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The use of personal projects analysis to enhance occupational therapy goal identification.

A significant aspect of the rehabilitation process for people with acquired brain injury (ABI) is personal goal setting (Turner, Ownsworth,

Turpin, Fleming, & Griffin, 2008). While it can be challenging to carry out client-driven goal setting with patients experiencing problems related to ABI, a sense of goal ownership is important for patients (Doig, Fleming, Cornwell, & Kuipers, 2009). Furthermore, working toward personally valued goals increases patients' perceptions of well-being as well as goal achievement (Dalton et al., 2012).

The Canadian Occupational Performance Measure (COPM; Law et al., 2005) is a widely used and well-researched tool for setting occupational therapy priorities and evaluating progress (Sykes, 2006; Wressle, Marcusson, & Henriksson, 2002). This assessment is divided into three areas of occupational performance: self-care, productivity, and leisure. Occupational therapists view the COPM as an exemplary method of promoting patient participation in rehabilitation goal setting (Rosewilliam, Roskell, & Pandyan, 2011).

While occupational therapists can use the COPM across diagnostic categories, some are reluctant to use it with patients who have cognitive impairments, since these patients may have difficulty identifying therapy goals (McColl et al., 2005). Some occupational therapists believe that a patient's lack of insight or self-awareness may make it difficult to establish goals that can be addressed in therapy, making the problem identification process both difficult and time consuming. Furthermore, some occupational therapists think that patients do not understand that difficulties in their daily lives are the focus of attention and intervention in their rehabilitation process (Wressle et al., 2002).

A crucial point in using goal identification procedures, such as the COPM, is that occupational therapists may need to provide support for patients with cognitive impairment so that these patients can participate in the formulation of personally meaningful therapy goals (Hobson, 1996). Such help may include discussion of the broad range of occupations that could be considered in therapy and reflection on occupations that are particularly important to each specific patient.

The elicitation module of Personal Projects Analysis (PPA) may provide an effective and efficient method to prime patients to identify occupational goals of high relevance (Maes & Karoly, 2005). Personal projects are activities carried out over time in a particular social context to achieve an end named and given meaning by the doer (Little, Philips, & Salmela-Aro, 2007). Kubina, Dubouloz, Davis, Kessler, and Egan (2013) described these activities as ones that could be "ongoing (for example, working, favourite pastimes), or single events (for example, planning a party or going on vacation), [or] relational concerns (for example, trying to improve a relationship with a family member)" (p. 237). They could be related to any aspect of a person's life, including health concerns (e.g., trying to improve one's physical fitness). In this way, "personal projects reflect everyday activities that are individually defined and personally valued" (Kubina et al., 2013, p. 237).

There is an important link between personal projects and occupations. Concrete personal projects, such as cleaning out the garage, could be considered occupations. More abstract projects, such as trying to be a better spouse, could be broken down into more concrete projects, such as spending time in mutually satisfying activities (Arcand-Dusseault & Egan, 2015). Exploration of a patient's personal projects, then, can provide important and individualized information regarding valued occupations (Arcand-Dusseault & Egan, 2015).

The PPA, developed by personalily psychologist Brian Little, is a flexible, multicomponent assessment used to elicit personal projects and determine their subjective characteristics. There are four modules or stages of the PPA: elicitation, appraisal, hierarchy, and cross impact. In the elicitation module, the concept of personal projects is briefly introduced and the person is asked to list all of his or her current projects. In the appraisal module, the person is asked to rate a selected number of projects on characteristics relevant to the research or clinical situation. In the hierarchy module, the person is asked to identify his or her reasons for doing each project. That is, the person is asked to identify the underlying goal of each project until the primary motivation for the project is reached. In the cross impact module, the person is asked to examine the effect of each project on the other projects (Little, 2011b).

The PPA guidelines and grids are available at Little's (2011a) website (http://www.brianrlittle.com/Topics/research/assessment-tools/). However, it is important to note that flexibility is a key characteristic of the PPA; those using the PPA are encouraged to select modules as required and adapt procedures to meet their research or clinical needs (Little, 2011b).

A version of the elicitation module of PPA has been developed to support occupational goal setting with people who have experienced a stroke (Kessler, Egan, Dubouloz, Graham, & McEwen, 2014; Kubina et al., 2013). To help patients reflect on their valued occupations, this version asks respondents to identify six important personal projects they were working on before the stroke. They are then asked whether the project has been completed. If not, they are asked whether the project is still important to them. Then, respondents are asked to identify six current personal projects and six personal projects they are hoping to pursue in the future.

The aim of including past, current, and future projects is to cue respondents to reflect on a range of occupations of personal importance. Another aim is that the elicitation of past and hoped for future projects may help communicate that the occupational therapist is open to their dreams of reengaging in past important occupations or pursuing valued future occupations. The elicitation for each time period is limited to six projects. This helps to ensure identification of a range of projects while not overwhelming the respondent.

When administered in this way, the elicitation module of PPA may provide an effective and efficient way to gain a precise and individualized vision of each patient's prior, current, and hoped for activities. It may provide an excellent method to help patients identify occupational therapy goals of high personal relevance. The goal of this project was to determine whether such use of the elicitation module of PPA can help patients in an ABI day program identify more meaningful occupational therapy goals than the COPM alone.

Method

To determine whether use of the elicitation module of PPA increases the relevance of COPM goals, ABI day program patients completed the COPM, as per usual care. Then they completed the elicitation module of PPA and, finally, reviewed their original COPM goals and revised these goals as they desired.

Participants

Participants were recruited from one ABI day program. Typically, patients are seen in this program three to six months post injury, following acute care and in-patient rehabilitation. In the day program, patients are generally seen by several rehabilitation professionals two days per week over eight weeks. A sample of ten consecutive patients was included in this study. Participants were included if they were able to communicate in English or French. There were no exclusion criteria. Each patient was seen by one of three occupational therapists who provide service to the patients who attend this program.

Procedure

Typically, the occupational therapist carries out the COPM at the beginning of the intervention to establish treatment goals. The COPM is a reliable and valid instrument to measure perceived performance of and satisfaction with the performance of occupational therapy goals (Carswell et al., 2004; Law et al., 2005). The COPM produces up to five areas each patient wishes to work on during therapy (goals), as well as the patient's perception of his or her current performance and satisfaction in each of these areas.

During the first occupational therapy session, the occupational therapists administered the COPM to the patients as per usual care. After completing the COPM, the patients rated their perceptions of the importance of each identified goal (on a scale of 1-10 with 1 being not important at all and 10 being extremely important) and their confidence that they could attain each of these goals (on a scale of 1-10 with 1 being not confident at all and 10 being completely confident).

During the next session, the participants identified personal projects using the elicitation module of PPA. That is, the participants identified six personal projects that they were carrying out just prior to their brain injuries (previous personal projects), six personal projects that they were currently working on (present personal projects), and six personal projects that they were hoping to work on in the future (future personal projects). While the occupational therapists had a set of instructions for project elicitation (see Appendix), they were encouraged to reword or expand on these instructions or provide other guidance as they felt necessary. The occupational therapists noted if completion of the PPA took more than one session.

Following the PPA completion, the participants were asked if they wished to revise any of their COPM goals. The therapists showed the participants the COPM goals that they identified previously to ensure that goal changes were not just a result of poor memory of the goals they formed previously. The participants were then asked if they would like to add or subtract goals or change the wording of the goals. Then, the participants were asked to rate the importance of each of the final goals (1-10) and how confident they were that they would be able to attain each of these goals (1-10). Goal Definitions

We defined changes in goals in the following manner. "Additional goals" were defined as an increased number of goals. For example, if a participant noted four COPM goals before project elicitation and five goals after, the participant's goals were judged to have increased by one. "Changed goals" were defined as initial goals that were replaced with different goals. For example, if the goal of walking was removed and replaced with yoga, the participant was judged to have a changed goal. "Reworded goals" were defined as goals that were essentially retained but had descriptors added or removed. For example, if the goal of going to the gym was changed to going to the gym twice a week, the participant was judged to have a reworded goal. This category of changed goals was further defined as "reworded goal--more specific" and "reworded goal--less specific." Finally, the time between the administration of the two COPMs was noted.

Following this data collection, two of the three occupational therapists who worked with the patients participated in an informal group interview. We asked the two therapists to comment on their experiences using the PPA and their perceptions of its usefulness.

Analysis

A combination of qualitative and quantitative methods was used to analyze the data. First, three of the authors individually examined pre and post COPM goals to identify additional goals, changed goals, and reworded goals. Individual results were compared and disagreements were settled through consensus.

Second, the range, average, and standard deviation were calculated for the number of additional, revised, and reworded COPM goals identified following the elicitation module of PPA. We also calculated the average number and standard deviation of more specific and less specific COPM goals. The average perceived importance of COPM goals before and after the PPA was then calculated, as well as the range and standard deviation. The same was done for the perceived attainability of goals. Changes in the importance and perceived attainability were analyzed using the Wilcoxon signed rank test as is appropriate for correlated samples where data derives from non-interval scales (Lowry, 2013). All calculations were carried out using Microsoft Excel or SPSS 20.

Finally, the therapists' feedback regarding the PPA process was analyzed by summarizing their responses on the usefulness of the elicitation module of PPA and the ease of using the module. The Ottawa Hospital and the University of Ottawa Health Science and Science Research Ethics Boards provided ethics review for the study.

Results

Ten consecutive patients were enrolled in the study. Among the ten participants, there were an equal number of men and women, with ages ranging from 21 to 62 years. Most had been working or attending school before their injury, but none were at the time of admission to the program (see Table 1).

While nine of the participants completed the elicitation module of PPA in one treatment session, one of the participants required additional time in a second treatment session. After completing the module, only one of the participants added COPM goals and this participant added two goals. It was noted that this participant was the only one who did not identify five COPM goals initially.

Seven of the participants changed between one and three of their goals for a total of 12 changed COPM goals (see Table 2). In half of these goals, the participants changed from an individually-focused goal to a goal that explicitly included the mention of another person. For example, one participant changed the goal of "improved word finding" to "helping my girlfriend."

Only three of the participants reworded goals for a total of six reworded COPM goals (see Table 2). The goals that were reworded after the use of the PPA were more frequently reworded to less specific goals rather than to more specific goals.

Goal importance and confidence was a little higher after using the elicitation module of PPA (see Table 2), but these changes were not statistically significant. It was noted that the mean pre-PPA ratings for both importance and perceived attainability were already relatively high; before the module was administered, 58% of the COPM goals had an importance of 9-10, and 42% of the COPM goals had a perceived attainability of 9-10 (with 10 being the highest rating possible).

According to the two therapists who provided feedback, the participants did not spontaneously provide any positive or negative feedback about the PPA. The therapists reported that they enjoyed getting to know more about their patients and their valued occupations through both project elicitation and discussion of the projects that occurred during and after project elicitation. The therapists believed that the PPA did help some of the participants identify more meaningful goals; however, they reported that what was most useful regarding the PPA was that it helped the therapists to get to know the patient better.

The therapists also found that the elicitation module of PPA helped them identify occupations that could be used as modalities to help patients to achieve more global occupational goals. For example, using the COPM, the participants often identified long-term global goals that could not be completely addressed during the 8-week ABI day program. Information from the PPA helped the therapists identify occupations that could be used to move toward these long-term goals. For example, when the participants identified complex, long-term goals, such as returning to work, past personal projects could be reviewed for occupations that could be used to work toward this goal, such as reading about a particular area of interest or volunteering with a specific organization.

When the therapists were asked if they would continue to use the elicitation module of PPA in the future, both confirmed that they planned to use it with their patients but not before initial assessments of levels of functioning in basic and instrumental activities and a general review of the patient's typical daily occupational performance issues through evaluations, such as the COPM.

They also stated that they planned to use it with select patients only.

When asked if they would change anything in the elicitation module of PPA as it was used in this study, they both mentioned that they would like to have a better definition of future projects. They noted that some of the participants had difficulty differentiating between present projects that were currently in the planning stages and future projects, and that they were also uncertain how far into the future to consider.

Discussion

With the results of this study, we broaden the existing literature regarding goal setting for individuals with ABI (Barnes, 2000; Lawler, Dowswell, Hearn, Forster, & Young, 1999; Malec, 1999). The findings of the present study demonstrate that the use of the elicitation module of PPA with the COPM may help some ABI day program patients set more meaningful goals than the COPM alone. The majority of the participants did change at least one of their COPM goals after project elicitation. As this study had no control group, it is not clear whether these changes were due to the use of the PPA or the passage of time. Any definitive examination of the impact of adding the elucidation module of PPA would need to include a control group. Such an examination would also benefit from follow up to see if the procedure had an impact on goal attainment.

Changes in average importance or perceived attainability of COPM goals after project elicitation were small and not statistically significant. It is important to note that importance and perceived attainability were quite high prior to project elicitation, so the lack of change in these areas could be due to a ceiling effect. On a similar note, it is possible that ABI day program patients generally have little difficulty identifying goals that they feel are important and attainable. If project elicitation is valuable, this value lies elsewhere.

Of note, goals were frequently changed from those that mentioned only the participant to goals that included another person; these goals often reflected occupations that allowed the participant to contribute to the well-being of another person. Socially imbedded goals that allow reciprocity may be particularly important in the process of reengagement in valued occupations following neurological injury (Kubina et al., 2013). The elicitation module of PPA may be particularly helpful in allowing patients to move away from individually focused goals to more ecologically valid occupational goals that promote social participation.

The therapists who used the elicitation module of PPA with the patients identified additional potential benefits. Not surprisingly, the therapists felt that project elicitation increased their understanding of the patients' occupations and values. Of interest is that the therapists reported that an awareness of the patients' personal projects helped them to identify meaningful occupations that could be used immediately as modalities to work toward important, long-term goals.

Limitations

Two major limitations of this study are noted. First, as stated above, the lack of a control group makes it difficult to ascribe any goal changes to personal project elicitation. The time between the pre COPM and the post COPM varied from 1 day to 28 days. Between COPM administrations, the participants may have attempted occupational goals established with the initial COPM and realized these goals were not immediately attainable (Turner et al., 2008). Experience trying activities related to their COPM goals may have led to increased self-awareness and changed goals. Furthermore, time between the COPM administrations may have allowed for reflection and establishment of more meaningful goals. Second, the small sample size makes any estimates of changes quite unreliable.

Conclusion

The results of this small study support further investigation of the usefulness of personal project elicitation in occupational therapy. The finding that the participants changed their COPM goals to reflect a social component is intriguing and warrants further investigation. Further work should be carried out to determine the usefulness of the PPA in identifying potential therapeutic occupations. In addition, future studies should be done to begin to identify patient characteristics that could be used to identify patients for whom addition of the elicitation module of PPA to evaluations would be useful. Finally, further research should include explicit study of the patients' perceptions of personal project elicitation and its potential contribution to their rehabilitation. A controlled study with a qualitative component is recommended as the next step in this program of research.

We concluded that the elicitation module of PPA may help some patients set more meaningful goals. Personal project elicitation may be a helpful tool for the therapists to get to know their patients better and to identify meaningful occupations to help them work toward their occupational goals.

DOI: 10.15453/2168-6408.1186

Mary Egan

University of Ottawa, megan@uottawa.ca

Lori Scott-Lowery

The Ottawa Hospital, lslowery@toh.on.ca

References

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Appendix

General Instructions for Personal Projects Elicitation

We are interested in studying the impact that your injury has had on the kinds of activities you do and the concerns that you have. All of us have a number of activities and concerns, or personal projects, at any given time that we think about, plan for, carry out, and sometimes (though not always) complete.

Some projects may be focused on achievement (for example, getting a job), others on the process (raising my children); they may be things we choose to do or things we have to do; they may be things we are working toward or things we are trying to avoid. Projects may be related to any aspect of your daily life, work, your relationships, home, leisure, and community, among others. Please think of projects in this broad way.

Here are some examples of projects:

Clean out the basement

Worry about my kids

Learn more about my ancestors

Exercise more often

Meet some new people

Organize my finances

Plan an outing

I would like you to think back to a week before your injury, and tell me about some of the most important or personally meaningful projects that you were working on at that time. To start, please take a few minutes to think about some of the important personal projects and activities you were working on in the week before your injury. For each project, please note whether you have completed it, you are still working on it, you are not working on it but you are still interested in pursuing it, or whether you are no longer interested in it.

Next, I would like you to think about your current projects.

Finally, I would like you to tell me about the projects you hope to work on in the future.
Table 1
Participant Characteristics

                                     N = 10

Men (%)                              5 (50)
Women (%)                            5 (50)
Average age in years (mean, range)   40.7 (16.0, 21-62)
Preinjury employment/study
  Working (%)                        8 (80.0)
  Studying (%)                       2 (20.0)
Postinjury employment/study
  Working (%)                        0 (0.0)
  Studying (%)                       0 (0.0)

Table 2
Changes in COPM Goals Following the PPA Per
Participant

                               Mean (SD)      Range

Additional goals               0.20 (0.63)    0-2
Changed goals                  1.20 (1.14)    0-4
Reworded goals                 0.60 (1.26)    0-4
More specific goals            0.25 (0.46)
Less specific goals            0.5 (1.07)
Importance rating              0.13 (0.22)
Confidence in achieving        0.19 (0.49)
Days between administrations   16 days (1-28
(range)                        days)

Note. COPM: Canadian Occupational Performance Measure, PPA:
Personal Projects Analysis, SD: Standard Deviation.
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Author:Egan, Mary; Scott-Lowery, Lori
Publication:Open Journal of Occupational Therapy
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
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