Literature searched for this review yielded no study which explored whether occupational therapy outcome measures are supportive of the recovery approach. Given that Irish Mental Health Services have committed to a recovery-orientated approach this raises a pertinent issue for occupational therapists in the sector. This study explores the extent to which occupational therapy specific outcome measures incorporate core recovery processes. Thus, the aim of this review is twofold:
Recovery is the central approach underpinning Irish Mental Health Services ( DH, 2020 ). Occupational therapy’s founding philosophies afford it with a unique scope for enhancing the advancement of recovery processes ( Gruhl, 2005 ; Merryman and Riegel, 2007 ). In recent years, a number of evidence-based and recovery focused outcome measures have emerged ( Brown et al., 2019 ); however, these measures are not discipline specific. To empower and support people to engage in meaningful occupations, therapists require sensitive assessments that draw from occupational therapy models capable of detecting changes in occupational performance ( Brown et al., 2019 ; AOTA, 2008 ).
In 2020, Sharing the Vision policy document was released. The continuous drive towards facilitating recovery-orientated services remains a central principle of the policy. It asserts a commitment that the future directions of the Irish Health Service will be designed in partnership with service users, families and carers ( DH, 2020 ).
The Vision for Change in 2006, was the first policy framework which saw the recovery approach placed as a fundamental part of Irish Mental Health Services [ Department of Health (DH), 2020 ]. It outlined the Government’s commitment to developing a recovery-orientated approach and the commencement of restructuring and evaluating services ( DH, 2020 ). It draws from the work of Leamy et al. and emphasises the need for partnerships between services and the person (and/or family members). This is a significant shift in Irish service delivery.
The findings demonstrated that these processes emerge at different stages in the recovery journey. Observing this, Leamy et al. (2011) mapped processes unique to each stage of applying Prochaska and Di Clemente’s (1982) transtheoretical model of behaviour change as shown in Table 1 .
Recovery ideals focus on the individual’s process and lived experiences; it involves the development of meaningful goals, personal growth and engagement in a meaningful life ( Kelly et al., 2010 ). The concept of a recovery approach to mental health has grown to be a prominent influencer of policy and practice internationally ( Field and Reed, 2016 ). It emerged following the progressive shift away from institutional settings and deficit-focused models ( Slade et al., 2014 ; Field and Reed, 2016 ). While there is no set model of recovery, it is generally described as a unique, non-sequential journey that involves personal growth towards the attainment of meaning in life ( Slade et al., 2014 ). A systematic narrative synthesis of 97 studies ( Leamy et al., 2011 ) included experiences of over 1,100 participants living with a mental health condition, the results of which established five recovery processes (CHIME):
Forty percent of adults in Europe have difficulties comprehending information related to health [ HSE and National Adult Literacy Agency (NALA), 2018 ]. Therefore, the accessibility of the language used in the measures is a key consideration in people’s active involvement in therapy. The degree to which the manuals of outcome measures adhered to Plain English guidelines was determined by asking 22 applicable questions drawn from the guidelines ( HSE and NALA, 2018 ). The measures were then graded as adhering, generally adhering or somewhat adhering to Plain English guidelines ( HSE and NALA, 2018 ).
This component aimed to consider the placement of the power balance. The questions asked to reflect this included the format of administration and looked at whether the person has any input with regards to sharing their reflections on their performance within the scoring and analysis.
The importance of promoting people’s active roles in therapy and service design is embedded throughout the themes of meaning, identity connectedness and empowerment ( Leamy et al., 2011 ). Partnership and collaboration are incorporated into the recovery alignment tool by reflecting on how the outcome measure is administered and scored.
This question centres on the outcome measures means of obtaining a personally determined goal rather than a clinical one. In the recovery alignment tool, the extent to which the person is involved in identifying strengths and in goal-setting signifies hope. The component was explored by observing if outcome measures contained: a personal goal-setting element and a means of regarding or documenting a person’s strengths and supports.
The second recovery process, hope, involves having ambitions and an optimistic view of one’s future ( Leamy et al., 2011 ). For services, this entails that a person is actively involved in their care planning and personal goal setting ( DH, 2020 ). Personal-centred goals carry more meaning and can support a sense of self-determination; increasing motivation towards goal attainment ( Synovec, 2015 ). Assessments and interventions which harness a person’s intrinsic, environmental and social supports promote self-belief and self-efficacy ( Synovec, 2015 ); the core supporting aspects of hope ( Leamy et al., 2011 ).
The recovery alignment tool focuses on how well the outcome measure is suited to each stage of recovery and to what extent personal experience is integrated. This was accomplished by reviewing clinical utility in manuals then comparing the content to descriptions of recovery stages outlined in Table 1 ( Leamy et al., 2011 ). Each outcome measure was categorised as generally suitable, maybe unsuitable or unsuitable for each recovery stage based on instructions from manuals. To enhance trustworthiness during this process, authors of each outcome measure were contacted with the preliminary category assigned. Input from the six authors who replied enabled the research team to refine the suitability rating process. The author’s feedback was generally supportive of the categorisation, with five authors concurring with the allocation. A fruitful discussion with one author enabled an agreement to be reached regarding the classification.
Person-centeredness was chosen to collectively describe the placement of the person, with their unique journey with individual meaning, at the centre, and the growth and nurturing of a person’s self-identity ( Leamy et al., 2011 ; DH, 2020 ). Empowerment relates to the acknowledgment of the person’s lived experience and their strengths or insights arising through their personal journey ( DH, 2020 ).
To systematically determine the extent to which the eight outcome measures aligned with the recovery framework, a tool was developed by the first and second authors. This involved modifying a tool created by Evans et al. (2000) to embed core recovery processes ( Leamy et al., 2011 ; DH, 2020 ). Research supervisors (second and third authors), the external advisor (fourth author) and peers contributed to the final version of the alignment tool. In the alignment tool the CHIME processes are grouped and represented using three headings: person-centeredness and empowerment, hope and partnership and collaboration.
Twenty outcome measures were identified and reviewed against inclusion criteria set out in Table 2 . Twelve were excluded due to the inclusion criteria, leaving eight measures to review. The included outcome measures were presented to an external advisor to explore their relevance to occupational therapy practice. The advisor was a Senior Occupational Therapist practicing in the Irish Adult Mental Health Service.
Identifying outcome measures was the priority for the search. Due to time constraints and to maintain focus on this paper’s aims, the included studies were not critically appraised.
Studies were published in 23 journals, most were published in the past 20 years (n = 72). Thirteen countries represented: Sweden was the most frequent (n = 31), followed by the USA (n = 15) and the UK (n = 11).
The systematic search yielded 84 included studies, data was extracted and categorised applying the Population, Intervention, Control, Outcome (PICO) format ( Cooke et al., 2012 ). Most studies were cross-sectional (n = 41) or cohort study designs (n = 22). Studies were classified by level of evidence according to the work of Sackett, 1989 . Most of the studies were level III (n = 54) and level IV (n = 14). Settings were relatively evenly distributed between community and inpatient services.
The MeSH headings, database specific subject headings and the list of databases searched to capture relevant studies have been stored by the authors. An expert librarian guided search strategy refinement. Thirteen databases were systematically searched between July 2017 and September 2019 complemented by hand searching key occupational therapy journals and harvesting references from included studies. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) diagram ( Figure 1 ) demonstrates the results of data collection and screening processes ( Moher et al., 2009 ).
The first aim of this review was achieved by completing a systematic search strategy. To meet the second aim, a narrative review methodology ( Hawker et al., 2002 ) was selected. This allowed insights and conclusions to be drawn regarding the alignment between recovery processes and the identified outcome measures ( Baumeister and Leary, 1997 ; Green et al., 2006 ) using a purpose-designed tool. Searches, data extraction and the recovery alignment appraisal process were cross-checked by a peer and discussed in supervision. An audit trail and key decisions were documented within research supervision records.
Results
The systematic search identified twenty occupational therapy-based outcome measures from the included 84 articles; of these eight met the inclusion criteria. The most frequently cited measures were the Canadian Occupational Performance Measure (COPM) (n = 16) and the Assessment of Motor and Process Skills (AMPS) (n = 12). In relation to the underlying theory, five of the eight outcome measures were derived from the Model of Human Occupation (MOHO). The Kohlman Evaluation of Living Skills (KELS) was the only outcome measure specifically designed for use with people experiencing mental health problems. The other outcome measures were not diagnostically bound. The AMPS was the only measure requiring software for scoring; other outcome measures include this as an option.
Table 3 provides information regarding the eight included outcome measures. The systematic search process also identified three emerging outcome measures which did not meet the inclusion criteria but are of note given their population focus within mental health and the level to which they were cited in the last ten years. The first was the Satisfaction with Daily Occupations (SDO) (n = 11) it measures a person’s perceived occupational performance and level of activity in occupational domains via interview (Eklund, 2009). The second was the Profile of Occupational Engagement in People with Severe Mental Illness (POES) and the alternate version, the Profile of Occupational Engagement in people with Schizophrenia (n = 10 combined). Both versions measure people’s time use to assess occupational patterns of engagement in ADLs and occupations (Bejerholm et al., 2006). The third measure was the Engagement in Meaningful Activates Survey (EMAS) (n = 4) The EMAS uses a Likert Scale to measure the extent to which people participate in meaningful activities (Goldberg et al., 2002).
The recovery alignment appraisal
To meet the second aim of the study the recovery alignment tool was used to assess the eight included outcome measures. The results (Figure 2) are detailed under the processes: person-centeredness and empowerment; hope; and partnership and collaboration. Each of these processes will be considered in turn. Recovery stages are represented in Figure 2 as corresponding numbers from one to five.
Person-centeredness and empowerment
Recovery stages are central to a personalised approach. The alignment of each tool specific recovery stages is illustrated in Figure 2. No outcome measures were found to be unsuitable in a recovery stage; therefore, Figure 2 only includes the generally suitable and may be unsuitable categories. Two of the four observation-based formats were suitable across all recovery stages (ACIS and MOHOST). All outcome measures were found to be generally suitable at stages four and five. Fisher and Jones (2007) do not recommend the AMPS for use when people are acutely unwell nor for those who are not presently engaging in ADLs; thus, AMPS may be unsuitable with some persons in recovery stage one.
Interview-style measures require a person to discuss life circumstances and the therapist explores occupational performance. As a consequence, interview-style formats may be unsuitable for some people in stages one and two of recovery. For example, the OPHI-II was assessed as being may be unsuitable at stages one to three given that an in-depth personal interview of life history may be distressing to some people in the early stages of recovery (Kielhofner et al., 2004). This also pertained to the KELS as it contains both interview and observational components.
The personal experience of the recovery journey was integrated into the COPM, OPHI-II and OCAIRS. These outcome measures use a semi-structured interview to attain personal narratives (Kielhofner et al., 2004; Forsyth et al., 2005; Law et al., 2005). Manuals of the other outcome measures emphasised the importance of personal narratives and rapport surrounding administration. Hence, the remaining six outcome measures informally integrate personal experience.
Hope
Personal goal-setting, documenting personal strengths and supports were factors linked to the process of hope in the recovery alignment tool. Goal-setting elements were found within the AMPS, COPM, OCAIRS OPHI-II and OSA. In contrast, the ACIS, KELS and MOHOST did not include goal-setting elements. Although not integral to administration of these measures, the manuals specified that results from the measures could be used to guide goal-setting via offering insights relating to performance in meaningful activities (Kohlman Thompson, 1992; Forsyth et al., 1998; Parkinson et al., 2004).
All outcome measures which used an interview format (COPM, OCAIRS, OPHI-II and OSA) provided a means of identifying strengths and supports. Observational formats do not directly address hope; however, the AMPS suggests that personal strengths and supports should be incorporated in the assessment and intervention process (Fisher and Jones, 2007). While the ACIS, KELS and MOHOST manuals do not explicitly address hope, it is embedded within the theory the measures draw upon (Kohlman Thompson, 1992; Forsyth et al., 1998; Parkinson et al., 2004).
Partnership and connectedness
All outcome measure manuals encourage interaction between the person and therapist, thus laying the foundation for a recovery partnership. Overall, the administration formats are mixed, four (the ACIS, AMPS, KELS and MOHOST) are observational formats and four are interview-styles (the COPM, OCAIRS, OPHI-II and OSA). The flexibility within semi-structured interview formats (COPM, OCAIRS and OPHI-II) present a stronger alignment with this process; offering a more balanced two-way interaction to capture valuable information compared with being observed performing a task.
Scoring and the interpretation of outcome measures rely upon clinical expertise, yet the OSA and COPM illustrate capacity to obtain the person’s perception of their performance via self-rating scales. The COPM and the OSA presented with the strongest alignment to partnership and connectedness given that they include the person’s input. The other six measures are solely scored by the occupational therapist.
Six of the outcome measures contained instructions for therapists to then explain, two of which (AMPS and COPM) adhered to Plain English guidelines (HSE and NALA, 2018) and the other four measures generally adhered (ACIS, OCAIRS, OPHI-II and MOHOST). Two measures contained instructions for the person. Of these three, one adhered (KELS) and one somewhat adhered to the guidelines (OSA).
