Running head: CONCEPTUAL PRACTICE MODEL 1

Conceptual Practice Model

Gretchen Kempf
The University of Scranton














CONCEPTUAL PRACTICE MODEL 2
Introduction
This paper focuses on the application of a conceptual practice model to the actual practice
of occupational therapy (OT). This paper will identify a client and then apply a conceptual
practice model to organize therapy based on that clients needs. Using the guidance provided by
conceptual practice model, appropriate treatment interventions to address the clients
occupational performance deficits, and an intervention activity to assist the client in
accomplishing short term and long-term goals, will be selected, described and examined.
Vignette of Client
Barbara, a 63-year-old female, was admitted to Pine Run Rehabilitation Health Center
(Pine Run) in Doylestown, Pennsylvania, in July of 2013, to recover from surgery on her right
foot. The surgery was necessitated by a severely infected wound which led to sepsis. Barbara
lives in a trailer with her husband, Mark, their twenty-one year-old son and their dog. Mark
works long hours and her son is a full time student at a local community college, leaving Barbara
alone in the house for much of the day. Her past medical history includes hypertension and
diabetic neuropathy. The neuropathy has left Barbara with nerve damage in her feet and she has
a loss of feeling from the ankles down. Barbaras OT evaluation at Pine Run revealed deficits in
various aspects of OTs domain, including deficits in the areas of occupation, client factors,
performance skills, and performance patterns.
Occupational Performance Deficits
As a result of her surgery, Barbaras weight-bearing status was decreased to non-weight
bearing; however, due to safety concerns about her use of crutches, it was determined that she
should be restricted to the use of a wheelchair for functional mobility purposes. This restrictive
weight-bearing status resulted in Barbara being completely dependent on others for bathing,
CONCEPTUAL PRACTICE MODEL 3
dressing, and functional mobility. This dependency, in turn, made Barbara feel despondent over
her sudden inability to perform the important roles that she had taken on in her life. As a wife
and as mother, her dependence weighed heavily on both her and her family. She had feelings of
anxiety and guilt when she was unable to complete simple tasks such as dressing herself
independently.
Barbara presented with multiple sensory dysfunctions and pain deficits, the most
prominent of which were proprioceptive dysfunction and her insensitivity to pain in her feet. For
example, because Barbara had no feeling in her surgically-treated foot, she would have no
awareness of when her foot would get stuck in the wheels of her wheelchair or when she would
bump it into walls while maneuvering her wheelchair. This lack of ability to feel pain caused her
to have a decreased awareness of her body position in space. Repeated blunt trauma to her foot,
of which she was not consciously aware, interfered with the healing of the surgical site.
Barbaras reduced weight-bearing status also left her unable to complete activities of
daily living (ADL) and instrumental activities of daily living (IADL), which include personal
hygiene and grooming, showering, dressing, functional mobility, toilet hygiene, home
management, and meal preparation (American Occupational Therapy Association [AOTA],
2008).
Clients Stated Goals
Barbara was highly motivated to regain control of her roles as a mother, wife, and pet
owner, and was able to easily identify OT goals. She had been independent in self-care tasks
prior to her hospitalization and felt it was extremely important that she could complete these
tasks on her own so that she did not become a burden to her family. In view of the fact that she
would be home alone for much of the day, she also identified transfers and functional mobility as
CONCEPTUAL PRACTICE MODEL 4
important areas for therapy to address. In addition, she felt strongly that home management and
pet care were two important IADLs that treatment should address.
Conceptual Practice Models
The Model of Human Occupation (MOHO) and the Biomechanical Model are two
possible conceptual practice models that can be used to organize therapy in Barbaras case. The
MOHO is a conceptual practice model that recognizes that there are numerous factors beyond
motor, cognitive, and sensory impairments that impede everyday occupations. Conversely, the
Biomechanical Model is a conceptual practice model that deals with problems related to
musculoskeletal capacities that underlie functional motion in everyday occupation (Kielhofner,
2009).
In Barbaras case, the MOHO would be applicable since it addresses her motivation for
occupation, routine patterning of occupational behavior, the nature of skilled performance, and
the influence of environment on occupation (Forsyth & Kielhofner, 2003; Kielhofner, 2009). The
MOHO also would assist in the structuring of treatment in a manner that incorporates the
opinions of the entire interdisciplinary team as to how to best return Barbara to maximum
functioning levels in her valued life roles.
By assessing Barbaras performance capacities, underlying physical limitations can be
identified (i.e., Barbaras reaching and bending abilities are being hindered when she is confined
to her wheelchair). These performance capacities can be addressed through the Biomechanical
Model. It is important to use the guiding principles of the Biomechanical Model in selecting
effective treatment interventions that develop Barbaras ability to perform ADL and IADL in a
new and different way than before. The Biomechanical Model will ensure that the areas of
CONCEPTUAL PRACTICE MODEL 5
strength and endurance are adequately addressed, both of which Barbara needs to provide
stability and mobility for performing her daily activities.
Theoretical Core Constructs and Intervention Guidelines
The MOHO serves as a source of concrete guidelines for determining what information
should be collected and as a source of conceptual guidelines for interpreting and integrating the
collected information into treatment sessions (Kielhofner, Burke & Igi, 1980). This conceptual
practice model is ultimately concerned with an individuals participation and adaptation in life
occupations (Kielhofner, 2009). It emphasizes that there are two main concepts to keep in mind
when assessing the relationship among an individuals inner characteristics (such as volition,
habitation, and performance capacity). The first is that human behavior is dynamic and context-
dependent (Forsyth & Kielhofner, 2003). This means that a persons inner-characteristics interact
directly with the environment in order to determine how that individual performs. The second
concept emphasizes that occupation is essential to self-organization. The occupations in which
an individual engages shape not only who that individual is, but also their motivational levels--
by creating ongoing experiences and maintaining or altering their performance capacities
(Forsyth & Kielhofner, 2003). The MOHO is a conceptual practice model that looks past
impairments and enables clients to recognize and focus on meaningful occupations in their lives.
As a client-centered and task-oriented approach, treatment is focused on the following goals:
determining what kinds of occupational engagement will enable the client to change and
determining what types of therapeutic strategies will be needed to support the client in the
desired change (Kielhofner, 2009).
Occupational therapists must gather and analyze important information about a client and
about the therapy process before using a conceptual practice model (Kielhofner, 2009). Through
CONCEPTUAL PRACTICE MODEL 6
evidence-based research, the strengths and weakness of a conceptual practice model have been,
and continue to be, identified. These research results enable therapists to have a better
understanding of when it is appropriate to use a particular model. Lee, Kielhofner, and Fisher
(2008) conducted an extensive review of the MOHO and its use in OT by current practitioners
and enumerated factors that would support the models use in a particular case and factors that
present a barrier to its use. The authors of this study determined that the strengths of the MOHO
were that it facilitated client-centered practice, structured treatment planning, and enhanced
professional identity and competence (Lee, Kielhofner & Fisher, 2008). According to Kielhofner
(2009), the model also addresses broad issues faced by clients with a variety of impairments and
is applicable throughout the life course of the client. Due to this broad umbrella, the MOHO has
been used with clients at many different levels of functioning and with many different diagnoses
(Kielhofner, 2009). Lee, Kielhofner, & Fisher (2008) stated that the MOHO is very helpful when
addressing personal causation (thoughts and feelings about personal capacities and effectiveness
in performance of everyday activities), occupational participation, and occupational roles.
Occupational Therapy Assessments
The MOHO determines a clients occupational performance deficits through the use of
various assessments that must be selected depending on a clients specific needs (Lee, Kielhofner
& Fisher, 2008). Barbara had a successful occupational history that was threatened by her newly
sustained injury. She maintained many different important roles throughout her life.
Assessments, therefore, should focus on her role changes and probable physical limitations since
these would be central to her ability to adapt to her environment in a new way. Assessments such
as the Modified Interest Checklist, Role Checklist, and the Occupational Circumstances
Assessment-Interview and Rating Scale (OCAIRS) would be beneficial to incorporate into
CONCEPTUAL PRACTICE MODEL 7
Barbaras treatment. The Modified Interest Checklist allows therapists to gather information
about a clients interest in, and engagement in, sixty-eight activities, most of which are leisure
activities (Kielhofner, 2009). Like the Modified Interest Checklist, the Role Checklist allows
therapists to better understand a clients valued roles in order to produce OT goals that are client-
centered (Kielhofner, 2009). Information gathered from interviews conducted pursuant to the
OCAIRS allows therapists to assess client values, goals, personal causation, interests, habits,
roles, skills, readiness for change, and environmental impact on participation (Kielhofner, 2009).
These assessments could assist the occupational therapists in their selection of activities and
tasks that Barbara would value, could perform, and could successfully complete (Kielhofner,
2009).
Guiding Treatment Interventions
As emphasized in the MOHO, it is important to structure and orient treatment so that it
allows for client-centered interventions and goals. Occupational therapists have reported that the
MOHO allows them to easily articulate client needs to interdisciplinary teams and allows them to
have influence over client treatment and discharge plans (Lee, Taylor, Kielhofner & Fisher,
2008). Three dimensions of doing can be identified when utilizing the MOHO. These three
levels include: occupational participation, occupational performance, and occupational skills
(Kielhofner, 2009). Under this model, then, how well Barbara participates, performs, and
demonstrates skills will serve as the basis to guide all treatment intervention activities and to
address her volition, habituation, and performance capacities. A disability can greatly effect
habituation (a process whereby people organize their actions into patterns and routines), which
may cause individuals to feel like they have lost important roles and routines that give their life
familiarity, consistency and relative ease (Forsyth & Kielhofner, 2003; Kielhofner, 2009).
CONCEPTUAL PRACTICE MODEL 8
Long Term Goals and Short Term Goals
Keeping in mind the overarching concepts of the MOHO, the following long term goals
(LTG) and short-term goals (STG) were developed to address Barbaras inability to perform
ADL and IADL independently:
Long Term Goals
o Barbara will perform all functional transfers independently by the end of week 8.
o Barbara will increase her sense of self-efficacy by performing all ADL
independently by the end of week 8.
o Barbara will enhance habituation by completing simple meal preparation
independently by the end of week 8 to regain important life roles.
Short Term Goals
o By the end of week 4, Barbara will complete morning routine ADL with minimal
assistance to increase her sense of self-efficacy.
o By the end of week 4, Barbara will complete toilet transfers with minimal
assistance.
o By the end of week 4, Barbara will increase upper body strength to 5/5, to assist
with self-care tasks and functional mobility and to assist with confidence in
functional mobility and home management.
o By the end of week 4, Barbara will complete a simple meal preparation with
supervision to structure habituation and regain important roles.
Intervention Activity
The most appropriate intervention activity for Barbara would be one that is occupation-
based. An occupation-based activity allows the client to engage in client-directed occupations
CONCEPTUAL PRACTICE MODEL 9
that match identified goals (AOTA, 2008). To use occupations/activities in a therapeutic way, it
is essential that context or contexts, activity demands, and client factors are all taken into
consideration and reflect clients goals. The activity I have chosen for Barbara is a meal
preparation activity to help enhance her sense of self-efficacy by completing an activity that goes
hand-in-hand with her valued life roles as a mother and a wife. Preparing a meal that she would
typically prepare if she was at home not only allows Barbara to engage in an occupation that is
meaningful to her, but it allows her to build a sense of self-efficacy and it reassures her that, even
though she may be in a wheelchair, she will still be able to do the things she always has done.
This activity also will help set a pattern or routine for her day. Practicing preparing a meal will
allow Barbara to establish how much time she needs to allow for the preparation of a simple
meal while utilizing a wheelchair. Therapist and client should engage in a consultation process to
collaborate about identifying problem areas, creating possible solutions, trying possible
solutions, and altering them as necessary for greater effectiveness (AOTA, 2008, pp. 656).
Though this is a hands on activity, it is essential that the education process be incorporated into
the different kitchen tasks. This will allow the therapist to educate and provide vital information
about kitchen safety.
Theory-Focused Activity Analysis
The chosen activity will not only require Barbara to prepare a meal, but it will also
require her to gather the ingredients and necessary equipment beforehand. Gathering the
ingredients will allow Barbara to practice functional mobility in a small space (such as a kitchen)
at a wheelchair level. Once the gathering of ingredients and preparing of the meal is complete, it
would be ideal to have Barbaras husband and son come into the facility to enjoy the finished
product. Incorporating Barbaras family into treatment will help instill her roles and values.
CONCEPTUAL PRACTICE MODEL 10
Skills are goal-directed actions in which a person utilizes while performing an activity
(Kielhofner, 2009). In this activity, specific skills such as gathering, handling, and sequencing
are addressed. Motor skills such as moving her body and or task objects, may be difficult for
Barbara at a wheelchair level, especially if she was required to bend or reach for specific items.
To solve this problem, her environment would have to be altered to make sure the items she used
most frequently were easily accessible to her.
This activity touches on numerous important goals such as: functional mobility,
enhancing self-efficacy, structuring habituation in Barbaras roles as a mother and wife in the
kitchen, as well as strengthening and endurance. This activity also can be upgraded or
downgraded depending on the level of challenge desired. For example, the complexity level of
the meal or recipe selected for preparation can be altered or the activity could be broken into
smaller segments. The goal would be to build Barbaras confidence in her ability to complete the
entire sequence of required steps and tasks.
Conclusion
In sum, the MOHO is the most appropriate conceptual practice model to organize therapy
for Barbara because it explores volition, habituation, and performance capacity, and addresses
the involvement of those aspects in a dynamic relationship with the environment. Impacted by
her loss of roles and inability to perform valued occupations, Barbara felt that she would be
unable to resume her normal life since weight-bearing restrictions left her wheelchair bound.
The MOHO examines Barbaras life through personal causation, self-efficacy, and
values/interests in order to determine client-centered goals and interventions. Barbara would
benefit from occupation-based interventions to instill hope (and to provide motivation) that she
will be able to continue performing important occupations and roles even at a wheelchair level.
CONCEPTUAL PRACTICE MODEL 11
The Biomechanical Model identifies underlying problems that may impede on Barbaras ability
to complete new established routines and strategies to enable her to complete meaningful
occupations. Although these underlying impairments will not be the focus of treatment, they are
important to note and to address along the way to increase Barbaras ability to complete tasks as
independently and safely as possible.


















CONCEPTUAL PRACTICE MODEL 12
References
American Occupational Therapy Association. (2008). Occupational therapy practice framework:

Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683.
Kielhofner, G. (2009). Conceptual foundation of occupational therapy practice. (4 ed., pp. 108-
126). Philadelphia: F.A. Davis.
Kielhofner, G., Burke, J. P., & Igi, C. H. (1980). A model of human occupation, part 4:
Assessment and intervention. American journal of occupational therapy, 34(12),
777-788.
Forsyth, K., & Kielhofner, G., (2003). In Kramer, P. Editor Hinojosa, J. Editor & Royeen, C. B.
Editor (Eds.), Perspectives in human occupation: Participation in life. (45-58).
Lippincott Williams & Wilkins.
Lee, S. W., Taylor, R., Kielhofner, G., & Fisher, G. (2008). Theory use in practice: a national
survey of therapists who use the Model of Human Occupation. American Journal of
Occupational Therapy, 62(1), 106-117.