The Canadian Occupational Performance Measure (COPM) in Denmark – state of the art
By Anette Enemark, BaOT, MsOT, ph.d., lektor, Københavns Professionshøjskole, anel@kp.dk
The COPM is a widely used tool in occupational therapy, and Anette Enemark has done a significant amount of research in this Canadian measurement. In this paper, she shares the questions that made research in the COPM her mission - and she provides the answers she found.
My story
In 1997, I came to the occupational therapy program in Copenhagen from a position as clinical supervisor on a hospital characterized by a body-oriented focus in our occupational therapy intervention. The following year in 1998, the World Federation of Occupational Therapists held the world congress in Ottawa, Canada, where some of my colleagues participated. The returnees' enthusiasm for the newly developed Canadian occupational therapy models and the associated measurement, the Canadian Occupational Performance Measure (COPM), was contagious.
However, although the COPM presented us with an occupational perspective, and thus seemed like the perfect fit for occupational therapy, I was skeptical. Therefore, as I began my further education, the COPM became the focus of my research. Till now, I together with a range of collaborators have published my Ph.D. thesis and 12 papers, of which the majority contributes to this paper (1–9) (see Table A).
Thus, in this paper, I will answer the four questions, I raised:
1)Does the COPM promote a client-centered practice – do we find the client’s occupational wishes?
The off-spring of the COPM was the Canadian development work of describing occupational therapy practice, which began in the late 1970s (10–12). Recognizing that occupational therapists' focus has to be on people's occupations, the Canadian occupational therapists were aware that client involvement was necessary: We cannot know what is important to other people without asking them.
To describe a therapeutic relationship, that involved the clients, the Canadian occupational therapists introduced the American psychotherapist Carl Rogers' approach from the 1950s-60s: Client-centered practice (CCP) (13).
Today, CCP form the core of the occupational therapy profession (11,14,15). In the meantime, an overall paradigmatic shift in the health-care sector har contributed place user involvement at the top of the agenda (11,14,15). As our study of COPM shows that COPM promotes a CCP (see Table 1), it only makes the use more current (1–4).
Table 1. The positive effects on client-centered practice achieved when using the COPM (View as PDF here).
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The occupational therapist achieves |
Achievements in the practice |
The client achieves |
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to get to know the client better, and gain increased awareness of the client's preferences, needs and values |
a possibility for goalsetting based on the client's own wishes for his or her (occupational) life |
improved self-insight |
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greater professional self-insight and pride due to the occupational perspective that is inherent in the COPM |
a partnership with the clients that lasts throughout the intervention process |
increased motivation and commitment to the intervention |
However, our study showed that the positive effects presuppose certain approaches from the occupational therapist, the client and conditions provided by the institution where the intervention takes place. For instance, a narrow expert- and body-based focus contradicts the use of COPM (3,15).
Re 1) Yes, the COPM promotes CCP by providing insight into the client's life and the opportunity for collaboration on what the client finds significant. COPM provides an opportunity to see and recognize the client's perception of their own occupational life. Valid use of COPM requires commitment and willingness to listen to the client's wishes.
2)Does the COPM facilitate an occupational perspective – what do we learn from the COPM?
The COPM is based on the Canadian Model of Occupational Performance and Engagement, CMOP-E (11), which describes how a person's occupational performance and engagement takes place in an interplay that involves the person's physical, affective and cognitive performance components, in the client’s physical, social, institutional and cultural environment (11).
The levels of occupational performance are described in the Canadian taxonomy TCOP (see table 2). As COPM is expected to identify issues in the client’s occupational performance, the identified issues should arise from the top two levels of TCOP (11).
Table 2. The Taxonomic Code of Occupational Performance (TCOP) (16).s.55
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Occupation, significant activity that is performed regularly, provides structure, and is given meaning and value. Divided into self-care, productive, leisure activities, e.g. dressing |
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Activity, a set of tasks with a specific end goal, eg putting on a shirt |
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Task, a set of actions that gives a specific result, e.g. to button buttons |
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Action, handling a set of functions that form a recognizable pattern, to grasp the button |
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Performance component, body functions, e.g. flexing fingers |
Our studies showed that the COPM is capable of identifying what is significant for the individual client (5,6). However, more than 1/3 of the identified problems according to TCOP were identified at the levels of task and body function according to the descriptions of the TCOP, which is not which is not compatible with the intention of COPM (6).
In our studies, the occupational therapists employed in the municipal institutions most often identified occupational performance issues from the upper levels of TCOP and a willing-ness to let the client determine the direction of the intervention. Conversely, occupational therapists employed in a hospital who considered themselves experts found it unethical and not trustworthy to empower the client to determine the course of treatment, and they often identified issues at the lower levels of the TCOP. Thus, it seemed evident that the individual occupational therapist's attitude towards the client's ability to participate and their level of their occupational issues had the greatest impact on the use of COPM (1,2,4,6).
Re 2) With COPM, we find the client's values and wishes for occupational engagement. COPM can identify the client’s unique occupational issues and promote an occupational perspective, but the use and results depend on the individual occupational therapist's attitude.
3)Can the COPM be used by all to all – what promotes / inhibits the use?
According to the manual the use of the COPM is not limited to occupational therapists. Likewise, it should be applicable for all clients.
Classically, the utility of measurements are examined by asking about users' experiences (17). As COPM involves two 'users' - the occupational therapist who administer the COPM and the client who responds - our studies include both the professionals and the clients.
Our study of COPM's utility as an interdisciplinary visitation assessment tool (with occupational therapists and physiotherapists) showed that the occupational therapists in general had a greater understanding of the concept of occupation and CCP and therefore demonstrated the most profound understanding of the COPM (13).
In our other studies we included both experienced occupational therapists and students. The studies documented that the COPM promotes an occupation-based goalsetting that gave the clients hope, and that an adequate use of the COPM requires: sufficient time, good interviewing skills, interdisciplinary agreement on and support for CCP, a physical environment that enables an occupation-based intervention (10–13).
We included a wide range of clients (in terms of gender, age and diseases) from many occupational therapy practice sites to find out if the COPM can be used for 'everyone'. Again, we found that use depended more on the occupational therapist's understanding of the COPM than on the client and setting (10–13).
Clients' perceptions of the COPM have only been described in a few studies (18). In ours, they said that they felt seen when the COPM was administered - sometimes for the first time even in long-term intervention processes (12,13).
Re 3) Yes, the COPM can be used by anyone who understands and commits to an occupational perspective and CCP. Several prerequisites for proper use were identified, e.g.: good interviewing skills, time and institutional support. The COPM seems to be applicable to all clients, but difficulties have been seen in clients with impaired disease recognition, impaired motivation, and impaired cognition.
4)Is the Danish version of the COPM valid and reliable?
As Danish occupational therapy becomes academicized, the demands for scientific based practice increase - also related to our measurements.
Based on COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments), an international multidisciplinary initiative focusing on the assessment of measurement tools (19), we have examined COPM's validity (if the tool measures what is intended), reliability (if the tool is trustworthy) and responsiveness (if the tool can provide ‘true’ changes).
The validity studies showed a lack of correlation with the other tools. The data on the clients’ occupational performance issues obtained with COPM are unique; the COPM measures something else than occupational competencies (measured by the OSA), well-being (measured by the WHO-5), and health (measured by the EQ-5L-5D) (16).
As mentioned, the validity of the COPM depends on if we identify the issues that is intended when administering the COPM, namely problems with the performance of occupations, cf. CMOP-E and TCOP (15,16). However, our study of the COPM’s utility showed that the COPM’s validity is challenged if the occupational therapist's desire to concretize an occupational problem e.g. attire, as it may lead to the identification of issues on lower levels in TCOP e.g. the task level identifying to button buttons (11,15).
When we pointed out these validity problems (12), in 2019 (3) the Appendix A of the COPM manual was removed, as it gave examples of COPM-identified problems that included tasks (scarce buttons) or actions (turning in bed) (30).
Our reliability study showed stable moderate correlations that were independent of the occupational therapists' experience, type of institution, and client diagnosis. The correlations were higher when data were collected by one occupational therapist (intra-rater-reliability) instead of by two (inter-rater-reliability). An occupational therapist can thus use COPM as a reliable measurement before and after an intervention (20). In the study, a coincidence in the score of +/- 3 points were seen. This means, that a difference between two COPM scores of less than 3 points may be an expression of measurable uncertainty (20).
Two factors made the scoring difficult. One was, if the occupational therapist found it difficult or strange to 'put numbers on' the perception of occupational performance. The other occurred if the client was to score the performance of an occupation they had not performed in their current condition (11,12,20).
Our responsiveness study confirmed that the COPM can document an obtained difference between the 1st and 2nd score. However, the above-mentioned measurement uncertainty was confirmed by a Minimal Important Change, ie. how big a difference does express a true change, of approx. 3.5 points. Previously it has been stated in the COPM manual that a change of 2 points was significant. However, since this is not be confirmed, this statement has also been removed from the current version of the manual (21).
Re 4) Yes, the Danish version of COPM is valid and reliable. The validity depends on the occupational therapist requesting occupational performance issues (cf. CMOP-E and TCOP), in which case unique data are obtained. Reliability depends on the client only scoring on occupations he or she has performed. The change achieved is credible when the difference exceeds approx. 3.5 points.
More questions
Research has contributed answers to my questions. I hope that the answers can improve the use of COPM in Denmark. But within the occupational therapy profession there are many more questions that require answers. Hopefully, my story can inspire other occupational therapists to take the path of research and contribute to answering other questions.
Table 3. The recommended use of Canadian Occupational Performance Measure (COPM)
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The COPM |
Recommendations |
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The COPM was developed in a collaboration between Canadian researchers and occupational therapists from practice in order to enable to assess and document changes in a client’s occupational performance based on a client-centered focus. Occupations are identified within self-care, what we need to do to get ready for the day, productivity, what we are obliged to do, and leisure, what we do out of desire. COPM is administered in 5 steps. However, it is perfectly legal to do only some of the steps, and you can also divide the interview into several times. |
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Step 1. Identification of occupational performance problems (OPP) |
DO NOT ask for problems but ask what the client would like to be able to do that they are currently unable to do satisfactorily. The three areas from the Canadian Model of Occupational Performance and Engagement: self-care, productivity, leisure should be assessed by general questions. Do only spend time finding the client's OPPs, do not investigate them further and do not start the intervention here - you do that later |
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Step 2. The client assesses the importance of each OPP |
Use the importance scale from 1-10, where 1 represents ‘not at all important’ while 10 represents ‘extremely important’, use the scores to talk with the clients about why the occupation is important. Tell the client that it is totally legit to have many important occupations
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Step 3. The client prioritizes of up to 5 OPP |
The client prioritizes up to 5 OPP they want to improve. It may be some the client does not score to 10, but still want to improve. If there is a discrepancy between the client's score and priorities, it is perfectly legal to ask why |
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Step 4. The client scores the prioritized OPP in relation to performance and satisfaction with performance |
It is easiest to score both performance and satisfaction for one OPP at a time. Both on scales from 1-10, where 1 represents 'I cannot perform at all' / 'I am not at all satisfied' while 10 represents 'I can perform extremely well' / 'I am extremely satisfied'. The occupational therapist must find it possible to score to send that signal to the client. |
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5. The prioritized OPP are reassessed |
The re-score should preferably take place WITHOUT either the client or the occupational therapist seeing the original score. The change must exceed 3.5 points to represent a ‘true’ change. |
Table 4. Overview of the studies on which the article is based
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Publication |
Participants and method |
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1. Enemark Larsen, A. 2019. PhD afhandling: Exploring client-centred practice in Danish occupational therapy and the influence of the Canadian Occupational Performance Measure. |
In addition to articles 3-5, my PhD also contains a questionnaire survey of Danish occupational therapists' experience of client-centered practice (15). |
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2. Enemark Larsen A, Carlsson G. Utility of the Canadian Occupational Performance Measure as an admission and outcome measure in interdisciplinary community-based geriatric rehabilitation. Scandinavian Journal of Occupational Therapy. 2012;19:204–13 |
Eighteen occupational therapists and physiotherapists from fitness centers in the municipality of Copenhagen participated in a study that tested COPM's ability as an interdisciplinary visitation tool. 124 geriatric clients were included and completed pre-tests, while 95 completed post-tests. All the participating therapists subsequently answered a questionnaire about their experiences of using COPM. COPM's ability to demonstrate change was analyzed with the Wilcoxon Signed-Rank Test. Any difference in data obtained between occupational therapists and physiotherapists was analyzed with Pearson’s chi-squared test. Data from the questionnaire on the therapists' experience of COPM's applicability were analyzed with descriptive statistics and a four-step modified grounded theory method. |
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3. Enemark Larsen A, Morville A-L, Hansen T. Translating the Canadian Occupational Performance Measure into Danish. Scandinavian Journal of Occupational Therapy. 2019; 26(1):33-45 |
A multi-step translation process was completed. This included professional translators and bilingual occupational therapists, as well as 15 occupational therapists and 37 of their clients who participated in pilot testing and were subsequently interviewed (cognitive debriefing). This also included an assessment of the Content validity index (CVI). Participants came from both somatic and psychiatric hospitals and municipal institutions. Finally, the tool was translated back into English and approved by the Canadian authors. |
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4. Enemark Larsen A, Rasmussen BA, Christensen JR. Enhancing a client-centred practice with the Canadian Occupational Performance Measure, A Scoping Review. Occupational Therapy International. 2018;595630:1-11 |
A five-step scoping review was conducted. First, a search strategy was designed, this was implemented in relevant databases, identified material both published and unpublished was accepted and data extracted from it. Finally, data from the 12 included studies were analyzed with a qualitative content analysis. |
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5. Enemark Larsen A, Winge CJ, Christensen JR. Clinical Utility of the Danish Version of the Canadian Occupational Performance Measure. Scandinavian Journal of Occupational Therapy. Epub ahead of print. June 2019 |
Qualitative interviews with 16 occupational therapists from three regional hospitals (two somatic and one psychiatric) and three municipal institutions (three somatic). The transcribed interviews were analyzed with a content analysis. |
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6. Enemark Larsen A, Wehberg S, Christensen JR. The validity of the Danish version of the Canadian Occupational Performance Measure (COPM). Occupational Therapy International, Special edition. April 2020, id 1309104 |
The validity of COPM was examined by 11 occupational therapists in a cross-sectional study in which 112 clients with varying diagnoses were included from a hospital and a municipal rehabilitation center. The validity was examined by comparing COPM with the Occupational Self-Assessment (OSA), the World Health Organization's Well-Being Index (WHO-5), and EuroQol's five domains, five levels questionnaire (EQ-5D-5L). These data were analyzed using descriptive statistical methods as well as the Spearman's correlation coefficient. Further comparison between COPM and OSA was conducted by other 11 occupational therapists respectively. from eight from practice and three associate professors from occupational therapy educations. These occupational therapists compared items from COPM with the standardized items from OSA. The agreement in their responses was analyzed using Fleiss' kappa statistics. After which the priority items from COPM and from OSA were compared with descriptive static methods (frequencies). |
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7. Enemark Larsen A, Wehberg S, Christensen JR. Looking into the content of the Canadian Occupational Performance Measure (COPM) – a Danish cross-sectional study. Occupational Therapy International, Special edition. May 2020, id 9573950 |
The identified activity problems from the 112 clients who participated in the validity study were included in a further assessment of COPM's content validity. In two studies, the activity problems were assessed. First in relation to which area of activity of COPM (self-care, productivity and leisure), they could be classified in. Next, six occupational therapy lecturers from occupational therapy educations in Denmark, participated in a determination of the taxonomic level (determined by Taxonomic Code of Occupational Performance, TCOP) the priority activity problems. |
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8. Enemark Larsen A, Wehberg S. Christensen JR. The reliability of the Danish Version of the Canadian Occupational Performance Measure. Submitted August 2020 |
151 clients from two hospitals and two municipal rehabilitation institutions were interviewed twice with COPM, either by the same occupational therapist (intra-rate reliability) or by two different occupational therapists (inter-rate reliability). Data were analyzed with intraclass correlation coefficients (ICC), coefficient of repeatability (CR) and Bland-Altman plots. |
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9. Enemark Larsen A, Christensen JR, Wehberg S. The responsiveness of the Danish Version of the Canadian Occupational Performance Measure. Working paper.
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Test-retest was performed with COPM, WHO-5, EQ-5D-5L-Vas on 88 clients included from a somatic hospital and two municipal rehabilitation institutions. In the post-test, clients were further asked to answer two questions (anchor questions answered on a 6-step likert scale ranging from much better performance / very satisfied to much worse performance / very dissatisfied) regarding their immediate experience of improvement in relation to ., how well they experience being able to perform their activities, and how satisfied they are with the change experienced. The intention was to assess COPM's ability to capture change in clients' activity performance, including determining a cut-off point, to indicate the least achieved change, which is an expression of a real change (Minimal Important Change MIC). Data were analyzed by calculating the mean change in COPM and then correlating it with the obtained changes in WHO-5 and EQ-5D-5L (Spearman's correlation). In addition, box-plots, scatterplots and receiver operating characteristic curves (ROC) were used |
Referencer
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1. Enemark Larsen A, Carlsson G. Utility of the Canadian Occupational Performance Measure as an admission and outcome measure in interdisciplinary community-based geriatric rehabilitation. Scand J Occup Ther. 2012;19(2):204–13.
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