Needs due to limitations in activity performance caused by pain intensity
Interrupted occupational performance
Given up occupational performance
Performs occupations with more effort
Increased pain in occupational performance
Having difficulties with perceived expectations
Is dependent on others for occupational performance
Stopped performing occupations
Needs for knowledge
Information about pain
Information about new ways of handling occupations
Needs for education to manage
Is tense/stressed due to pain
Has difficulties adjusting to changes
Is in the workplace during sick leave
Needs due to discouragement/adjustment difficulties caused by pain intensity
Is supported to regain occupations
Stopped performing occupations
Has temporal rest/work/leisure imbalance
Needs changes in the home or workplace
Needs due to dependency
Is dependent on others
Needs due to work-related factors
Needs changes in the home or workplace
Would like to be in the workplace during sick leave
It is well described in the literature that different perspectives give different results regarding needs assessment. Occupational therapists, patients, and caregivers often assess needs differently (e.g., Kersten et al. 2000; Müllersdorf 2002; Müllersdorf and Söderback 2002; Preston et al. 2012) which can be manifested in various ways. For instance, needs assessed by caregivers and palliative care inpatients resulted in the caregivers identifying quantitatively more unmet needs than the patients did (Jeyasingam et al. 2008). Another study showed disagreement on a qualitative base, but with results opposite to that of the former reference. Home residents self-perceived their potential to rehabilitation higher than their carers did (Chang et al. 2011).
It is quite obvious that professionals and patients assess differently. Patients ought to be experts on their own needs (Burnett and Yerxa 1980; Bunston et al. 1994) and should be expert on their needs. As Wiersma (2006, p. 118) puts it: “The perspective of the beholder is important because discrepancies between the patient and the professional are substantial with respect to number as well as type of needs.” On the other hand, professionals have accumulated experience from treating many patients with the same problem, and could therefore have valuable insight to add to the patient’s perspective. Patients often desire to participate in planning their rehabilitation but it is crucial to remember that all patients are individuals and may react differently to the same issue although having the same diagnosis (Peoples et al. 2011). Shared decision making about treatment may be preferred by some patients while others prefer to transfer the decision to health-care professionals (Proot et al. 2000). A client-centered perspective combined with a recommended (Polit and Beck 2004) and straightforward elucidation would be to use several perspectives representing expertise from different angles on the same topic—a form of triangulation. That is, the patient, the professional and the relatives share their experience using assessment instruments and come to an agreed realistic solution through discussions/interviews.
It is not only between the patient and the professionals that incongruence occurs, differences also arise between professionals. Perceptions of rehabilitation needs have been found to be poorer among general practitioners (Kersten et al. 2000) and physicians in cancer care (Ganz 1990) compared to other professionals. This fact necessitates that all members of the rehabilitation team play an active role in identifying the patient’s needs in their specific area of expertise.
Aspects of Needs
The guidance on how needs should be defined for clients/patients to be candidates for occupational therapy and for being included as a part of occupational therapists’ professional knowledge should be sought in relation to the meaning of occupational therapy. Occupation as a core concept in occupational therapy gives an indication of interpretation and choice. First of all, unmet needs must be a priority in all health care and rehabilitation . What needs should occupational therapists focus on? Basic needs—as in having a decent life—and functional needs—defined as being able to do one’s job—(Benn and Peters 1964) are probably the obvious choices for occupational therapists. Unresolved and/or unexpressed needs (Bunston et al. 1994) are also appropriate for occupational therapists as daily life tasks often seem to remain unresolved or unexpressed by clients or health-care professionals in general.
The most common and recommended ways of collecting data for a needs assessment are: questionnaires, interviews, observations, and/or self-reports from key informants using, e.g., Critical Incident Techniques (Boberg et al. 2003; Bruhn and Trevino 1979; Soriano 1995). The choice of method depends highly on what instrument the assessor will have access to. Studies have shown that a combination of an assessment instrument with a discussion/interview has a more valid outcome than if an assessment instrument alone is used (Liu et al. 2005). It is also worth remembering that the highest predictor of a successful rehabilitation is the patient’s own belief in effective treatments and the ability to learn to cope with the situation (Jensen et al. 2000; Man et al. 2004).
Requirements for Needs Assessment and Target Groups
All assessments should be done systematically and with the appropriate focus, using instruments that are valid and reliable. However, practice does not always live up to theory, which gives us some issues to deal with.
The OTNA was first developed for the selection of patients with cancer at cancer clinics for participation in occupational therapy and rehabilitation (Söderback and Hammersly 1997; Söderback et al. 2000). OTNA was further developed for patients with chronic pain who were seeking primary health care. Two different versions—one for occupational therapists (OTNA-P(ain)) and one for the patients (OTNA-P(ain-Patients); Müllersdorf and Söderback 2000; Müllersdorf 2002) were developed based on the knowledge that professionals and patients often assess the same needs differently and which was also proved for chronic pain. In addition, the OTNA-P includes suggested interventions based on a literature review of proposed occupational therapy interventions for patients with chronic pain (Müllersdorf 2002).
Another approach to needs assessment is to use general but still patient-specific instruments developed for use in OT. These instruments are not developed to assess needs based on a specific population. Instead, they are based on general aspects of occupation for various populations such as mental health , pain or stroke , or on problems as an effect of symptoms typical for different populations. A well-known, used worldwide, psychometrically tested, valid, and reliable instrument is the Canadian Occupational Performance Measure (Carswell et al. 2004). It uses a dialog technique between the patient and the occupational therapist to set the goals for desired occupations. With this instrument, it is possible to unite different perspectives, i.e., the patient’s and the professional’s, and to set goals to meet the patient’s needs.
Assessment instruments based on a framework, a model, or a theory are also available. An example is the foundation of the variety of assessment instruments that belong to the Model of Human Occupation (MOHO; Kielhofner 1992). Among these, 14 are now available on the Internet (www.uic.edu/depts/moho/). The instruments have been translated to different languages and are therefore accessible for many occupational therapists. Examples of instruments based on MOHO are the Assessment of Communication and Interaction Skill (ACIS) covering three domains (physicality, information exchange, and relations) to describe communication and interaction skills; Child Occupational Self-Assessment (COSA) is aimed at assessing children’s perceptions and perceived importance of everyday activities; and the Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) which structures information about occupational participation among adolescents or adult populations.
The abovementioned instruments are just a selection from the set of needs assessment instruments available and described in the literature. However, a vast variety of assessment tools for different populations and purposes exist. In the UK, for example, 117 different assessment tools are recognized for use by occupational therapists (www.connectingforhealth.nhs.uk/systemsandservices/data/snomed). The choice should, as mentioned before, be considered thoroughly beforehand regarding how the results from the data collection will be used.
Rehabilitation Medicine Needs Assessment Instruments
A rehabilitation needs assessment for patients with disabilities, developed by Kersten et al. (2000), is a general tool assessing met needs and satisfaction with the services provided with the aim of detecting and prioritizing unmet needs in rehabilitation . The Perceived Limitations in Activities and Needs Questionnaire (PLAN-Q) was developed based on the theoretical framework of Kirshner and Guyart (1985). It is aimed at assessing rehabilitation needs among patients with neuromuscular disorders (Pieterse et al. 2008).
Care/Caring Needs Assessment Instruments
Needs assessment instruments for care, including the area of daily occupations, are also available. Examples of such instruments are the Needs Assessment Tool (NAT) for use in palliative care (Waller et al. 2010), and the Camberwell Assessment of Needs (CAN; Phelan et al. 1995) for use in mental health . The Care Needs Assessment Pack for Dementia (CarenapD) was constructed to detect needs among individuals with dementia and to specify the care required to meet the detected needs (Chung 2006). An instrument for determining older people’s need for nursing care is the Nursing Needs Assessment Tool (Slater and McCormack 2005). An assessment tool for planning the discharge of patients from the hospital to the home or nursing home is the Discharged Patients’ Enquiry Questionnaire. Here, outcome is assessed in accordance with the interplay of factors in the discharge process, the patients’ perceptions of the quality of the care, and his/her needs for compensatory help with the performance of daily activities (Söderback 2008).