table 3).
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OCCUPATIONAL THERAPY IN HEALTH CARE TABLE 3. Types of Leisure Assessment (n = 103) n (%)
Informal Interview with client Interview with caregivers Observation Chart Review/Team Members Formal Specific to facility
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Published
99 (94.3%) 98 (99%) 8 (8%) 10 (10%) 7 (7%) 18 (27.2%) 15 (83%) 4 (22%)
Note. Some therapists reported using more than one type of leisure assessment.
The question of whether the assessment of leisure occupations varies according to variables such as practice setting, patient diagnosis, and/or primary method of reimbursement resulted in one significant finding. Therapists working in acute care settings reported assessing leisure significantly less than therapists working in other settings, t(105) = 2.045, p < .05. Field notes taken during the interviews included statements by therapists that their ability to focus on leisure had been reduced by shorter lengths of stay and less treatment time with clients. When asked whether their assessment of leisure varied according to diagnosis, 42.9% of therapists reported that it did. However, when asked to explain how it varied, 22.2% said that it varied based on diagnosis and the others reported that it actually varied according to other criteria, such as age (13.3%), cognitive ability (26.7%), setting/ level of care (22.2%), severity of disability (24.4%), activity level of clients (11.1%), and needs and goals of client (6.7%). Frequency of leisure assessment did not vary significantly based on primary source of reimbursement, F(105) = 2.33, p = .079. In field notes, therapists gave examples of when they were denied reimbursement for leisure related treatment. When asked whether other disciplines within facilities were assessing leisure instead of occupational therapists, 81% reported that there was at least one other discipline in their facility that was also assessing leisure. From this group, 64% said recreational therapy also assessed
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Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
leisure, 25% said physical therapy, 7% said speech therapy, 14% said activities, and 14% said other. Field notes indicated that many therapists had given up the area of leisure to therapeutic recreation because they did not want to overlap in services. The final research question asked: How do occupational therapists define leisure? The definitions of leisure fell into three categories, and 61% of the therapists gave a definition that fit into more than one of these categories. Leisure was defined as an activity done for enjoyment, relaxation, and fun (82%), as time outside of work, self-care, and rest (64%), and as purposeful, meaningful activity (10%) by those who were surveyed. Use of Leisure Assessment in Treatment Planning Additional information was gathered from respondents regarding their use of leisure assessment to plan treatment. Seventy-five percent of the therapists reported using information gathered during leisure assessment (formal and informal) to plan treatment. This was significantly correlated with frequency of leisure assessment, t(105) = 2.84, p < .05. The most common ways this information was used during treatment included: (1) using leisure interest as a way to focus on development of component skills (38%), (2) using leisure activity itself to promote future participation (35%), (3) using leisure activity as a motivator to increase interest/participation in therapy (32%), (4) developing ways to adapt leisure activity to client’s current skill level (11%), and (5) writing goals related to leisure interest (9%).
DISCUSSION These findings indicate that a majority of occupational therapists in various practice settings are assessing leisure as part of the evaluation process, although not as frequently as work or self-care. The results indicate a trend for those working in psychosocial areas to assess leisure more frequently than those in physical disabilities, however this difference was not significant (p = .18). Although occupational therapists do assess leisure, the majority used informal methods with most relying on gathering information during interviews with clients. Only a few therapists reported observ-
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ing performance of leisure occupations. Although they may be addressing performance issues in their interviews, this was not indicated by therapists’ responses. This suggests that leisure assessment may be focused on gathering broad information about leisure interests rather than the performance of leisure activities. In other words, occupational therapists may just be ‘‘scratching the surface’’ when it comes to leisure assessment. This was also reflected in the ways therapists reported using leisure assessment to plan treatment. More therapists reported using leisure interests as a motivator and as a way to develop component skills (e.g., strength, endurance) rather than for promotion of future performance of the leisure activity. Very few therapists reported using formal leisure assessments, which may be due to the lack of standardized leisure assessments available. Most of those therapists using formal assessments are using ones designed by their facility. Generally, these formal assessments are of the interest checklist format, which also limits the gathering of more detailed information related to actual performance skills and difficulties. Almost half of the therapists surveyed reported varying their leisure assessment based on diagnosis or some other criteria, such as cognitive disability or severity of disability. This suggests a need for the development of more representative assessments that may be used for a variety of individuals. The remainder of the therapists reported assessing leisure in the same manner for every individual, and this may indicate that therapists would be receptive to the use of a more standardized way of assessing leisure that could meet the needs of all clients. It was found that therapists in acute care settings assess leisure less frequently than therapists working in other settings. This was supported by additional comments from many therapists who reported that their focus on leisure has been forcibly decreased by shorter lengths of stay and less treatment time with clients overall. Although there were no significant findings related to reimbursement, many therapists also reported decreased assessment of leisure secondary to concerns in that area. They were able to cite specific examples of not receiving reimbursement for leisure related treatment, as most payers were primarily concerned with independence in self-care as the primary necessity for discharge.
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Another factor that was cited as a reason for reduced leisure assessment was the existence of other disciplines in their facilities that were assessing leisure, especially therapeutic recreation. Field notes taken during the interviews suggested that occupational therapists may rely on other disciplines to assess and intervene in the area of leisure. As a profession, occupational therapy advocates that leisure is one of the three primary occupations of individuals and yet it appears to be more focused on self-care and work. It may be risking its holistic approach by placing unequal emphasis on the three areas and contradicting the assertion that a balanced lifestyle is necessary for occupational functioning. When asked for their definition of leisure, the most common definition was time outside of work and self-care coupled with an activity done for fun and relaxation. This is congruent with the definitions found in the literature, except those that relate to state of mind or as a meaningful activity. This may impact the degree to which they assess leisure and where they prioritize leisure in the treatment planning process. Evidence of this relationship may be found between the degree to which therapists value leisure and whether they use information from the leisure assessment to plan treatment interventions. Those therapists that reported greatly valuing leisure also reported using the information from their leisure assessments to plan treatment interventions. Field notes suggest that some therapists view leisure as a luxury to which they wish they had more time to focus their efforts. Since the results indicate that frequency of assessment is highly correlated with how much therapists valued leisure, one can infer that they value leisure less than work or self-care in their practice of occupational therapy. An interesting correlate was the finding that therapists in psychosocial practice areas valued leisure in their practice more than those therapists working in physical disabilities. The lack of valuing by some therapists, which directly relates to their frequency of leisure assessment, suggests that some therapists are not treating the whole person as the profession’s principles assert. Three limitations are to be considered with regard to the study. First, the sample used in the study may not be representative of occupational therapists in the United States. The accessible subjects are only those belonging to their state associations which may limit the ability to generalize the results. Second, although attempts were made to clearly define the survey terms, especially ‘‘formal’’ and ‘‘infor-
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OCCUPATIONAL THERAPY IN HEALTH CARE
mal’’ with regards to types of assessments, some subjects may have been influenced by their own definitions. Finally, given that the primary researchers interviewed all subjects and coded the data, interpretation of the results may be subject to personal bias. In conclusion, there is a need to develop formal leisure assessments in order to adhere to the principles of the profession that advocates for addressing all occupations. Further research should be done to look at meaningfulness of leisure to individuals according to criteria such as age and diagnosis, in order to create more useful and representative assessments. Also, the relationship between one’s definition of leisure and their value of leisure in the treatment planning could be further investigated. More specific research that investigates the effects of factors such as reimbursement and length of stay on occupational therapy leisure assessment and treatment is also needed. REFERENCES Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. San Francisco: JosseyBass. DiLorenzo, T. M., Prue, D. M., & Scott, R. R. (1987). A conceptual critique of leisure assessment and therapy: An added dimension to behavioral medicine and substance abuse treatment. Clinical Psychology Review, 7, 597-609. Drummond, A., & Walker, M. (1996). Generalization of the effects of leisure rehabilitation for stroke patients. British Journal of Occupational Therapy, 59, 330-334. Fisher, A. G., & Short-DeGraff, M. (1993). Improving functional assessments in occupational therapy: Recommendations and philosophy for change. American Journal of Occupational Therapy, 47, 199-201. Hemphill, B. J. (1980). Mental health evaluations used in occupational therapy. American Journal of Occupational Therapy, 34, 721-726. Hopkins, H. L., & Smith, H. D. (1993). Occupational therapy (8th ed.). Philadelphia: J. B. Lippincott. Howe, C. Z. (1985). Possibilities for using a qualitative research approach in the sociological study of leisure. Journal of Leisure Research, 17, 212-224. Jongbloed, L., & Morgan, D. (1991). An investigation of involvement in leisure activities after a stroke. American Journal of Occupational Therapy, 45, 420-427. Lawlor, M. C. (1994). Development of a standardized telephone interview instrument. Occupational Therapy Journal of Research, 14, 38-50. Mann, W. C., & Talty, P. (1991). Leisure activity profile: Measuring use of leisure time by persons with alcoholism. Occupational Therapy in Mental Health, 10(4), 31-41. Matsutsuyu, J. (1967). The Interest Checklist. American Journal of Occupational Therapy, 11, 179-181. Neulinger, J. (1976). The need for and the implications of a psychological conception of leisure. The Ontario Psychologist, 8(June), 13-20.
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Parker, M. D. (1996). The relationship between time spent by older adults in leisure activities and life satisfaction. Physical & Occupational Therapy in Geriatrics, 14(3), 61-71. Primeau, L. A. (1996). Work and leisure: Transcending the dichotomy. American Journal of Occupational Therapy, 50, 569-577. Reynolds, F. (1997). Coping with chronic illness and disability through creative needlecraft. British Journal of Occupational Therapy, 60, 352-356. Shaw, S. (1984). The measurement of leisure in everyday life. Leisure Sciences, 7, 1-24. Smith, R. O. (1992). The science of occupational therapy assessment. Occupational Therapy Journal of Research, 12, 3-15. Soderback, I., & Hammarlund, C. (1993). A leisure-time frame of reference based on a literature analysis. Occupational Therapy in Health Care, 8, 105-133. Taylor, L. P. S., & McGruder, J. E. (1996). The meaning of sea kayaking for persons with spinal cord injuries. American Journal of Occupational Therapy, 50, 39-46. Wallen, M., & Walker, R. (1995). Occupational therapy practice with children with perceptual motor dysfunction: Findings of a literature review and survey. Australian Occupational Therapy Journal, 42, 15-25.
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Heather Turner, BS, OTS Sandra Chapman, BS, OTS Alyce McSherry, BS, OTS Sheama Krishnagiri, PhD, OTR/L Janet Watts, PhD, OTR/L
ABSTRACT. Occupational therapy asserts that leisure, along with self-care and work, is a primary occupation of individuals and essential to occupational functioning. The purpose of this study was to explore the leisure assessment practices of occupational therapists in a variety of settings. A telephone survey, developed by the researchers, was administered to 105 occupational therapists in North Carolina, Pennsylvania, and Virginia. In addition, face to face interviews were conducted with 15 occupational therapists using the telephone survey as a guide. The results indicated that therapists report assessing leisure primarily through informal methods, especially through interview/discussion with their clients. The frequency with which they assessed leisure was significantly correlated with how much they valued leisure in their practice of occupational therapy. Lastly, therapists practicing in psychosocial areas valued leisure significantly more than those practicing in physical disabilities. [Article copies available for a fee from The Haworth Document DeliveryService:1-800-342-9678.E-mailaddress:[email protected] ]
KEYWORDS. Occupational therapy, leisure, assessment
Heather Turner, Sandra Chapman, and Alyce McSherry are graduate students at Virginia Commonwealth University. Sheama Krishnagiri and Janet Watts are faculty of the Department of Occupational Therapy, School of Allied Health Professions, Medical College of Virginia Campus, Virginia Commonwealth University in Richmond, VA. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
73
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OCCUPATIONAL THERAPY IN HEALTH CARE
INTRODUCTION
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Occupational therapy’s holistic principles assert that play/leisure skills and interests, as part of a balanced lifestyle, are vital to an individual’s well-being and long-term health (Primeau, 1996; Taylor & McGruder, 1996). Accordingly, the occupational therapist assists clients in exploring leisure interests, in performing leisure occupations, and in balancing leisure with work and self-care. This role in maintaining occupational balance warrants occupational therapy assessment of leisure in the clinical setting.
LITERATURE REVIEW Despite the theoretical foundation of the profession that leisure is a primary occupation of human beings and essential to occupational functioning, the profession has contributed little to the theoretical and practical knowledge of leisure in the clinical setting. A review of the literature shows that occupational therapists have researched leisure activity patterns and how they are affected by disability, with an emphasis on the personal meaning attached to such activities. These studies, however, have been limited to patients with specific diagnoses, such as stroke (Drummond & Walker, 1996; Jongbloed & Morgan, 1991). Leisure activities have also been evaluated by occupational therapists as a form of coping and for their effect on self-concept and life satisfaction (Parker, 1996; Reynolds, 1997). Leisure, as a concept, has been defined in the literature by various disciplines, such as sociology, psychology, and recreation. Some definitions include leisure as free time away from work, as specific types of activities that produce pleasure and relaxation, and as a state of mind which is the subjective state of the individual during leisure participation (Csikszentmihalyi, 1975; Howe, 1985; Neulinger, 1976). The profession of occupational therapy defines leisure as ‘‘skill and performance in choosing, performing, and engaging in activities for amusement, relaxation, spontaneous enjoyment, and/or self-expression’’ (Hopkins & Smith, 1993, p.911). This definition seems to encompass the many ways leisure has been defined by other disciplines. Leisure assessments range from formal, standardized assessments to more informal assessments. These assessments may be categorized
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Turner et al.
75
into one of the following types: interest checklists, history taking, activity patterns, and subjective assessments of leisure attitudes (DiLorenzo, Prue, & Scott, 1987; Matsutsuyu, 1967). A critical problem currently facing many disciplines, including occupational therapy, is the lack of functional and standardized assessments of leisure (Fisher & Short-DeGraff, 1993; Mann & Talty, 1991; Soderback & Hammarlund, 1993). For an instrument to be standardized it should have a clearly written administration protocol and established reliability and validity. Those assessments within the field of occupational therapy that are standardized have often been fragmented into smaller parts and then used in an adapted, non-standardized fashion (Smith, 1992). In the area of leisure, further research is needed regarding assessment procedures in clinical settings, if and how leisure is being used in treatment, and continued examination of the effectiveness of such treatment. More specifically, with respect to leisure assessment procedures, it is also important to explore how occupational therapists define leisure, methods commonly used to assess leisure, and whether this assessment is used to plan treatment activities. In order to provide a basis for future efficacy studies regarding occupational therapy treatment in the leisure performance area, we must first gain information regarding their assessment and intervention practices in clinical settings (Wallen & Walker, 1995). There is a paucity of information in the literature about leisure assessment practices, but there are studies that have investigated practice patterns within the profession (Hemphill, 1980). All have involved some type of descriptive research, most often using survey methods such as questionnaires and telephone interviews (Lawlor, 1994). The foundation of the profession rests on the inclusion of leisure in treatment, and this process begins with assessment.
PURPOSE OF THE STUDY The intent of this research study is to explore the leisure assessment practices of occupational therapists across various practice settings. It is important to generate such research to examine the validity of the theoretical foundation and the occupational therapy principles that govern the profession. The need to ascertain if and how leisure assessments are included in the evaluation procedure is important in order to
76
OCCUPATIONAL THERAPY IN HEALTH CARE
contribute to theoretical knowledge and practical treatment interventions in the clinic. METHODS
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Sample The names of 230 occupational therapists were systematically selected from the North Carolina, Pennsylvania, and Virginia professional organizations’ membership directories. Criteria for participation included: currently practicing as a registered occupational therapist and serving clients ages 13 and older. Registered occupational therapists were the focus because they are trained to administer evaluations, and since leisure is considered an occupation of adolescents and adults, participants must be working with clients ages 13 and older (Hopkins & Smith, 1993). Instrumentation A 10 to 20 minute telephone survey was used to gather data followed by interviews with a sub-sample. The survey included demographics and close-ended as well as open-ended questions. Questions addressed were frequency of evaluation of self-care, work, and leisure; type of leisure assessment (formal and informal); use of leisure to plan treatment activities; and definitions of leisure. The face to face interviews were conducted using the telephone instrument as a guide along with established probes. Pilot Study Two pilot studies were conducted to evaluate the instrument and the procedures. The telephone survey was administered to 10 occupational therapy graduate students and 5 registered occupational therapists in the Richmond area. Respondents were asked at the end of the survey to comment on the overall clarity of the instrument. The pilot test with the graduate students indicated that the administration time adhered to the 20 minute limit. Also, the probing techniques used for each question were adequate, and no difficulties were
Turner et al.
77
reported with the survey questions. Pilot administration of the survey with occupational therapists resulted in several changes to ensure accuracy of responses and clarity of the instrument.
Occup Ther Health Downloaded from informahealthcare.com by Korea University on 12/26/14 For personal use only.
Procedures Invitations to participate in the study were sent two weeks prior to the telephone survey. Telephone calls were then made to the selected therapists in afternoons and early evenings. If the therapists were not available, a systematic method was followed for making call backs. Therapists who reported using formal assessments, either specific to their facility or published, were asked to send copies of them to the researchers. Face to face interviews were later conducted with 15 occupational therapists in the Richmond area to increase the validity of the findings. Field notes were taken during the interviews to record any additional information offered by the therapists after they had answered the established questions. To establish interrater reliability of the recording of therapists’ responses to open-ended questions, 22 randomly selected surveys were completed by two interviewers simultaneously. An independent party compared the interviewers’ written responses to each question and rated their similarity on a scale of 1 to 10. For each question, the exact agreement between interviewers as judged by the independent party ranged from 80% to 100%. Data Management and Analysis Preliminary categories were established by the researchers for each of the five open-ended questions. These categories were confirmed by an independent rater. The researchers then independently coded the answers to those questions according to the categories and then met to compare and determine final coding for data analysis. The frequency of responses for each category was calculated. Summary statistics were calculated. Multiple t-tests were used to determine if significant differences existed between practice settings with respect to frequency of leisure assessment and valuing of leisure. Since many therapists reported working in more than one setting, it was necessary to compare therapists in each individual setting with all of the remaining respondents. In addition, t-tests were used to deter-
78
OCCUPATIONAL THERAPY IN HEALTH CARE
mine if frequency of leisure assessment varied based on other demographic information, such as method of reimbursement. The correlation between frequency of assessment and value of leisure was also calculated. RESULTS
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Demographics The final sample size of 105 yielded an overall response rate of 61%. Table 1 reports descriptive statistics. Eighty-seven percent of the respondents reported their primary area of practice as physical disabilities and 13% reported it as psychosocial. Frequency of Leisure Assessment The first research questions asked: ‘‘Are occupational therapists assessing leisure as part of the evaluation process and, if so, how frequently?’’ and ‘‘Do occupational therapists value leisure within their practice of occupational therapy?’’ One hundred and three of the 105 subjects reported assessing leisure. Therapists were asked to rate how often they gather information about leisure, self-care, and work (see Table 2). The percentage of therapists who almost always or always gathered information about leisure was 67.7%, about self-care was 89.5%, and about work was 72.4%. Therapists in psychosocial TABLE 1. Demographics of Sample (n = 105) n
%
M (SD)
range
Gender Female Male
92 13
87.6% 12.4%
-------
-------
State North Carolina Pennsylvania Virginia
25 46 34
23.8% 43.8% 32.4%
----------
---------1-52
Years work experience
105
----
13.1 (9.2)
Hours worked/week
105
----
36.6 (10.8)
Percent time in direct care
105
----
68.5% (24.9)
3-60 10%-100%
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TABLE 2. Frequency of Leisure Assessment and the Valuing of Leisure Across Practice Settings (n = 105)
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n
Frequency of Leisure Assessment
Valuing of Leisure
M (SD)
M (SD)
By primary practice area Psychosocial Disabilities Physical Disabilities
14 91
4.39 (0.79) 3.97 (1.12)
* 4.29 (0.91) 3.66 (1.02)
By setting Acute Care Inpatient Rehabilitation Outpatient Rehabilitation Home Health LongTerm Care Hand Therapy
24 24 20 14 29 17
3.62 (1.11)* 4.50 (1.02) 4.10 (0.97) 4.29 (0.99) 4.07 (1.03) 3.82 (1.07)
3.44 (1.05) 3.94 (1.18) 3.68 (0.77) 4.07 (0.92) 3.74 (1.18) 3.32 (0.81)
Note. Therapists rated how frequently they assessed leisure on a scale of 1 to 5, with 1 meaning never and 5 meaning always, and how much they valued leisure on a scale of 1 to 5, with 1 meaning not at all and 5 meaing a great deal. Some therapists reported working in multiple settings. *p < .05
settings reported assessing leisure more frequently than those working in physical disabilities, although this difference was not significant, t(105) = 1.35, p = .18. Frequency of leisure assessment was significantly correlated with how much the therapists valued leisure within their practice of occupational therapy, r = .5064, t(105) = 5.961, p < .05. In addition, therapists working in the area of psychosocial disabilities reported valuing leisure significantly more than those working in physical disabilities, t(105) = 2.16, p < .05. Leisure Assessment When asked what types of leisure assessments (informal, formal) are used most frequently, 5% reported using formal assessments only, 83% used informal assessment methods only, and 12% used both formal and informal. Of the occupational therapists who used some type of formal assessments, 79% reported using one specific to their facility and 21% used assessments that were published. Information regarding the types of formal and informal assessment methods used by therapists was gathered (see Table 3).
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OCCUPATIONAL THERAPY IN HEALTH CARE TABLE 3. Types of Leisure Assessment (n = 103) n (%)
Informal Interview with client Interview with caregivers Observation Chart Review/Team Members Formal Specific to facility
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Published
99 (94.3%) 98 (99%) 8 (8%) 10 (10%) 7 (7%) 18 (27.2%) 15 (83%) 4 (22%)
Note. Some therapists reported using more than one type of leisure assessment.
The question of whether the assessment of leisure occupations varies according to variables such as practice setting, patient diagnosis, and/or primary method of reimbursement resulted in one significant finding. Therapists working in acute care settings reported assessing leisure significantly less than therapists working in other settings, t(105) = 2.045, p < .05. Field notes taken during the interviews included statements by therapists that their ability to focus on leisure had been reduced by shorter lengths of stay and less treatment time with clients. When asked whether their assessment of leisure varied according to diagnosis, 42.9% of therapists reported that it did. However, when asked to explain how it varied, 22.2% said that it varied based on diagnosis and the others reported that it actually varied according to other criteria, such as age (13.3%), cognitive ability (26.7%), setting/ level of care (22.2%), severity of disability (24.4%), activity level of clients (11.1%), and needs and goals of client (6.7%). Frequency of leisure assessment did not vary significantly based on primary source of reimbursement, F(105) = 2.33, p = .079. In field notes, therapists gave examples of when they were denied reimbursement for leisure related treatment. When asked whether other disciplines within facilities were assessing leisure instead of occupational therapists, 81% reported that there was at least one other discipline in their facility that was also assessing leisure. From this group, 64% said recreational therapy also assessed
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leisure, 25% said physical therapy, 7% said speech therapy, 14% said activities, and 14% said other. Field notes indicated that many therapists had given up the area of leisure to therapeutic recreation because they did not want to overlap in services. The final research question asked: How do occupational therapists define leisure? The definitions of leisure fell into three categories, and 61% of the therapists gave a definition that fit into more than one of these categories. Leisure was defined as an activity done for enjoyment, relaxation, and fun (82%), as time outside of work, self-care, and rest (64%), and as purposeful, meaningful activity (10%) by those who were surveyed. Use of Leisure Assessment in Treatment Planning Additional information was gathered from respondents regarding their use of leisure assessment to plan treatment. Seventy-five percent of the therapists reported using information gathered during leisure assessment (formal and informal) to plan treatment. This was significantly correlated with frequency of leisure assessment, t(105) = 2.84, p < .05. The most common ways this information was used during treatment included: (1) using leisure interest as a way to focus on development of component skills (38%), (2) using leisure activity itself to promote future participation (35%), (3) using leisure activity as a motivator to increase interest/participation in therapy (32%), (4) developing ways to adapt leisure activity to client’s current skill level (11%), and (5) writing goals related to leisure interest (9%).
DISCUSSION These findings indicate that a majority of occupational therapists in various practice settings are assessing leisure as part of the evaluation process, although not as frequently as work or self-care. The results indicate a trend for those working in psychosocial areas to assess leisure more frequently than those in physical disabilities, however this difference was not significant (p = .18). Although occupational therapists do assess leisure, the majority used informal methods with most relying on gathering information during interviews with clients. Only a few therapists reported observ-
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ing performance of leisure occupations. Although they may be addressing performance issues in their interviews, this was not indicated by therapists’ responses. This suggests that leisure assessment may be focused on gathering broad information about leisure interests rather than the performance of leisure activities. In other words, occupational therapists may just be ‘‘scratching the surface’’ when it comes to leisure assessment. This was also reflected in the ways therapists reported using leisure assessment to plan treatment. More therapists reported using leisure interests as a motivator and as a way to develop component skills (e.g., strength, endurance) rather than for promotion of future performance of the leisure activity. Very few therapists reported using formal leisure assessments, which may be due to the lack of standardized leisure assessments available. Most of those therapists using formal assessments are using ones designed by their facility. Generally, these formal assessments are of the interest checklist format, which also limits the gathering of more detailed information related to actual performance skills and difficulties. Almost half of the therapists surveyed reported varying their leisure assessment based on diagnosis or some other criteria, such as cognitive disability or severity of disability. This suggests a need for the development of more representative assessments that may be used for a variety of individuals. The remainder of the therapists reported assessing leisure in the same manner for every individual, and this may indicate that therapists would be receptive to the use of a more standardized way of assessing leisure that could meet the needs of all clients. It was found that therapists in acute care settings assess leisure less frequently than therapists working in other settings. This was supported by additional comments from many therapists who reported that their focus on leisure has been forcibly decreased by shorter lengths of stay and less treatment time with clients overall. Although there were no significant findings related to reimbursement, many therapists also reported decreased assessment of leisure secondary to concerns in that area. They were able to cite specific examples of not receiving reimbursement for leisure related treatment, as most payers were primarily concerned with independence in self-care as the primary necessity for discharge.
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Another factor that was cited as a reason for reduced leisure assessment was the existence of other disciplines in their facilities that were assessing leisure, especially therapeutic recreation. Field notes taken during the interviews suggested that occupational therapists may rely on other disciplines to assess and intervene in the area of leisure. As a profession, occupational therapy advocates that leisure is one of the three primary occupations of individuals and yet it appears to be more focused on self-care and work. It may be risking its holistic approach by placing unequal emphasis on the three areas and contradicting the assertion that a balanced lifestyle is necessary for occupational functioning. When asked for their definition of leisure, the most common definition was time outside of work and self-care coupled with an activity done for fun and relaxation. This is congruent with the definitions found in the literature, except those that relate to state of mind or as a meaningful activity. This may impact the degree to which they assess leisure and where they prioritize leisure in the treatment planning process. Evidence of this relationship may be found between the degree to which therapists value leisure and whether they use information from the leisure assessment to plan treatment interventions. Those therapists that reported greatly valuing leisure also reported using the information from their leisure assessments to plan treatment interventions. Field notes suggest that some therapists view leisure as a luxury to which they wish they had more time to focus their efforts. Since the results indicate that frequency of assessment is highly correlated with how much therapists valued leisure, one can infer that they value leisure less than work or self-care in their practice of occupational therapy. An interesting correlate was the finding that therapists in psychosocial practice areas valued leisure in their practice more than those therapists working in physical disabilities. The lack of valuing by some therapists, which directly relates to their frequency of leisure assessment, suggests that some therapists are not treating the whole person as the profession’s principles assert. Three limitations are to be considered with regard to the study. First, the sample used in the study may not be representative of occupational therapists in the United States. The accessible subjects are only those belonging to their state associations which may limit the ability to generalize the results. Second, although attempts were made to clearly define the survey terms, especially ‘‘formal’’ and ‘‘infor-
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mal’’ with regards to types of assessments, some subjects may have been influenced by their own definitions. Finally, given that the primary researchers interviewed all subjects and coded the data, interpretation of the results may be subject to personal bias. In conclusion, there is a need to develop formal leisure assessments in order to adhere to the principles of the profession that advocates for addressing all occupations. Further research should be done to look at meaningfulness of leisure to individuals according to criteria such as age and diagnosis, in order to create more useful and representative assessments. Also, the relationship between one’s definition of leisure and their value of leisure in the treatment planning could be further investigated. More specific research that investigates the effects of factors such as reimbursement and length of stay on occupational therapy leisure assessment and treatment is also needed. REFERENCES Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. San Francisco: JosseyBass. DiLorenzo, T. M., Prue, D. M., & Scott, R. R. (1987). A conceptual critique of leisure assessment and therapy: An added dimension to behavioral medicine and substance abuse treatment. Clinical Psychology Review, 7, 597-609. Drummond, A., & Walker, M. (1996). Generalization of the effects of leisure rehabilitation for stroke patients. British Journal of Occupational Therapy, 59, 330-334. Fisher, A. G., & Short-DeGraff, M. (1993). Improving functional assessments in occupational therapy: Recommendations and philosophy for change. American Journal of Occupational Therapy, 47, 199-201. Hemphill, B. J. (1980). Mental health evaluations used in occupational therapy. American Journal of Occupational Therapy, 34, 721-726. Hopkins, H. L., & Smith, H. D. (1993). Occupational therapy (8th ed.). Philadelphia: J. B. Lippincott. Howe, C. Z. (1985). Possibilities for using a qualitative research approach in the sociological study of leisure. Journal of Leisure Research, 17, 212-224. Jongbloed, L., & Morgan, D. (1991). An investigation of involvement in leisure activities after a stroke. American Journal of Occupational Therapy, 45, 420-427. Lawlor, M. C. (1994). Development of a standardized telephone interview instrument. Occupational Therapy Journal of Research, 14, 38-50. Mann, W. C., & Talty, P. (1991). Leisure activity profile: Measuring use of leisure time by persons with alcoholism. Occupational Therapy in Mental Health, 10(4), 31-41. Matsutsuyu, J. (1967). The Interest Checklist. American Journal of Occupational Therapy, 11, 179-181. Neulinger, J. (1976). The need for and the implications of a psychological conception of leisure. The Ontario Psychologist, 8(June), 13-20.
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Parker, M. D. (1996). The relationship between time spent by older adults in leisure activities and life satisfaction. Physical & Occupational Therapy in Geriatrics, 14(3), 61-71. Primeau, L. A. (1996). Work and leisure: Transcending the dichotomy. American Journal of Occupational Therapy, 50, 569-577. Reynolds, F. (1997). Coping with chronic illness and disability through creative needlecraft. British Journal of Occupational Therapy, 60, 352-356. Shaw, S. (1984). The measurement of leisure in everyday life. Leisure Sciences, 7, 1-24. Smith, R. O. (1992). The science of occupational therapy assessment. Occupational Therapy Journal of Research, 12, 3-15. Soderback, I., & Hammarlund, C. (1993). A leisure-time frame of reference based on a literature analysis. Occupational Therapy in Health Care, 8, 105-133. Taylor, L. P. S., & McGruder, J. E. (1996). The meaning of sea kayaking for persons with spinal cord injuries. American Journal of Occupational Therapy, 50, 39-46. Wallen, M., & Walker, R. (1995). Occupational therapy practice with children with perceptual motor dysfunction: Findings of a literature review and survey. Australian Occupational Therapy Journal, 42, 15-25.
