Doi: 10.5014/ajot.2013.67s47

Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S1 Evolution of This Document . . . . . . . . . . . . . . . . . . . . .S2 Vision for This Work . . . . . . . . . . . . . . . . . . . . . . . . . .S3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S3 Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S4 Occupations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S5 Client Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S7 Performance Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . .S7 Performance Patterns . . . . . . . . . . . . . . . . . . . . . . . . . .S8 Context and Environment . . . . . . . . . . . . . . . . . . . . . . .S8 Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S9 Overview of the Occupational Therapy Process . . . . .S10 Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . . . . .S13 Intervention Process . . . . . . . . . . . . . . . . . . . . . . . . .S14 Targeting of Outcomes . . . . . . . . . . . . . . . . . . . . . . . .S16 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S17 Tables and Figures Table 1 . Occupations . . . . . . . . . . . . . . . . . . . . . . . . .S19 Table 2 . Client Factors . . . . . . . . . . . . . . . . . . . . . . . .S22 Table 3 . Performance Skills . . . . . . . . . . . . . . . . . . . .S25 Table 4 . Performance Patterns . . . . . . . . . . . . . . . . . .S27 Table 5 . Context and Environment . . . . . . . . . . . . . . .S28 Table 6 . Types of Occupational Therapy Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S29 Table 7 . Activity and Occupational Demands . . . . . . .S32 Table 8 . Approaches to Intervention . . . . . . . . . . . . . .S33 Table 9 . Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . .S34 Exhibit 1 . Aspects of the Domain of Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S4 Exhibit 2 . Process of Occupational Therapy Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . .S10 Exhibit 3 . Operationalizing the Occupational Therapy Process . . . . . . . . . . . . . . . . . . . . . . . . . . . .S17 Figure 1 . Occupational Therapy’s Domain . . . . . . . . . .S5 Figure 2 . Occupational Therapy’s Process . . . . . . . . .S10 Figure 3 . Occupational Therapy Domain and Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S18 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S36 Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S40 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S40 Appendix A . Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S41 Appendix B . Preparation and Qualifications of Occupational Therapists and Occupational Therapy Assistants . . .S47

Copyright © 2014 by the American Occupational Therapy Association .

When citing this document the preferred reference is: Ameri- can Occupational Therapy Association . (2014) . Occupational therapy practice framework: Domain and process (3rd ed .) . American Journal of Occupational Therapy, 68(Suppl . 1), S1– S48 . http://dx .doi .org/10 .5014/ajot .2014 .682006

The American Journal of Occupational Therapy S1 Copyright © 2014 by the American Occupational Therapy Association.

PREFACE The Occupational Therapy Practice Framework: Domain and Process, 3rd edi- tion (hereinafter referred to as “the Framework”), is an official document of the American Occupational Therapy Association (AOTA). Intended for oc- cupational therapy practitioners and students, other health care professionals, educators, researchers, payers, and consumers, the Framework presents a sum- mary of interrelated constructs that describe occupational therapy practice.

Definitions

Within the Framework, occupational therapy is defined as the therapeutic use of everyday life activities (occupations) with individ- uals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy practitioners use their knowl- edge of the transactional relationship among the person, his or her en- gagement in valuable occupations, and the context to design occupa- tion-based intervention plans that facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and social interaction) needed for successful participation. Occupational therapy practitioners are concerned with the end result of participation and thus enable engagement through ad- aptations and modifications to the environment or objects within the environment when needed. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non–disability-related needs. These services include acquisition and preservation of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. (adapted from AOTA, 2011; see Appendix A for additional definitions in a glossary)

When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2006). Occupational therapists are responsible for all aspects of oc- cupational therapy service delivery and are accountable for the safety and ef- fectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2009). Addi- tional information about the preparation and qualifications of occupational therapists and occupational therapy assistants can be found in Appendix B.

OCCUPATIONAL THERAPY PRACTICE

FRAMEWORK: Domain & Process 3rd Edition

S2 March/April 2014, Volume 68(Supplement 1) Copyright © 2014 by the American Occupational Therapy Association.

Evolution of This Document

The Framework was originally developed to articulate occupational therapy’s distinct perspective and contri- bution to promoting the health and participation of per- sons, groups, and populations through engagement in occupation. The first edition of the Framework emerged from an examination of documents related to the Occu- pational Therapy Product Output Reporting System and Uniform Terminology for Reporting Occupational Therapy Services (AOTA, 1979). Originally a document that re- sponded to a federal requirement to develop a uniform reporting system, the text gradually shifted to describing and outlining the domains of concern of occupational therapy.

The second edition of Uniform Terminology for Oc- cupational Therapy (AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and published in 1989. The document focused on delineating and defining only the occupational performance areas and occupational performance components that are addressed in occupa- tional therapy direct services. The third and final revision of Uniform Terminology for Occupational Therapy (AOTA, 1994) was adopted by the RA in 1994 and was “expanded to reflect current practice and to incorporate contextual as- pects of performance” (p. 1047). Each revision reflected changes in practice and provided consistent terminology for use by the profession.

In Fall 1998, the AOTA Commission on Practice (COP) embarked on the journey that culminated in the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002b). At that time, AOTA also published The Guide to Occupational Therapy Practice (Moyers, 1999), which outlined contemporary practice for the profession. Using this document and the feedback received during the review process for the third edition of Uniform Terminology for Occupational Therapy, the COP proceeded to develop a document that more fully articu- lated occupational therapy.

The Framework is an ever-evolving document. As an official AOTA document, it is reviewed on a 5-year cycle for usefulness and the potential need for further refinements or changes. During the review period, the COP collects feedback from members, scholars, authors, practitioners, and other stakeholders. The revision pro- cess ensures that the Framework maintains its integrity while responding to internal and external influences that should be reflected in emerging concepts and advances in occupational therapy.

The Framework was first revised and approved by the RA in 2008. Changes to the document included

refinement of the writing and the addition of emerging concepts and changes in occupational therapy. The ra- tionale for specific changes can be found in Table 11 of the second edition of the Framework (AOTA, 2008, pp. 665–667).

In 2012, the process of review and revision of the Framework was initiated again. Following member re- view and feedback, several modifications were made to improve flow, usability, and parallelism of concepts within the document. The following major revisions were made and approved by the RA in the Fall 2013 meeting:

• The overarching statement describing occupa- tional therapy’s domain is now stated as “achiev- ing health, well-being, and participation in life through engagement in occupation” to encom- pass both domain and process.

• Clients are now defined as persons, groups, and populations.

• The relationship of occupational therapy to orga- nizations has been further defined.

• Activity demands has been removed from the do- main and placed in the overview of the process to augment the discussion of the occupational ther- apy practitioner’s basic skill of activity analysis.

• Areas of occupation are now called occupations. • Performance skills have been redefined, and Table

3 has been revised accordingly. • The following changes have been made to the in-

terventions table (Table 6): o Consultation has been removed and has been in-

fused throughout the document as a method of service delivery.

o Additional intervention methods used in prac- tice have been added, and a clearer distinction is made among the interventions of occupations, activities, and preparatory methods and tasks.

o Self-advocacy and group interventions have been added.

o Therapeutic use of self has been moved to the process overview to ensure the understanding that use of the self as a therapeutic agent is inte- gral to the practice of occupational therapy and is used in all interactions with all clients.

• Several additional, yet minor, changes have been made, including the creation of a preface, reorga- nization for flow of content, and modifications to several definitions. These changes reflect feedback received from AOTA members, educators, and other stakeholders.

The American Journal of Occupational Therapy S3 Copyright © 2014 by the American Occupational Therapy Association.

INTRODUCTION

The purpose of a framework is to provide a structure or base on which to build a system or a concept (American Heritage Dictionary of the English Language, 2003). The Occupational Therapy Practice Framework: Domain and Process describes the central concepts that ground occu- pational therapy practice and builds a common under- standing of the basic tenets and vision of the profession. The Framework does not serve as a taxonomy, theory, or model of occupational therapy.

By design, the Framework must be used to guide occupational therapy practice in conjunction with the knowledge and evidence relevant to occupation and oc- cupational therapy within the identified areas of prac- tice and with the appropriate clients. Embedded in this document is the profession’s core belief in the positive relationship between occupation and health and its view of people as occupational beings. Occupational therapy practice emphasizes the occupational nature of humans and the importance of occupational identity (Unruh, 2004) to healthful, productive, and satisfying living. As Hooper and Wood (2014) stated,

A core philosophical assumption of the profes- sion, therefore, is that by virtue of our biological endowment, people of all ages and abilities require occupation to grow and thrive; in pursuing occu- pation, humans express the totality of their being, a mind–body–spirit union. Because human exis- tence could not otherwise be, humankind is, in essence, occupational by nature. (p. 38) The clients of occupational therapy are typically

classified as persons (including those involved in care of a client), groups (collectives of individuals, e.g., families, workers, students, communities), and populations (col- lectives of groups of individuals living in a similar lo- cale—e.g., city, state, or country—or sharing the same or like characteristics or concerns). Services are pro-

vided directly to clients using a collaborative approach or indirectly on behalf of clients through advocacy or consultation processes.

Organization- or systems-level practice is a valid and important part of occupational therapy for several reasons. First, organizations serve as a mechanism through which occupational therapy practitioners provide interventions to support participation of those who are members of or served by the organization (e.g., falls prevention program- ming in a skilled nursing facility, ergonomic changes to an assembly line to reduce cumulative trauma disorders). Sec- ond, organizations support occupational therapy practice and occupational therapy practitioners as stakeholders in carrying out the mission of the organization. It is the fidu- ciary responsibility of practitioners to ensure that services provided to organizational stakeholders (e.g., third-party payers, employers) are of high quality and delivered in an efficient and efficacious manner. Finally, organizations em- ploy occupational therapy practitioners in roles in which they use their knowledge of occupation and the profession of occupational therapy indirectly. For example, practi- tioners can serve in positions such as dean, administrator, and corporate leader; in these positions, practitioners sup- port and enhance the organization but do not provide cli- ent care in the traditional sense.

The Framework is divided into two major sections: (1) the domain, which outlines the profession’s purview and the areas in which its members have an established body of knowledge and expertise, and (2) the process, which describes the actions practitioners take when providing services that are client centered and focused on engagement in occupations. The profession’s under- standing of the domain and process of occupational therapy guides practitioners as they seek to support cli- ents’ participation in daily living that results from the dynamic intersection of clients, their desired engage- ments, and the context and environment (Christiansen

Vision for This Work Although this revision of the Framework represents the latest in the profession’s efforts to clearly articulate the occupational therapy domain and process, it builds on a set of values that the profession has held since its found- ing in 1917. This founding vision had at its center a profound belief in the value of therapeutic occupations as a way to remediate illness and maintain health (Sla- gle, 1924). The founders emphasized the importance of

establishing a therapeutic relationship with each client and designing a treatment plan based on knowledge about the client’s environment, values, goals, and de- sires (Meyer, 1922). They advocated for scientific prac- tice based on systematic observation and treatment (Dunton, 1934). Paraphrased using today’s lexicon, the founders proposed a vision that was occupation based, client centered, contextual, and evidence based—the vi- sion articulated in the Framework.

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& Baum, 1997; Christiansen, Baum, & Bass-Haugen, 2005; Law, Baum, & Dunn, 2005).

Although the domain and process are described sepa- rately, in actuality they are linked inextricably in a transac- tional relationship. The aspects that constitute the domain and those that constitute the process exist in constant inter- action with one another during the delivery of occupational therapy services. In other words, it is through simultane- ous attention to the client’s body functions and structures, skills, roles, habits, routines, and context—combined with a focus on the client as an occupational being and the practitioner’s knowledge of the health- and performance- enhancing effects of occupational engagements—that out- comes such as occupational performance, role competence, and participation in daily life are produced.

Achieving health, well-being, and participation in life through engagement in occupation is the overarching statement that describes the domain and process of oc- cupational therapy in its fullest sense. This statement acknowledges the profession’s belief that active engage- ment in occupation promotes, facilitates, supports, and maintains health and participation. These interrelated concepts include

• Health—“a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (World Health Organiza- tion [WHO], 2006, p. 1).

• Well-being—“a general term encompassing the total universe of human life domains, including physical, mental, and social aspects” (WHO, 2006, p. 211).

• Participation—“involvement in a life situation” (WHO, 2001, p. 10). Participation naturally oc- curs when clients are actively involved in carrying out occupations or daily life activities they find pur- poseful and meaningful. More specific outcomes of

occupational therapy intervention are multidimen- sional and support the end result of participation.

• Engagement in occupation—performance of oc- cupations as the result of choice, motivation, and meaning within a supportive context and environ- ment. Engagement includes objective and subjec- tive aspects of clients’ experiences and involves the transactional interaction of the mind, body, and spirit. Occupational therapy intervention focuses on creating or facilitating opportunities to engage in occupations that lead to participation in desired life situations (AOTA, 2008).

Domain Exhibit 1 identifies the aspects of the domain, and Fig- ure 1 illustrates the dynamic interrelatedness among them. All aspects of the domain, including occupations, client factors, performance skills, performance patterns, and context and environment, are of equal value, and together they interact to affect the client’s occupational identity, health, well-being, and participation in life.

Occupational therapists are skilled in evaluating all aspects of the domain, their interrelationships, and the client within his or her contexts and environments. In ad- dition, occupational therapy practitioners recognize the importance and impact of the mind–body–spirit con- nection as the client participates in daily life. Knowledge of the transactional relationship and the significance of meaningful and productive occupations form the basis for the use of occupations as both the means and the ends of interventions ( Trombly, 1995). This knowledge sets occupational therapy apart as a distinct and valuable ser- vice (Hildenbrand & Lamb, 2013) for which a focus on the whole is considered stronger than a focus on isolated aspects of human function.

OCCUPATIONS

CLIENT FACTORS

PERFORMANCE SKILLS

PERFORMANCE PATTERNS

CONTEXTS AND ENVIRONMENTS

Activities of daily living (ADLs)*

Instrumental activi- ties of daily living (IADLs)

Rest and sleep Education Work Play Leisure Social participation

Values, beliefs, and spirituality

Body functions Body structures

Motor skills Process skills Social interaction skills

Habits Routines Rituals Roles

Cultural Personal Physical Social Temporal Virtual

*Also referred to as basic activities of daily living (BADLs) or personal activities of daily living (PADLs).

Exhibit 1. Aspects of the domain of occupational therapy. All aspects of the domain transact to support engagement, participation, and health. This exhibit does not imply a hierarchy.

The American Journal of Occupational Therapy S5 Copyright © 2014 by the American Occupational Therapy Association.

The discussion that follows provides a brief expla- nation of each aspect of the domain. Tables included at the end of the document provide full descriptions and definitions of terms.

Occupations

Occupations are central to a client’s (person’s, group’s, or population’s) identity and sense of competence and have particular meaning and value to that client. Several definitions of occupation are described in the literature and can add to an understanding of this core concept:

• “Goal-directed pursuits that typically extend over time, have meaning to the performance, and in- volve multiple tasks” (Christiansen et al., 2005, p. 548).

• “The things that people do that occupy their time and attention; meaningful, purposeful activity; the personal activities that individuals choose or need to engage in and the ways in which each in- dividual actually experiences them” (Boyt Schell, Gillen, & Scaffa, 2014a, p. 1237).

• “When a person engages in purposeful activities out of personal choice and they are valued, these clusters of purposeful activities form occupations

(Hinojosa, Kramer, Royeen, & Luebben, 2003). Thus, occupations are unique to each individual and provide personal satisfaction and fulfillment as a result of engaging in them (AOTA, 2002b; Pierce, 2001)” (Hinojosa & Blount, 2009, pp. 1–2).

• “In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are ex- pected to do” (World Federation of Occupational Therapists, 2012).

• “Activities . . . of everyday life, named, organized, and given value and meaning by individuals and a culture. Occupation is everything people do to occupy themselves, including looking after them- selves . . . enjoying life . . . and contributing to the social and economic fabric of their communities” (Law, Polatajko, Baptiste, & Townsend, 1997, p. 32).

• “A dynamic relationship among an occupational form, a person with a unique developmental struc- ture, subjective meanings and purpose, and the

Social Participation

Education

Play

Work

ADLs

Leisure

IADLs

Rest/ Sleep

Client Factors

Performance Skills

Performance Patterns

Figure 1. Occupational therapy’s domain. Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.

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resulting occupational performance” (Nelson & Jepson-Thomas, 2003, p. 90).

• “Occupation is used to mean all the things peo- ple want, need, or have to do, whether of physical, mental, social, sexual, political, or spiritual nature and is inclusive of sleep and rest. It refers to all aspects of actual human doing, being, becoming, and belonging. The practical, everyday medium of self-expression or of making or experiencing meaning, occupation is the activist element of hu- man existence whether occupations are contem- plative, reflective, and meditative or action based” (Wilcock & Townsend, 2014, p. 542).

The term occupation, as it is used in the Framework, refers to the daily life activities in which people engage. Occupations occur in context and are influenced by the interplay among client factors, performance skills, and performance patterns. Occupations occur over time; have purpose, meaning, and perceived utility to the cli- ent; and can be observed by others (e.g., preparing a meal) or be known only to the person involved (e.g., learning through reading a textbook). Occupations can involve the execution of multiple activities for comple- tion and can result in various outcomes. The Framework identifies a broad range of occupations categorized as activities of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation (Table 1).

When occupational therapy practitioners work with clients, they identify the many types of occupations clients engage in while alone or with others. Differences among persons and the occupations they engage in are complex and multidimensional. The client’s perspective on how an occu- pation is categorized varies depending on that client’s needs and interests as well as the context. For example, one person may perceive doing laundry as work, whereas another may consider it an IADL. One group may engage in a quiz game and view their participation as play, but another group may engage in the same quiz game and view it as education.

The ways in which clients prioritize engagement in selected occupations may vary at different times. For ex- ample, clients in a community psychiatric rehabilitation setting may prioritize registering to vote during an elec- tion season and food preparation during holidays. The unique features of occupations are noted and analyzed by occupational therapy practitioners, who consider all components of the engagement and use them effectively as both a therapeutic tool and a way to achieve the tar- geted outcomes of intervention.

The extent to which a person is involved in a particular occupational engagement is also important. Occupations

can contribute to a well-balanced and fully functional life- style or to a lifestyle that is out of balance and characterized by occupational dysfunction. For example, excessive work without sufficient regard for other aspects of life, such as sleep or relationships, places clients at risk for health prob- lems (Hakansson, Dahlin-Ivanoff, & Sonn, 2006).

Sometimes occupational therapy practitioners use the terms occupation and activity interchangeably to de- scribe participation in daily life pursuits. Some scholars have proposed that the two terms are different (Chris- tiansen & Townsend, 2010; Pierce, 2001; Reed, 2005). In the Framework, the term occupation denotes life en- gagements that are constructed of multiple activities. Both occupations and activities are used as interventions by practitioners. Participation in occupations is consid- ered the end result of interventions, and practitioners use occupations during the intervention process as the means to the end.

Occupations often are shared and done with others. Those that implicitly involve two or more individuals may be termed co-occupations (Zemke & Clark, 1996). Care- giving is a co-occupation that involves active participation on the part of both the caregiver and the recipient of care. For example, the co-occupations required during parent- ing, such as the socially interactive routines of eating, feed- ing, and comforting, may involve the parent, a partner, the child, and significant others (Olson, 2004); the activities inherent in this social interaction are reciprocal, interac- tive, and nested co-occupations (Dunlea, 1996; Esdaile & Olson, 2004). Consideration of co-occupations supports an integrated view of the client’s engagement in context in relationship to significant others.

Occupational participation occurs individually or with others. It is important to acknowledge that clients can be independent in living regardless of the amount of assistance they receive while completing activities. Clients may be considered independent when they perform or di- rect the actions necessary to participate, regardless of the amount or kind of assistance required, if they are satisfied with their performance. In contrast with definitions of independence that imply a level of physical interaction with the environment or objects within the environment, occupational therapy practitioners consider clients to be independent whether they perform the component activ- ities by themselves, perform the occupation in an adapted or modified environment, use various devices or alterna- tive strategies, or oversee activity completion by others (AOTA, 2002a). For example, people with a spinal cord injury who direct a personal care assistant to assist them with their ADLs are demonstrating independence in this essential aspect of their lives.

The American Journal of Occupational Therapy S7 Copyright © 2014 by the American Occupational Therapy Association.

Occupational therapy practitioners recognize that health is supported and maintained when clients are able to engage in home, school, workplace, and com- munity life. Thus, practitioners are concerned not only with occupations but also with the variety of factors that empower and make possible clients’ engagement and participation in positive health-promoting occupa- tions (Wilcock & Townsend, 2014).

Client Factors

Client factors are specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations (Table 2). Client factors are affected by the presence or absence of illness, disease, deprivation, disability, and life experiences. Although cli- ent factors are not to be confused with performance skills, client factors can affect performance skills. Thus, client factors may need to be present in whole or in part for a person to complete an action (skill) used in the execution of an occupation. In addition, client factors are affected by performance skills, performance patterns, contexts and environments, and performance and participation in activities and occupations. It is through this cyclical rela- tionship that preparatory methods, activities, and occu- pations can be used to affect client factors and vice versa.

Values, beliefs, and spirituality influence a person’s motivation to engage in occupations and give his or her life meaning. Values are principles, standards, or qualities considered worthwhile by the client who holds them. Be- liefs are cognitive content held as true (Moyers & Dale, 2007). Spirituality is “the aspect of humanity that refers to the way individuals seek and express meaning and pur- pose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the sig- nificant or sacred” (Puchalski et al., 2009, p. 887).

Body functions and body structures refer to the “phys- iological function of body systems (including psycho- logical functions) and anatomical parts of the body such as organs, limbs, and their components,” respec- tively (WHO, 2001, p. 10). Examples of body functions include sensory, musculoskeletal, mental (affective, cog- nitive, perceptual), cardiovascular, respiratory, and en- docrine functions. Examples of body structures include the heart and blood vessels that support cardiovascular function (for additional examples, see Table 2). Body structures and body functions are interrelated, and oc- cupational therapy practitioners must consider them when seeking to promote clients’ ability to engage in desired occupations.

Moreover, occupational therapy practitioners un- derstand that, despite their importance, the presence,

absence, or limitation of specific body functions and body structures does not necessarily ensure a client’s success or difficulty with daily life occupations. Occu- pational performance and various types of client fac- tors may benefit from supports in the physical or so- cial environment that enhance or allow participation. It is through the process of observing clients engaging in occupations and activities that occupational therapy practitioners are able to determine the transaction be- tween client factors and performance and to then create adaptations and modifications and select activities that best promote enhanced participation.

Client factors can also be understood as pertaining to individuals at the group and population level. Al- though client factors may be described differently when applied to a group or population, the underlying tenets do not change substantively.

Performance Skills

Various approaches have been used to describe and catego- rize performance skills. The occupational therapy literature from research and practice offers multiple perspectives on the complexity and types of skills used during performance.

Performance skills are goal-directed actions that are observable as small units of engagement in daily life oc- cupations. They are learned and developed over time and are situated in specific contexts and environments (Fisher & Griswold, 2014). Fisher and Griswold (2014) categorized performance skills as motor skills, process skills, and social interaction skills (Table 3). Various body structures, as well as personal and environmen- tal contexts, converge and emerge as occupational per- formance skills. In addition, body functions, such as mental, sensory, neuromuscular, and movement-related functions, are identified as the capacities that reside within the person and also converge with structures and environmental contexts to emerge as performance skills. This description is consistent with WHO’s (2001) In- ternational Classification of Functioning, Disability and Health.

Performance skills are the client’s demonstrated abilities. For example, praxis capacities, such as imitat- ing, sequencing, and constructing, affect a client’s mo- tor performance skills. Cognitive capacities, such as per- ception, affect a client’s process performance skills and ability to organize actions in a timely and safe manner. Emotional regulation capacities can affect a client’s abil- ity to effectively respond to the demands of occupation with a range of emotions. It is important to remember that many body functions underlie each performance skill.

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Performance skills are also closely linked and are used in combination with one another as a client en- gages in an occupation. A change in one performance skill can affect other performance skills. Occupational therapy practitioners observe and analyze performance skills to understand the transactions among client fac- tors, context and environment, and activity or occupa- tional demands, which support or hinder performance skills and occupational performance (Chisholm & Boyt Schell, 2014; Hagedorn, 2000).

In practice and in some literature, underlying body functions are labeled as performance skills and are seen in various combinations such as perceptual–motor skills and social–emotional skills. Although practitioners may focus on underlying capacities such as cognition, body structures, and emotional regulation, the Framework defines performance skills as those that are observable and that are key aspects of successful occupational par- ticipation. Table 3 provides definitions of the various skills in each category.

Resources informing occupational therapy practice related to performance skills include Fisher (2006); Po- latajko, Mandich, and Martini (2000); and Fisher and Griswold (2014). Detailed information about the ways performance skills are used in occupational therapy prac- tice may be found in the literature on specific theories and models such as the Model of Human Occupation (Kielhofner, 2008), the Cognitive Orientation to Daily Occupational Performance (Polatajko & Mandich, 2004), the Occupational Therapy Intervention Process Model (Fisher, 2009), sensory integration theory (Ayres, 1972, 2005), and motor learning and motor control the- ory (Shumway-Cook & Woollacott, 2007).

Performance Patterns

Performance patterns are the habits, routines, roles, and rituals used in the process of engaging in occupations or activities that can support or hinder occupational per- formance. Habits refers to specific, automatic behaviors; they may be useful, dominating, or impoverished (Boyt Schell, Gillen, & Scaffa, 2014b; Clark, 2000; Dunn, 2000). Routines are established sequences of occupations or activities that provide a structure for daily life; rou- tines also can promote or damage health (Fiese, 2007; Koome, Hocking, & Sutton, 2012; Segal, 2004).

Roles are sets of behaviors expected by society and shaped by culture and context; they may be further con- ceptualized and defined by a client (person, group, or population). Roles can provide guidance in selecting oc- cupations or can be used to identify activities connected with certain occupations in which a client engages.

When considering roles, occupational therapy practi- tioners are concerned with how clients construct their occupations to fulfill their perceived roles and identity and whether their roles reinforce their values and beliefs. Some roles lead to stereotyping and restricted engage- ment patterns. Jackson (1998a, 1998b) cautioned that describing people by their roles can be limiting and can promote segmented rather than enfolded occupations.

Rituals are symbolic actions with spiritual, cultural, or social meaning. Rituals contribute to a client’s iden- tity and reinforce the client’s values and beliefs (Fiese, 2007; Segal, 2004).

Performance patterns develop over time and are in- fluenced by all other aspects of the occupational therapy domain. Practitioners who consider clients’ performance patterns are better able to understand the frequency and manner in which performance skills and occupations are integrated into clients’ lives. Although clients may have the ability to engage in skilled performance, if they do not embed essential skills in a productive set of engagement patterns, their health, well-being, and participation may be negatively affected. For example, a client who has the skills and resources to engage in appropriate grooming, bathing, and meal preparation but does not embed them into a consistent routine may struggle with poor nutrition and social isolation. Table 4 provides examples of performance patterns for persons and groups or populations.