Hindawi Occupational erapy International Volume 2020, Article ID 3071405, 13 pages https://doi.org/10.1155/2020/3071405 Research Article Clinical Utility of the Canadian Occupational Performance Measure in Older Adult Rehabilitation and Nursing Homes: Perceptions among Occupational Therapists and Physiotherapists in Spain Elisabet Capdevila ,1 María Rodríguez-Bailón,2 Maria Kapanadze,1 and Mariona Portell3 1 Escola Universitària d’Infermeria i Teràpia Ocupacional de Terrassa (EUIT), Universitat Autònoma de Barcelona (UAB), C/de la Riba, 90, 08221 Terrassa, Spain 2 Department of Physiotherapy (Occupational Therapy), Facultad Ciencias de la Salud, Universidad de Málaga (UMA), C/Arquitecto Francisco Peñalosa, 3, 29017 Málaga, Spain 3 Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona (UAB), Campus de Bellaterra, Cerdanyola del Vallès, Spain Correspondence should be addressed to Elisabet Capdevila; elisabetcapdevila@euit.fdsll.cat Received 4 July 2020; Revised 25 October 2020; Accepted 16 November 2020; Published 10 December 2020 Academic Editor: Andrea Gl ssel Copyright © 2020 Elisabet Capdevila et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Scientific evidence that supports the psychometric properties of the COPM as a tool to enable personalized care has been repeatedly shown. However, there is a lack of studies about its utility within the Spanish research community. Aim. This qualitative study seeks to ascertain the perceptions of professionals from social health centers, nursing homes, and Spanish rehabilitation services about the clinical utility of the COPM as a standardized instrument. Methods. Thirty occupational therapists and physiotherapists in four focus groups discussed the experience of applying the COPM. The interpretative phenomenological analysis (IPA) incorporated a multidimensional model of clinical utility based on the components of acceptable, appropriate, accessible, and practicable by the clients, professionals, and institutions. Results and Discussion. The results of the utility study showed that the COPM helped professionals and clients to gain significant involvement in the treatment process. The COPM contributed to the process of further goal setting, occupation-based, and client-centered, thus achieving considerable satisfaction from the clients that had treatment. The professional training and adaptation to the geriatric population were vital to this process. Conclusion. The COPM is a useful and viable tool for the institutions that are supportive of a client-centered approach in the Spanish context. 1. Introduction The COPM uses a semistructured interview format directed at identifying the issues and problems of occupa- The Canadian Occupational Performance Measure (COPM) tional performance, as well as to detect changes in a client’s was designed to provide an occupation-focused outcome perception of improvement over time [4, 5]. It allows the cli- measure, and it defends the importance of the client being ents to identify and prioritize issues and problems of personal involved in the intervention process [1, 2]. This client- care, leisure, and productivity. This instrument takes into centered tool is seen as an important resource to cope with account the context, personal circumstances, and life history the complex problems derived from ageing and dependence of the client [6]. Besides showing prioritized problems, the situations in most countries [3]. initial administration of the COPM serves to guide clinical 2 Occupational Therapy International reasoning and helps to set the goals of the intervention ensur- patients and is core to the occupational therapy interventions ing that the clients’ needs are addressed and that they con- [26, 27]. Moreover, the need to provide evidence on the util- sider the occupation during the rehabilitation process [4, 5, ity of a practice centered on the client’s needs has been estab- 7]. In professional practice, this measure facilitates commu- lished [5]. nication between professionals and clients [1, 2]. Commonly, clinical utility means the usefulness of inter- The COPM has been translated into more than 35 lan- vention for, or in, clinical practice shown through clinical guages. One of the properties that has been studied in differ- efficacy studies or economic evaluations [28]. The judgments ent cultural adaptations of the COPM is its utility. We over instrument usefulness should involve multiple aspects undertook the narrative literature review on this topic that such as administration facility and time, simplicity of the for- included English and Spanish language studies published mat, clearness of the questions, and facility of the correction between 1994 and 2019. Using the databases CINAHL Com- and register. Besides, it should permit an interpretation of the plete, PubMed, ERIC, EBSCOhost, Scopus, APA PsycInfo, findings and the benefits of the use of the instrument as well MEDLINE, ScienceDirect, SciELO, Dialnet, and Redalyc, as an acceptance degree of the tool by the client or therapist we employed the following keyword searches: “Canadian among other aspects [9, 14]. Occupational Performance Measure”, “clinical utility”, “fea- Possibly, Smart’s (2006) multidimensional model of clin- sibility”, “rehabilitation”, “nursing homes”, and “elderly”. ical utility created a broader vision about the concept. It con- We found 52 articles of relevance to our study. By tuning ceptualizes clinical utility as a multidimensional judgment the search strategy, the final articles were reduced to 16. about the usefulness, benefits, and drawbacks of an interven- The initial studies about the clinical utility of the COPM tion, encompassing four components: acceptable, appropri- were performed by the authors that designed the instrument ate, practicable, and accessible. We propose to use this [2, 8]. Lately, various researchers published studies and model to judge the use of the COPM. The acceptable compo- reviews that considered a utility perspective at the benefits nent includes the opinion or degree of acceptance of the for the clients as well as the improvements in professional assessment or intervention by healthcare professionals practices, tied to different contexts and cultures [9–13]. Our (HCPs), clients, and their families in the organizational con- review of these studies showed (a) the COPM helps the client text or society in general. The opinions and perceptions of all to be aware of the existing problems and it helps to identify parties are essential information as well as the ethical, moral, the goals of the intervention, encouraging the participation or social implications. The appropriate component draws on and adherence of the client in the rehabilitation process [1, the effectiveness of the measure in terms of relevance and 12, 14]; (b) it helps in developing more individualized pro- adaptability to the intervention. The practicable component grams, as well as helping to improve clinical decision- has to do with a degree of functionality and suitability of making and facilitating interdisciplinary work teams [1, 4, the instrument in the particular practice context. Also, it 12–17]; (c) it is useful for institutions and as a measure for includes the need for capacity building and skill training of the outcomes at different levels of care, and at the same time, the healthcare personnel. The accessible component shows it empowers the user for better self-management [18]; (d) as economic considerations (license purchase, training, etc.) far as we know, no studies have been done on the COPM util- [28]. ity within the Spanish research community. In the Spanish context of elderly care and rehabilitation, 2. Purpose of Study the standardized assessment instruments used in the services of occupational therapy and physiotherapy are directed at The aim of this study was to analyze the clinical utility of the functional measurement only in terms of activities of daily COPM in interdisciplinary rehabilitation services of Spanish living (ADL), such as the Barthel Index (BI) or the Functional social healthcare centers and nursing homes, using Smart’s Independence Measure [19–21]. Moreover, these measures (2006) multidimensional model of clinical utility, specifically usually are focused on the performance components, and it (1) learning about the perceptions of occupational therapists is not clear that the client needs or wants to evaluate these and physiotherapists about the use of the COPM as a client- components [1]. The conventional approach to treatment centered measure, and if it was acceptable and appropriate for in Spain is static and protocolized and is not producing satis- clients, their families, therapists, and institutions, (2) docu- factory results, and these increase health and social care costs menting the experiences of the administration and usability [22, 23]. As a response to these concerns, Spanish healthcare of the measure in everyday practice, as well as the training professionals (HCPs) and researchers propose an alternative needs, exploring the practicable component, and (3) recol- conceptual framework that includes the active participation lecting and analyzing the opinions of the occupational thera- of clients [24, 25]. However, the switch to client-centered pists and the physiotherapists about the accessibility of the practice (CCP) requires an overhaul of the standardized measure. Besides, it was expected that the findings would and useful occupational therapy instruments that can be solve the cost-effectiveness balance as well as the viability of shared with the physiotherapists of the same center. Some the necessary resources. studies underline that the shared vision towards the improve- ment of the functional outcomes and shared use of the 3. Methods COPM significantly support the quality of the interdisciplin- ary work [16]. The client-centered approach means profes- 3.1. Ethics. The present research was approved by the CST sional praxis should emerge from the perspectives of Clinical Research Ethics Committee (CREC) of the Terrassa Occupational Therapy International 3 Table 1: Participant characteristics (N = 30). the participants’ characteristics. It was the first time that the participants were using the COPM in their services. M (SD) Variable Range or n 3.4. Procedure. The procedure was divided into three phases Age in years, M (SD) 35.5 (5.4) 27–44 throughout a year. In the first stage, the participants com- Gender pleted the training before the administration of the measure. Female 28 The 8-hour training included theoretical and fieldwork ses- Male 2 sions centered on the use and application of the COPM and Years working as an occupational the CCP. The process for the administration of this evalua- 14 (6.4) 4–25 tion tool is available in Table 2. The facilitators explained therapist/physiotherapist the occupational therapy basic terminology to physiothera- Work setting pists upon request. Additionally, the researchers enabled Older adult rehabilitation 15 the digital platform that included the reference materials, Home care 15 video examples, and interactive group forum to solve the Type of center doubts and questions throughout the investigation period. Private or semiprivate 22 In the second stage, the participants that provided a follow- Public 8 up of the clients administered the COPM to more than 10 Professional of them within the next eight months. In the third stage, the researchers invited the participants by email for the focus Occupational therapist 22 group discussions and grouped them by their availability. Physiotherapist 8 This stage included the data collection process. Health Consortium (Consorci Sanitari de Terrassa) via a res- 3.5. Data Collection. The research respected the main charac- olution dated July 18, 2016. It strictly followed the ethical cri- teristics of a focus group [31, 32]: (a) a semistructured inter- teria outlined, including participation consent from each view sustained in a group of people about the common theme center and participant. of interest proposed by the investigator, (b) the homoge- neous character of the group to eliminate communication barriers, (c) moderator-expert on the topic, and (d) manage- 3.2. Study Design. The current study follows the qualitative able size of the group (5–10 persons). research tradition framed by interpretative phenomenologi- Previously to the sessions, the researchers developed the cal analysis [29, 30]. The theoretical underpinnings of IPA semistructured interview script that included general themes belong to Husserl’s phenomenology and hermeneutics, com- to respect the IPA process when guiding the focus group bined with symbolic interactionism [29]. IPA is especially dynamics. All groups maintained the same structure. Each appropriate for healthcare research as it permits to relate focus group session started from the presentation of general findings to dominating theoretical perspectives and explore information, the goals of the sessions, and the dynamic ele- how clients, in our case, within focus groups, ascribe meaning ments (the group norms and confidentiality, the open turns, to their experiences in their interaction with the practice the importance of the free expression of the opinions to be environment. Besides, this type of analysis acknowledges that able to establish the interactive dialogues within the groups, the researcher’s engagement carries an interpretative ele- etc.). Subsequently, the facilitators encouraged the partici- ment, even more if the principal investigator or research pants to reflect on three core aspects around the concept of assistants are part of the focus groups [29, 31]. In this study, clinical utility by (1) writing about three themes and visualiz- the phenomenon of utility was investigated in depth, based ing them to facilitate thematic tracking throughout the ses- on emerging themes from data, and later on interpreted by sion and (2) moderating the free opinion discussions and Smart’s conceptual framework [28]. The focus group tech- open interactive dialogues, emphasizing the importance of nique was chosen to guide the qualitative data recollection individual opinions. These three core themes or aspects were design [31]. aimed to fit the specific objectives of the study: (1) the consid- eration of the pros and cons about the use of the instrument 3.3. Study Sample. The participants were recruited through (acceptable and appropriate components), (2) the process of the professional association of Catalonia by email. The prin- learning during the implementation (practicable component), cipal investigator requested professionals to express their and (3) future expectations (accessible component). Table 3 motivation for training in the use of the COPM and research shows the related questions that guided the focus groups. participation. After, the interested researchers undertook two Each session lasted approximately 90 minutes. Video informative sessions open to occupational therapists and recording and voice recording were done with the consent physiotherapists of the area. A total of 30 healthcare profes- of the focus group participants. Researcher HCPs codified sionals (HCPs) participated in the study: 22 occupational all materials that included personal information of the clients therapists and 8 physiotherapists, representing a total of 20 before the session to ensure confidentiality as well as asking social health centers and nursing homes in Catalonia. All for the written consents of clients. The principal investigator participant physiotherapists were working in an interdisci- shared the moderation with the physiotherapist and the plinary team with occupational therapists. Table 1 shows occupational therapy teacher trained in the COPM. All 4 Occupational Therapy International Table 2: Process for the administration of Canadian Occupational Performance Measure. The initial semistructured interview that addresses daily routines when identifying what the person wants, needs, or has to do in the Step 1 Problem definition three areas of occupational performance proposed by the Canadian Model of Occupational Performance26,27: self-care, productivity, and leisure. Ask the person to rate on a scale from 0 to 10 how important each of Step 2 Rating importance these problems is. Choose the five most prioritized issues in terms of the importance given by the person. Steps 3 and 4 Scoring Ask the person to rate on a scale from 0 to 10 their performance of each activity (degree of performance) and their satisfaction with the way they are carried out (degree of satisfaction). After carrying out the intervention/rehabilitation with the client, Step 5 Reassessment administer the performance and satisfaction scales again. Table 3: Clinical utility conceptualization, themes, and focus group questions. Conceptualization proposed by Smart (2006) Focus group questions Component Aspects To professionals (1) Use of COPM Acceptable To clients (including families and/or caregivers) (a) What advantages/positive aspects/benefits have you had as a To society (public or stakeholder groups) professional when using the COPM Effective during the intervention? What advantages were associated with the client/family relationship, or with the interdisciplinary team of the center/institution? Does it work as expected? Was there any impact on the intervention? Appropriate (b) What difficulties/problems did you find Relevant (or do you see in the present) as a professional when using the COPM during the intervention? What difficulties were associated with the client/family relationship, or with the interdisciplinary team of the center/institution? Functional (2) Learning process Suitable (c) How would you describe learning during the process of administration of the Practicable COPM? Training or knowledge What elements favored or hampered this learning? Resource implications (3) Future expectations (d) Could you describe the future use of the COPM? Do you intend to incorporate Accessible the measure into your day-to-day Procurement practice? Why would you do so? Could you propose the aspects of the improvement? sessions were led with the support of two research assistants was a room at the university. The other two sessions were who observed and took the field notes of the process. The held at the centers facilitated by the participants to fit best research assistants had exhaustive information about the with the timetable and day schedule to achieve the maximum study and the COPM and were previously trained in the possible assistance from them. The language used was native focus group technique. The meeting place for two sessions to all participants: Catalan or Spanish. Table 4: The interpretative phenomenological analysis of the obtained data. Focus group interview themes Codes Subcategories Categories Component groups Awareness (benefits) (27) Advantages: clients and family Listening (benefits) (8) The implication/participation in the intervention process (17) Benefits or limitations expressed by the client or the family: client characteristics Result improvement (10) (age; physical, cognitive or emotional Characteristics of the client (13) states; social and cognitive aspects); Unawareness of the professional role (3) comprehension of the role of OT; Emotional state (3) participation of the client; the difficulty of Disadvantages: clients and family grading; awareness; need and problem Cognitive deterioration (3) identification, and goal setting; and Occupational Therapy International Difficulty in scoring (28) implication in the treatment process. Identification of the problems and goals (15) Institutionalization, conformism (8) Client-centered practice (15) Active listening (6) Advantages: OT, PT, and the Major dedication to the case/attention Benefits or limitations (a) perceived by the interdisciplinary team quality improvement (20) professionals: the effectiveness and efficacy Use of COPM of the intervention; occupational Acceptable and appropriate Professional role and the team (8) performance problem identification; Knowledge about the client, his/her needs setting the goals; efficiency of the interview; and goals (16) evaluation of the results of the Competences related to use of the intervention; register of the changes; and measure (15) decision-making process during the Intervention effectiveness/results (6) intervention; (b) related to knowledge and Disadvantages: OT, PT, and the skills in CCP; and (c) related to the interdisciplinary team Personal satisfaction (4) characteristics of the workplace (contract Limitations CCP (11) types, resources available, team, and the Environment/institution (6) role of OT). Resources (8) Availability of time (11) Social health/residencies characteristics (2) Advantages: institution and society Benefits or perceived limitations related to Grade of implementation of the CCP (18) their institution: philosophy or culture of Generation of the change/evidence (3) the center; the grade of the implementation of the CCP; cultural and social levels; job Disadvantages: institution and Context (6) and work organization; general cultural society Resources (14) and social levels; resources; and evidence. Social/cultural implications (3) 5 6 Table 4: Continued. Focus group interview themes Codes Subcategories Categories Component groups Characteristics (4) Characteristics of the process of Sessions/administration (3) administration of the measure: How? (during the session, two different sessions, Need in explication/adaptation (7) individual patient particularities/reactions, The time of administration (9) Administration process need in adapting the grading process, etc.) Where? (department, room, with or The moment of administration (7) without family, etc.) When? (first time, first week, etc.). How was the learning process perceived? Learning process (changes at the initial stage, initial Practicable The process of learning (49) Learning process difficulties, etc.) Reliability. The utility of the information, of the support provided, and of the materials and Training videos. The implication of the use of the measure to the teamwork (changes, level of the Interdisciplinary teamwork (26) Teamwork process interest, participation, and renegotiations of the professional limits). Use of the measure starting from the research closure. Application in the center Future (55) Future or departments of OT; interest of the Future expectations center. Accessible The occasionality of incomes (23) Includes resources needed for the measure Professionals resources (7) to be used: economic and Resources Infrastructure (7) infrastructure/time/personal/materials. Occupational Therapy International Occupational Therapy International 7 3.6. Data Analysis and Quality of Data. The principal inves- able and appropriate to participants and their families, ther- tigator ensured the literal transcription of the focus group apists, and institutions, generally. data and the field notes using the SoundScriber program. Besides, the data were systematically sorted and uploaded 4.1.1. The Participants’ Opinion about the Client Experiences using Atlas.ti 8. The key stages of IPA were respected [30]: with the COPM. The professionals perceived that using (1) reading and rereading of the transcribed text (emerging COPM made participants feel heard. The clients and their codes and subcodes), (2) identifying and labeling themes family members expressed the gratitude for the time devoted and grouping them together as clusters (categories), and (3) both for evaluation and intervention: introducing the structure into the analysis using Smart’s con- They liked to talk a lot and be listened to. It was their ceptual framework [28]. time. They were grateful for this approach (P13). The subsequent coding and subcoding were an iterative Another of the highlights was that this way of assessing process guided on the basis of the contributions of authors increased the awareness of clients about their own needs, who have published about the utility of the COPM [4, 5, 9, according to participants. The way to set the scene for the 14, 16] and the consensus achieved by researchers [33]. Fur- interview helped to understand the life of the client in greater ther, these codes, subcodes, and themes were categorized depth, enhancing the insight of the client about the situation. based on the conceptualization proposed by Smart [28] (see The way of interviewing them, above all, makes them Table 4). This allowed to sort the information by participants aware of the problems at the family level, harsh situations…. in each component. (P18). Throughout the intervention, clients progressed in the 3.7. Techniques to Enhance Trustworthiness. The following level of awareness they had about their needs. Mostly, when activities were undertaken to ensure the trustworthiness of discharge from rehabilitation was imminent, clients focused the process: the data were verified by giving back the tran- their demands on the realities of their home environment. scriptions to the participants of the focus groups for the revi- All participants agreed that the clients reported satisfac- sion of the content [31, 33], and the triangulation was carried tion with the process of goal setting which was directly out separately by a research assistant and occupational ther- impacting their motivation and making them more involved apy researcher familiar with and trained for the use of the in the process. This way, the clients felt themselves being instrument, but objectively outside the fieldwork and the active participants in the intervention. They reported that sample of the participants to contrast the citations, codes, the intervention and the results were efficient and positive. and categories. Intercoder reliability (Atlas.ti 8) was calcu- Although there was no performance improvement in many lated at 70% concurrence using initial coding of one sample cases, the clients reported significant satisfaction in occupa- data of the focus group that was selected at random. Using tional performance. a mutually agreed upon coding scheme, our intercoder reli- The level of involvement of the patient, I think, rises ability was calculated at 92%. A third researcher followed when you have confronted him/her with his/her problems. the process by reading transcripts and checking appoint- When a person is prioritizing them and saying, “I want to ments, codes, and categories [33]. A total of four researchers achieve this!” the level of involvement is higher (P1). were involved in the analysis process and met regularly. All the participants agreed there were two essential limi- tations while using the COPM with the clients. The first dif- 3.8. The Use of the COPM: Acceptable and Appropriate ficulty was to identify and name the problems, needs, or Components. This section addresses the findings related to aspects/goals that they preferred to work with, whether it the perception that the participants had about the use of was due to a complex emotional or cognitive state of the cli- the COPM as a client-centered measure, and if it was accept- ent. The participants attributed this to the life conditions that able and appropriate to participants and their families, ther- the person was experiencing at the time of evaluation. How- apists, and institutions, generally. ever, some focus group members argued that it could be due to the respect and authority granted to healthcare personnel 4. Findings for decision-making, especially among older people, who often accepted the loss of autonomy with resignation. The findings were structured following the concepts set by This is a generation where professionals or their children Smart [28]. The report attempted to reflect the authenticity always make the decisions, and it is precisely like, “Are you of the information as much as possible, gathering textual asking that of me? No, you are the professional, and I am words when both using concepts and transmitting the mean- not. No, you decide” (P10). ing of the message. The idea was to maintain the exact sense The participants reported that the second major limita- expressed by the participants. For each block, the differences tion was the difficulty in understanding and differentiating between the workforce environments of each of them were the concepts of performance and satisfaction as well as item highlighted. scoring. Older adults were merely habituated to self-rate numerically and even less when grading using a Likert scale 4.1. The Use of the COPM: Acceptable and Appropriate from 1 to 10. Despite facilitating the visual support of the Components. This section addresses the findings related to scale, in many cases, it was essential to adapt and give quali- the perception that the participants had about the use of tative examples of the meaning of each number. Some partic- the COPM as a client-centered measure, and if it was accept- ipants explained a feeling of discomfort among the clients. 8 Occupational Therapy International I have had a vast, colossal difficulty (….) Prioritize, The other day, I checked the data collection register, and I they did well; they knew what they wanted more, but… was happy seeing the results of the intervention. I could the occupational performance! The satisfaction item! It observe the Barthel had the threshold effect so high, and was difficult to explain the meaning of this item [satisfac- the COPM showed specific changes in the occupational per- tion]! (P29). formance. I believe that for the research (...) it presents a A senior lady thought she [the therapist] was giving her scope of interest for therapists (P16). an exam (...), [so the lady] decided to go out, and she told me: “Look, don’t do this to me anymore”! (P23). 4.1.3. Acceptable and Appropriate Components of the COPM for the Institutional Context. The participants reported most 4.1.2. The Participants’ Opinion about the Acceptable and centers continued working from a mechanistic paradigm in a Appropriate Components of the Measure for Everyday hierarchical and authoritarian way, where the institution Practice. Some of the participants recognized that the gave the limits, and the services set the program objectives client-centered approach forms an intrinsic part of their pro- and goals for the intervention. The participants argued the fession, but their day-to-day practice and working years executive directors of the center should commit themselves made them conform to the philosophy set in the center. At to promote the change of paradigm and the structural a professional level, the use of the COPM instrument sup- reforms. In general, they considered that including the posed a significant change in the perspective and the way of COPM as an interdisciplinary evaluation tool would have working by respecting personal decisions and what had permitted to recollect the personalized data and raise the meaning and sense for a person. realistic goals of the interventions. The participants discussed That is a kind of reminder of what your work many times this would have supported the establishment of the CCP in should consist of — at least I see it that way. It is supposed the center and would have generated evidence and improve- that we, as therapists, already have that internalized, but dur- ments in treatment. ing the day-to-day practice (...) the philosophy of the institu- They must be convinced; they must be and there should tion makes you forget about these things (P23). be a commitment to an idea with the changes that this Although the majority of interviews required more time implies (P5). to administer the COPM than their previous evaluations, It must follow the philosophy of the center (…) and pro- the participants considered that this time was crucial for hav- fessionals (…) if they do not understand that you are there ing better engagement, establishing confidence, and partici- for the goals of the patient and not for those of the institution pation of the person. … You are bumping into the wall (P16). I, as a therapist, was centred more on listening to the The participants with more years of experience at the problems and changing the assessment I always give… come same institution had difficulty visualizing how the client- on, explain what’s on your mind? (P12). centered approach could be implemented. Notably, it was It helps you to go deeper into the person, creating a space evident within the rehabilitation services, where the bio- for communication necessary for acknowledging the values medical model was implemented for many years. Further- and beliefs of a person. more, at a social level, the participants discussed people There is a change because I sit with the clients in the were already accustomed to the offer of specific services, interviews, which many times is impossible. However, fol- and they tended to adapt to the possibilities they might lowing this process, I sat with the patients, and I established have offered. another type of bonding with them. The link they had with There must be a change at the social level, at the overall me or with the goals was very different. Just administering level (…) This treatment that we want to offer at the level the COPM was already more person-centred (P13). of the nursing home, the CCP, I see it as more precise or The participants reported the use of the COPM helped to more applicable, but at the hospital level … [thinks] … visualize or determine goals. It also permitted to justify the resources, you have particular hours, you have a specific application of a particular type of treatment. workload. I do not know (P12). Sometimes, when you want to introduce technical aids, One of the critical aspects the participants contemplated they are very reluctant. However, instead, if you say: “Well, for being able to use the COPM was the degree of implemen- since you have told me that you would like to achieve tation of the CCP in the center. Even though all reported hav- this…there is no other way…let us see if we try it with this ing some training about the client-centered practice product”. And, well, I believe there was more acceptance encouraged by the institution, only several participants noted (P1). the services and centers adopted this approach in reality. Often, the participants that were observed working with The CCP is a fundamental right… it is supposed (P4) … the particular goals decided by the clients stimulated the theory, yes, but in practice (P1). improvement in the intervention outcome. They reflected The CCP is widely discussed…but, in reality, it could not the reason could be that the person does with what he or be easily incorporated into practice (P1). she wants or desires, not what was imposed by others. More- Few professionals commented on the contribution of the over, relying on their self-report, the COPM permitted to specific means and actions of support by the institution to visualize the changes, especially related to rehabilitation that implement the CCP. Currently, it is not possible to work allowed obtaining more specific evidence about the therapeu- out many objectives due to either institutional norms or the tic work. lack of resources. Occupational Therapy International 9 4.2. The COPM as a New Tool: Practicable Component. This At the end of the study, the participants expressed many section addresses the findings related to the opinion of the doubts. These questions conveyed a general interest in participants about administration details of the measure, proper application of the COPM, and some requested more everyday use, and training needs of the occupational thera- training in certain aspects of the theoretical foundations pists and physiotherapists. and practical abilities. In most cases, the COPM was administered in one ses- Regarding future use of the COPM, most participants sion. The participants reported the administration of the expressed their motivation to use the measure partially or COPM in two sessions in cases where the client had difficul- entirely, depending on the specific cases. They believed the ties, as they were tired physically or emotionally. attitudinal change in the institutional context and the inter- Due to the difficulty mentioned earlier in understanding disciplinary team could have promoted the incorporation of and evaluating the concepts used in the tool, many therapists the measure into day-to-day practice. Notably, all of them opted to adapt the COPM to the characteristics of the client, expressed the intention of adopting implicit elements of the change the concepts to words of daily use, and, in the case of COPM, such as listening, asking about the client’s desires the rating, transform the numeric into qualitative evaluation. and priorities of their occupational performance, or clarify- In some cases, they used visual icons (faces). ing and recalling the therapeutic goals. Initially, the professionals reported the time dedicated to It means acting more for what one wants … let us not passing the COPM was around 1.5 hours. The time oscillated, impose our goals … if not, keep in mind, above all, what each more or less, depending on the client’s particular situation and person really wants (P15). needs: whether the administration was taking place in a nurs- ing home (30-60 min in cases of elderly with complex needs) 4.3. The Cost-Effectiveness and Viability of the Necessary or a rehabilitation center (15-20 min). The time decreased Resources: Accessibility Component of the COPM. This sec- when the therapists mastered the practice. The use of the mea- tion reflected the findings related to the opinion of the partic- sure implied the process of training and learning. The partici- ipants about the cost-effectiveness and viability of resources pants confirmed that they gained the following skills: the that are necessary for the successful application of the COPM ability, confidence, and naturalness along with the regular in the practice context. application of the measure. The main aspects of these skills, Although the institutions can easily acquire the COPM, besides instructional and methodological parts, were the appli- most of the participants highlighted key resource constraints cation of ethics and practice-based evidence. The participants for making the use of the measure broadly accessible. These illustrated these observations through various examples of key were the low personnel ratio, the short time of admission of skills: (1) determining the appropriate time for the administra- the patient in the case of rehabilitation centers, and poor tion, (2) knowing with whom it can be applied, (3) guiding the infrastructure of the institution. interview when the person is not aware of the problems, (4) Of course, I find that in day-to-day practice, you go in confronting the reality of clients without violating them, (5) such a hectic manner that during the first evaluation I am adapting the measure to the characteristics of each person, already intervening [Everybody: “Yes, yes, yes”.) (P3). (6) splitting out and shaping the goals, explained by the client, Before the time for convalescence was two months, and and (7) knowing how to graduate the intervention or to regu- now they are pushing you to do it in four weeks (P12). late the degree of involvement of the family. The time is one thing, and the resources are another (…) The first interview I did was a difficult experience, For example, there is no kitchen. These are things that are because there was a lot of effort, a lot of time, and, above of very meaningful for them and very basic; it is their day-to- all, I wasn’t confident with the tool (P13). day life that they want to keep going (P25). All groups commented that it was essential that the client Or if you need to provide supervision and there is no was minimally adapted to the environment of the center at staff, and you cannot do it (P24). the time of the first assessment. In the case of rehabilitation, Sometimes 10 minutes or a quarter of an hour more here, the average number of days for the adaptation was two or you will do a lot of work for a while, no? [“Yes, yes, of course” three, and in the nursing homes, this number was extended (P14)]. But sometimes you will not (P10). to the first weeks. In some social healthcare centers, the ther- The participants reported that the acquisition of the apists proposed using the COPM in the middle of the overall COPM and the improvement in terms of necessary resources treatment process. The underpinning argumentation of this as infrastructure, available time and human resources, would new vision was the orientation of the goals to the discharge. help the quality and efficiency of the intervention as well as We are holding the meeting with the family members in professional satisfaction in the long term. the middle of the intervention, at approximately two months (P16). The participants underlined that they gained skills 5. Discussion through the training offered by the principal investigator and that having available the digital platform with the materials This study is aimed at exploring the clinical utility of the as well as further follow-up of the questions that might have COPM in interdisciplinary rehabilitation services of Spanish raised in the practice context was helpful. Based on the self- social healthcare centers and nursing homes, mainly focusing report, the participants improved in the parameters of ability, on the perceptions of the occupational therapists and physio- security, and fluency when administrating the COPM. therapists. This section discusses the main findings by 10 Occupational Therapy International grouping them using the multidimensional model of clinical [4, 5, 15]. The instrument was appropriate for the detection utility of Smart [28]. of changes in occupational performance [10]. Explorations about acceptable and appropriate compo- The participants reported having personal paternalistic nents show the major findings indicated that the use of the views and beliefs that served as a limitation to client- COPM implied an attitudinal change of the interdisciplinary centered practice and when defending the client’s personal teams towards a more holistic and client-centered approach. convictions. Similar to the findings of Colquhoun et al., they The participants reported these views helped the teams to assumed they knew what would be the best for the clients or recover humanistic principles, respect, collaboration, and what they would be able to do. Parker and Sykes considered recognition of self-determination. They recognized the client this dynamic [10, 36]. Previous studies showed that it had as an active agent in the process and acknowledged respect to do with the adoption of the new paradigm, the difficulty, for autonomy as a fundamental value [26, 27]. and the dedication time needed to accept this new perspec- One of the aspects most valued by the clients and their tive, even if the professionals had previous training [1, 2]. families was the time for listening and the dedication by the This highlighted the importance of obtaining theoretical healthcare personnel, which is seen as an example of quality knowledge of the Canadian Model of Occupational Perfor- healthcare. The semistructured interviews generated a depth mance and Engagement (CMOP-E) to understand the theo- that helped the clients to improve their degree of awareness retical foundations of the instrument [26, 27]. From this about their situation [16] and thus identify their problems point of view, we recommend the involvement of profes- [5, 10, 34]. There were doubts among the participants about sionals in continuous education. the appropriate timing for the interview. The initial study Concerning the practicable component, as also observed of utility by Toomey indicated the difficulty of gaining in the present study, Parker and Sykes indicated that apply- insight in some acute situations as well as cognitive or ing the COPM with clients helped to develop competencies emotional states while using the measure [17]. The same (enabling/empowerment) [10]. These skills permitted them author suggested choosing the best time to administer to participate actively in the selection of and decision- the tool, always under the criteria of the professional [2]. making about their goals and bring clear motivation and Therapists should keep in mind that the clients need to involvement in the treatment process. As highlighted in pre- have minimal capacity to establish a conversation with vious studies, this could have created a unique engagement the professionals [5]. with active participation in the intervention of more relevant The difficulties in identifying or naming problems [2] in occupational issues [14]. Additionally, it would have allowed many cases were the themes linked to the lack of habit. Tra- more efficient results [34]. ditionally, the professional defined the problem and recom- The considerations mentioned above emphasize the mended types of interventions. For some clients, a client- aspects that go beyond the mere administration of a measure. centered perspective implied a change that was difficult to Knowledge of the interviewing techniques, competencies of assimilate, or they could perceive it as a lack of professional communication, and clinical reasoning are needed to reach competence. They expected a professional to be an expert consensus with the client to generate coherent and realistic [12]. The nondirective approach, especially in older adults, therapeutic goals. Only experience, training, and daily praxis is still perceived as less valuable due to past experiences as can help the professional to acquire these competencies and passive recipients of services. In addition, some clients felt feel comfortable with the instrument. This shows the neces- confused and insecure because of the many questions from sity for each therapist to find personal strategies when con- the professional [1]. Moreover, the revision of Stevens et al. ducting the interview [1, 2, 5, 14]. Moreover, like any showed that older adults were reluctant to express their con- evaluation instrument, it requires learning and practice [36]. cerns because of their fear that professionals could interpret Regarding the accessible component, it was crucial to the low-scored items as a complaint [12]. keep in mind that many participants reported that in specific The participants agreed that giving primacy to the clients contexts and with particular cultures, the integration of the and empowering them to create the bonds of mutual trust CCP happened at different levels [37]. However, the partici- allowed to obtain the relevant information and demands pants confirmed that institutions with hierarchical and pro- based on their desires and needs. These were always real tocolized structures offered few opportunities to carry out and genuine/authentic, as considered by Bodiam [35], and meaningful activities. This inevitably led to the institutional- could not be obtained in other types of assessments. The ization of the clients. The clients got habituated and never open questions about clients’ needs permitted to contemplate demanded or protested. Added to the specific characteristics new dimensions and a broader spectrum of aspects of the of older adults, many with complex needs from disabling occupational life of people [5]. The in-depth character of pathologies or low resources, the accommodation to this sit- the interview helped to discover meaning and sense for the uation many times deprived them of meaningful perfor- client, and the process itself became meaningful. This fact mance and, further on, alienated them from significant life reflected the idea that the clients had exceptional knowledge experiences. The findings showed the use of the measure pro- of their occupational lives. They know their needs better than moted and reinforced the CCP [10, 14]. Besides the clients, anyone [26]. The CCP offered and enhanced the opportuni- their families, and the interdisciplinary teams accepted the ties for them to participate in their occupational lives, measure, its usefulness in everyday practice should imply opposed to feeling deprived of performing meaningfully, so the process of cultural adaptation at all levels (personal, pro- the goal and the intervention got oriented to the occupation fessional, social, attitudinal, and institutional). Occupational Therapy International 11 The routine application of the COPM in the future is COPM. The authors could not get direct self-reporting from complex, although all professionals who participated in the clients but tried to solve this limitation, ensuring that they the study were constant in its use [1, 4]. Some factors that engaged the clients and encouraged them to share their go beyond the decisions and opinions of the therapists opinion. condition the future use of the COPM. However, all pro- Another limitation of the study was particular to the fessionals expressed convictions about its efficacy. Accord- qualitative tradition: the researchers could avoid posing the ing to Toomey, the therapist needs to have the support of direct question about the difficulties or problems related to the institution/management teams to integrate the CCP the use of the measure, focusing only on the generic themes. and to promote efficient use of the COPM [17]. It is evident This decision was made to obtain concrete answers and to that the needs and motivations of the therapists are funda- respect the time inversion of the clients, but it was clear that mental factors for bringing changes to their practice. However, each question can condition the response. We tried to ensure researchers agree that these decisions will always be impacted the trustworthiness of the study by other mechanisms by work contexts [28]. Working on goals prioritized by the cli- described in the article. ents made the institution acquire more materials and All the participants were occupational therapists and resources, improving spaces to complete different tasks (for physiotherapists interested in the COPM; therefore, the example, accommodate the areas to make garden activities). study was not pretending to generalize the results to other Administration of the COPM required additional time [5, professionals. It contemplated the diversity of the centers 17]. However, Wressle et al. established that [18] “a focus on and interdisciplinarity, but the integration of other profes- problems that are important for patients makes more efficient sional profiles or professionals of the centers who had previ- use of rehabilitation resources”. ous interest would have enriched the research. There was an attempt to compensate for the biases provoked by the pres- 5.1. Future Lines of Research. The current study derived in sure of the group dynamics or by the researcher following several future lines of research. Some were formulated by the principle of reflexibility. Researchers ensured that the the therapists who participated in the study, such as an adap- IPA was completed correctly. The centers were combined tation of the COPM to the older adult population with mild so that the participants did not know each other, and some cognitive difficulties and/or few personal abilities, which of them did not know the principal investigator [33]. was also underlined in other studies [1, 4, 5, 12, 13, 16, 18]. This kind of adaptation was discussed by other authors, such 6. Conclusion as Toomey [17], and could be extrapolated to the different fields of pediatric care or mental health, where the character- This study analyzes the complexity of factors involved when istics of the clients can present similar difficulties. introducing a new measure into Spanish health services. In general, all participants expressed satisfaction with Numerous studies from other countries established that the their role and being able to work with the goals desired by main limitations in the use of the COPM involved the clients the client. This underlines a mutual satisfaction with the pro- and the experience of the professional [23]. However, the cess. It would be interesting to analyze the relationship current investigation pointed out that the principal limitation between the COPM implementation and the improvement had to do with institutional policies and services. The results of work engagement, which is one of the main elements in showed multiple benefits for everyday practice and the the prevention of burnout. aspects that motivate clients, professionals, and institutions This study revised the components related to the clinical when applying the COPM in the overarching framework of utility of the COPM. The researchers will examine other psy- the client-centered practice. One of the significant challenges chometric properties of the instrument like validity, reliabil- is to advance and opt for what the professionals and clients ity, and responsiveness in subsequent studies with Spanish believe in, see, and consider as beneficial, thus supporting samples. social progress in general. It will be a challenge to explore the multidimensional clinical utility, integrating the voices of other key actors Data Availability implied in the change [28, 36]. It would be preferable to con- trast and triangulate the opinions of the family members and Access to data is restricted. We are according to the Spanish caregivers or receive a contribution from the institutional data protection legislation not allowed to submit the data or perspective. Also, it could be interesting to use a framework give access to the data used for the analyses. of indirect observation with diachronic analysis in order to detect how the interaction of the key actors changes in Disclosure response to a greater COPM use [38, 39]. The authors propose to continue working on, exploring, This work was completed in partial fulfillment of the first and resolving the detected limitations related to the institu- author’s requirements for a doctoral degree. tional and healthcare policies that are usually alienated from the day-to-day professional reality and praxis. Conflicts of Interest 5.2. Limitations. This study focused on the self-report that The authors declare that there are no conflicts of interest professionals gave on how the clients have perceived the regarding the publication of this paper. 12 Occupational Therapy International Acknowledgments [9] L. Enemark, C. J. Winge, and J. R. Christensen, “Clinical utility of the Danish version of the Canadian Occupational Perfor- The authors would like to thank the collaboration of the 22 mance Measure,” Scandinavian Journal of Occupational Ther- healthcare centers and residences in Catalonia for their active apy, pp. 1–12, 2019. involvement. Notably, we are grateful to the participants, [10] D. M. Parker and C. H. Sykes, “A systematic review of the occupational therapists, and physiotherapists for their critical Canadian Occupational Performance Measure: a clinical prac- professional contributions about the use of the COPM, as tice perspective,” British Journal of Occupational Therapy, well as their clients for the willingness to follow the study. vol. 69, no. 4, pp. 150–160, 2016. Also, the authors gratefully acknowledge the support of a [11] D. Roe, T. Brown, and L. Thyer, “Validity, responsiveness, and Spanish government subproject Integration ways between perceptions of clinical utility of the Canadian Occupational qualitative and quantitative data, multiple case develop- Performance Measure when used in a sub-acute setting,” Dis- ment, and synthesis review as main axis for an innovative ability and Rehabilitation, vol. 42, no. 19, pp. 2772–2789, 2020. future in physical activity and sports research (PGC2018- [12] A. Stevens, A. Beurskens, A. Köke, and T. van der Weijden, 098742-B-C31) (2019-2021) (Ministerio de Ciencia, Inno- “The use of patient-specific measurement instruments in the vación y Universidades/Agencia Estatal de Investigación/- process of goal-setting: a systematic review of available instru- Fondo Europeo de Desarrollo Regional) that is part of ments and their feasibility,” Clinical Rehabilitation, vol. 27, no. 11, pp. 1005–1019, 2013. the coordinated project New approach of research in phys- ical activity and sport from mixed methods perspective [13] S.-Y. Yang, C.-Y. Lin, Y.-C. Lee, and J.-H. Chang, “The Cana- (NARPAS_MM) (SPGC201800 × 098742CV0). Also, we dian Occupational Performance Measure for patients with stroke: a systematic review,” Journal of Physical Therapy Sci- gratefully acknowledge the support of the Generalitat de ence, vol. 29, no. 3, pp. 548–555, 2017. Catalunya Research Group (GRUP DE RECERCA E [14] L. Gustafsson, G. Mitchell, J. Fleming, and G. Price, “Clinical INNOVACIÓ EN DISSENYS (GRID)). Tecnología i aplica- utility of the Canadian Occupational Performance Measure ció multimedia i digital als dissenys observacionals (Grant in spinal cord injury rehabilitation,” British Journal of Occupa- 2017 SGR 1405). tional Therapy, vol. 75, no. 7, pp. 337–342, 2012. [15] H. L. Colquhoun, L. J. Letts, M. C. Law, J. C. MacDermid, and C. A. Missiuna, “Administration of the Canadian Occupational References Performance Measure: effect on practice,” Canadian Journal of Occupational Therapy, vol. 79, no. 2, pp. 120–128, 2012. [1] Y.-H. Chen, S. Rodger, and H. Polatajko, “Experiences with the COPM and client-centred practice in adult neurorehabilita- [16] L. Enemark and G. Carlsson, “Utility of the Canadian Occupa- tion in Taiwan,” Occupational Therapy International, vol. 9, tional Performance Measure as an admission and outcome no. 3, pp. 167–184, 2002. measure in interdisciplinary community-based geriatric reha- bilitation,” Scandinavian Journal of Occupational Therapy, [2] M. Law, H. Polatajko, N. Pollock, M. A. Mccoll, A. Carswell, vol. 19, no. 2, pp. 204–213, 2010. and S. Baptiste, “Pilot testing of the Canadian Occupational Performance Measure: clinical and measurement issues,” [17] M. Toomey, D. Nicholson, and A. Carswell, “The clinical util- Canadian Journal of Occupational Therapy, vol. 61, no. 4, ity of the Canadian Occupational Performance Measure,” pp. 191–197, 1994. Canadian Journal of Occupational Therapy, vol. 62, no. 5, pp. 242–249, 1995. [3] World Health Assembly 69, Multisectoral action for a life course approach to healthy ageing: draft global strategy and [18] E. Wressle, A.-M. Eeg-Olofsson, J. Marcusson, and plan of action on ageing and health report by the secretariat, C. Henriksson, “Improved client participation in the rehabili- World Health Organization, Geneva, Switzerland, 2016. tation process using a client-centred goal formulation struc- ture,” Journal of Rehabilitation Medicine, vol. 34, no. 1, [4] H. Colquhoun, L. Letts, M. Law, J. MacDermid, and pp. 5–11, 2002. M. Edwards, “Feasibility of the Canadian Occupational Perfor- mance Measure for routine use,” British Journal of Occupa- [19] J. J. Baztán, J. Pérez del Molino, T. Alarcón, E. San Cristóbal, tional Therapy, vol. 73, no. 2, pp. 48–54, 2010. G. Izquierdo, and J. Manzarbeitia, “Indice de Barthel: instru- [5] E. Wressle, J. Marcusson, and C. Henriksson, “Clinical utility mento válido para la valoración functional de pacientes con of the Canadian Occupational Performance Measure - Swed- enfermedad cerebrovascular,” Revista Española de Geriatría y ish version,” Canadian Journal of Occupational Therapy, Gerontología, vol. 28, no. 1, pp. 32–40, 1993. vol. 69, no. 1, pp. 40–48, 2016. [20] F. I. Mahoney and D. W. Barthel, “Functional evaluation: the [6] M. Law, S. Baptiste, A. Carswell, M. C. MA, H. J. Polatajko, and Barthel Index,” Maryland State Medical Journal, vol. 14, N. Pollock, Medida Canadiense de Desempeño de Funciones pp. 61–65, 1965. Ocupacionales, CAOT Publications ACE, Otawa, ON, 3rd edi- [21] G. Grimby and G. Thylander, Guide for Use of the Uniform tion, 2014. Data Set for Medical Rehabilitation, State University of New [7] C. Donnelly, C. O’Neill, M. Bauer, and L. Letts, “Canadian York at Buffalo, Buffalo, 1991. Occupational Performance Measure (COPM) in primary care: [22] P. Sanchez, I. Bullich, C. Cabanes, and C. Ferrando, Pla direc- a profile of practice,” American Journal of Occupational Ther- tor sociosanitari, Direcció General de Planificació en Salut, apy, vol. 71, no. 6, pp. 7106265010p1–7106265010p8, 2017. Barcelona, Catalonia, 2017. [8] M. A. McColl, M. Paterson, D. Davies, L. Doubt, and M. Law, [23] M. V. Zunzunegui and F. Béland, “Políticas intersectoriales “Validity and community utility of the Canadian Occupational para abordar el reto del envejecimiento activo. Informe Performance Measure,” Canadian Journal of Occupational SESPAS 2010,” Gaceta Sanitaria, vol. 24, Supplement 1, Therapy, vol. 67, no. 1, pp. 22–30, 2000. pp. 68–73, 2010. Occupational Therapy International 13 [24] WHO, “Envejecimiento activo: un marco político,” Revista Española de Geriatría y Gerontología, vol. 37, Supplement 2, pp. 74–105, 2002. [25] B. Méndez and E. Capdevila, “Historia de la terapia ocupacio- nal: su desarrollo en geriatría,” in Terapia Ocupacional en Ger- iatria: principios y pràctica, pp. 3–10, Editorial Masson, Madrid, 3th edition, 2010. [26] Canadian Association of Occupational Therapists (CAOT), Enabling occupation: an occupational therapy perspective, CAOT Publications ACE, Ottawa, ON, 2002. [27] E. A. Towsend and H. Polatajko, Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well- Being and Justice through Occupation, CAOT Publications ACE, Otawa, ON, 2007. [28] A. Smart, “A multi-dimensional model of clinical utility,” International Journal for Quality in Health Care, vol. 18, no. 5, pp. 377–382, 2006. [29] D. Biggerstaff and A. R. Thompson, “Interpretative phenome- nological analysis (IPA): a qualitative methodology of choice in healthcare research,” Qualitative Research in Psychology, vol. 5, no. 3, pp. 214–224, 2008. [30] C. Willig, Introducing Qualitative Research in Psychology, M. Keynes, Ed., Press OU, UK, 3rd edition, 2013. [31] R. A. Krueger and M. A. Casey, Focus Groups: a Practical Guide for Applied Research, Sage Publications, Thousand Oaks, Calif, 3rd edition, 2000. [32] L. Letts, S. Wilkins, M. Law, D. Stewart, J. Bosch, and M. Westmorland, Guidelines for critical review form: qualita- tive studies (version 2.0), McMaster University Occupational Therapy Evidence-Based Practice Research Group, 2007. [33] M. Curtin and E. Fossey, “Appraising the trustworthiness of qualitative studies: guidelines for occupational therapists,” Australian Occupational Therapy Journal, vol. 54, no. 2, pp. 88–94, 2007. [34] A. Švajger and B. Piškur, “The clinical utility of the Canadian Occupational Performance Measure in vocational rehabilita- tion: a qualitative study among occupational therapists in Slo- venia,” Work, vol. 54, no. 1, pp. 223–233, 2016. [35] C. Bodiam, “The use of the Canadian Occupational Perfor- mance Measure for the assessment of outcome on a neuroreh- abilitation unit,” British Journal of Occupational Therapy, vol. 62, no. 3, pp. 123–126, 2016. [36] H. L. Colquhoun, R. Islam, K. J. Sullivan, J. Sandercock, S. Steinwender, and J. M. Grimshaw, “Behaviour change domains likely to influence occupational therapist use of the Canadian Occupational Performance Measure,” Occupational Therapy International, vol. 2020, Article ID 3549835, 12 pages, 2020. [37] T. Martínez Rodríguez, La atención centrada en la persona en los servicios gerontológicos: modelos de atención e instrumentos de evaluación, Universidad de Oviedo, 2015. [38] M. T. Anguera, “Is it possible to perform “liquefying” actions in conversational analysis? The detection of structures in indi- rect observations,” in The Temporal Structure of Multimodal Communication, L. Hunyadi and I. Szekrényes, Eds., vol. 164, pp. 45–67, Springer Cham, 2020. [39] M. T. Anguera, M. Portell, S. Chacón-Moscoso, and S. Sanduvete-Chaves, “Indirect observation in everyday con- texts: concepts and methodological guidelines within a mixed methods framework,” Frontiers in Psychology, vol. 9, 2018.