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assessment

Assessing the level of Creative Ability

The occupational therapist’s task is to assess and therefore identify the person’s level of creative ability. This includes identifying the person’s levels of motivation and action for each occupational performance area (personal management, work ability, social ability and use of free time), and importantly, who the person is.

The theory of creative ability considers how we become who we are through ‘doing’: doing and becoming. Therefore, who a person is, is tremendously important. The OT’s task is therefore to know the client and his/her current level of creative ability. This should be the focus of both assessment and intervention.

Assessment leads to identifying the overall level of creative ability: what the client is motivated towards and the behaviour and skills that he/she has and is motivated towards. Assessment also leads to identifying the phase of the level (therapist-directed, patient-directed or transitional). The phase indicates how far through the level the client has progressed and this is helpful for knowing how to provide intervention.

It is possible to be on a level and phase for one occupational performance area and on a different level and phase for another. You may know of clients whose ability to perform tasks (work ability) is good but their social ability (relating to people) is poor. This can be quite confusing and lead us to make wrong assumptions about the client’s reasons for this behaviour. The model helps occupational therapists through assessment, to understand these differences in performance and guides us in how to develop all occupational performance areas.
Assessing clients accurately takes practice supported by training – as for any skill, assessing creative ability is not something that can be learned from only reading a book or written guidance. With practice you are very likely to find that the assessment becomes easier – as for most things in life! After all, we understand that for our clients, the ability ‘to do’ comes through ‘doing’ and this applies to occupational therapists too!

Assessing creative ability involves:

• An assessment process
• Knowing what to assess
• Assessment methods
• Assessment recording tools

Assessment process
De Witt (2005) states that the assessment process is:
1) assessing level and phase in each occupational performance area;
2) concluding the level and phase of action in each occupational performance area;
3) presume the level of motivation.
Essentially, it is the actions of the client that indicate what he/she is motivated towards and this is why ‘presuming the level of motivation’ is the last stage of the process.

What do I assess?

The requirements of assessment are to assess creative ability with consideration of the client’s pathology and history, and know the client as an individual. Remember that creative ability is influenced by how one is ‘made up’ physically – the physical self (body), the psychological self (mind) and drive, influenced by the environment. Just as you would with any other model, the MCA asks you to know the client holistically, taking into consideration the influence of the environment on occupational performance.

Knowing the client includes an interest in who he/she is as a person: developed out of the past, is now in the present and may become in the future – who is he/she? What are his/her life roles; interests, responsibilities – occupational life? What has his/her life experience been – what opportunities has he/she had? (remember that creative ability develops in response to the demands of the environment). What direction will his/her life take post therapy – what will it consist of – what skills does this person need? How does he/she perceive themselves now – as a changed person who has been traumatised/ is ill / has problems? Aspirations? etc

With knowing the client in mind, the model guides our interest in the motivation and action (functional ability) of the client –creative ability. It is very important that you read the detailed descriptions of the levels of creative ability in the literature (i.e. de Witt 2005). The descriptions are effectively the ‘criteria’ against which you assess clients – you look to see which description of a level matches the client’s presentation. To be familiar with the levels as described in the literature is therefore essential.

Within the description of each level, there is mention of how a person on each level relates to materials, objects (and tools), people and situations (MOPS). If you think about what the world (in occupational terms) consists of, the occupational world can be seen as being made up of MOPS. When you read the descriptions of the levels, look for comment upon these – you will see that they are mentioned. A person’s ability to relate to MOPS improves up through the levels. The assessment identifies the client’s ability to relate to these. How the client relates to these is captured by considering the components of creative ability (table 1). Again, these are commented upon in the description of each level.

What is assessed in order to identify the person’s level of creative ability is listed in the left hand column of table 1. The right hand column provides prompts about these components.

Table 1: Motivation & Action: Components

Assessment Methods

As for all occupational therapy, whilst working with the model therapists should refer to notes, the family/carers and others involved in the client’s care for information on pathology, history, occupational circumstances and life etc, etc. In addition to this, the OT assesses by using the following assessment methods:
Observation
Interview                               
Social Evaluative Task        
Task assessment

Observation

Observation is the key assessment method, because you are looking for skills and behaviours that indicate a level of creative ability. Observation takes place every time you see the client - literally. The client’s appearance in terms of how he/she is dressed; how clean / shaven/make-up/washed /brushed hair; behaviour; social interaction etc., may give you an indication of the level. As for all practice, one must take into consideration the cultural norms for the client. However, societal norms and awareness of these (presenting oneself in particular ways/ to particular standards or expectations in certain situations), is an aspect for assessment. Social ability is often considered to be the easiest to assess from observation. Clients on the lower levels of creative ability are easiest to identify because the absence of skills is striking.

Refer to the descriptions in de Witt (2005) of the levels of creative ability. Each description refers to behaviours and skills one would expect to see in relation to personal management, work ability, use of free time and social ability. It is these that you ‘look for’.

Example: The person is willing to try doing things, but is unsure about how to do tasks and his/her skills are poor. Motivation is directed towards exploring the environment and his/her ability to influence it. Interaction is mainly for communication (rather than developing relationships) and conversation is superficial/has little depth. Personal management is fair – tries, and has an awareness of the need to be clean and properly dressed (norm awareness), but doesn’t always wash and dress him/herself well. Personal management is good with supervision. During free time, tends to act as a spectator and watches others. Can use very basic tools okay. Can use tools to make a product but because he/she is learning or re-learning how to use tools and perform tasks, the quality of the end product is often poor. Can manage tasks of 3-4 steps. The person has low frustration tolerance. The person is aware that different situations require different behaviours but has difficulty selecting the right behaviour. Becomes very anxious in unfamiliar situations and has difficulty controlling his/her emotional reactions.

This is a shortened description of a client on the level of Self-presentation (Explorative action)

Your own observations are important but you can also make use of the observations of others. These are after all, what is frequently documented in notes; presented and discussed at handovers and ward rounds etc. if working in an in-patient setting, remember that the nursing staff are able to observe clients at times outside of your working hours and can provide extremely valuable information. Family are also a valuable source of information. Think about asking colleagues questions about the client’s behaviours and skills as a means of gaining assessment information.

With practice, you may find that you can listen to discussions about a client in a ward round and from that information, get a sense of, or make initial assumptions about the level of the client.

Interview  

Just as you would normally do within your practice, the model asks you to find information from the client about his/her occupational life and performance. An interview guide is not provided by the model. If you use your own initiative, you should be able to identify questions that you could use as part of an interview.

As an occupational therapist, what do you usually ask your clients about their occupational lives?

Perhaps questions such as: how do you spend your time? Do you work? What is your social life like – do you have one? Are you close to your family or have close friends? What are your interests – do you have any hobbies – how do you spend your spare time? What are the most important aspects of your day to day life? What do you feel you are good at / have problems with? – and so on.

There is nothing in the model to suggest that these questions are not valid – they must be. As occupational therapists, we are all concerned with the same, core issues. That is, a person’s occupational performance in the occupational performance areas of their lives. If you wish to conduct a comprehensive interview, you may find MOHO useful – it is a model that many therapists use alongside the Model of Creative Ability.
Using the Model of Creative Ability, your thinking with regards to the questions you ask and the answers you receive will be influenced by the model’s theory - the answers will contribute to your understanding about the client’s level. The answers (and narratives if sought) will also of course, provide valuable information about the client as a person.

The way that the client gives his/her answers and responds to/engages in the interview, will also indicate his/her client level.

To interview or not to interview?

Clients that are on the level of Tone could not be interviewed as they cannot respond. Clients on the level of Self-differentiation are likely to be able to give limited information about themselves, and are most likely to be able to talk about their lives during ‘informal interviews’ or talking during activity. From Self-presentation upwards, it becomes increasingly possible for clients to engage in conversation and more formal interviews.

As therapists, you may talk informally about their day, what they like to do etc (informal ‘interview’), or you may be able to sit and have a lengthy discussion about a broad range of issues and for quite a long time (formal interview / gaining a client’s narrative about their lives and abilities). You judge how to handle an interview and whether it should be formal or informal ‘chat’.

What the model provides for you, is a means of making use of informal or casual conversations/interviews as well as the more planned, formal interviewing. How much a client can engage in a discussion and the quality of his interaction is an indicator of a level, as is how much effort you have to put in to make the conversation work/how much you have to adapt to the presentation of the client. This is a great aspect of the model: no experience or information is wasted. Everything about the client is made use of and very clearly assists with the assessment.

When to interview

It is not always possible to interview clients before seeing them participate in activity. It is necessary to decide when in the OT process to interview (or assess by other means) in response to the demands on us of the environment.

Some services such as acute assessment services, are pressured and have a rapid turnover. Time has to be used efficiently. Therefore, a formal interview may not be performed as the first part of the assessment, but informal means are used as time is spent with clients doing activities within the assessment and intervention process. Some therapists consider information from the ward round, notes, nurse handovers as ‘interview information’ which they later gain more detail on when they work with the client (Sherwood 2005).

Alternatively, therapists working in less pressured, longer term services may have more time with clients that are able to engage in an interview, and therefore spend more time with an interview. The model is flexible – the interview is used to the best effect according to the context.

The service context is likely to serve clients on particular levels of creative ability. Acute clients are likely to be on the lower levels of creative ability and therefore less likely to be able to engage in formal interviews, whilst community services are likely to serve higher levels – this makes the interview more possible. See ‘the model of creative ability in context’.

Social evaluative group & Task assessment

A social evaluative group is a group situation which presents opportunities for social interaction and awareness of others. OTs observe clients in social, group situations such as meal times, in lounge areas or within OT groups (as part of on-going assessment during intervention), to gain assessment information.

In terms of using a group specifically for assessment, many OTs perform a task assessment within a group setting and therefore use these two assessment methods at the same time.

The task assessment is considered a formal assessment which helps to identify the level. Whilst information from ward rounds, notes, interviews and observation leads to being able to ‘sense’ the level of creative ability, the task assessment helps to identify the level more clearly, or confirm that one’s assumptions were correct (or not).

The task assessment consists of facilitating the client’s participation in performing a task – the task needs to be an unfamiliar one. That is, a task that the client would not normally do. This is to minimise the assessment findings being skewed by clients using habituated skills – for example, putting on shoes is a task undertaken everyday and can be done almost without thinking about it. An unfamiliar task better assesses the components of creative ability. Central to the task assessment, is the assessment of task concept.

Task assessment within a group setting

Some OTs have an ‘assessment group’ in which one task is presented to all clients in the group.

An example is doing a simple collage on a simple, given theme. A range of basic materials and tools are provided. Although there be clients on different levels, this is a task that each could succeed at (it is assumed that clients on the level of Tone would not be brought into this assessment situation).

Although the collage activity is the same for all levels in the group, it has the potential to meet clients’ needs at a range of levels. Clients who are functioning on a lower level such as Self-Differentiation may need a lot of support to participate and succeed whilst clients on a higher level such as Imitative Participation may need demonstration of how to use some tools only, and be able to produce a good quality end product fairly independently. How the clients respond to the demands presented indicates a level of creative ability.

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