Evidence Based Practice Symposium - McMaster University

Evidence Based Practice Symposium 

Occupational Therapy Class of 2012 

June 12, 2012 

PROJECT TITLE 

Qualitative interviews for Transition to Adulthood with 

Cyberguide Evaluation (TRACE)-2 study 

Moving On... Teen Independence Program: Program 

evaluation of outcome measures 

Looking at child behaviour measures from a different 

angle 

Child and Youth 

STUDENT 

PRESENTERS 

Shannon Hudson 

Evelyn Kosteltz 

Laura Snyder 

Sarah Winter 

Participation of children with disabilities: A scoping review Sarah Greenwood 

Briana Ogilvie 

Brenna Tonkin 

Innovations for children’s safety in vehicles: Conducting a 

usability evaluation of car seat testing of premature infants 

among frontline staff 

Evaluation of a social skills program for children between 

the ages of 5-11 

Scoping review: Development of an assessment protocol 

for the independent living program at ErinoakKids 

Development of education material for parents: Play 

positions to enhance upper limb development in babies 

and toddlers 

The experience of therapeutic riding on children with 

autism spectrum disorder: A parent’s perspective 

Journey of recovery: The impact of occupational therapy 

within a community-based adult mental health service 

Exploring experiences with the WiiFit in a communitybased 

program for individuals with schizophrenia 

Mild cognitive impairments and dementia: Are older 

adults slipping through the cracks? 

PROJECT 

SUPERVISORS 

Debra Stewart 

Andrea Morrison 

Julia Lockhart 

Beverley Wasmund Peter Rosenbaum 

Alisha Gardener 

Laura Kogon 

Vishalla Singh 

Elissa Whitman 

Kristel Lazo 

Rachel Pedros 

Sarah Cain 

Mallory Carson 

Rebecca Baldwin 

Megan Meekison 

Adult / Older Adult Mental Health 

Amanda Barillaro 

Aliza Ladak 

Ashley Lal 

Leandra Lorello 

Jillian Goodbrand 

Aimee Sweers 

Quinn Klassen 

Emma Grace 

Sarah Shallwani 

PAGE 

Mary Law 

Dana Anaby 9 

Brenda Vrkljan 

Scott McBean 

Kara Lee 

Ana Maria Isihi 

Tanya Eimantas 

John Greenaway 

Joe Trovato 

Lowana Lee 

Angela Meyer 

Kim Hewitt 

Jocelyn Harris 

Gord Hirano 

Susan Pettit 

3 

5 

7 

11 

13 

15 

17 

19 

21 

23 

25

PROJECT TITLE 

Beyond silence: Building support for peer education in a 

healthcare workplace 

STUDENT 

PRESENTERS 

Jessica Beaudoin 

Nicole Enser 

Adult / Older Adult Physical Health 

Social participation challenges for women aging with HIV Lisa Blenkhorn 

Jennifer Siemon 

Participation limitations after distal radius fractures: 

Linking with the ICF 

The psychometric properties of the MacHANd 

Performance Assessment (MPA) 

Expert panel review of a community-based exercise 

programme for individuals living with chronic obstructive 

pulmonary disease (COPD) 

Age friendly transit in Hamilton: Assessment using a 

travel chain perspective 

Technology 

Dyan Beavis 

Chantelle Glenn 

Nikki Lord 

Sarah Salter 

Elizabeth Landman 

Annemarie Muhic 

PROJECT 

SUPERVISORS 

Sandra Moll 

Patty Solomon 

Seanne Wilkins 

Joy MacDermid 

Tara Packham 

Katie Fisher Kirsti Reinikka 

Amanda Enns 

Brittany Strauss 

Mobile health strategies and occupational therapy Teresa Couto 

Lauren Harris 

The use of social media by occupational therapists: 

Recommendations for the College of Occupational 

Therapists of Ontario 

Accessibility of the teaching and learning environment at 

McMaster University as perceived by students with 

disabilities 

Program evaluation of an interprofessional event: Are 

we making a difference at McMaster? 

Reflective journaling: A learning tool for McMaster 

University student occupational therapists in the 

practicum setting 

Through the lens of the male OT student: Motivation 

factors to enter the OT profession 

Education 

Community 

Leanne Fernandez 

Jessica Yu 

Kanishka Baduge 

Csilla Gresku 

Kait Hammel 

Katie Rincker 

Kait Toohey 

Ashlen Kain 

Jackie Bull 

Katelin Wakefield 

Gawain Tang 

Patrick Whalen 

Exploring occupational community Erich Bogensberger 

Kent Tsui 

Lori Letts 

Christy Taberner 

PAGE 

27 

29 

31 

33 

35 

37 

39 

Elinor Larney 

Bonny Jung 41 

Beth Marquis 

Bonny Jung 

Lorie Shimmell 

Bonny Jung 

Bonny Jung 

Michael Chan 

Joyce Tryssenaar 

43 

45 

47 

49 

51

Transition to Adulthood with Cyberguide Evaluation (TRACE) 2 Research Project 

Qualitative study of the use and impact of a transition coordinator and Youth KIT among adolescents with chronic 

health conditions. 

Authors 

Dana Henderson, Shannon Hudson, & Evelyn Kosteltz, MScOT Candidates 2012, McMaster University 

Supervisor: Deb Stewart, MScOT Reg. (Ont.) 

Acknowledgements 

We would like to acknowledge the assistance of Elena Skoreyko Wagner, Deb Stewart, and members of the TRACE 

2 study team for their contributions to our research project. 

Abstract 

Background There is evidence indicating that the transition from pediatric to adult health care for youth with chronic 

medical conditions often results in negative outcomes for this population, including poor health care or getting lost 

in the system. This evidence demonstrates the current need to enable youth with chronic medical conditions to 

effectively transition from the pediatric healthcare setting to the adult healthcare setting. The Transition to 

Adulthood with Cyberguide Evaluation (TRACE) study was developed to evaluate the use, utility and impact of two 

healthcare transition interventions: the Youth KIT (Keeping it Together for Youth) and an online mentor (called 

‘TRACE’) to aid in improving the health care transition planning and practice for youth with chronic medical 

conditions. Methods A qualitative phenomenological approach was used to explore the experiences and perceptions 

of youth and their caregivers about the Youth KIT© and TRACE mentor in helping the youth transition from 

pediatric to adult services. A total of eleven youth and seven caregivers were interviewed. An inductive content 

analysis process was used for data analysis using the guidelines of Elo & Kyngas (2007). Results Analysis of the 

interview transcripts yielded 9 superordinate themes and related subthemes. Themes included: About the study, 

Experiences, Supports, Barriers, Self-management, Parent role, Perceived need, Recommendations, and Overarching 

themes of transition . Conclusion Participants did not appear to benefit from the TRACE interventions in relation to 

their health care transition. However, there were some benefits regarding general life transitions such as budgeting 

and going to school. Revisions to the interventions were recommended by youth and caregivers. 

Introduction 

There is evidence indicating that for youth with chronic medical conditions the transition from the pediatric 

healthcare setting into the adult healthcare setting often results in negative outcomes for this population, including 

poor health care or getting lost in the system (Gorter, Stewart, & Woodbury-Smith, 2011; Grant & Pan, 2011). The 

Transition to Adulthood with Cyberguide Evaluation (TRACE) study was developed to evaluate the use, utility and 

impact of two healthcare transition interventions: the Youth KIT (Keeping it Together for Youth) and TRACE 

(CanChild, 2012). The Youth KIT is a tool to aid youth with chronic conditions in obtaining, organizing, and 

sharing personal information to promote self-management as they transition into adulthood (CanChild, 2012; Gorter 

et al., 2011). TRACE is an online “cyber guide” or mentor that is available to interact with the participants through 

Ability Online (CanChild, 2012). The TRACE study is now in its second phase (TRACE 2) and this student project 

focused on the qualitative component to evaluate how youth with various chronic medical conditions utilize the two 

transition interventions throughout their transition into the adult health care system. This was done by exploring the 

experiences and perceptions of the youth and caregivers regarding the TRACE mentor and the Youth KIT, while 

also exploring their overall experiences during the transition into the adult health care services (CanChild, 2012). 

Literature Review 

For youth with chronic conditions, the move from pediatric to adult services, while generally seen as a 

logical and welcome aspect of their emerging autonomy (van Staa, Jedeloo, vanMeteren, & Latour, 2011), is often 

experienced as a time of adjustment characterized by uncertainty and lack of information and support (van Staa et 

al., 2011; Kirk, 2008; Young, Barden, Mills, Burke, Law, & Boydell, 2009). Parents and caregivers of youth with 

chronic medical conditions or disabilities express challenges in this transition including feeling unprepared for and 

uninvolved in their child’s service transition, and they have concerns regarding continuity of support and expertise 

in adult services (Kirk, 2008). Both youth and caregivers have also reported that they feel there is a lack of access to 

a variety of health care professionals, lack of professional knowledge, lack of information provided, uncertainty 

regarding the transition process, and a need for more information and more support in transitioning to adult care 

(Young et al., 2009). Evidence reflects that parents are frequently concerned about this transition, as they find it 

challenging to step aside and shift roles to allow their youth to accept more responsibility for their self-management, 

and feel safer in the pediatric services (Allen, Channon, Lowes, Atwell, & Lane, 2011; van Staa et al., 2011).

Parental resistance to letting their youth become more independent during the transition to adult services is often 

cited as a barrier to transition; however, parents are a source of valued social support, and the transition process does 

not acknowledge the support and interdependencies frequently found in youth-parent relationships (Allen et al., 

2011). 

Methods 

A qualitative phenomenological approach was used to explore the experiences and perceptions of youth 

and their caregivers about the Youth KIT© and TRACE mentor in helping the youth transition from pediatric to 

adult services. Youth already enrolled in the TRACE 1 or TRACE 2 study and their caregivers were recruited for 

interviews. A total of eleven youth and seven caregivers agreed to participate in semi-structured interviews 

concerning their experiences and perceptions with the Youth KIT© and TRACE mentor. A conventional inductive 

content analysis process was used for data analysis. 

Results 

The study resulted in 9 superordinate themes: About the study: This study found that although the 

participants appreciated the availability of the services and supports, these two interventions were not used to their 

full capacity. Experiences: Many of the participants were going through multiple transitions and experiences in their 

lives. Supports and barriers: The participants reported social, cultural, physical, institutional, transportation, 

information, and temporal factors as both supports and barriers for their transitions. Self-management: The majority 

of youth reported that they were independent in managing their medical needs and that they saw themselves 

becoming more independent in decision-making and directing their own care in the future. Parental role: Many of 

the youth continued to receive assistance from their parents. Many parents also reported an understanding and 

willingness to allow their youth to become more independent. Perceived need: The majority of participants reported 

that although they felt the Youth KIT and online mentor were useful and well organized, they didn’t see a need for 

the two resources. They thought it would be better suited for individuals with more significant disabilities or who 

lacked supports. Recommendations: The participants recommended having the interventions available through 

different mediums, such as a mobile phone application; they also recommended that they be more personalized to 

individual needs; and education should be provided to the parents and youth at an earlier stage, prior to transition. 

Overarching themes of transition: Multiple transitions were occurring while the youth were transitioning into the 

adult health care system including beginning post-secondary school, which seemed to be more of a priority for most 

youth. 

Conclusions/ Future Directions 

This study demonstrates that participating youth and their caregivers did not find the Youth KIT or TRACE 

mentor useful in assisting the youth to transition to the adult health care system, although benefits were noted 

regarding the assistance provided for other general life transitions. The study also demonstrates the complexity of 

the transition including the interdependent relationship between parents and their youth, the perceived need of the 

tools during the transition, and the ‘behind the scenes’ support and role that parents play throughout young 

adulthood. The Youth KIT and TRACE mentor tools would benefit from revisions based on youth and caregiver 

recommendations to improve their utility during the transition from pediatric to adult health care services. 

References 

Allen, D., Channon, S., Lowes, L., Atwell, C., & Lane, C. (2011). Behind the scenes: The changing roles 

of parents in the transition from child to adult diabetes service. Diabetic Medicine, 28, 994-1000. 

CanChild: Centre for Childhood Disability Research (2012). TRansition to Adulthood with Cyber guide 

Evaluation (TRACE). Retrieved February 29, 2012. from http://www.canchild.ca/en/ourresearch/trace.asp. 

Gorter, J. W., Stewart, D., & Woodbury-Smith, M. (2011). Youth in transition: Care, health and 

development. Child: Care, Health and Development, 37, 757-763. doi: 10.1111/j.1365-2214.2011.01336.x 

Grant, C., & Pan, J. (2011). A comparison of five transition programmes for youth with chronic illness in 

Canada. Child: Care, Health and Development, 37, 815-820. doi: 10.1111/j.1365-2214.2011.01322.x 

Kirk, S. (2008). Transitions in the lives of young people with complex healthcare needs. Child: Care, 

Health and Development, 34(5), 567-575. doi: 10.1111/j.1365-2214.2008.00862.x 

Van Staa, A. L., Jedeloo, S., van Meeteren, J., & Latour, J. M. (2011). Crossing the transition chasm: 

Experiences and recommendations for improving transitional care of young adults, parents and 

providers. Child: Care, Health and Development, 37(6), 821-832. doi: 10.1111/j.1365-2214.2011.01261.x 

Young, N. L., Barden, W. S., Mills, W. A., Burke, T. A., Law, M., & Boydell, K. (2009). Transition to 

adult-oriented health care: Perspectives of youth and adults with complex physical disabilities. Physical & 

Occupational Therapy in Pediatrics, 29(4), 349-361. doi: 10.3109/01942630903245994

Acknowledgement: We would like to thank our supervisors 

Andrea Morrison, Julia Lockhart, and Deb Stewart along with the 

clinical team at the Children’s Developmental Rehabilitation 

Programme for their contributions to this project. 

Abstract 

Moving On…Teen Independence Program: Program Evaluation of Outcome Measures 

Purpose: To examine the outcome measures utilized in the 

Abstract 

Moving On... program for their validity in describing the 

outcomes of the program. The Moving On... Teen 

Independence Program (MOTIP) is a nine-day program run 

by the Children’s Developmental Rehabilitation Programme 

(CDRP) in Hamilton, Ontario. This program aims to improve 

community-based living skills of adolescents who have a 

disability and are preparing to transition to adulthood. 

Methods: A retrospective chart review as well as a focus 

group with MOTIP clinicians was conducted to examine the 

effectiveness of the program and the outcome measures used. 

Descriptive statistics, paired samples t-tests and content 

analysis were used in the analysis of the data. Results: 

Participants experienced significant improvement in their 

perception of their performance (p

Results 

Population: Participants ranged in age from 15 to 19 years 

and had diagnoses of Cerebral Palsy, Spina Bifida, 

Progressive Spastic Paraparesis, Chromosomal Abnormalities, 

Developmental Coordination Disorder, or Head Injury with 

the majority of participants having Cerebral Palsy (73.3% of 

all participants). Participants’ GMFCS levels range from level 

1 to level 4 with the majority of the participants at level 3 or 4 

(both with 33.3% of participants respectively). 

COPM: Participants experienced significant improvement in 

their perception of performance (p

LOOKING AT CHILD BEHAVIOUR MEASURES FROM A DIFFERENT ANGLE 

Beverley Wasmund, MSc. OT candidate 2012; Peter Rosenbaum, MD, CanChild Centre for Childhood Disability Research 

Abstract 

Current attitudes and theories about child 

development, behaviour and disability are considerably 

different than they were at the time when many currently 

popular behavioural measures were originally developed. 

Modern approaches to the clinician-client relationship 

emphasize family-centred care and the tenet that parents are 

the experts on their child. It is important, therefore, to consider 

the history of commonly-used parent-rated behaviour 

measures. An awareness of the perspective, structure and 

functional capacity of these measures will enable clinicians to 

know whether these tools enable them to identify children 

with challenging behaviours accurately and measure the 

efficacy of interventions. In this paper we examine seven 

commonly-used behavioural measures and compare their 

features to concerns voiced by parents of children with 

challenging behaviours. We conclude with a discussion of an 

alternative method for evaluating children’s behaviour. 

Introduction 

Anecdotal reports from parents suggest that 

behavioural screening measures often do not capture their 

concerns. Common behavioural questionnaires are based on 

data obtained from a variety of test populations but they 

cannot possibly account for the unique situation of every child 

and their family environment. As a result, some parents find 

that their children’s behaviours are dismissed as ‘typical’ and 

they do not receive the support they feel they need. 

If the behavioural questionnaire is written in a 

language other than the first language of the parents, the intent 

of some of the questions may be misunderstood. Furthermore, 

based on the structure and items of some questionnaires, 

parents may not be able to convey adequately what they find 

most problematic in a way that is consistent with the content 

and format of the questionnaire. 

Most behavioural measures focus on specific 

behaviours and use closed-ended rather than open-ended 

questions. This limits parents’ ability to describe the impact 

and meaning of the behaviour on their daily lives. As a result, 

many nuances of the problem behaviour may be missed. 

Measures designed as diagnostic tools are not 

necessarily appropriate as outcome measures unless they have 

been validated for that purpose. 

With these limitations in mind, we asked the 

question: Do current child behaviour assessments measure 

what parents find most distressing about their child’s 

behaviour? If they do not, it is important to determine how to 

identify accurately those in need of service and ensure that the 

interventions provided are making a meaningful improvement. 


The terms challenging behaviour or problem 

behaviour are often used interchangeably. Emerson (2001) 

defined challenging behaviour is as follows: 

... culturally abnormal behaviour(s) of such an intensity, 

frequency or duration that the physical safety of the person or 

others is likely to be placed in serious jeopardy, or behaviour 

which is likely to seriously limit use of, or result in the person 

being denied access to, ordinary community facilities (p. 3). 

Emerson also noted, “many challenging behaviours appear to 

be functional adaptive responses to particular environments” 

(p. 4) and “behaviour can only be defined as challenging in 

particular contexts” (p. 8). 

Most qualitative research on challenging childhood 

behaviour is related to a specific disability such as autism, 

ADHD or developmental delay. There is a paucity of literature 

describing parents’ perspectives in general terms, i.e. 

regardless of what kind of behaviour is occurring, what 

characteristics of the behaviour are most distressing to parents. 

Researchers who have used qualitative methods to study the 

experiences of parents and family members have identified 

five common experiences: eternal vigilance, frenetic pace, 

worry, social isolation and a distinction between episodic, 

dangerous behaviour and more frequent, less dangerous 

behaviour described as difficult (Fox, Vaughn, Wyatte & 

Dunlap, 2002; Turnbull & Ruef, 1996; Werner Degrace, 

2004). Keen and Knox (2004) noted the difficulty of 

measuring the efficacy of a behavioural intervention and 

suggested that clinicians work “collaboratively with the family 

to identify their own measures” (p. 62). 

Methods 

A database of 520 quantitative, peer-reviewed 

research articles dated 1986-2007 from a larger parenting 

study served as the basis for this research. Articles which had 

titles containing the word ‘behaviour’ were selected. A total 

of 43 studies were examined and a short list of the most 

frequently-occurring parent-rated measures was generated: 

Child Behavior Checklist (CBCL) (Achenbach and Edelbrock, 

1981), Conners’ Parent Rating Scale (CPRS) (Conners et al., 

1998), Parenting Stress Index – Short Form (PSI-SF) (Abdin, 

1995), Questionnaire on Resources and Stress Short Form 

(QRSS-SF) (Friedrich, Greenberg, & Crnic,1983), Vineland 

Adaptive Behaviour Scales II (Vineland II) (Sparrow, 

Cicchetti & Balla, 2005), and Social Skills Rating System 

(SSRS) (Gresham & Elliott, 1990). The Social Skills 

Improvement System – Rating Scales (SSIS) (Gresham & 

Elliott, 2008), a revised version of the SSRS, was used for the 

analysis as the original could not be located in the public 

domain. Although used less frequently, the Strengths and 

Difficulties Questionnaire (SDQ) (Goodman, 1997), was also 

included in this list on the basis of its citation frequency 

elsewhere. The measures were compared with respect to the 

following features: dates of original and revised versions, 

intended population, source of items, test population, % of 

positive or prosocial items, % of items related to parents’ 

experiences or perceptions of their own lives, % of concepts 

other than the child’s behaviour, and measurement scale. 

Results 

Items - Although most child behaviour research 

involves children with disabilities, only three of the measures 

we examined were developed with data obtained from children 

with disabilities (ie., the QRSS-SF, the SSRS, and the 

Vineland II). The CBCL, CPRS and SDQ all used data from 

child psychiatric clinics in the development of the measures. It 

is noteworthy that the PSI, which is based on data from 

healthy, typically developing children, is often used in studies 

of atypically developing children. Furthermore, although most 

of the measures were originally designed to elicit feedback 

from parents, the items for the measures were generated by 

clinicians, not parents. Authors of the CBCL and QRS-SF

used parents’ responses to their questionnaires to further refine 

the questions – but the content came from clinicians. Focus on 

problems – The CBCL and PSI-SF do not contain any 

positive items and the number of positive items in the CPRS is 

in the order of 5%. The QRS and SDQ contain 35% and 40% 

positive items, respectively. Only the SSIS and the Vineland II 

are weighted more heavily toward positive items. Impact on 

parents - Child behaviour and the impact of the behaviour on 

parents’ lives are inextricably linked, yet most measures do 

not address the impact on parents. Four of the measures 

(CBCL, SSIS, SDQ and Vineland II) do not contain any items 

related to the parents’ emotions or experiences regarding their 

child’s behaviour. Approximately 2% of the questions in the 

CPRS pertain to the feelings of the parent; in contrast 

approximately 50% of the PSI-SF and 63% of the QRS 

address parents’ emotions and experiences. Variable content 

- Several measures contained items that appeared to be related 

to concepts other than child behaviour. The CBCL, CPRS and 

SDQ each contain two items related to the way in which other 

people perceive or treat the child. In addition, the CBCL 

contains three items related to academic, speech or motor 

problems and the QRS contains two items related to the 

child’s excess of free time. The CPRS is noteworthy in that 

approximately 8% of its items are related to the child’s 

learning difficulties. Scaling - All of the measures use a 

relatively narrow scale (3 to 5 points) to rate the frequency of 

each behaviour. The SSIS is significant in that it rates the 

importance of items in addition to their frequency; however, it 

does so for the positive items only. Negative items in the SSIS 

are rated only with respect to their frequency. 

Discussion 

The results from our analysis indicate that common 

behaviour measures contain items developed primarily from 

the clinician’s perspective; emphasize the frequency of 

negative behaviours; and generally do not address the impact 

of the behaviour on the parents. Given these findings, we 

suggest that there are several other important factors to 

consider when assessing challenging behaviour and evaluating 

the outcome of a behavioural intervention: 

• Each child with challenging behaviour and their family is 

unique – what is distressing and causes dysfunction for one 

family may not be a problem for another family. Thus it is 

important to try to acquire an individualized sense of this 

child’s behaviour in this family. 

• It is not merely the frequency of occurrence that 

characterizes a challenging behaviour. Intensity (ranging from 

minor to extreme manifestation of the behaviour), safety (i.e. 

dangerous versus difficult), duration and social isolation are 

also features of the behaviour. 

• Eliminating the behaviour entirely may take a very long time 

or may not be achievable. Perhaps it is possible to change 

some aspects of the behaviour that are most distressing to 

parents, and thereby reduce its impact. 

• Rather than scoring a large number of behaviours on only 

one parameter (i.e. frequency of the behaviour), it may be 

more insightful to score a few behaviours in greater detail (i.e. 

on several parameters). Each parameter could be scored with 

respect to the degree of problem it poses for the parent, i.e. on 

a scale of 1 to 10 where 1 represents a slightly problematic 

issue and 10 represents an extremely problematic challenge. 

This method is similar to that used in the Canadian 

Occupational Performance Measure (Law et al., 2005). 

The parameters of a particular behaviour might be 

defined in the following manner: frequency (how often the 

behaviour occurs), amplitude (the intensity with which the 

behaviour is manifested), duration (how long a particular 

occurrence of the behaviour lasts), location (where the 

behaviour occurs), and time of day the behaviour occurs. 

There are several advantages to this method of 

looking at a child’s problem behaviour. First, parents are able 

to focus on a few behaviours of greatest concern to them 

rather than a large number of pre-selected behaviours 

addressed in the items of standard measures, many of which 

may not be relevant to their family at that point in time. 

Second, since parents identify the problem behaviours 

themselves, the measure is always culturally relevant, never 

out-of-date and tailored to the unique situation of each family. 

Thus it embodies family-centred practice and the concept that 

parents are the experts on their children and the best reporters 

of the behaviours and their impact. Third, analysis of various 

parameters of the behaviour enhances understanding of the 

behaviour and identifies specific aspects of the behaviour to 

target for intervention. Finally, use of a 10-point interval scale 

rather than scales such as “never/sometimes/often” should 

improve the ability of the instrument to measure change. 

Conclusion 

Popular child behaviour measures tend to measure 

the relative frequency with which a large number of possible 

behaviours occur. When designing interventions for children 

who exhibit challenging behaviours, it may more insightful to 

have parents identify a few behaviours of primary concern and 

analyze these in greater detail. Given the length of time it 

takes to change most challenging behaviours, it may be 

possible to improve the situation by addressing the most 

problematic features of the behaviour and thereby shape the 

behaviour to a more acceptable manifestation. The key 

principle described in this paper is to rate each parameter 

(frequency, amplitude, duration, location, time of day) with 

respect to the degree to which it poses a problem for the 

parents. 

Key References 

Emerson, E. (2001). Challenging behaviour: analysis and 

intervention in people with severe intellectual 

disabilities (2 nd ed.). Cambridge, UK: Cambridge 

University Press. 

Fox, V., Vaughn, B.J., Wyatte, M.L., & Dunlap, G. (2002). 

We can’t expect other people to understand: Family 

perspectives on problem behaviour. Exceptional 

Children, 68, 437-450. 

Keen, D., & Knox, M. (2004). Approach to challenging 

behaviour: A family affair. Journal of Intellectual & 

Developmental Disability, 29, 52-64. 

Turnbull, A.P., &Ruef, M. (1996). Family perspectives on 

problem behavior. Mental Retardation, 34, 280-293. 

Werner DeGrace, B. (2004). The everyday occupation of 

families with children with autism. American Journal 

of Occupational Therapy, 58, 543-550. 


The authors wish to thank Dr. Lucyna Lach for 

providing the database, Dr. Nora Fayed for her advice 

regarding analysis of measures and N. Nemeth whose 

observations and insights served as the catalyst for this project.

Participation in Children and Youth with Disabilities: 

A scoping review 

Briana Ogilvie, Sarah Greenwood & Brenna Tonkin, MSc. OT Candidates 2012, McMaster University 

Project supervisor: Mary Law, PhD, OT Reg. (Ont) 

Abstract 

Introduction 

Pg. 1 

Methods

Results 

Discussion Conclusion 

Pg. 2 

2 

Donec sit amet arcu.

Innovations for Children’s Safety in Vehicles: 

Conducting a Usability Evaluation of Car Seat Testing of Premature Infants Among Frontline Staff 

Project Supervisor: Brenda Vrkljan PhD, OT, Reg. (Ont). 

Students: Laura Kogon MSc OT Candidate 2012 & Alisha Gardener MSc OT Candidate 2012 

Abstract: Preterm infants are at higher risk for health complications when in a semi-upright position, which is the common 

position for automobile travel using car seats. 1, 2 Guidelines have been established for these infants to minimize the risk by 

ensuring the infant is optimally positioned in their car seat. The purpose of this study is to describe a positioning protocol 

implemented by nurses in a neonatal intensive care unit (NICU), prior to infant discharge. In order to capture the nurses’ 

behaviours, a usability checklist was developed. This checklist was utilized to quantify and qualify the nurse’s behaviours 

when positioning an infant in their car seat. Four nurses and four infants were recruited by a sample of convenience. Data was 

collected through videotapes and questionnaires. Results from the study demonstrate that there are consistencies and 

inconsistencies in nursing behaviours when positioning an at-risk infant in their car seat, despite the availability of positioning 

guidelines. Limitations and implications for practice are discussed. 

Introduction: Motor vehicle collisions are a leading cause of 

death for young children in Canada. 1 Determining effective 

strategies that optimize positioning of infants in car seats has 

become a focus of both researchers and policy makers. When 

car seats are used correctly in motor vehicle collisions, there is a 

71% reduced risk of infant mortality and 67% reduced risk of 

injury. 3 Infants born prematurely have been identified as having 

an even higher risk when positioned in a semi-upright position, 

as required by most car seats 3 . These risks include: 

• Apnoea (temporary absence/cessation of breathing) 2,4,5 

• Bradycardia (slow heartbeat) 2,4,5 

• Hypoxia 2,4,5 

• Problems with the size and ‘fit’ of the car seat itself. 4,5 

To ensure premature infants are safe for travel by car seat, the 

Infant Car Seat Challenge (ICSC) has been recommended by the 

American Academy of Pediatrics (AAP). The ICSC is designed 

to assess the safety of at-risk infants in their car seat prior to 

hospital discharge. Guidelines for ICSC suggest that any infant 

born at less than 37 weeks gestation or who has respiratory 

complications endure a 90 minute observation period in their car 

seat prior to discharge 6 . 

Literature Review: Guidelines have been developed by 

Transport Canada and the Canadian Pediatric Society (CPS) to 

outline some recommendations on appropriate positioning 

strategies for preterm and low-birth weight infants. Key points 

include: 

• Use of blanket rolls to fill space at head, crotch, sides 

• Shoulder straps originate at or slightly below the shoulder 

and should be tightened to 1 finger width at collarbone 

• Infant should not wear bulky clothing (e.g., snowsuit) 

• Buttocks should be positioned at the back of the seat 

• The use of a 5-point harness 

• Chest clip positioned at armpit level 

• Car seat positioned at a 45 degree angle in vehicle as well as 

during in-hospital, pre-discharge ICSC evaluation 

• Car seat positioned on the floor during in-hospital evaluation 

Despite the availability of these guidelines, there is no available 

evidence confirming how nurses actually position these infants 

in their respective car seats. Clinical procedures involved with 

preparing preterm/at-risk infants for discharge range from 

formal ICSC testing to caregiver car seat education. Common 

across hospitals is an understanding on how to best position 

these infants in their car seats in preparation for discharge. 

Project Objective: 

To describe the positioning protocol implemented by nurses 

prior to the discharge of preterm and/or at-risk infants. 

Research Question: What are nurses in an Ontario hospital 

doing to position premature/at-risk infants in their car seat prior 

to hospital discharge? 

Methods: 

Study Design: Concurrent nested strategy (Mixed Methods): 

This design allows for collection of quantitative and qualitative 

data to occur simultaneously using a single source of data 7 . 

Participants: A total of 4 videos were analyzed that featured: 

4 nurses employed in a level 2 nursery in Ontario and 4 infants 

ready for discharge. 

Data collection stages: 

1) Questionnaires: Provided to the nurses and the infant’s family 

to obtain demographic information 

2) Videotapes: Recorded videos of each nurse positioning an 

infant into their car seat 

3) Creation (& Validation) of a Usability Checklist: Developed 

using a task-analysis of infant car seat positioning strategies 

utilized by nurses in the videos 

Validation of checklist: 

• Two registered nurses were recruited through a sample of 

convenience and were provided with identical training on how 

to use the usability checklist. 

• Inter-rater reliability (Kappa): 95.7% (excellent) 8 

Data Analysis: The usability checklist was used as a tool to 

describe and document the observed/heard behaviours 

throughout the videos. This checklist was used to collect 

objective data that was then tabulated and used to quantify nurse 

behaviours. Both qualitative and quantitative data collected 

using the usability checklist was then utilized to identify 

consistencies and inconsistencies in nurses’ verbal and nonverbal 

behaviours. 

Results: 

Demographic Information: Clinical experience in the NICU and 

with car seat testing ranged from three months to 23 years.

Results (Cont’d) 

Key Areas of Infant Positioning from the Usability Checklist: 

✔ Indicates a positioning guideline that was implemented by a nurse 

✗ Indicates a positioning guideline that was not implemented by a nurse 

# of 

Nurses 

Positioning Guidelines 

Car Seat Setup: 

✔✔✔✔ Car seat contained a five-point harness 

✗✗✗✗ 

Discussed or ensured that the car seat was 

positioned at a 45 degree angle 

✗✗✗✗ Positioned the car seat on the floor 

Fastening the Infant in the Car Seat: 

Positioned the chest clip at the infant’s armpit 

✔✔✔✔ level 

Ensured the infant’s bottom was positioned at 

✔✔✔✔ the back of the car seat 

✔✔✔✗ 

Ensured the infant was not wearing bulky 

clothing 

✔✔✗✗ 

Ensured that the shoulder straps originated at 

(or slightly below) the infant’s shoulders 

✔✔✗✗ 

Tightened the shoulder straps to one finger 

width at the infant’s collarbone 

Truck Positioning: 

✔✔✔✗ Checked for extra space at the crotch 

When extra space was identified at the crotch, 

✔✔✗✗ 

rolled towels/blankets were positioned at the 

crotch to prevent submarining 

Consultation: 

✔✔✔✔ 

Provided the caregiver(s) with education 

regarding proper car seat positioning strategies 

✗✗✗✗ Consulted with another healthcare professional 

Discussion: Ensuring premature infants are optimally positioned 

in their car seat is a priority. Current practice recommendations 

from the CPS, Transport Canada, and the Ontario Ministry of 

Transportation (MTO) support many of the nurse practices 

observed throughout the four videos. It is evident that all nurses 

included in this study were committed to providing the infant 

and their caregivers with car seat safety education and 

positioning strategies. All the nurses had knowledge of the 

hospital’s protocol for infant car seat positioning, which was 

evident from the checklist analysis. 

Positioning premature infants in car seats remains challenging: 

Despite the availability of positioning recommendations through 

CPS, Transport Canada, MTO, and hospital guidelines, evidence 

from this study suggests that hospital protocols and nursing 

behaviours are not always consistent with these 

recommendations. This was evident by the inconstancies found 

in nursing practices throughout the videos. 

Clinical Implications: 

Nurse Training: Findings indicate that there is no standardized 

training provided to nurses as demonstrated by the inconsistent 

nurse behaviours. The discrepancies between the nurses’ 

behaviours observed in this study highlight a need for more 

resource allotment for educating and training nurses on infant 

car seat safety. 

Quality Control: Given the importance of proper positioning 

strategies for infant safety, it is important to ensure that each 

infant and caregiver receive positioning strategies that are 

consistent with practice recommendations. This research 

highlights a need for developing hospital protocols to promote a 

consistent quality of care. For example, incorporating a usability 

checklist similar to the one proposed in this study can assist in 

guiding and monitoring nurse practices. 

Future Directions for Clinical Research: 

• Exploring what different hospitals are doing across the 

province to position an infant in their car seat would provide a 

broader sense of current practices. 

• Future research should focus on reviewing the relationship 

between caregiver education and infant car seat positioning 

and safety. 

• Research should explore what nurses are specifically doing to 

position an infant in preparation for the ICSC and implications 

for pass/fail. 

Limitations: 

As videotapes were used as a primary method for data 

collection, error and bias may be a limiting factor of this study. 

This error and bias exists, as participants may act differently 

when they know they are being videotaped and/or actions may 

not have been accurately captured during the videos. In addition, 

usability testing identifies n=5 is ideal for ensuring saturation, 

however this study included n=4. For this reason, sample size is 

a potential limitation of this study. 

Conclusions: This pilot study is the first to actually evaluate 

how nurses position premature or at-risk infants in their car seat, 

prior to discharge from the NICU. Further research is needed to 

provide a basis to support changes in hospital protocol that will 

support consistent training, quality assurance, and knowledge 

translation amongst frontline staff. 

Acknowledgements: We would like to thank the following 

individuals for their guidance: Brenda Vrkljan, PhD, OT, 

Catherine Moher, MSc, RN & Heather Boyd, MSc, OT. 

References: 

1. Public Health Agency of Canada. (2008). Leading Causes of 

Death and Hospitalization in Canada. Retrieved from 

http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/index-eng.php1 

2. Bull, M., & Engle, W. (2009). Safe transport of preterm and 

low birth weight infants at hospital discharge. American 

Academy of Pediatrics, 123, 1424-1429. 

3. Transport Canada. (2008). Transporting infants and children 

with special needs in personal vehicles: A best practices guide 

for healthcare practitioners. Retrieved March 23, 2012 from 

http://www.tc.gc.ca/media/documents/roadsafety/TP14772e.pdf 

4. Lincoln, M. (2005). Car seat safety: Literature review. 

Neonatal Network, 24, 29-31. 

5. Canadian Pediatric Society, (2000). Assessment of babies for 

car seat safety before hospital discharge. Paediatric Child 

Health, 5, 53-56. 

6. Howard-Salsman, K., (2006). Car seat safety for high-risk 

infants. Neonatal Network, 25, 117-129. 

7. Creswell, J.W. (2003). Research design: Qualitative, 

quantitative, and mixed methods approaches. (2nd ed.). 

Thousand Oaks, CA: Sage Publications, Inc. 

8. Fleiss, J. L. (1981). Statistical methods for rates and 

proportions. New York: John Wiley & Sons.

Abstract 

Evaluation of a Social Skills Program for Children Between the Ages 5-11 

By: Vishalla Singh and Elissa Whitman, MSc (OT) Candidates (2012), McMaster University 

Supervisors: Kara Lee and Scott McBean, Occupational Therapists, George Jeffrey Children’s Treatment Center 

Background: According to the World Health Organization (WHO) International Classification of Function (ICF), social 

participation is an aspect of healthy living and can be fostered within activity groups (WHO, 2001). The literature supports the 

effectiveness of social skills training and many outcome measures have been developed to assess social skills. However, it remains 

unclear as to what outcome measure is most appropriate for measuring social skills. Purpose: The purpose of this project was to 

recommend a social skills outcome measure that clinicians at the George Jeffrey Children’s Centre (GJCC) could use to evaluate 

change in the social skills of children (5-11) participating in a Social Skills Programs offered at the Centre. Methods: Firstly, a 

comprehensive literature review was executed to determine what social skills outcome measures currently exist. Secondly, 7 

criteria were established in order to choose the most relevant outcome measure for the GJCC Social Skills Program. Thirdly, the 

limitations of the chosen outcome measure were addressed through the creation of a Clinician Outcome Measure and a Self- 

Reflection Scale. Findings: 37 pediatric social skills measures were found in the literature review. Based on the 7 pre-determined 

criteria, the Social Skills Rating System (SSRS) was determined to be most appropriate. Two limitations were noted with the 

SSRS: lack of a clinician report tool and no self-report measure for children 8 and below. These limitations were addressed 

through the creation of a Self-Reflection Scale for children under the age of 8 and a Clinician Outcome Measure. Directions for 

future research are discussed. Conclusions: Findings revealed that the SSRS was the most appropriate outcome measure for use 

with the GJCC Social Skills Program. The SSRS combined with the Clinician Outcome Measure and Self-Reflection Scale will 

allow clinicians at GJCC to evaluate change in children’s social skills over time. 

Part 1: Literature Review 

Introduction 

The purpose of the project was to determine whether an 

adequate outcome measure to assess social skills existed that 

met the needs of the Social Skills Program at GJCC (for 

children 5-11 of various diagnoses, offers 3 levels of 

programming). Therefore, we conducted a literature review, 

which indicated that group-based social skills interventions 

can have a positive impact on the development of social skills 

for many individuals experiencing social skills deficits 

(Castorina & Negri, 2011; Cotugno, 2009; Koenig et al., 

2010; Reichow & Volkmar, 2009; White, Koenig & Scahill, 

2007). In addition, there are currently 37 pediatric social 

skills measures that were found in the literature. One of the 

limitations of measuring the effectiveness of social skills 

groups identified in the literature is a lack of valid, reliable, 

and sensitive outcome measures to evaluate social skills 

(White, Koenig, & Scahill, 2007). The most relevant 

measures were selected based on 7 criteria (see below). 

Methods 

We used the focused clinical question: what outcome 

measures are being used to evaluate social skills? The search 

strategy was as follows: (1) 14 databases searched; (2) 

inclusion criteria: published in English, available through the 

McMaster libraries, involved a social skills program, and 

reported an outcome measure related to social skills; (3) 

exclusion criteria: adjunct studies that explicitly involved a 

medical intervention in addition to a social skills intervention. 

We also contacted all of the Ontario Association of 

Children’s Rehabilitation Services (OACRS) members to 

determine if they were using any social skills assessments. 

Criteria considered when selecting the most relevant outcome 

measure were: (1) good reliability; (2) good validity; (3) good 

clinical utility; (4) used in 3 or more studies; (5) used for 

children 5-11; (6) used with multiple diagnoses; and (7) used 

in a variety of environments (i.e. home, school, and therapy 

sessions). 

Results and Discussion 

Five social skills measures (see Table 1) met 4 or more of the 

criteria and were further reviewed. 

Table 1: Summary of relevant social skills measures. 

Autism Social 

Skills Profile 

(ASSP) 

Social 

Responsiveness 

Scale (SRS) 

Social Skills 

Rating System 

(SSRS) 

Matson 

Evaluation of 

Social Skills for 

Youngsters 

(MESSY) 

Structured Role- 

Play 

Assessments 

• Description: Likert scale; completed 

by parents; measures frequency of 

social behaviours; designed for 

social skills groups; 6-17; Autism. 

• Met 4/7 criteria. 

• Description: diagnostic tool; 

completed by clinician; measures 

severity of social impairment; 4-18; 

Autism. 



by parents, teachers, and participant; 

measures frequency of social 

behaviours; 3-18; multiple 

diagnoses. 



by parents, teachers, and participant; 

measures frequency of social 

behaviours; 4-18; multiple 

diagnoses. 


• Description: observable behaviours 

of social skills within a structured 

setting. 


Since the SSRS met all 7 criteria, it was determined to be 

most appropriate for the GJCC Social Skills Program. 

However, 2 limitations were noted: (1) no self-report measure 

for children below 8, and (2) no clinician tool for measuring 

change in the participants’ social skills. 

1

Issue Part 2: #: Development [Date] of Self-Reflection Scale and Clinician Outcome Measure 

Dolor Sit Amet 

Introduction 

To address the limitations identified in the SSRS in part 1 of 

the project, the following tools were developed: 

(1) Self-Reflection Scale – the purpose of the scale is to allow 

clinicians at the GJCC to ascertain the child’s (8 and under) 

perception of their own social skills. 

(2) Clinician Outcome Measure – the purpose of the measure 

is to allow clinicians at the GJCC to measure changes in 

children’s social skills throughout the sessions offered in the 

Social Skills Program. 

Methods 

The Self-Reflection Scale was created with reference to a 4point 

Likert scale self-report measure developed by another 

member of the Ontario Association of Children’s 

Rehabilitation Centers (OACRS) (A. DeFinney, personal 

communication, Feb. 28, 2012). Changes were made to the 

scale so that questions were aligned with the GJCC social 

skills program and reflected previous research uncovered 

during the literature search in part 1, i.e. a list of commonly 

observed behaviours used in social skills assessments. 

With respect to the Clinician Outcome Measure, clinicians at 

the GJCC requested that a Likert scale be used since it would 

provide an ordinal measurement of subjective clinical 

evaluations (K. Lee & S. McBean, personal communication, 

March 14, 2012). Therefore, a brief literature review 

regarding the ideal number of response categories that should 

make up a rating scale was undertaken. 

Results and Discussion 

The Self-Reflection Scale was created for children below the 

age of 8 to report on their perception of their own social 

skills. 

With regards to the Clinician Outcome Measure, the evidence 

suggested that overall reliability, validity, and discriminating 

power are significantly higher for Likert scales with response 

categories of 7 points (Preston & Colman, 2000). The 

Clinician Outcome Measure consists of the following: 

(1) Three sections – one for each social skills group offered 

within the GJCC Social Skills Program; and 

(2) Two scales – one that measures the extent to which the 

child can describe a particular social skill (Descriptive Scale), 

and one that measures the degree of independence the child 

has when performing a particular social skill (Implementation 

Scale). 

Conclusion 

The SSRS met 7/7 criteria, but had 2 limitations that were 

addressed through the creation of a Self-Reflection Scale and 

Clinician Outcome Measure. 

Future Directions 

Future directions may include the following: 

(1) Trial the SSRS for the Social Skills Program (currently 

being done at GJCC); 

(2) Trial the Clinician Outcome Measure for the Social Skills 

Program (currently being done at GJCC); 

(3) Trial the Self-Reflection Scale for the Social Skills 

Program (currently being done at GJCC); 

(4) If the SSRS is an appropriate outcome measure for the 

Social Skills Program, use the SSRS to determine the 

effectiveness of the Social Skills Program; 

(5) Determine the reliability and validity of the Clinician 

Outcome Measure; and 

(6) Determine the reliability and validity of the Self-Reflection 

Scale. 

References 

Castorina, L.L., & Negri, L.M. (2011). The inclusion of 

siblings in social skills training groups for boys with 

Asperger syndrome. Journal of Autism and Developmental 

Disorders, 41, 73-81. 

Cotugno, A.J. (2009) Social competence and social skills 

training and intervention for children with Autism Spectrum 

Disorders. Journal Autism and Developmental Disorders, 

39, 1268-1277. 

Koenig, K., White, S.W., Pachler, M., Lau, M., Lewis, M., 

Klin, A., & Scahill, L. (2010). Promoting social skill 

development in children with pervasive developmental 

disorders: A feasibility and efficacy study. Journal of 

Autism and Developmental Disorders, 40, 1209-1218. 

Preston, C.C., & Colman, A.M. (2000). Optimal number of 

response categories in rating scales: reliability, validity, 

discriminating power, and respondent preferences. Acta 

Psychologica, 104, 1-15. 

Reichow, B. & Volkmar, F.R. (2010). Social skills 

interventions for individuals with autism: Evaluation for 

evidence-based practices within a best evidence synthesis 

framework. Journal of Autism and Developmental 

Disorders, 40, 149-166. 

White, S. W., Koenig, K., & Scahill, L. (2007). Social skills 

development in children with autism spectrum disorders: A 

review of the intervention research. Journal of Autism 

Developmental Disorders, 37, 1858-1868. 

World Health Organization (WHO). (2001). International 

Classification of functioning, disability, and health 

(IFC). Geneva, Switzerland: World Health 

Organization. 


We would like to thank Kara Lee and Scott McBean for their 

enthusiasm and guidance throughout this project and for 

allowing us to become involved with the Social Skills Program. 

We appreciate the input provided by Kerstin Blazina and Kate 

Clower, Speech Language Pathologists, during the 

development of the descriptive scale for the Clinician Outcome 

Measure. Finally, it was a pleasure to work alongside the 

dedicated staff at GJCC. 

Link to Prezi 

http://prezi.com/tzss6jsazy99/social-skills-outcome-tool/ 

2 

2

Scoping Review: Development of an Assessment Protocol for the 

ErinoakKids Independent Living Program 

Student Investigators: Kristel Lazo & Rachel Pedros, MSc OT Candidates 2012, McMaster University 

Project Supervisors: Anna Maria Isihi, OT Reg (Ont), Jon Greenaway, SW, Joe Trovato, M.A., C. Psyche Associate, & 

Tanya Eimantas, BScOT, MSc, OT Reg (Ont) 

ABSTRACT: Purpose: To determine which skills or characteristics best promote independent living in youth with disabilities and 

revise an assessment protocol for the ErinoakKids Centre for Treatment and Development Independent Living Program (ILP) that 

measures these skills. Method: A scoping review was conducted to explore research published from 1980 through to 2011 that 

pertained to the determinants of independent living. Studies included participants with physical or intellectual disabilities, focused on 

personal skills or characteristics, and examined the transition to adulthood/independent living. The authors identified assessments that 

measure key factors and reviewed the psychometric properties of the most suitable assessments. Current ILP assessment protocol was 

revised. Results: Twelve studies met the inclusion criteria. Self-determination and social skills were found to be significant factors 

associated with positive independent living outcomes. The recommendations for the revised assessment protocol included the addition 

of the Arc’s Self-Determination Scale and the Social Skills Improvement System Rating Scale (SSIS-RS). Conclusion: It is 

recommended that the ErinoakKids Centre for Treatment and Development ILP incorporate measures of self-determination and social 

skills, as these are important personal characteristics contributing to successful independent living outcomes. 

Introduction 

Successful transition into independent living is a critical stage 

in development for adolescents with disabilities (Healy & 

Rigby, 1999). Research has shown that adults with disabilities 

are less likely to engage in paid employment, participate in 

recreational activities and also experience difficulty navigating 

the adult health care system and accessing community supports 

(Stewart, Law, Rosenbaum, & Wills, 2001). To assist 

adolescents with disabilities throughout the transition process, 

many children’s treatment centres (CTC) across Ontario have 

developed programs that aim to facilitate and foster 

independent living. The term “independent living” stems from 

a philosophy founded on the premise that individuals with 

disabilities have the right to make personal decisions that 

impact all areas of their life (Centre for Independent Living in 

Toronto, 2012). Research into independent living examines 

various post-school outcomes, such as continuing education, 

employment, and community involvement (Test, Mazzotti, 

Mustian, Fowler, Kortering, & Kohler, 2009). The Independent 

Living Program (ILP) at ErinoakKids Centre for Treatment 

and Development aims to enable youth with physical 

disabilities to achieve personal goals and develop a set of 

essential life skills (ErinoakKids, 2012). The ILP is an 

overnight program where participants between the ages of 16 

and 19 live within a college residence for approximately ten 

days with personal care support (ErinoakKids, 2012). 

Literature supports the effectiveness of independent living 

programs; however, limited research is available that examines 

the correlations between personal characteristics and 

independent living. Understanding what personal 

characteristics best promote independent living will enable 

independent living programs to assess these skills and develop 

appropriate interventions. To address this gap in literature, the 

following research question was developed: What compilation 

of assessments is best suited to measure the skills and 

characteristics essential to independent living for adolescents 

with disabilities entering the Independent Living Program at 

ErinoakKids? The purpose of this scoping review was to 

analyze the literature and determine which skills or 

characteristics best promote independent living, and create an 

assessment protocol that measures these skills. 

Methods 

The authors employed scoping review methodologies 

identified by Arskey and O’Malley (2005) and Levac, 

Colquhoun, and O’Brien (2010). This methodology is ideally 

suited for topics that have not been examined in detail, that 

explore broad research questions, and utilize a wide variety of 

study designs (Arksey & O’Malley, 2005). They are also well 

suited for summarizing and disseminating research for the 

purpose of making policy recommendations (Arksey & 

O’Malley, 2005). This scoping review resulted in 

recommendations for the ErinoakKids ILP assessment 

protocol. The following online databases were utilized to 

identify studies pertaining to personal characteristics that 

promote successful independent living: MedLine, PsycInfo, 

CINAHL, ERIC, AMED, and Embase. Articles were reviewed 

for the following inclusion criteria: studies pertaining to youth 

with physical and/or intellectual disabilities, focus on personal 

characteristics and independent living, peer-reviewed, English 

language, published after 1980 and conducted in North 

America/Europe. Articles were excluded if they focused on 

interventions/programs, or the challenges impeding successful 

independent living. Thematic data pertaining to personal 

characteristics was extracted and summarized in chart form. A 

list of identified personal characteristics was compiled. The 

authors identified key personal characteristics based on the 

strength of evidence and number of supporting studies. 

Suitable assessments measuring the key personal 

characteristics were reviewed for psychometric properties and 

clinical utility using established guidelines (Law, 2004). 

Recommendations were made to revise the current ILP 

assessment protocol. 

Results 

Twelve articles met the inclusion criteria. Results of thematic 

analysis highlighted several personal skills and characteristics 

associated with positive independent living outcomes. The list 

of personal skills identified in thematic analysis included: selfdetermination, 

social skills, positive attitude towards future 

independent living, higher level of experience in practical 

living skills, intelligent quotient, absence of maladaptive or 

problem behaviour, self-efficacy, self-esteem, internal locus of

control, and level of physical function. Five articles in the 

scoping review summary included self-determination as a 

critical skill for successful independent living. Selfdetermination 

incorporates self-realization, self-awareness, 

empowerment and autonomy (Wehmeyer, Palmer, Soukup, 

Garner, & Lawrence, 2007). Four articles demonstrated a link 

between independent living and social skills (social problem 

solving, peer support, communication, cooperation, assertion, 

responsibility, empathy, engagement and self control). Several 

assessments measuring social skills and self-determination 

were reviewed to determine suitability for the ILP based on 

population, purpose of measure, and ease of use. Two 

assessments fit the needs of the program, and psychometric 

properties and clinical utility were reviewed further. The 

revised assessment protocol, including current and 

recommended additions is detailed in Table 1. 

Table 1. Revised ILP Assessment Protocol 

Assessment (Authors) Description 

Arc’s Self- 

72 item evaluative self-report 

Determination Scale* measure that assesses an 

(Wehmeyer, 1995) adolescent’s overall level of selfdetermination, 

designed for youth 

with cognitive, development, or 

physical disabilities. 

Canadian Occupational An evaluative, semi-structured 

Performance Measure interview tool that addresses 

(COPM) 

occupational performance and 

(Law, Baptiste, Carswell, satisfaction in occupation self- 

McColl, Polatajko, & 

Pollock, 1990) 

care, productivity, and leisure. 

Goal Attainment Scale An evaluative method for 

(GAS) 

determining personalized goal 

(Kiresuk, Smith, & achievement over time, typically 

Cardillo, 1994) 

using a five-point scale. 

Perceived Self-Efficacy 8 item evaluative self-report 

Scale 

measure that assesses level of self- 

(Chen, Gulley, & Eden, 

2001) 

efficacy. 

Social Skills 

An evaluative measure of youth 

Improvement System social skills designed to assess 

Rating Scale (SSIS- several dimensions of social skills 

RS)* 

using an optional multi-rater 

(Gresham & Elliot, questionnaire format. Self-report 

2008) 

form includes seven sub-scales of 

social skills. 

* Recommended additions to the current ILP protocol 

Discussion & Implications 

The above recommendations for the ILP assessment protocol 

will provide ErinoakKids with valid and reliable standardized 

assessments. These measures are clinically useful, fit the needs 

of the program and assess the key characteristics identified in 

the scoping review. In addition, programs similar to 

ErinoakKids ILP can include these assessments within their 

protocol. The standardized assessments will enable 

ErinoakKids to conduct high-quality longitudinal studies with 

appropriate outcome measures. The authors recommend that 

future research projects compare self-determination and social 

skills between adolescents who attend the ILP and those who 

do not. Although this scoping review focused on personal 

characteristics, the authors recognize the important role of 

environmental factors in predicting successful independent 

living outcomes. Environmental factors could potentially 

impede or improve independent living outcomes. It is 

important to recognize the interaction between personal 

characteristics, environmental contexts, and the demands of an 

individual’s independent living goals. The Person, 

Environment, Occupation framework (PEO; Law, Cooper, 

Strong, Stewart, Rigby & Letts, 1996) can be a useful tool for 

occupational therapists to address barriers to independent 

living and capitalize on client strengths. The authors 

recommend that future research incorporate the examination of 

environmental factors, personal characteristics, and the 

occupational demands of transitioning to independent living. 

Limitations 

Overall, there is limited conclusive research regarding personal 

characteristics and independent living. This scoping review did 

not exclude studies on the basis of study design or 

methodology. Due to lack of updated research, some studies 

included within this review used designs that were less 

rigorous, such as narrative reviews. While the inclusion of low 

quality studies is acceptable for a scoping review, future 

research should strive for higher methodological rigour. 

Conclusion 

This study has presented a review of the literature on skills and 

characteristics that promote successful independent living for 

youth with disabilities. This scoping review identified that selfdetermination 

and social skills are important predictors of 

independent living outcomes. The Arc’s Self-Determination 

Scale and the Social Skills Improvement System Rating Scale 

are recommended additions to the current assessment protocol 

at the ErinoakKids ILP. 

References 

• Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8, 19-32. 

• Centre for Independent Living in Toronto. (2012). Retrieved March 29, 2012, from: http://cilt.ca/what_is_il.aspx 

• ErinoakKids. (2012). Retrieved March 29, 2012, from: http://www.ErinoakKids.ca/index.cfm?pgID=182 

• Healy, H., & Rigby, P. (1999). Promoting independence for teens and young adults with physical disabilities. Canadian Journal of Occupational Therapy, 66, 240-250. 

• Law, M. (2008). Outcome Measures Rating Form Guidelines. [PDF Document]. Retrieved March 19, 2012, from: 

http://www.canchild.ca/en/canchildresources/resources/measguid.pdf 

• Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. 1996. The Person-Environment-Occupation Model: A transactive approach to occupational 

performance. Canadian Journal of Occupational Therapy, 63, 9-23. 

• Levac, D., Colquhoun, H., & O’Brien, K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5, 69-78. 

• Stewart, D.A. Law, M.C., Rosenbaum, P., & Willms, D.G. (2001). A qualitative study of the transition to adulthood for youth with physical disabilities. Physical & 

Occupational Therapy in Pediatrics, 21, 3-21. 

• Test, D.W., Mazzoti, V.L., Mustian, A.L., Fowler, C.H., Kortering, L., & Kohler, P. (2009). Evidence-Based secondary transition predictors for improving post 

school outcomes for students with disabilities. Career Development for Exceptional Individuals, 32, 160-181. 

• Wehmeyer, M. L., Palmer, S. B., Soukup, J.H., Garner, N.W., & Lawerence, M. (2007). Self-determination and student transition planning knowledge and skills: 

Predicting involvement. Exceptionality, 15, 31-44. 


We would like to thank our supervisors at ErinoakKids for their continued support and guidance throughout the project.

Development of Education Material for Parents: 

Play Positions to Enhance Upper Limb Development in Infants 

Lowana Lee, OT Reg. Ont, Sarah Cain, M.Sc. OT Candidate, Mallory Carson, M.Sc. OT Candidate 

Abstract 

The researchers conducted a literature review and held discussions with clinicians to identify the optimal position 

for children to be in during awake or “play” time that promotes upper limb development, and to identify caregivers’ 

current knowledge of the topic. With this information, the researchers created a first draft of a parent education 

package. 

Introduction 

In 1995, a public awareness campaign entitled “Back to Sleep” was created to give guidelines for parents for the 

recommendation of placing infants on their backs to sleep to avoid the risk of Sudden Infant Death Syndrome 

(SIDS) (Zachry, & Kitzmann 2011). With the increasing amount of attention on SIDS, and prone sleeping being its 

number one risk factor, caregivers of infants have avoided putting their infants in prone all together (2011). 

Tremblay et al. (2012) published a systematic review to create Canadian recommendation guidelines for activity 

of children from birth to four years old. The guidelines that were developed stated that infants (less than 1 year of 

age) should be physically active several times a day, particularly through floor-based play (i.e. in prone) (2012). 


Search Strategy 

Databases Searched: CINAHL, MedLine, OTseeker, PEDro, EMBASE 

Keywords: upper limb, upper extremity, play, positioning, tummy time, prone, infant, toddler, weight bearing 

Inclusion Criteria: Articles had to be published after 1992, as this was when the AAP released sleep position 

guidelines, articles also had to be relevant to infants and toddlers. A total of 8 articles were appraised using the 

McMaster critical review forms for qualitative and quantitative research 

Main Findings 

Physical Activity and Play Positioning for Infants 

Overall, the literature on positioning infants during awake (or play) time suggests that prone (or tummy time) is 

the most advantageous to motor development, especially in the earlier stages of infancy (Dudek-Schreiber, & 

Zalazny, 2007; Monson, Deitz, & Kartin, 2003; Pin, Elderidge, & Galea, 2007; Salls, Silverman, & Gatty, 2002). 

Caregiver Awareness 

Overall, caregivers of infants are not typically aware of the benefits of being in prone position for play and 

‘tummy time’ (Koren, Reece, Kahn-D’angelo, & Medeiros, 2010; Mildred, Beard, Dallwitz, & Unwin, 1995; 

Zachry, & Kitzmann, 2011). 

Knowledge Dissemination 

Overall, parents do not typically receive a lot of information regarding play positioning. The most beneficial type 

of communication tool is the use of printed materials (Jennings, Sarbaugh and Payne, 2005). 

Conclusion 

There has been an identified need for infants to be engaged in physical activity for motor development and that 

playtime in the prone position helps infants reach developmental motor milestones quicker. Parents are not aware of 

the details of infant play positioning, and are more likely to have their children in a supine position due to the fear of 

SIDS. Overall, this review has identified the following gaps in the literature: play positions to promote upper limb 

development and how to disseminate this information to caregivers and those within their circle of care. 

Methods 

To address the gaps within the literature, the researchers created questions to be discussed with an interprofessional 

group of clinicians that have experience with positioning to promote upper limb development with infants, and their 

caregivers. A total of two physiotherapists and three occupational therapists from Children’s Developmental 

Rehabilitation Program (CDRP) were contacted. 

Questions: 1. What population of children do you work with? 2. Do you believe you work on upper or lower limb 

development more often in practice? 3. What techniques do you use to promote upper limb development? 4. Do you 

provide any upper limb development education packages to parents? 5. What evidence have you used to support 

your practices regarding upper and lower limb development? 

• Each discussion was between 30-60 minutes 

• Notes were taken by researchers during discussions 

• Notes were informally analyzed by researchers to identify common responses 

• Common utilized resources were given to researchers by the therapists

Discussion 

Common Themes from Discussions 

• Techniques used by clinicians: All Occupational Therapist (OT)s interviewed had a focus on tummy time 

techniques to promote upper limb development in early infancy. All OTs interviewed also mentioned that tummy 

time should be initiated as soon as possible, grading the activities (eg. increasing amounts of time) as the infant 

begins to tolerate the position longer. 

• All OTs and Physiotherapist (PT)s stated that they photocopy resources available to them to give to parents in 

regards to different positions that promote upper limb development. Some of these resources were mentioned to 

be outdated, and not parent-friendly, so many of the clinicians mention producing their own “homework sheets” 

on triplicates that depict specific positions and play ideas 

• All of the clinicians use the CDRP printed handout for parents about “Tummy Time” 

• All clinicians mentioned a lack of an education package that incorporates the necessary information regarding 

the specific techniques they wished to use, while being easily understood by parents of all backgrounds. 

• OTs were more likely to work on upper limb development in practice, PTs were more often to work on lower 

limb development, however they would not neglect the upper limb. 

• The interviewed PTs reported focusing on balance and strength development through weight bearing in 

prone/sitting, and the use of equipment. They also noted the importance of being in prone and tummy time 

techniques, being congruent with the OTs. Other focuses that were specified were: reducing tone, NDT, feeding, 

fine motor, and righting reactions. 

• Minimal scholarly evidence was utilized by clinicians. 

Development of the ‘Prone to Play’ Parent Education Package 

• Identified that prone was the optimal positioning for upper limb motor development during play. This was 

through the use of the literature, clinician responses and CDRP ‘Tummy Time’ printed 

handout 

• Identified strategies currently being used by clinicians to promote upper limb 

development 

• Identified that the most effective method for knowledge dissemination to parents 

through was through the use of printed information 

• Created play ideas in the prone position. This was through use of the clinicians’ 

responses, clinicians’ resources and researchers’ clinical experience 

• The researchers compiled personally illustrated pictures and information to develop the first draft of the parent 

education package 

Future Direction 

The researchers have made several recommendations for future research 

• Longitudinal studies would be beneficial to see the long term benefits that play positioning can have on a child, 

as the current literature does not examine gross motor developmental milestones past the age of two years 

• Including a range of demographics when sampling, as there have been identified cultural differences that could 

affect motor development (e.g. swaddling infants) 

• The exploration into the Prone To Play parent education package usefulness and comprehensiveness 


Hamilton Health Sciences: Children’s Developmental Rehabilitation Program 


Dudek-Schreiber, L., Zalazny, S. (2007). The effects of prone positioning on the quality and acquisition of developmental milestones in four 

month old infants. Pediatric Physical Therapy, 19(1), 48-55. 

Jennings, J., Sarbaugh, B., & Payne, N. (2005). Conveying the message about optimal infant positions. Physical & Occupational Therapy In 

Pediatrics, 25(3), 3-18. 

Koren, A., Reece, S.M., Kahn-D’angelo, L., & Medeiros, D. (2010). Parental information and behaviours and provider practices related to 

tummy time and back to sleep. Journal of Pediatric Health Care, 24(4), 222-230. 

Mildred, J., Beard, K., Dallwitz, A., Unwin, J. (1995). Play position is influenced by knowledge of SlDS sleep position recommendations. J. 

Paediatr. Child Health 31, 499-502. 

Monson, RM., Deitz, J. Kartin, D. (2003). The relationship between awake positioning and motor performance among infants who slept 

supine. Pediatric Physical Therapy, 15, 196-203. 

Pin, T., Eldridge, B., & Galea, M. (2007). A review of the effects of sleep position, play position, and equipment use on motor development in 

infants. Developmental Medicine & Child Neurology, 49(11), 858-867. 

Salls, J., Silverman, L., & Gatty, C. (2002). The relationship of infant sleep and play positioning to motor milestone achievement. American 

Journal Of Occupational Therapy, 56(5), 577-580. 

Tremblay, M., LeBlanc, A., Carson, V., Choquette, L., Connor Gorber, S., Dillman, C. … Timmons, W. (2012). Canadian Physical Activity 

Guidelines for the Early Years (aged 0–4 years). Applied Physiology, Nutrition and Metabolism, 37, 345–356 

Zachry, A. H., & Kitzmann, K. M. (2011). Caregiver awareness of prone play recommendations. American Journal Of Occupational Therapy, 

65(1), 101-105. doi:10.5014/ajot.2011.09100

THE EXPERIENCE OF THERAPEUTIC RIDING ON CHILDREN WITH AUTISM 

SPECTURM DISORDER: A PARENT’S PERSPECTIVE 

Rebecca Baldwin, BA; Megan Meekison, BSc; 

Bonny Jung, PhD, Med, OT Reg. (Ont.).; Angela Meyer, OT Reg. (Ont.); and Ann Caine, SRN (Eng) 

ABSTRACT: Therapeutic riding (TR) is an alternative/complementary therapy that is often consulted by parents of children with autism 

spectrum disorder (ASD) due to potential therapeutic benefits, but there is a scarcity of evidence providing support for these benefits, 

particularly from a qualitative perspective. The present study used a phenomenological approach to examine the experience of TR on 

children with ASD, from their parent’s perspective. Four children participated in the typical riding program at Sunrise Therapeutic Riding 

and Learning Centre. Before and after their child’s involvement in TR, parents participated in semi-structured interviews to provide an 

understanding of their expectations and experiences, respectively. Thematic analysis was used to develop the overall theme, “TR 

exceeded parent’s expectations,” and the associated sub-themes, “perceived therapeutic benefits exceeded expectations,” “success was 

attributed to the TR environment and child’s motivation to participate,” and “importance of TR as an opportunity for participation in 

meaningful recreation.” This pilot study sheds light on how children with ASD and their families experience TR, the generalizability of 

the perceived benefits, as well as reasons why TR is perceived to be both an effective leisure and therapeutic activity. These results serve 

as an important step in gaining a holistic understanding of TR’s impact, and so implications for this research area and OT practice are 

discussed. 

INTRODUCTION: Autism Spectrum Disorder (ASD) consists of five neurodevelopmental conditions that are characterized by 

abnormalities in social interaction, communication, as well as severely restricted interests/highly repetitive behaviours (Phetrasuwan, 

Shandor-Miles, & Mesibov, 2009). The prevalence of ASD is estimated to be 60 per 10 000 people in developed countries, with an age of 

onset in childhood (Levy, Mandell, & Schultz, 2009). Functionally, the deficits of ASD may impact the ability of a child to engage in 

meaningful social activities, leisure pursuits, and self-care and productivity occupations. Epidemiological studies suggest that 13 to 30 

percent of children with ASD engage in problem behaviours that warrant intervention (Wing & Potter, 2002). Since no curative treatment 

exists, it is common for parents to consult alternative and/or complementary therapies, one of which is animal assisted therapy (AAT; 

Harrington, Rosen, Gamecho, & Patrick, 2006). Evidence suggests that AAT results in decreases in various undesirable behaviours and 

increases in adaptive social and communicative behaviours for individuals with ASD (e.g., Martin & Farmum, 2002). One type of AAT is 

therapeutic horseback riding (TR). While TR is popular for this population, a debate exists as to whether this is an effective intervention 

for promoting physical, psychosocial, cognitive, social-behavioural, and emotional benefits, or if these programs should be considered as 

adapted leisure activities that promote sportsmanship and athleticism (Rosenbaum, 2009). 

LITERATURE REVIEW: The available evidence indicates that a variety of clinical populations may incur physical benefits from TR, 

such as improved postural control and balance, fine motor function, and general motor performance, as well as psychosocial benefits 

related to emotion, socialization, quality of life and self-confidence. With respect to the ASD-specific TR literature, a comprehensive 

review only uncovered 4 relevant studies. First, a small randomized control trial by Bass, Duchowny and Llabre (2009) found significant 

improvements in several sensory and psychosocial domains in children with ASD following 12 weekly TR sessions, some of which did 

not persist at follow-up. Second, Taylor et al. (2009) provided preliminary evidence, through 3 case studies, of improvements in volition 

following a 16 week hippotherapy program. Third, Wuang, Wang, Huang and Su (2010) found that children with ASD demonstrated 

improved motor proficiency and sensory integrative functions following participation in 20 weeks of 60-minute mechanically simulated 

TR sessions. Finally, in a before-after study of 20 children with ASD by Kern et al. (2011), weekly 60-minute TR lessons for 24 weeks 

demonstrated a reduction in the severity of autism symptoms, significant improvements in measures of parent-child interaction, marginal 

reductions in negative regard, and good/very good ratings on the Treatment Satisfaction Survey. Parents also stated that their children 

enjoyed riding and actually began to look forward to their lessons. 

RATIONALE: Despite much promise of the aforementioned studies, there is a marked scarcity of completed studies and quality evidence 

in the literature that provide support for the therapeutic value of EAA/T for individuals with ASD. Furthermore, there is a conspicuous 

lack of qualitative exploration in this field, including investigation into the experiences of riders and/or their families. In addition, the 

generalizability and transferability of the potential recreational and/or therapeutic benefits of TR to daily functioning in home, school and 

community contexts has remained unaddressed. Finally, research needs to shed light on the debate between the therapeutic versus 

recreational benefits of TR, from the consumer’s perspective. 

PURPOSE: The purpose of this pilot project was to examine the experience of weekly TR on children with ASD, from their parents’ 

perspectives, and to provide methodological guidance for a future larger scale study of the same topic. In line with phenomenological 

research, it is believed that occupations, such as TR, are best understood through exploring the individual’s experience of doing it, since 

the interaction of the person’s ability and the demands of the task, and the meaning they attach to it, is perceived by the individual. 

RESEARCH QUESTION: From the perspective of a parent who has a child with ASD, how does EAA/T, in the form of therapeutic 

horseback riding, impact their child’s behaviour, ability to participate in their daily activities, and their family life? 

DESIGN: This study used a phenomenological approach to examine the lived experience of TR for children with ASD, from their 

parents’ perspective. As the study participants, the children’s parents were interviewed using semi-structured interviews before and after

their child’s involvement in TR. Thematic analysis was conducted on the pre- and post- intervention interview data and overall themes 

were created. Triangulation methods were used in order to ensure the accuracy and trustworthiness of the data. 

Riding Program - The TR program was delivered to the children of the study participants by instructors certified through the Canadian 

Therapeutic Riding Association (CanTRA) at Sunrise Therapeutic Riding and Learning Centre. The children experienced individualized, 

30 minute riding instruction sessions, once per week, for a total of 8 weeks. The TR intervention included a mounted portion, which 

aimed to promote communication, as well as provide vestibular, sensory, auditory, visual and tactile stimulation, and an un-mounted 

portion, which was designed to provide sensory stimulation and educate riders on horsemanship. 

Sampling - Participants were purposefully recruited based on convenience from the pre-existing client wait-list at Sunrise. 

Participants – Inclusion Criteria: Parents were recruited to participate in this study if their child was between the ages of 4 and 12 years 

of age, had a formal diagnosis of ASD (by a physician), and had no previous (significant) experience with TR. 

Participants and their Children: A total of 3 parents (nfemale=3) of 4 children (nmale=1) aged 4 to 9 years of age took part in the study. 

RESULTS: Overall Theme: Therapeutic Riding Exceeded Parent’s Expectations – Although parents believed that TR may have 

therapeutic benefits, their main expectation was that it would enable their children's participation in a community-based, physical, 

meaningful and enjoyable recreational activity. During post-interviews, parent's reported that TR exceeded their expectations with respect 

to perceived therapeutic benefits and opportunity for recreation. Three sub-themes illustrate why parents perceived TR to be successful. 

1. Perceived therapeutic benefits exceeded expectations – Examples of the reported therapeutic benefits included satisfying sensory 

needs, decreasing anxiety, increasing self-esteem, providing opportunities for social and communication skill-building, as well as 

improvements in behaviour. 

2. Success was attributed to the TR environment and their child’s motivation to participate – According to parents, all children 

loved horses and looked forward to TR. With respect to the TR center, aspects of the environment that parents perceived supported their 

children’s participation in TR included welcoming staff, a calm atmosphere, a lack of stress, and a focus on horses. 

3. The importance of TR as an opportunity for participation in meaningful recreation – According to parents, TR met their 

children’s unmet need for an accessible, fun recreational/sports activity. The parents also reported that this recreational participation met a 

need for physical activity that their children were not experiencing from other activities/therapies. 

DISCUSSION/CONCLUSION: Descriptive qualitative benefits that were found are consistent with quantitative literature exploring the 

effect of TR and AAT for children with ASD (e.g., Bass et al., 2009; Taylor, 2009; Wuang et al., 2010l; and Kern et al., 2011). These 

qualitative results are also consistent with theories of human-animal attachment and social support, as well as CMOP-E and PEO. 

Implications for OT: Children with ASD may benefit from the incorporation of animals into therapy sessions; and other recreational 

activities could be adapted to enable the highly valued recreational participation of children with ASD. 

TR Program Development: It is important to consider environmental factors and the motivating quality of TR when designing programs. 

Conclusion: Overall, the current study sheds light on how children with ASD and their families experience TR, the generalizability of the 

perceived benefits to home, school and community contexts, as well as reasons why it is perceived to be both an effective leisure activity 

AND therapeutic activity. 

FUTURE DIRECTIONS: The results of this pilot study will be published in the CanTRA Caller and the Canadian Horse Journal, and 

publication will be sought in “Autism” and the “Journal of Autism and Developmental Disorders.” Future research in this area should 

continue to explore the qualitative nature of TR, which has been grossly unexamined to date. This is what Angela Meyer, Ann Caine and 

potentially OT students in 2013 plan to do with a larger-scale study of the same topic. 

ACKOWLEDGMENTS: We would like to thank all of our participants for taking the time to complete our interviews and engage in 

member checking procedures. We would also like to thank Krista Breen, Cathi Illerbrun, and all the wonderful staff and volunteers at 

Sunrise for working with us on this exciting project – your involvement was instrumental to the completion of this project! 

SEMINAL REFERENCES: 

Bass, M. M., Duchowny, C. A., & Llabre, M. M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism and 

Developmental Disorders, 39, 1261-1267. 

Harrington, J. W., Rosen, L., Gamecho, A., & Patrick. (2006). Parental perceptions and use of complementary and alternative medicine practices for children with autism 

spectrum disorders in private practice. Behavioral Pediatrics, 27, S156-S161. 

Kern, J. K., Fletcher, C. L., Garver, C. R., Mehta, J. A., Grannemann, B. D., Knox, K. R., Richardson, T. A., & Trivedi, M. H. (2010). Prospective trial of equine-assisted 

activities in autism spectrum disorder. Journal of Alternative Therapies in Health and Medicine, 17, 14-20. 

Levy, S. E., Mandell, D. S., & Schultz, R. T. (2009). Autism. The Lancet, 374, 1627-1638. 

Martin, F., & Famum, J. (2002). Animal-assisted therapy for children with pervasive developmental disorders. West Journal of Nursing Research, 24, 657-670. 

Phetrasuwan, S., Shandor-Miles, M., & Mesibov, G. B. (2009). Defining autism spectrum disorders. Journal for Specialists in Pediatric Nursing, 14(3), 206-209. 

Rosenbaum, P. (2009). A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy. 

Developmental Medicine & Child Neurology, 51, 88-91. 

Taylor, R. R. , Kielhofner, G., Smith, C., Butler, S., Cahill, S. M. , Ciukaj, M. D., & Gehman, M. (2009). Volitional change in children with autism: A single-case design 

study of the impact of hippotherapy on motivation. Occupational Therapy in Mental Health, 25, 192-200. 

Wuang, Y., Wang, C., Huang, M., & Su, C. (2010). The effectiveness of simulated developmental horse-riding program in children with autism. Adapted Physical Activity 

Quarterly, 27, 113-126. 

Wing, L., & Potter, D. (2002). The epidemiology of autism spectrum disorders: Is the prevalence rising? Mental Retardation and Developmental Disabilities Research 

Review, 8, 151-161.

Journey of Recovery: The Impact of Occupational Therapy within a 

Community-based Adult Mental Health Service 

Amanda Barillaro, Aliza Ladak, Ashley Lal, Leandra Lorello, MSc OT Candidates 2012, McMaster University 

Supervisors: Kim Hewitt, MSc. OT & Lisa Bigam, MSW 

Faculty Consultant: Jocelyn Harris, Ph D. OT 

Institutional Affiliation: Trellis Adult Mental Health & Developmental Services (Adult Services Program) 

Acknowledgement 

We would like to thank our supervisors Kim Hewitt, Lisa 

Bigam, and Jocelyn Harris, along with the clients and clinical 

team at Trellis for their contributions to this project, as well as 

Seanne Wilkins for her guidance. 

Abstract 

Purpose: To explore the impact of occupational therapy (OT) 

services on adults with serious mental illness (SMI) receiving 

intensive support coordination services from the Trellis Adult 

Services Program. This study aims to answer the question: 

What are the experiences of individuals with serious mental 

illness receiving provisional OT services from a communitybased 

adult mental health program? Methods: A 

phenomenological approach was used to describe the lived 

experience of adults with SMI. Twenty potential participants 

were purposefully selected. Semi-structured interviews were 

conducted with eight participants. Transcripts were coded 

manually and subsequently categories and themes were 

generated. Results: Six major themes emerged related to the 

participants’ experiences of engagement in OT services. The 

first three themes related to the participants’ direct experiences 

with OT services and the final three themes related to the 

impact of OT on recovery at large. Conclusion: The findings 

indicate that engaging in OT services led the participants to 

shift their focus away from their mental illness, towards 

participation in day-to-day activities. Despite this shift, 

participation in these activities was found to be a difficult 

process that often needed formal ongoing support. Therefore, 

the main preliminary recommendation that emerged from this 

study was to trial OT services within the Adult Services 

Program for one year. This recommendation aims to address 

the limited exposure and improve the continuity of OT services 

provided. 

Introduction 

To date, the Adult Services Program has supported three 

student OT placements in the last two years. However, this 

program does not have permanent OT services. The student 

occupational therapists’ services consisted of assessment using 

the COPM (Law et al., 2005) and a supplementary goal setting 

and implementation group. Anecdotal reports from clients and 

staff suggested these OT placements have had a positive 

impact on clients. The relevance of this study lies in its 

potential to enhance client care by offering a comprehensive 

understanding of the impact OT services in order to inform 

program-specific recommendations. These recommendations 

will help inform how OT can best be integrated into the Adult 

Services Program. 


Psychiatric Rehabilitation (PSR) & Occupational Therapy 

PSR and OT attend to the person and environmental 

factors of the client in order to enable safe, successful, and 

satisfying engagement in everyday life (1). In addition, OT has 

long been recognized for client-centered practice and its 

holistic perspective of the client, which is also seen in PSR and 

recovery-oriented practices (2). The focus of both fields lies in 

addressing barriers with activities and social participation as 

well as creating supportive environments (1). 

Occupation & SMI 

Within the context of mental health, much literature exists 

supporting the belief that engagement in meaningful 

occupation plays a key role in an individual’s recovery, health 

and well-being, and quality of life. Furthermore, there are a 

number of occupational challenges commonly experienced by 

this population, making occupational therapists well suited to 

enable participation in meaningful activities and elicit the 

potential healing that activities hold (3). 

COPM & Mental Health 

The COPM facilitates individuals to work with their 

mental health providers to achieve goals; thus aligning with 

recovery principles of client choice and empowerment (4). The 

COPM has successfully been used among mental health 

populations to highlight occupational issues in assessment, 

identify occupationally-centred treatment goals, and aid in 

recovery (5). Challenges reported in using the COPM with the 

mental health population include that it requires the individual 

to have insight into areas posing occupational challenges, and 

that occupational issues identified by the therapist and the 

client may differ (6). 

Intensive Case Management (ICM) & SMI 

ICM is an evidence-based model of service delivery for 

this population and is the model employed by Trellis (7). It 

involves a multidisciplinary approach to care and focuses on 

providing intensive assistance to individuals with SMI for 

practical issues like medications, housing, and finances (7). 

These goals are achieved by connecting and arranging services 

while using a client-centered approach, focusing on client 

strengths and increasing community integration (7). 

Methods 

Design: A hermeneutic, or interpretive, phenomenological 

approach was selected to describe the lived experience of 

adults with SMI in provisional OT services in a community 

setting. Participants: Eight out of twenty purposefully selected 

participants recruited from the Adult Services Program at 

Trellis were involved in this study. Participants received

provisional OT services at Trellis within the past two years. 

Procedure: Face-to-face semi-structured interviews over a twoweek 

period in March of 2012. Semi-structured interviews 

were audiotaped in order to generate denaturalized verbatim 

transcripts of the interviews for data analysis. Data Analysis: 

Through an inductive approach, each transcript was coded 

independently, line by line manually, by two investigators. A 

book of codes was devised through discussions among 

investigators to ensure consistency. Upon completion of coding 

each transcript, the four investigators came together to cluster 

codes into categories and finally into themes. 

Results/Discussion 

Six major themes emerged from the data related to the 

participants’ experiences of engagement in OT services. The 

first three themes related to the participants’ direct experiences 

with OT services: increasing self-awareness through the use of 

the COPM; the value of groups as a medium for doing; and 

doing as a function of self, support and situation. The final 

three themes related to the impact of OT on recovery at large: 

occupation as an invaluable tool for recovery; putting recovery 

into perspective; and occupational goals as a source of 

motivation. 

The core concepts of PSR were mirrored in the OT 

services provided. Firstly, the use of the COPM elicited 

specific goals that the participants wanted to work on. 

Secondly, through the ‘Goal Setting and Doing’ group, they 

were provided with the skills necessary to break down goals 

into manageable steps. Lastly, working on these goals with the 

student occupational therapist proved to be a valuable 

environmental support as this was tailored to each individual’s 

stage in recovery. The COPM enabled the participants to 

evaluate their participation in the occupations of everyday 

living, which is an ideal fit with the expertise of occupational 

therapists. This places occupational therapists in a well-suited 

role to navigate this process. 

Finally, research indicates that individuals with a SMI 

find engagement in meaningful activities to be a transformative 

and healing process (3).This was echoed by the majority of 

participants in our study. Seven out of eight participants were 

very passionate about advocating for occupation as a seminal 

part of their lives and contributor to recovery. 

Recommendations 

The following are provisional recommendations based on the 

study’s findings as well as participants’ suggestions: 

� Trial OT services within the Adult Services Program at 

Trellis for one year. 

� Evaluate the impact of the one-year trial OT services. 

� Investigate the impact of OT services from the perspective 

of Trellis case managers. 

Study Limitations 

� Views expressed by the participants may not reflect all 

service users as only 8 out of 20 clients participated. 

� The time each participant spent with the occupational 

therapist varied from one visit to numerous weeks, which 

may have impacted the experiences the participants had 

with OT services. 

� Not all individuals who interacted with an occupational 

therapist attended the group for various reasons, which led 

to limited data surrounding the experience of the groups. 

Future Directions 

This study aimed to investigate the potential impact of 

provisional OT services within the Adult Services Program at 

Trellis in order to provide preliminary recommendations to the 

agency. Results highlighted the positive impact of OT services 

for the participants of the study. Engaging in OT services led 

participants to shift their focus away from their mental illness, 

towards participation in day-to-day activities. Despite this shift, 

participation in these activities was found to be a difficult 

process that often needed formal ongoing support. Therefore, 

the main provisional recommendation that emerged was to trial 

OT services within the Adult Services Program for one year. 

This recommendation seeks to address the limited exposure 

and improve the continuity of OT services provided. This study 

has contributed to the profession by supporting the literature to 

advocate for the OT role within a PSR framework, ICM teams 

and the mental health system at large. This study exemplifies 

how the unique skill set and scope of practice of OT can 

enhance one’s recovery and participation in everyday living. 

The addition of OT services to Trellis will promote 

interdisciplinary collaboration, effective use of resources, and 

continuity of care to the valued clients it serves. Future 

research should seek to evaluate this trial service via the use of 

COPM, as well as investigate the impact of OT services from 

the perspective of Trellis case managers. 

References 

1. Krupa, T., Fossey, E., Anothony, W. A., Brown, C., & Pitts, D. B. 

(2009). Doing daily life: How occupational therapy can inform 

psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 

32, 155-161. 

2. Pitts, D. B. (2009). Introduction to special section on occupational 

therapy. Psychiatric Rehabilitation Journal, 32, 151-154. 

3. Mee, J., & Sumsion, T. (2001). Mental health clients confirm the 

motivating power of occupation. British Journal of Occupational 

Therapy, 64, 121-128. 

4. Kirsh, B. & Cockburn, L. (2009). The Canadian Occupational 

Performance Measure: A tool for recovery-based practice. Psychiatric 

Rehabilitation Journal, 32, 171-176. 

5. Chesworth, C., Duffy, R., Hodnett, J., & Knight, A. (2002). Measuring 

clinical effectiveness in mental health: Is the Canadian Occupational 

Performance an appropriate Measure? British Journal of Occupational 

Therapy, 65, 30-34. 

6. Law M, Baptiste M, Carswell A, McColl M, Polatajko H, Pollock N. 

(2005). The Canadian Occupational Performance Measure (COPM; 

4th ed.). Ottawa: CAOT Publications, ACE. 

7. Schaedle, R., McGrew, J. H., Bond, G. R., & Epstein, I. (2002). A 

comparison of experts' perspectives on assertive community treatment 

and intensive case management. Psychiatric Services, 53, 207-210.

A Springboard to Physical Activity: Exploring Experiences with the Wii Fit in a Community-based Program 

for Individuals with Schizophrenia 

Students: Jillian Goodbrand, Quinn Klassen, Aimee Sweers 

Supervisor: Gord Hirano, Hamilton Program for Schizophrenia 

Research Contacts: Bonny Jung, Briano de Rezzie 

Abstract: This phenomenological study explored the experience of engaging in an eight week Wii Fit program for 

six clients at the Hamilton Program for Schizophrenia (HPS), a community based treatment and rehabilitation 

program. Methods: Six male participants were recruited via convenience sampling from HPS. The three coinvestigators 

conducted individual semi-structured interviews prior to and immediately following an eight week Wii 

Fit Program. Interview data and field notes were actively read to develop a code directory and then analyzed for 

themes. Triangulation was achieved through use of member checking, and comparison of interview data to field note 

observations. Findings and Discussion: Six key themes related to participant’s perceptions of physical activity and 

experience with the Wii Fit program emerged through analysis of the interview data and field notes taken by the cooperative 

education student during participants Wii Fit sessions. The participants experiences with the Wii Fit 

suggest that the virtual reality system has the potential to provide individuals with schizophrenia an opportunity to 

engage in unique, meaningful and motivating physical activities. Conclusion: This study may be help to encourage 

future virtual rehabilitation research in the area of mental health. 

Introduction: This phenomenological study explored 

the experience of engaging in an eight week Wii Fit 

program for six clients at the Hamilton Program for 

Schizophrenia (HPS), a community based treatment 

and rehabilitation program. A previous quantitative 

pilot study conducted at HPS monitored the effect of 

engaging in a four week Wii Sports Program on 

participants’ physical abilities, cognition and selfesteem, 

but revealed no statistically significant change 

in these areas. However, a questionnaire assessing 

participants experience of the Wii Sports Program 

revealed they enjoyed and had fun with the gaming 

system and felt it supported an increased level of 

physical activity. The researchers’ of the present study 

desired to gain a deeper understanding of how the Wii 

Fit influenced a client’s perception of physical activity 

and to explore the potential continuation of the 

program at HPS after the study’s completion. Action 

Over Inertia 1 , a mental health workbook, laid a 

foundation to explore a consumer’s perception of 

participating in the physical activity games on the Wii 

Fit. 

Literature Review: Virtual reality technology such as 

the Nintendo Wii is an increasingly popular 

intervention in occupational therapy as a means to 

improve fitness levels, and provide motivation to 

achieve measurable goals using the game’s scoring 

system 2 . There is an increasing body of literature on 

the use of interactive video games in rehabilitation 

settings, although much of this is focused on 

populations with physical and cognitive limitations. 

Previous research has revealed that individuals with 

Schizophrenia had poor attendance in fitness programs 

due to lack of motivation caused by negative 

symptoms of the illness such as avolition 3 . Bacon et al. 

(2012) reinforce the hypothesis that the Wii Fit has the 

potential to be a motivating, meaningful tool which 

enhances and alters the perception of physical activity 

for individual with mental illness. 

Methods: For this before-after phenomenological 

study, ethics approval was obtained through the 

McMaster Research Ethics Board. Participants were 

recruited from HPS, after advertising the study to all 

clients of the program. All six male volunteers were 

included in the study. Qualitative data was collected 

from pre- and post- semi-structured interviews, as well 

as field notes collected by a co-operative education 

student. The researchers met after each interview to 

discuss experiences and ensure agreement. Data was 

transcribed to text for analysis, actively read by all 

three researchers, and individually coded. The 

researchers met to cooperatively create a code 

directory, then collectively analysed for themes 4 . An 

audit trail and reflexive journaling was used by all 

researchers to encourage trustworthiness. Researchers 

met with five of six participants of the study to ensure 

agreement with the final themes. 

Findings and Discussion: Six key themes related to 

participant’s perceptions of physical activity and 

experience with the Wii Fit program emerged through 

analysis of the interview data and field notes taken by 

the co-operative education student during participants 

Wii Fit sessions. 

Motivated by Meaning: In the initial interviews, 4 out 

of 6 of the participants described either regular 

participation in physical activity, or a desire to increase 

their participation in physical activity. Two participants 

indicated that they did not participate in very much 

physical activity and also explained that increasing 

their physical activity level was not a priority. During 

the eight week Wii Fit program, all of the participants 

attended two sessions with the Wii Fit each week, and 

none of the participants missed more than one session. 

The responses in the follow-up interviews indicated 

that the participants found the Wii Fit to be a 

meaningful activity in which they were motivated to 

participate. 

Walking as Physical Activity: In both the initial and 

follow-up interviews, participants highlighted walking

as one of their main forms of physical activity. Their 

responses indicated that walking can be both a 

necessary mode of transportation, as well as an 

enjoyable and accessible form of physical activity. 

Meeting an “Activity Quota”: In both the initial and 

follow-up interviews, participants described the 

importance of maintaining an optimal level of activity 

participation, describing the importance of having a 

balance in both types of activities, and in the number 

and duration of the activities. The types of activities 

that participants described were wide-ranging, and 

covered all areas of occupation: self-care, productivity, 

and leisure. Participants highlighted the importance of 

balancing their level of activity, as participation in too 

many activities could increase stress, while 

participation in too few could lead to boredom. One 

participant described his stress level in relation to 

participation in activities: “It is a comfortable stress 

level... I’m not too busy and I don’t feel bored or 

lethargic.” During the eight week Wii Fit program, no 

participant missed more than one session, indicating 

that the Wii Fit was a complementary addition to the 

participants current activity routines. 

Multifactorial Influences on Physical Activity 

Participation: Participants identified a wide range of 

factors that influence their ability to engage in physical 

activity, both personal and environmental. Somewhat 

surprising was the number of participants that 

identified physical injuries or other pre-existing 

conditions as the main factors limiting their 

participation in physical activity. Participants also 

highlighted the role that schizophrenia plays in their 

engagement in physical activity, both with motivation 

and medication management. Participants also 

identified the role of socio-economic and other 

environmental factors such as time commitments and 

the nature of the communities in which they live. 

Wii Fit as a Springboard to Variety: Participants 

described engagement in Wii Fit sessions as a 

motivating factor to increase physical activity levels in 

daily life. Transferability of participation in physical 

activity between Wii Fit sessions and meaningful 

physical engagement in the community emerged as a 

major theme within post Wii Fit interviews. During the 

Wii Fit sessions participants reported plans to start 

attending a gym, or a desire to try jogging in the 

community as they enjoyed jogging on the Wii Fit. 

After the Wii Fit sessions were completed, participants 

discussed the connection between engaging in Wii Fit 

games and the “real life” activity. One participant 

described participation in the WiiFit program as: “ a 

springboard to get back in to exercising on my own, 

like jogging and swimming, or just hiking on the Bruce 

Trail.” 

Sense of Accomplishment: The overarching belief in 

the ability of physical activity to provide a sense of 

accomplishment, evident in all initial interviews, is 

expressed in one participant’s statement: “I’m 

accomplishing something. Yeah, doing something with 

my health, taking responsibilities.” Field notes which 

emerged during the sessions highlighted participants 

desire to try new games. The games were described as 

both physically and mentally demanding, and 

participants were observed to work up a sweat during 

their sessions if they desired to play games requiring a 

high level of physical exertion. The challenges 

presented within the games which were successfully 

overcome evoked a universal sense of accomplishment. 

Limitations: All participants in the study were male. 

The session facilitator was highly motivating and it is 

difficult to determine the extent of her influence on the 

high retention rate and positive participant experiences. 

Conclusions and Future Directions: The principles 

of participation outlined in Action Over Inertia indicate 

participation in meaningful activity can promote health 

and well-being for individuals with SMI. Based on the 

themes that emerged, it appears that the Wii Fit has the 

potential to provide individuals with schizophrenia an 

opportunity to engage in meaningful physical activity 

and was a valuable tool for increasing physical activity 

in individuals at HPS. These findings support the those 

found by Bacon et. al. (2012) in the examination of the 

WiiFit in a forensic mental health setting. 

Future Directions: It would likely be beneficial for 

similar community programs to offer the Wii Fit to 

clients with mental illnesses as a way to encourage 

physical activity. This study may be a “springboard” to 

encourage future virtual rehabilitation research in the 

area of mental health, to complement the focus on 

physical treatment. In the words of one of the 

participants, “Video games are fun, ya know?” 

Acknowledgements: The co-investigators would like 

to express our appreciation to the participants, staff at 

HPS, the Wii Fit facilitator Yarima Gomez, and Aliza 

Ladak who was fundamental in recruitment. 


3. Bacon, N., Farnworth, L., & Boyd, R. (2012). The 

use of the wii fit in forensic mental health: exercise for 

people at risk of obesity. British Journal of 

Occupational Therapy, 75, 61-68. 

4. Kielhofner, G. (2006). Research in Occupational 

Therapy: Methods of Inquiry for Enhancing Practice. 

New York: F.A. Davis. 

1. Krupa, T., Edgelow, M., Chen, S., Almas, C., Perry, 

A., Radloff-Gabriel, D., Jackson, J., & Bransfield, M. 

(2010). Action over inertia. Ottawa, ON: CAOT 

Publications ACE. 

2. Schultheis, M., & Rizzo, A. (2001). The 

application of virtual reality technology in 

rehabilitation. Rehabilitation Psychology, 46, p. 296- 

311.

Abstract 

Mild Cognitive Impairments and Dementia: Are Older Adults Slipping through the Cracks? 

Emma Grace and Sarah Shallwani, M.Sc. OT Candidates 2012, McMaster University 

Supervisors: Susan Pettit and Barb Ansley 

Purpose: To determine the frequency with which geriatric 

patients are admitted to the Complex Medical Rehabilitation 

Unit (CMRU) with an undetected mild cognitive impairment 

(MCI)/dementia, and also to examine the relationship between 

the Assessment of Motor and Process Skills (AMPS) and 

cognitive screening assessments currently administered on the 

CMRU. Methods: A retrospective case series design was used 

and data for a total of 136 patients admitted onto the CMRU 

between January 2009 to December 2011 were reviewed. 

Results: In total, 34% of the participants without a formal 

diagnosis of MCI/dementia upon admission demonstrated 

symptoms equivalent to dementia. Weak correlations were 

observed with the AMPS motor scores and selected cognitive 

screening assessments, and moderate correlations were 

obtained for the AMPS process scores (p < .05). Conclusion: 

The findings provide preliminary evidence for the use of the 

AMPS in supporting physicians in diagnosing MCI and 

dementia. Furthermore, this study confirms the high frequency 

of older adults entering the CMRU without a diagnosis of 

MCI/dementia despite the presence of cognitive-functional 

decline. 


Prevalence of MCI and Dementia 

According to a recent report detailing the widespread epidemic 

of dementia, approximately 500,000 Canadians have dementia 

today, costing the Canadian society nearly $15 billion each 

year. 1 Current forecasts predict that over the next 30 years, 

significant increases will be found in the incidence of 

dementia, mortality associated with this condition, and also the 

economic burden attributable to dementia. Considering the 

detrimental costs of dementia both on an individual and 

societal level, national campaigns have called attention to 

dementia and the importance of facilitating early detection. 2 

Under-diagnosis of MCI and Dementia 

While early detection has been noted to be imperative for the 

management of both MCI and dementia, significant obstacles 

continue to impede this from occurring. Some of these issues 

include: difficulty differentiating between early symptoms of 

these conditions and normal ageing, time restraints of 

physicians, limited knowledge of existing guidelines regarding 

dementia and MCI diagnosis, and also difficulties 

communicating a diagnosis due to stigma. 3 

Relevance to the AMPS 

The AMPS may provide physicians with a greater 

understanding of a patient’s cognitive-functional decline. For a 

diagnosis of MCI or dementia to be established, physicians 

need to observe a decline in the patient’s social or 

occupational functioning. The AMPS is an observational 

evaluation that has been designed to evaluate the quality of an 

individual’s performance of activities of daily living. Final 

scores on this assessment indicate amount of assistance a 

patient requires to live independently in the community, as 

well as specific skills that are impacting the patient’s ability to 

function. The AMPS has been used in a variety of clinical 

populations, including older adults with dementia, and its 

potential in supporting a diagnosis of MCI or dementia should 

be further investigated. 4 

Methods 

Design: This study adopted a retrospective case series design. 

Participants: Ethics approval was obtained from the 

Hamilton Health Sciences and McMaster Faculty of Health 

Science Research Ethics Board. Data were retrieved from the 

Hamilton Health Sciences National Rehabilitation Reporting 

System and retrospectively reviewed for 1073 patients. Based 

on the inclusion criteria of this study data, a total of 136 

patients (81 female and 55 male) were reviewed. Specifically, 

demographic information on age, length of stay, admitting 

diagnosis, co-morbidities, and participant scores on the 

following measures were reviewed. 

Measures: 

The AMPS: An observational assessment that evaluates motor 

and process skills through performance of activities of daily 

living (ADL) and instrumental activities of daily living 

(IADL) 

Cognitive Performance Test: A standardized assessment tool 

used to measure performance of persons with dementia on 

specific ADL and IADL tasks that require information 

processing skills. 

Montreal Cognitive Assessment: A pen and paper 

cognitive screening tool for individuals with suspected MCI. 

Clock Drawing Test: A cognitive screening tool for 

individuals with suspected cognitive impairment and 

dementia, which also measures spatial dysfunction and 

neglect. Participants are evaluated by drawing of a clock with 

a fixed time. 

Standardized Mini-Mental Status Examination: A pen and 

paper cognitive screening tool for individuals with suspected 

dementia. 

Results 

Frequency of Undetected Dementia 

To determine the frequency with which older adults are being 

admitted to the CMRU with an undiagnosed MCI or dementia, 

scores on the SMMSE as well as the patient’s admitting 

diagnoses were reviewed. In total, 97 participants out of the 

106 participants, or 92%, did not have a diagnosis of MCI or 

dementia upon admission. Of these participants, 33 scored 

below the cutoff for the SMMSE, which means that 34% of 

the participants without a formal diagnosis of MCI/dementia 

upon admission demonstrated symptoms equivalent to 

dementia.

AMPS Correlations 

To determine the association between the AMPS and the 

cognitive screening assessments that are currently being 

administered on the CMRU, correlational analyses were 

conducted. More specifically, Pearson correlations were 

conducted between the AMPS motor and process skill scores 

and the SMMSE and MOCA scores. As well, Spearman’s rank 

correlations were conducted between the AMPS motor and 

process skill scores and the CPT and CDT scores. Weak 

correlations were observed with the AMPS motor scores and 

selected cognitive screening assessments, with no correlations 

reaching levels of significance. Conversely, moderate 

correlations were observed for the AMPS process scores and 

all identified cognitive screening assessments (SMMSE, r = 

.41, p < .001; MOCA, r = .38, p < .05; CPT, r = .43, p

Beyond Silence: Building Support for Peer Education in a Healthcare Workplace 

Jessica Beaudoin and Nicole Enser, M.Sc. OT Candidates 2012, McMaster University 

Project Supervisor: Sandra Moll, PhD, OT Reg. (ON) 

In affiliation with Hamilton Health Sciences (HHS) 

ABSTRACT 

Background: A high proportion of healthcare workers experience mental health issues and many of these workers do 

not seek help or receive the support that they need due to barriers of stigma and discrimination. Objectives: To 

explore the individual and institutional forces that affect responses to employees with mental health issues. 

Additionally, to identify strategies to improve the level of support for workers who are struggling. Methods: A 

qualitative exploration was conducted to understand stakeholders’ experiences of mental health issues in the 

workplace. Eighty-three employees participated in either in-depth interviews or online surveys. Results: Interview 

and survey data revealed that silence and inaction are common responses to employees with mental illness. Through 

qualitative analysis, four main themes were identified as influencing these actions, including: (a) Attitudes; (b) 

Knowledge; (c) Skills; and (d) Workplace context. Conclusion: Interview data suggests a need to target all four 

identified themes in order to facilitate positive action and creation of an effective early intervention strategy catered 

to the needs of a healthcare facility. 

BACKGROUND 

Mental health in the workplace has become a 

forefront issue in Canadian mental health policy 1 . 

Untreated mental health disorders significantly impact 

the workplace, accounting for up to 70% of total 

disability claim costs 2 . In Ontario, healthcare workers 

have one of the highest disability rates 3 . Despite the 

prevalence of mental illness, silence and a reluctance to 

disclose due to fears of stigma and discrimination mask 

these issues and pose as a barrier to receiving support 4 . 

Education, therefore, is needed to decrease the stigma 

preventing employees from accessing help. 

This study represents the first phase of a project 

designed to develop a peer-led education program 

within a large healthcare facility. Using a Knowledgeto-Action 

Framework, this pilot study will address the 

knowledge creation/synthesis steps by involving 

individuals from across the Hamilton Health Sciences 

(HHS) organization 5 . Results from the study will be 

used to guide the development of a mental health 

education curriculum tailored to meet the needs of 

healthcare workers. 

OBJECTIVES 

The main objectives of this study were to explore 

individual and institutional forces that affect responses 

to employees with mental health issues, and to identify 

learning needs and strategies to improve the level of 

support for workers who are struggling with mental 

health issues. 

METHODS 

Research Design 

A qualitative exploration of the lived experience of 

employees with mental health issues and workplace 

stakeholders who interact with them was conducted. 

Recruitment 

A recruitment poster was posted on the HHS intranet, 

and within the facilities. Recruitment was also done by 

means of snowball sampling, whereby existing 

participants recruited co-workers. Participants were 

purposefully selected for interviews to tap into a range 

of perspectives including position, role, gender, and 

site. Due to high response rates, an open-ended online 

questionnaire was also developed to support additional 

involvement. 

Study Participants 

A total of 83 participants were recruited from all sites 

in HHS: Hamilton General Hospital, McMaster 

University Medical Center, Chedoke Hospital, 

Juravinski Hospital, and St. Peter’s Hospital. Eight 

interviews were conducted with employees with lived 

experience (E) and eight interviews were conducted 

with stakeholders (S) at the hospital (managers, union 

reps, Human Resources, coworkers). Additionally, 67 

participants were online respondents (OR). Participants 

were primarily female and in clinical roles. 

Data Collection 

Ethics approval was obtained from the WSIB Research 

Advisory Counsel and two methods of data collection 

were used: in-depth interviews and an online 

questionnaire. 

In-depth interviews. Sixteen key informants 

were interviewed using an interview guide to explore 

their perspectives on how employee mental health 

issues are addressed in the organization, and to identify 

barriers to support. All interviews were tape-recorded 

and transcribed verbatim by independent researchers. 

Online questionnaire. Sixty-seven employees 

completed open-ended questions in an online 

questionnaire. The questionnaire was generated using 

the same interview guide from the in-depth interviews. 

Data Analysis 

Qualitative analysis of the interview and questionnaire 

data followed an iterative process of identifying the 

social and institutional forces that influenced 

perspectives on mental-ill health at work. Data was 

analysed using N’Vivo software and line-by-line 

coding to identify categories. Subsequently, thematic 

analysis was conducted to formulate key themes 

regarding learning needs and barriers to supporting

workers with mental health concerns. 

RESULTS 

Interview and questionnaire data were combined and 

revealed a range of responses to workers with mental 

health issues, including silence, inaction, and a lack of 

support. Qualitative analysis revealed that these actions 

were shaped by four key themes: 

Theme 1. Negative attitudes and stigma towards 

workers with mental illness 

Participants discussed the effect negative attitudes have 

on action or inaction in the workplace. 

“Thinking back, the shame I felt at having a problem 

was a barrier to me seeking out help for it.” [OR] 

Theme 2. Lack of knowledge of mental illness 

Participants spoke to a lack of understanding of mental 

illness and supports within the organization and shared 

perspectives on what education was needed to help 

support individuals. 

“The affected people need more information about 

where help is available.” [OR] 

Theme 3. Limited communication skills 

Participant responses reflected barriers of not knowing 

what to say, or how to address issues. 

“... You do know but you don’t know what to say.” [S8] 

Theme 4. An organizational context lacking in 

support 

Participants described a stressful workplace that did 

not promote the mental health of its employees. 

“…Organizational culture is a huge influencer and 

that that probably plays the largest role in determining 

workplace health.” [S1] 

DISCUSSION 

Study results suggest that the absence of 

knowledge and skills, combined with stigmatizing 

attitudes in an unsupportive workplace, results in 

silence and inaction. The future direction of this project 

is to implement and evaluate an education strategy that 

will promote early intervention for workers with 

mental illness. The themes identified emphasize the 

need to target all of these areas to effectively facilitate 

provision of support. The following strategies are 

recommended for implementing an education-based 

early intervention initiative: 

1. Build a workplace culture of support. Attitudes, 

skills and knowledge do not function in isolation, 

therefore a supportive workplace context is necessary. 

It is recommended that stakeholders and champions be 

engaged at all levels of the organization, from frontline 

workers to union reps and high level managers, to 

facilitate change. 

2. Change negative attitudes in the workplace. One 

educational approach in addressing stigmatizing 

attitudes is through contact-based education whereby a 

peer, someone with lived experience of mental illness, 

would provide the education. This evidence-based 

format of delivery has been reported to increase 

positive perceptions and decrease stigmatizing attitudes 

towards individuals with mental illness 6 . 

3. Increase mental health literacy. Education should 

focus on providing an understanding of the signs and 

symptoms of mental illness and what resources and 

supports are available, both within and outside of the 

workplace. 

4. Foster communication skills to overcome silence. 

Education is needed on concrete communication 

strategies for speaking with an employee who is ill, or 

communicating challenges. The workplace would 

benefit from protocols and procedures outlining who, 

when, and how to voice any concerns. 

Strengths and Limitations 

Participants were predominantly female, welleducated, 

clinical employees who volunteered for the 

study, which may indicate a bias in perspectives. 

Additionally, member checking is planned but not yet 

completed. 

A strength of this study was the triangulation of 

methods through in-depth interviews, an online 

questionnaire, and involvement of the advisory group. 

This allowed for increased participant involvement and 

higher credibility and validity of results. Another 

strength was in conducting purposeful sampling to 

obtain multiple perspectives. 

CONCLUSION 

Many individual, social and institutional forces 

shape how people respond to employees with mental 

health issues, therefore a multi-pronged, multi-layered 

education strategy is needed to create positive change. 

ACKNOWLEDGEMENTS 

Thank you to Sandra Moll, Erika Pond Clements, and 

our HHS partners Andrew Doppler and Lisa Gilmour. 

REFERENCES 

1. Mental Health Commission of Canada. (2012). 

Changing directions, changing lives: The mental health 

strategy for Canada. Retrieved from 

http://strategy.mentalhealthcommission.ca/pdf/strategy 

-text-en.pdf 

2. Sroujian, C. (2003). Mental health is the number one 

cause of disability in Canada. Insurance Journal, 8. 

3. Health Canada (2009). Environmental Scan on 

Workplace Health in Canada. Ottawa: Author. 

4. Stuart, H. (2006). Mental illness and employment 

discrimination. Current Opinion in Psychiatry, 19, 

522-526. 

5. Graham et al. (2006). Lost in knowledge translation: 

Time for a map? The Journal of Continuing Education 

in the Health Professions, 26, 13-36 

6. Corrigan, P.W., River, L., Lundin, R.K., Penn, D.L., 

Uphoff-Wasowski, K. & Campion, J. (2001). Three 

strategies for changing attributions about severe mental 

illness. Schizophrenia Bulletin, 27(2), 187-195

Exploring Social Participation in Women Aging with HIV 

Lisa Blenkhorn and Jennifer Siemon, M.Sc. O.T. (2012) Candidates 

Project Supervisors: Patty Solomon (Ph.D., P.T.) & Seanne Wilkins (Ph.D.) 

School of Rehabilitation Science, McMaster University, Hamilton, Ontario 

Abstract 

Objective: The present study aims to explore the social participation experiences of women aging with HIV to create a conceptual model 

illuminating both their experiences, and how rehabilitation professionals may better support this client population. Methods: Using a grounded 

theory approach, 20 women over the age of 50 with HIV-positive status participated in semi-structured interviews exploring various aspects of 

social participation. Interviews were audio-recorded, transcribed, and coded. The codes were analyzed and compiled to elicit themes. The 

themes informed a conceptual model that outlined the factors related to the women’s social participation, and was grounded in the data. 

Findings: Participants identified several factors that were related to their social participation. These factors fell into four overarching themes: 

social engagement, social isolation, contrasting perceptions, and contextual factors. Factors related to social engagement included: feeling 

connected with people, with spirituality, and through volunteer work. Factors associated with social isolation included: lacking a desire to 

pursue relationships, perceiving physical appearance unfavourably, living with mental health issues, and experiencing barriers to employment. 

Contrasting perceptions that were experienced differently included: looking ahead to the future, disclosing HIV status, being mobile 

physically and in the community, coping with and managing HIV, and caring for others. Contextual factors also emerged that related to social 

participation, including: viewing instrumental supports as inadequate and experiencing stigma related to gender, age, culture, and HIV status. 

Conclusions: Women who are aging with HIV experience many factors that positively and negatively influence their social participation. 

Elements of the environment also influence social participation. Rehabilitation professionals are focused on enabling participation, 

acknowledging the environment, and facilitating client-centred change, and are thus well-equipped to support this client population. 

INTRODUCTION & LITERATURE REVIEW 

Adults older than 50 years comprise an increasing proportion of 

people infected with the human immunodeficiency virus (HIV) 1 . 

This reality is largely attributable to the development and 

introduction of highly active anti-retroviral therapies (HAART) 

– medications that have increased survival in people with HIV 

and transformed HIV from a terminal illness to a manageable 

and chronic disease. Individuals with HIV often face challenges 

related to their social participation 2 . Social participation is an 

indicator of wellbeing that refers to one’s involvement in social 

activities, such as volunteering, recreation, work, and cultural 

practices, all of which are influenced by a sense of belonging, 

the presence of social networks, and trust in others. Social 

participation challenges experienced by individuals with HIV 

stem from a variety of circumstances, including limited social 

networks, living in poverty, and stigma 3,4 . The added 

dimensions of aging and being female render older women with 

HIV particularly vulnerable to social participation challenges. 

METHODS 

Methodology: Charmaz’s grounded theory approach 5 was used 

to explore social participation among aging women with HIV. 

Participants: Participants were recruited through HIV clinics and 

AIDS Service Organizations (ASOs). Participants were women 

(19 born female, 1 MTF transgender) 50 years of age and over 

(mean age 55.30 years, range of 50-69) who had a diagnosis of 

HIV/AIDS (year of diagnosis range 1986-2010). 

Data collection: Participants were interviewed individually faceto-face 

or over the telephone by a trained and experienced 

research assistant. Interview questions explored various aspects 

of social participation, including self-care and household 

management, relationships with family, friends and romantic 

partners, work, and access to healthcare and social support 

services. The interviews were audio-recorded and transcribed. 

Data analysis: The authors read the transcribed interviews to 

obtain a sense of the overall content and meaning of the 

women’s experiences. Three transcripts were then coded 

independently. The authors met to establish a coding scheme, 

after which the remaining transcripts were coded independently. 

The codes were analyzed and compiled to elicit themes. The 

themes informed a conceptual model that outlined the factors 

related to the women’s social participation, and was grounded in 

the data. 

RESULTS 

The women identified several factors that were related to their 

social participation. These factors fell into four overarching 

themes. Those which were experienced positively by the women 

comprised the theme of social engagement and those 

experienced negatively represented the theme of social isolation. 

The theme of contrasting perceptions encompassed elements of 

social participation that were framed positively by some women, 

but unfavourably by others. The theme of contextual factors 

emerged as parts of the environment that also affected social 

participation. 

Social engagement 

Connecting with people 

Participants emphasized the benefits of having friends and 

family who provided emotional support and comfort as well as 

practical assistance: “I have this sort of little inner sanctum of 

good people that I trust” (136). 

Connecting with spirituality 

Having spiritual or faith-based connections enabled social 

engagement, and helped women to cope with their health 

challenges and with life in general: “I feel [church is] where I 

have gotten a lot of my emotional strength… to make peace with 

myself” (134). 

Connecting through volunteer work 

The women discussed how, through their volunteer work with 

ASOs, they related to others with similar experiences, and felt 

personally fulfilled: “it’s a passion to be able to share my 

experience especially if it’s helped someone else” (108). 

Social isolation 

Lacking a desire to pursue relationships 

Some women expressed that it was easier to be alone and that 

they did not have the desire to engage socially. Some attributed 

this feeling to being older and having less energy. 

Perceiving physical appearance unfavourably 

Many of the women expressed that they were unhappy with their 

physical appearance and described how this affected their selfconcept. 

Some described that their perception of their 

appearance was a barrier to their social participation; “I didn’t 

want to go out, I didn’t want to associate with anyone. I didn’t 

want to go to a family dinner because my face was so haggard” 

(144).

Living with mental health issues 

Having mental health challenges seemed to add another 

dimension of stigma and further contributed to participants 

feeling marginalized by society. 

Experiencing barriers to employment 

Receiving disability supports instead of working or enjoying 

retirement seemed to be a frustrating issue for many women. 

Some of the participants described that these supports create a 

disincentive to obtain employment. 

Contrasting perceptions 

Looking ahead to the future 

Feeling hopeful: Some women spoke of the positive aspects of 

aging, such as growing old with their families, retirement, and 

travel. Being HIV-positive seemed to inspire a fighting spirit in 

some women: “I want to be the oldest bitch before I die” (130). 

Feeling stuck and living day by day: Women spoke negatively 

of the future with regards to their deteriorating health and being 

a burden on others. They expressed a general uncertainty for the 

future and had few concrete plans, but instead lived “one day at 

a time” (147). In this sense, some women appeared to be ‘stuck’. 

Disclosing HIV status 

Some women were considerate and deliberate about when, how, 

and to whom they disclosed their HIV status, which helped to 

form supportive and trusting relationships. Others expressed 

being fearful of disclosing and subsequently being judged. 

Being mobile physically and in the community 

The extent to which women were mobile was a contributing 

factor to their overall social and community participation. 

Coping with and managing HIV 

Feeling well and in control: Some women indicated that they 

were feeling well, in spite of their health challenges, and had 

learned to accept their limits and be “kinder” to themselves. 

Making adjustments to their day-to-day living allowed them to 

ascertain a sense of personal control over their lives: “I try to 

live my life to make it as good as it can be… so I have to 

balance” (136). 

Feeling overwhelmed and underserved: Some women expressed 

frustrations regarding the many health management 

responsibilities they had, such as managing their many 

medications and attending medical appointments. They also felt 

that the current services available to them did not adequately 

address their psychosocial needs: “unfortunately with this 

disease is it can cause some pain and there’s not a drug or 

anything that you can do to help it” (130). 

Caring for others 

Some women spoke of caring for others as being a complicating 

factor as they aged with HIV, while others spoke of it positively, 

saying that their children gave hope and meaning to their lives. 

Contextual factors 

Experiencing stigma 

The women described perceiving stigma related to: 

Gender and sexual orientation: The women felt that prevailing 

societal beliefs that HIV affects primarily gay men meant that 

they were not “in with the in crowd” (128). Gender-based 

assumptions limited their ability to obtain support and access 

services. 

Aging: Participants also conceptualized stigma as it pertains to 

older adults with HIV, and indicated how, as older women, their 

appearance did not fit with societal expectations regarding how 

people with HIV look: “I don’t look like an HIV-positive 

person, you know, I’m too old, too grey, whatever. I don’t fit 

into anybody’s idea of what it is” (136). 

HIV: Many women described being the target of stigmatizing, 

discriminatory actions that they attributed to their HIV-positive 

status. The source of this discrimination was sometimes 

healthcare providers. 

Culture: Some of the women described being the target of 

stigma or discrimination based on their cultural background, or a 

location in which they had previously lived. 

Viewing instrumental supports as inadequate 

Participants indicated that their social participation was limited 

by instrumental supports, such as government-run housing 

subsidies and income support programs, which were inadequate. 

DISCUSSION AND FUTURE DIRECTIONS 

The results of this study elucidate a variety of factors associated 

with social engagement and social isolation in women aging 

with HIV, as well as several contextual factors that relate to 

women’s overall social participation. Given that rehabilitation 

focuses on enabling participation, these findings may assist 

therapists in identifying challenges to participation with clients 

and facilitating the collaborative development of client-centred 

goals. 

These findings add to the current body of knowledge 

regarding social participation in clients with HIV by 

illuminating in more detail the particular experiences of aging 

women. This is the first study, to the authors’ knowledge, 

examining social participation in aging women with HIV 

through a rehabilitation lens. 

However, questions still remain that could be addressed 

by future research. The women in this study frequently had 

difficulty pinpointing whether their challenges they experienced 

were due to age-related processes, HIV infection, or side effects 

of the medications they took. The women also reported sensing 

layers of stigma, but were generally unable to articulate whether 

the stigma they felt was attributable to sexism, ageism, or 

negative sentiments toward people with HIV. Future research 

might clarify the relationships between these intertwined levels 

of complexity. 

CONCLUSION 

Women who are aging with HIV experience barriers and 

facilitators to their social participation, which is also impacted 

by elements of their environment. Rehabilitation professionals, 

with a focus on enabling participation and facilitating clientcentred 

change, are well-equipped to support this client 

population in optimizing their social participation. 

ACKNOWLEDGEMENTS 

We would like to thank the women for their participation in this 

study, as well as Nicole Gervais for her assistance with data 

collection and her administrative support. 

KEY REFERENCES 

1. Public Health Agency of Canada. (2010). HIV/AIDS among older 

Canadians. In HIV/AIDS epi updates (chap. 6). Retrieved from 

http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/pdf/ 

EN_Chapter6_Web.pdf 

2. Shippy, R.A., & Karpiak, S.E. (2005). Perceptions of support among older 

adults with HIV. Research on Aging, 27, 290-306. 

3. Emlet, C.A. (2006). “You're awfully old to have this disease”: Experiences 

of stigma and ageism in adults 50 years and older living with HIV/AIDS. 

The Gerontologist, 46, 781-790. doi: 10.1093/geront/46.6.781 

4. Solomon, P., & Wilkins, S. (2008). Participation among women living with 

HIV: A rehabilitation perspective. AIDS Care, 20, 292-296. 

5. Charmaz, K.C. (2006). Constructing grounded theory: A practical guide 

through qualitative analysis. Thousand Oaks, CA: SAGE.

Activity Limitations and Participation Restrictions following Distal Radius Fracture 

Student Researchers: Dyan Beavis, Chantelle Glenn, Nikki Lord, Sarah Salter 

Abstract (DB) 

Supervisor: Joy MacDermid 

Abstract 

Purpose: to identify and classify the most commonly reported activity limitations and participation restrictions following 

distal radius fracture (DRF), using the International Classification of Functioning, Disability and Health (ICF) as a 

framework. Method: 403 participants (mean age 55.8 years, SD = 14.8), were recruited within ten days post DRF. Using the 

Patient Specific Participation Scale (PS 2 ) participants listed and indicated their ability to engage in personally meaningful 

areas of participation. Participant responses were linked to ICF categories following linking rules. The most common codes 

were identified using univariate analyses. Results: Analyses revealed a wide range of participant-reported challenges, 

spanning 8 of the 9 chapters included in the ICF activity and participation domain. The most common code linked to 

participant responses was d850 (Remunerative employment), 44.7% of participants reported a response linked to this code. 

The chapters which had highest frequency of codes linked were: 1. Community, Social and Civic Life (d9); 2. Domestic Life 

(d6); and, 3. Interpersonal Interactions and Relationships (d7). Conclusion: Results of this study suggest that DRF interferes 

with an individual’s participation in society; this is an important finding because it highlights the social implications of DRF. 

Introduction 

The purpose of this study was to use the International 

Classification of Functioning Disability and Health, (ICF) 

(WHO, 2001), as a framework to identify and classify the 

most common client-reported activity limitations and 

participation restrictions following DRF. This knowledge 

will enable therapists to determine services which will 

effectively decrease individuals’ disability and improve their 

overall quality of life following DRF. By using the ICF 

framework and terminology this study utilized a common 

language and will promote interdisciplinary collaboration in 

the understanding, assessment and treatment of DRF. 

The Patient-Specific Participation Scale (PS 2 ) was used to 

identify participant reported activity limitations and 

participation restrictions. Participants identified personally 

meaningful areas of participation and indicated the impact of 

DRF on their ability to engage in these. The PS 2 has been 

demonstrated to be a simple, valid, and client-centred tool 

applicable for use with individuals who have experienced 

DRF (MacDermid, 2008). 


The existing research investigating the impact of DRF 

highlights the physical impairments and functional 

limitations experienced by individuals following DRF 

(MacDermid, Roth, & Richards, 2003). An effort to examine 

the broader level participation restrictions that these 

individuals face has not yet been made. Literature suggests 

that the experience following a DRF includes significant 

pain, decreased range of motion and strength, and functional 

limitations such as a decreased ability to engage in usual 

household chores, self care, work, and recreation activities 

(Dekkers & Soballe, 2004; MacDermid, Richards, & Roth, 

2001; MacDermid et al., 2003). 

Previous studies have demonstrated the usefulness of the 

ICF framework in conceptualizing the health effects of DRF. 

Harris, MacDermid and Roth (2005) found strong correlations 

between participants’ self reported measurements of 

impairment, activity limitations, and participation restrictions 

and their overall physical health, which supported the use of the 

ICF when evaluating the impact of DRF. Using the ICF 

framework, and a sample of individuals with a DRF, Squitieri, 

Reichert, Kim, & Chung, (2010) found activity and participation 

outcome variables contributed the largest proportion of the 

observed variance in patient satisfaction, indicating the clinical 

significance of these areas. These findings highlight the value of 

using the ICF as a framework for evaluating the impact of DRF 

and demonstrate the need to further investigate the activity 

limitations and participation restrictions following DRF. 

Methods 

Participants were recruited from the Hand and Upper Limb 

Centre in London, Ontario ten days post DRF. Using the PS 2 

participants listed personally meaningful areas of participation 

and indicated the impact of DRF on their ability to engage in 

these. Responses which participants indicated were affected by 

their DRF were included in the linking procedure and analysis. 

Each participant response was linked to a corresponding ICF code 

according to the linking rules outlined by Cieza et al. (2005). 

Agreement in linking was obtained between all four authors prior 

to data analysis. 

Participant responses were linked to ICF codes within the 

Activities and Participation chapters. IBM SPSS Statistics 

Version 20 was used to compute the frequencies of all ICF codes 

linked to responses on the PS 2 . The results obtained from this 

descriptive analysis were used to summarize study findings in 

three different ways: 1) the twenty ICF codes that were most 

frequently linked to participant responses; 2) the frequency of 

ICF codes linked to participant responses within each Activities 

and Participation chapter; and, 3) the five most frequently linked 

codes within each Activities and Participation chapter. 

Results 

The convenience sample included 403 persons, with a mean 

age of 55.8 years (SD=14.0, age range 18-84). The majority of 

participants were female (72.5%).

The ICF code that was most frequently linked to participant 

responses was d850 (Remunerative employment), with 44.7% 

of participants reporting a response linked to this code. The 

code for Family relationships (d760) was the second most 

commonly occurring code, with 30.0% of participants reporting 

challenges linked to this code. The third, fourth and fifth most 

commonly linked codes were d920 (Recreation and leisure), 

d9201 (Sports) and d5701 (Maintaining diet and fitness), 

respectively. Chapter 9 (Community, Social and Civic Life), 

had the highest frequency of linked codes (see figure one). 

Participants reported challenges which were linked to codes 

across 8 of the 9 Activity and Participation chapters; the most 

common code within each chapter is listed in table 1. 

Figure 1. Number of participant responses linked to codes 

within each Activities and Participation chapter. 

d1 – Learning and Applying Knowledge; d2 – General Tasks and Demands; 

d3 – Communication; d4 – Mobility; d5 – Self-Care; d6 – Domestic Life; d7 

– Interpersonal Interactions and Relationships; d8 – Major Life Areas; d9 – 

Community, Social and Civic Life 

Table 1. Most frequently linked ICF code in each 

Activities and Participation chapter 

Chapter ICF Code Frequency 

d1 d170 (Writing) 4 

d2 N/A N/A 

d3 d3601 (Using writing machines) 14 

d4 d450 (Walking) 26 

d5 d5701 (Managing diet and fitness) 86 

d6 d660 (Assisting others) 80 

d7 d760 (Family relationships) 121 

d8 d850 (Remunerative employment ) 180 

d9 d920 (Recreation and leisure) 99 

Discussion 

The results of this study revealed participants experienced a 

wide range of occupational issues following DRF. The activity 

limitations and participation restrictions indicated as affected 

involved all areas of occupation, including self-care, 

productivity and leisure. 

The social implications of DRF were highly evident in this 

study, particularly related to the following chapters in the ICF: 

Community, Social and Civic Life, and Interpersonal 

Interactions and Relationships. Social implications of physical 

injuries have been demonstrated in past research, and social 

abilities are key aspects of health related quality of life (Beaton 

& Schemitsch, 2003). Past research has indicated that social 

relationships can be highly important and meaningful; 

therefore it is important to further understand how these are 

affected by DRF and what services may help address these 

challenges. 

Another major finding was the effect that DRF has on work 

related engagements. Work is a key aspect of health related 

quality of life, has been seen as a key aspect of personal and 

social identities, plays a significant role in community 

participation and meeting psychosocial needs, and can affect 

physical and mental health (COT, 2010). These findings 

combined with the previously demonstrated importance of work, 

indicate the need for services to improve engagement and 

facilitate more rapid return to work for this population. 

Domestic life was another area that was indicated to be highly 

affected by participants. This signifies the attention that is 

required to address these specific activities, particularly for 

females, as they are almost 4x more likely to experience DRF 

than males, and are often more involved in domestic life tasks 

(Thompson, Taylor, & Dawson, 2004). 

Conclusion 

The results of this study suggest that the experience of a DRF 

can result in activity limitations and participation restrictions 

across each of the domains of self-care, productivity and leisure. 

Paramount was the finding that a large number of participants 

indicated restrictions in their social and community lives. Given 

that research in this area has primarily focused on the physical 

implications of DRF, this is an important finding because it 

highlights, for the first time, the social implications of this injury. 

References 

Beaton, D.E. & Schemitsch, E. (2003). Measures of health-related quality 

of life and physical function. Clinical orthopaedics and related 

research, 413, 90-105. 

Cieza, , A., Geyh, S., Chatterji, S., Kostanjsek, N., Ustun, B., & Stucki, G. 

(2005). ICF linking rules: An update based on lessons learned. 

Journal of Rehabilitation Medical, 37, 212-218. 

College of Occupational Therapists. (2010). Working for health: 

Occupational therapy and how it can benefit your organization. 

Retrieved from: 

http://www.cot.co.uk/sites/default/files/marketing_materials/public/w 

orking-for-health-leaflet.pdf 

Dekkers, M., & Soballe, K. (2004). Activities and impairments in the early 

stage of rehabilitation after Colles’ fracture. Disability and 

Rehabilitation, 26(11), 662-668. 

Harris, J. E., MacDermid, J. C., Roth, J. (2005). The 

International Classification of Functioning as an explanatory model of 

health after distal radius fracture: A cohort study. Health and Quality 

of Life Outcomes, 3(73). 

MacDermid, J. C. (2008). Development and validation of a brief- 

patient specific participation scale. 

MacDermid, J., Richards, R., & Roth, J. (2001). Distal radius fractures: A 

prospective outcome study of 275 patients. Journal of Hand Therapy, 

14(2), 154-164 

MacDermid, J., Roth, J., & Richards, R. (2003). Pain and disability 

reported in the year following a distal radius fracture: A cohort study. 

BMC Musculoskeletal Disorders, 4(24). 

Squitieri, L., Reichert, H., Kim, H. M., Chung, K. C. (2010). Application of 

the Brief International Classification of Functioning, Disability, and 

Health Core Set as a conceptual model in distal radius fractures. 

Journal of Hand Surgery, 35A, 1795-1805. 

Thompson, P. W., Taylor, J., & Dawson, A. (2004). The annual incidence 

and seasonal variation of fractures of the distal radius in men and 

women over 25 years in dorset, UK. Injury, 35(5), 462-466. 

World Health Organization. (2001). International Classification of 

Functioning, Disability and Health: ICF. Geneva: Switzerland.

The Psychometric Properties of the MacHANd Performance Assessment (MPA) 

Elizabeth Landman BHSc, MScOT(c) & Annemarie Muhic BA, MScOT(c) 

Abstract 

This measurement study examined reliability and validity 

of the MacHANd Performance Assessment (MPA) with a 

hand-injured population. The MPA is a standardized 

assessment under development that uses everyday 

functional tasks to examine the grasp and pinch patterns of 

the hand. Purpose: To determine if the MPA is a reliable 

and valid measure of function to be used with individuals 

following hand injury. Methods: Participants receiving 

therapy following hand trauma or surgery (n=41) were 

recruited from hand therapy clinics throughout the 

Hamilton/Niagara Region. At baseline visit, two raters 

simultaneously observed and scored the MPA, the Jebsen- 

Taylor hand assessment, Patient Rated Wrist and Hand 

Evaluation and grip/ pinch strength dynamometry. 

Available participants also repeated the assessments again 

within one week of baseline. Results: The MPA 

demonstrates good to high inter-rater reliability and 

excellent test-retest reliability. Item-total correlations were 

very strong at a=0.95. Preliminary explorations of 

construct and criterion validity confirmed hypothesized 

relationships between MPA scores and other measures. 

The MPA is an easy to use functional assessment for 

individuals with hand injuries based on performance of 

everyday tasks. This study provides initial estimates of the 

psychometric properties of the MPA in patients with hand 

injuries. 

Introduction 

Across the healthcare landscape, there is a strong 

movement towards routine utilization of outcome 

measures in clinical practice. In hand therapy, few 

performance-based hand assessments, which examine 

participation and activity limitations, have been developed 

explicitly for traumatic hand injuries, and data on the 

psychometric properties is of varied quality, or nonexistent 

(Van de Ven-Stevens et al., 2009). The Ahuja 

Hand Performance Assessment (AHPA), is a standardized 

test battery developed in Hamilton by a hand therapist 

over 25 years ago. It was pilot-tested for a heterogeneous 

population of hand function problems with promising 

results; however, this data was never published. The 

MacHANd Performance Assessment (MPA) was created 

as an adaptation of the AHPA in 2010. The concepts of the 

assessment are identical but implemented differently for 

reproducibility and face validity. The scoring has been reworded 

and common everyday items have replaced the 

original test kit. The clinical experience of therapists using 

the MPA in clinical practice has demonstrated it has 

potential utility both for description and evaluation of 

hand function; two of the three purposes for selection 

of a measurement instrument (Rudman & Hannah, 1998). 

In the absence of another reliable and valid performancebased 

assessment, this test was evaluated for the hand 

trauma and post-surgical population served by the Hand 

Therapy Clinic at HHS and other community facilities. 


A review of the literature on hand assessments revealed 

two systematic reviews. The first, a systematic review 

published in 2009 (Van de Ven-Stevens et al) reviewed 23 

instruments but found no performance-based measures of 

hand function that met all the criteria for sound clinimetric 

evaluation properties. They identified that a need exists 

for: “…reliable and validated instruments to evaluate 

changes and, if possible, to predict the outcomes of 

different interventions.” ( p.152) 

A similar systematic review of activity and 

participation measurement tools examined 15 tools, 

including both self-report and performance based tests 

(Schoneveld, Wittink, and Takken, 2009). They reported 

on 5 performance tests designed for all types of hand 

injuries but felt clinimetric data was weaker overall for the 

performance tests, specifically in the area of validity. 

Purpose 

The purpose of the study is to determine if the MPA is a 

reliable and valid method of assessing hand performance 

in persons after hand trauma or reconstructive surgery of 

the hand. 

Key Questions: 

• Does the MPA demonstrate acceptable levels of interrater 

and test-retest reliability? 

• Does the MPA represent a single construct (hand 

performance/ hand function) and how well do the items 

relate to that construct? 

• How does hand function as measured by the MPA 

compare to hand function as measured by the Jebsen- 

Taylor Hand Function Test (JTHFT) (Jebsen, Taylor, 

Trieschmann, Trotter & Howard; 1969), the selfreported 

upper extremity pain and disability as 

measured by the Patient Rated Wrist and Hand 

Evaluation (PRWHE) (MacDermid & Tottenham, 

2004), and grip and pinch strength? 

Methods 

Design 

Participants with hand injury or reconstructive 

surgery were asked to undergo a battery of assessments for 

the purpose of comparing the results of the assessment 

across limbs, across raters, across different methods of 

measurement, and across time. 

On a baseline visit, 2 different raters 

simultaneously observed and scored the MPA, which was 

completed with both the affected and unaffected hands. 

Additionally, the participant completed the Jebsen-Taylor 

Hand Function Test (JTHFT) with the affected hand only, 

as well as bilateral testing of grip strength using the 

JAMAR dynamometer, and lateral pinch strength using 

the pinch strength dynamometer. Participants were also 

asked to complete a self-report questionnaire of pain and 

disability, the Patient Rated Wrist and Hand Evaluation 

(PRWHE). At the end of the baseline visit, participants

The Psychometric Properties of the MacHANd Performance Assessment (MPA) 

Elizabeth Landman BHSc, MScOT(c) & Annemarie Muhic BA, MScOT(c) 

were invited for a second visit within one week to repeat 

the MPA as well as grip and pinch strength measures. 

Ethics 

Ethics approval was obtained from the joint 

McMaster University/Hamilton Health Science Research 

Ethics Board, and the Hotel Dieu-Shaver Research Ethics 

Board. Informed consent was obtained from all 

participants and financial compensation was not offered. 

Participants 

Participants were recruited from hand therapy 

clinics at the General site of Hamilton Health Sciences, 

Hotel Dieu-Shaver, and Upper Ottawa Physiotherapy. 

Most assessments were completed in conjunction with 

hand therapy sessions at each site. The documentation and 

measurement procedures took a total of approximately 90 

minutes. 

Inclusion Criteria 

1. Hand or upper limb injury or surgery to a single limb 

for which the participant is still receiving therapy. 

2. No contraindications for lifting, grasping, pinching or 

sustained activity at this point in the patient’s recovery as 

per standard management protocols (ie. 8 weeks post nonfixated 

fracture, 8 weeks post flexor tendon repair, 4 

weeks post carpal tunnel release, 12 weeks post 

arthroplasty). 

3. Able to provide informed consent. 

Exclusion Criteria 

1. Confounding diagnoses – whiplash, nerve root 

compression, and/or bilateral peripheral neuropathy, 

systemic disease such as rheumatoid arthritis. 

2. Open wounds on testing sites. 

3. Pre-morbid functional deficits 

Results/Discussion 

• The MPA demonstrated good to high inter-rater 

reliability (ICC (average measures) = 0.96), and 

excellent test-retest reliability (ICC (average measures) 

= 0.99; ICC (single measures) = 0.99). 

• Item Total Correlation (ITC) (a= 0.95) found that all 

items of the items of the MPA work together to test 

hand function; the high ITC may suggest item 

redundancy (Streiner & Norman, 2008). 

• Internal consistency was explored using factor analysis 

and found a 3-component solution, but there were no 

clear patterns or trends to indicate what the components 

might be. 

• As a measure of criterion validity, the researchers 

compared MPA scores (score out of 100) between 

affected and unaffected hands and confirmed the a priori 

hypothesis that they would be significantly different 

(Mean Diff = 18.29, 95%CI = 14.36-22.22, p < 0.001) 

• Further adding to criterion validity, a moderate negative 

(r= -0.47, p

Expert Panel Review of a Community-based Exercise Programme for Individuals Living With Chronic 

Obstructive Pulmonary Disease (COPD) 

Katie Fisher, MSc OT Candidate 

Project Supervisor: Kirsti Reinikka, BHScPT, MPH 

Research Team: Shelley Prevost, RRT, MASc (resp) 

Abstract 

Background: The effectiveness of pulmonary rehabilitation is well documented for people living with chronic 

obstructive pulmonary disease (COPD). However, a gap continues to exist regarding the maintenance of gains 

made in outpatient pulmonary rehabilitation programmes. This paper provides support for the development of 

an evidence-based community-based exercise programme for individuals living with COPD to be led by 

fitness instructors in the community of Thunder Bay, Ontario. Methods: An expert panel review was 

conducted to determine the content validity of the exercise programme. Lynn’s two-stage process was used to 

develop and validate content and a modified Delphi procedure was utilized to evaluate consensus across the 

expert panel. The programme was subsequently modified in response to the expert panel’s feedback to 

establish consensus on a final exercise programme. Results: Thirty five out of the original forty-one exercises 

were included in the final exercise programme based on receiving adequate content validity (>70% CVI, mean 

>3.4) following two rounds of review. The overall programme was also deemed comprehensive and feasible 

(80% CVI, mean 3.2). Conclusions: This study provides the foundation for the implementation of an 

evidence-based community-based exercise programme that is comprehensive, feasible, clear, safe, and relevant 

and can be led by fitness instructors for people living with COPD in the community. 

INTRODUCTION 

For individuals with COPD, pulmonary 

rehabilitation (PR) is recommended as an 

important, evidence-based component of disease 

management however there is limited access to PR 

in Canada (Nici et al., 2006). PR is delivered by a 

multi-disciplinary team of health care providers 

and is effective at improving health-related quality 

of life, exercise capacity, dyspnea, and fatigue 

(Lacasse et al., 2006). There is no consensus on the 

longevity of gains from PR. Community-based 

maintenance programmes delivered by healthcare 

providers for individuals with COPD have shown 

to maintain exercise capacity, regular physical 

activity, and health related quality of life following 

outpatient PR programmes (Lacasse et al., 2006). 

As there does not appear to be an end-point in 

terms of the benefits of community-based exercise 

programmes and there are decreased costs 

associated with ongoing participation, it appears 

timely to determine an optimal model to support 

people living with a chronic disease. 

METHODS 

Five experts consented to participate and were 

selected based on their clinical expertise with 

COPD and/or exercise programming for people 

living with chronic disease and drawn from across 

Canada. Lynne’s (1986) two-stage process for 

content validation guided the development and 

validation of the exercise programme. Stage one 

(development stage) consisted of a review of the 

literature to identify exercises for inclusion in the 

development of a community-based exercise 

programme for individuals with COPD. Stage two 

(agreement stage) consisted of the expert panel 

review of the exercise programme to determine the 

content validity of the programme. The original 

forty-one exercises in the programme were 

reviewed by the expert panel for content validity; 

specifically, the relevance of each exercise, the 

clarity of instructions and the safety of each 

exercise, and the comprehensiveness of the 

programme as a whole, and rated on a four point 

Likert rating scale. The panel provided comments 

for each exercise and commented on the 

comprehensiveness and feasibility of the entire 

programme. An electronic survey that was pilot 

tested and utilized during prior expert panel 

reviews was used to collect responses. A modified 

Delphi process was used to analyze the degree of 

written consensus among the expert panel, who 

were not in contact at any point. Level of 

agreement for each individual exercise and 

comprehensiveness of the programme was 

determined using the Content Validity Index 

(CVI), median, and means for relevance, clarity, 

and safety of each exercise as well as the 

comprehensiveness of the programme. A CVI of 

0.70 was chosen as the minimum level of 

consensus required. Two rounds of reviews were 

anticipated to achieve consensus. In the first round 

of review any items receiving adequate content 

validity were included in the final programme, 

items receiving unacceptable content validity were 

eliminated, and items receiving questionable

content validity were amended based on the 

experts’ comments and included in a second round 

of review. This process of amendment and 

additional review continued until consensus of all 

exercises was reached. 

RESULTS 

Evaluation of the comprehensiveness of the entire 

programme achieved adequate content validity 

(80% CVI, mean 3.2) with the mean reflecting 

consensus on the need for minor additions or 

deletions of exercises in the programme. Written 

comments indicated the programme was 

comprehensive and that minor modifications were 

necessary. Comments indicated the programme 

was feasible to be conducted in the community as 

a ninety minute class run by a trained fitness 

instructor. Twenty seven exercises received 

adequate content validity (>70% CVI, mean >3.4) 

and therefore were not sent out for additional 

review. Four exercises received unacceptable 

content validity (3.4) and were 

included in the final programme. Two exercises 

received unacceptable content validity (

Age-Friendly Transit in Hamilton: Assessment using a Travel Chain Perspective 

Amie Enns and Brittany Strauss, MSc. OT Candidates 2012, McMaster University 

Project Supervisors: Lori Letts, PhD, OT Reg. (Ont.), FCAOT and Dr. Margaret Denton, PhD 

In affiliation with the Hamilton Council on Aging (HCoA) 

Background: The age-friendly initiative recognizes transportation as a key domain that influences the health and quality of life of 

older adults. The inability to access transportation can lead to reduced participation in community and social activities. Purpose: 

This study aimed to evaluate the accessibility and usability of the Hamilton Street Railway (HSR) for older adults, using a travel 

chain perspective. Methods: Ten older adults living in Hamilton completed a bus trip, individual interviews and participated in a 

focus group. Qualitative analysis was used to identify themes that reflected participants’ experiences and age-friendliness. Findings: 

Positive customer service, passenger’ attitudes/behaviours, affordability, planning, and the physical environment were identified as 

supportive of older adults’ bus access and use. Safety and physical ability were recognized as important factors that influence bus trip 

experiences. Conclusions: The study provided preliminary findings regarding users’ experiences and helped to develop 

recommendations to further the age-friendly initiative in Hamilton. 

Introduction 

The World Health Organization (WHO) describes age-friendly 

environments as those that support quality of life for older adults by 

facilitating ease of participation, health and security (WHO, 2007). 

Older adults often require more supportive and enabling 

environments to accommodate for the social and physical changes 

inherent to the aging process (Broom et al., 2010). In response to 

this, the WHO introduced the Age-Friendly initiative to provide 

guidelines that address the specific needs of older adults living in 

the community (WHO, 2007). The Hamilton Council on Aging 

(HCoA) is a senior driven organization dedicated to making 

Hamilton more age-friendly through the WHO’s Age-Friendly 

initiative. In previous years the HCoA, in collaboration with 

students, has focused on assessing neighbourhood walkability and 

accessibility of grocery stores and pharmacies. Transportation is 

another component of the Age-Friendly initiative, which is an 

important means of mobility for older adults living in the 

community. The HCoA has therefore deemed it important to 

determine the “age-friendliness” of Hamilton’s transit system, the 

Hamilton Street Railway (HSR). 


Difficulties using public transportation, specifically the bus 

system may be linked to accessibility and usability issues (Iwarsson 

et al., 2003). Challenges accessing and using public transportation 

occur when there is a poor fit between the innate capacities of the 

user, the demands of the task, and the person’s environment 

(Broome et al., 2010). To properly address the usability and 

accessibility issues of the bus system, researchers emphasize the 

importance of using a travel chain perspective to evaluate the entire 

chain of events while travelling from origin to destination i.e., 

planning the trip, purchasing bus tickets, waiting at the bus stop, 

etc. (Iwarsson et al., 2003). The travel chain perspective proposes 

that poor accessibility at any stage of the bus trip can be a barrier to 

a person’s ability to use the bus system. Most studies employing a 

travel chain perspective have been conducted in Australia (Broome 

et al., 2010) and Sweden (Carlsson, 2004; Iwarsson et al., 2003), 

with limited research focused within Canada. The literature 

suggests that consumers themselves are experts on usability issues 

and are essential in identifying areas of need, which may facilitate 

environmental changes (Iwarsson et al., 2003; WHO, 2007). 

Therefore, this study provides a new contribution by using both 

objective and subjective perspectives to obtain a comprehensive 

understanding of accessibility and usability of the HSR. 

Methods 

Purpose 

The purpose of this research was to: (1) evaluate the 

accessibility and usability of the HSR using a travel chain 

perspective, (2) describe the impact of the environment on older 

adults’ community mobility; and (3) with the results, develop 

recommendations to further Hamilton’s age-friendly initiative. 

Research Question 

Using a travel chain perspective, to what extent is the HSR 

accessible and usable for older adults in Hamilton, Ontario? 

Design and Ethics Approval 

A descriptive, qualitative design was used to explore and 

understand participants’ lived experiences accessing and using the 

HSR. Ethics approval was obtained from the Student Research 

Ethics Committee of the HHS/FHS at McMaster University. 

Participants 

The sample included ten older adults over the age of 65. The 

majority of participants were women (n=7). Participants were 

volunteers with HCoA and resided in Hamilton. Most participants 

(n=8) considered themselves frequent bus users (1+ time/day), and 

all participants perceived themselves as healthy and independent 

with mobility, despite one participant who used a gait aid. Consent 

was obtained from all participants. 


Data was collected from individual interviews with participants, 

observation of and report of their ability to access and use the HSR, 

and a follow-up focus group with eight of the participants. 

Individual bus trips were completed within the city of Hamilton. 

Individual interviews began at each participant’s home where 

questions about history of bus use and the process of planning a trip 

were explored. Observation commenced following the initial 

interview and continued throughout the duration of the bus trip 

until participants reached their destination. A field note form was 

used to collect objective and subjective data that evaluated each of 

the links within the travel chain. Following the individual bus trips, 

a focus group enabled member checking of findings. 

Data Analyses 

Conventional content analyses were used to generate findings. 

Key concepts with similar meanings were organized into categories

from which themes emerged. Themes reflected the general 

experiences of participants and age-friendliness. 

Results 

Seven themes emerged from the data relating to older adults 

experiences’ with HSR bus access and use: 

Planning: The HSR facilitated the renewal and purchase of bus 

passes. Participants relied on pamphlets or communication with bus 

drivers or passengers to obtain information about scheduling. 

Familiarity with the bus route and schedules assisted participants 

with planning, especially for the return trip. 

Affordability: All participants perceived the bus as an affordable 

mode of transportation. Participants were appreciative of the 

“Golden Buss Pass” for users over 80 years. Participants reported 

the payment options for pass purchases (i.e. cash, direct deposit) 

provided choice and was supportive of their financial status. 

Physical environment (a) on the bus, b) outside of the bus, c) space 

and crowding: Participants expressed concern with identifying the 

bus number as it approached, advertisements positioned across 

windows obstructing the view and the audio announcing system 

was too low. Accessible low floor buses provided ease with 

embarking/disembarking. The vertical poles, handrails, accessible 

seats, announcing system and options to signal need to disembark 

were identified as supportive of older adults’ bus use. Most bus 

stops were located close to the participants’ homes and offered a 

shelter and bench to rest; signage at the bus stop was not always 

present. Participants reported pedestrian crosswalks signalled too 

quickly for their needs. Crowding on the bus varied throughout the 

day and was associated with buggies, strollers, wheelchairs and gait 

aids. All participants were able to navigate the bus regardless of 

space and crowding. 

Customer service/accommodations: Participants reported bus 

drivers were often friendly and accommodating. Unfriendly bus 

drivers had a negative effect on participants’ experience. Bus 

drivers were identified as a primary source of information for users. 

Participants reported it is important for driver’s to be aware of 

safety risks (i.e. enough time for participants to seat before moving, 

pull close to curb for safe disembarking). 

Physical ability: Participants recognized it was their responsibility 

to be aware of their physical limitations and accommodate as 

necessary (i.e. rest when needed). 

Passengers’ attitudes and behaviours: Participants identified that 

most passengers on the bus are polite and accommodating. They 

also recognized that others’ behaviours could not be controlled. 

Negative attitudes and behaviours were associated with passengers 

of all ages. 

Safety: Participants reported safety impacted their trip and 

influenced bus use. They identified a personal responsibility to be 

aware of safety risks and plan the trip accordingly, as well the 

HSR’s responsibility to ensure passengers arrive safely to their 

destination. 

Discussion/Limitations 

Among these themes, safety was identified as being embedded 

within all aspects of age-friendly travel. Many of the participants 

felt the role of the bus driver was to facilitate a safe bus trip from 

origin to destination. In addition, participants identified that 

organization on the bus influenced their trip and felt that managing 

crowding is both a responsibility of the HSR and the passengers 

themselves. It was anticipated that there would be greater 

challenges with bus access and use for older adults. Although this 

may be partly attributed to the sample, findings from this study 

illustrate that the HSR has already implemented policies and 

guidelines to support bus use for older adults. The 

recommendations developed from the findings help to further 

progress to the HSR to becoming more age-friendly. 

The participants recruited were more homogenous than 

originally intended, limiting the diversity in experiences observed. 


Short Term Long Term 

-Eliminate advertisements 

across windows 

-Increase readability of signs 

on and off the bus 

-Increase volume of 

announcing system 

-Emphasize proper boarding 

organization by driver 

-Education on proper bus 

etiquette 

-Increase time at pedestrian 

crosswalks 

-Increase number of rest areas 

-Increase frequency and 

development of new routes 

based on changes to the city 

Implications for Occupational Therapy (OT) 

Using a public transit system is an occupation in itself and a 

means to access other community-based occupations. The WHO’s 

age-friendly initiative focuses on removing barriers in the 

environment that may impact older adults’ participation in 

occupations. Use of a travel chain perspective allows OTs to 

evaluate all aspects of the occupation of riding transit to help 

determine barriers and supports. By advocating for changes to the 

transit system, older adults are enabled to participate in occupations 

within their communities, enhancing their health and quality of life. 

Conclusions 

Given the importance of transportation in the lives of older 

adults, this study provided preliminary findings regarding the users’ 

experiences and perceived issues with accessing and using the 

HSR. Creating an age-friendly transit system will involve 

overcoming the barriers and maximizing the facilitators inherent to 

bus use. Further research should be conducted targeting infrequent 

bus users with greater physical challenges to determine if their 

accessibility and usability issues reflect those identified here. 


We would like to thank Lori Letts and Dr. Margaret Denton for 

their continued support and guidance throughout this project. We 

would also like to acknowledge Shelagh Kiely, the HSR and the 

participants for their assistance throughout this process. 

References 

Broome, K., Worrall, L., McKenna, K., & Boldy, D. (2010). Priorities for an agefriendly 

bus system. Canadian Journal on Aging, 29(3), 435-444. 

Carlsson, G. (2004). Travelling by urban public transport: Exploration of usability 

problems in a travel chain perspective. Scandinavian Journal of Occupational 

Therapy, 11 (2), 78-89. 

Hamilton Council on Aging (HCoA). (2010). Age-friendly Hamilton: First report to 

our community. Retrieved from 

http://www.coahamilton.ca/pdf/hamilton,%20a%20city%20for%20all%20ages.pdf 

Iwarsson, S., Stahl, A., & Carlsson, G. (2003). Accessible transportation: Novel 

occupational therapy perspectives. In L. Letts, P. Rigby, & D. Stewart (Eds.), 

Using environments to enable occupational performance (pp. 235-251). 

Thorofare: SLACK Incorporated 

World Health Organization. (2007). Global age-friendly cities: A guide. Geneva: 

Author

Factors for Occupational Therapists to Consider in the Implementation of Mobile Health (“mHealth”) 

Strategies with Populations with Cognitive Impairments: A Scoping Review 

By: Teresa Couto and Lauren Harris, M.Sc. OT (2012), McMaster University 

Project Supervisor: Christy Taberner, OT Reg. (Ont.) 

Abstract: Mobile electronic devices, such as smartphones, are becoming increasingly popular as self-management tools for 

individuals with cognitive impairment. Occupational therapists are often involved in the process of choosing and learning to use such 

devices. Purpose: To identify factors that occupational therapists should consider when using or recommending mobile technology as 

external cognitive aids. Methods: A scoping review was completed. Themes were identified using scholarly evidence, grey literature, 

and key informant consultations. Results: Six themes were identified and validated: 1) Clinician knowledge/confidence, 2) Assessing 

client needs, 3) Hardware and software considerations, 4) Memory aid functions, 5) Client training and support, and 6) 

Outcomes. Conclusions: The themes identified are discussed in the context of a common occupational therapy practice framework, 

the Canadian Practice Process Framework. Implications of the potential roles of occupational therapists in the design and 

implementation of mobile health solutions are discussed. 

Introduction 

Individuals with cognitive impairment often experience 

numerous difficulties in their everyday lives as a result of the 

resulting deficits. Common difficulties involve the ability to 

perform various occupations such as activities of daily living 

(ADLs), employment, and social activities, all of which can lead 

to decreased independence in areas of self-care, productivity, 

and leisure 1 . To date, the consensus based on best evidence for 

improvement in functional outcomes supports the use of 

compensation strategies. Mobile electronic devices such as 

smartphones are excellent tools through which preventative and 

self-management care can be provided 2 . With the increasing 

mainstream use of cell phones and smartphones, there is 

enormous potential for the use of such devices as portable 

electronic memory aids for individuals with cognitive 

impairments 3 . In considering the therapeutic use of mobile 

devices in healthcare, there is potential for preventative and selfmanagement 

applications that are available for a variety of 

chronic conditions. A scoping review was undertaken because 

the field is emerging and scoping reviews are designed to 

examine the breadth of emerging fields 4 . The results of the 

scoping review aim to contribute to the growing body of 

research in the mobile health (mHealth) field, and ultimately 

inform the development of best practice guidelines. 

Methods 

This scoping review follows a documented six-stage 

framework 4 . The research question is: What factors should 

occupational therapists (OTs) consider in the use of mHealth 

strategies for health promotion and management for populations 

with cognitive impairments? A systematic search of the online 

databases Medline, EMBASE, and CINAHL was conducted. 

Inclusion/Exclusion criteria: Articles were included in the 

study if they focused on a population with any cognitive 

impairment, compensatory strategies for cognition, and use any 

portable, electronic device that is used with the general public. 

Articles were excluded if they focused exclusively on devices 

that are one-function only, for example pagers or global 

positioning system (GPS). No studies were excluded based on 

publication year. A total of twenty-eight articles were included 

for this review. 

Data extraction: The authors extracted common variables from 

each of the included articles and together extracted six major 

themes that encompassed each of the variables and answered the 

research question. A data extraction table was then created to 

include each of the six themes. The authors read all articles and 

extracted data accordingly. To ensure consistency of data 

collection, both authors reviewed one article independently and 

reviewed together. 

Consultations: Four clinicians were chosen by convenience 

sampling and were contacted to discuss themes that were found 

in the literature review. The clinicians chosen for consultations 

were considered key informants for this topic based on their 

extensive experience with populations with cognitive 

impairments and special interest in mobile technology. One key 

informant is also a researcher in the field. Throughout each 

consultation, the authors described the six themes found in the 

literature, and the informants provided feedback based on their 

experience, knowledge and research. 

Results 

The following six themes were generated from the literature and 

key informants. 

1. Clinician Knowledge/confidence: Clinicians’ likelihood to 

recommend such technology was found to be directly related to 

their current beliefs or attitudes toward technology, previous 

training, current use, familiarity, and confidence in available 

evidence to support its use 5 . It is the responsibility of the 

clinician to keep him/herself informed about the potential use of 

such devices in order to provide client-centred care. 

2. Assessing client needs: There are several considerations when 

determining appropriateness of portable electronic technology as 

compensatory cognitive aids. These considerations include 

cognitive, physical and affective attributes of the client 6 . 

According to the evidence, compensatory electronic memory 

aids are most suitable for individuals with insight into their 

deficits, and mild to moderate cognitive impairments. It is 

important for clinicians to consider all cognitive supports and 

challenges, including executive functioning and problem 

solving, information processing, and previously acquired 

knowledge and skills. 

3. Hardware and Software Considerations: Clinicians who 

recommend mobile technology should consider the features of 

both hardware and software in order to provide the best fit for 

the client. Such features include: portability and size of the 

device, ease of use of keyboard or touch screen, durability of the 

device, ergonomic design, cost of the device and service, battery 

life and the ease of changing/charging battery 7 . The evidence 

supports the need for customizability of the software based on

individual client needs and preferences. 

4. Client Training and Support: The use of specific training 

protocols designed to promote success, known as errorless 

learning, reduced client frustration in several studies, ultimately 

maintaining client interest and motivation. Family and/or 

caregiver support were also found to enable the successful use of 

a mobile device 8 . 

5. Memory Aid Functions: Common memory aid functions 

include reminders, calendars, GPS/navigators, social directory, 

to-do lists and a conversation log 3 . Other functions include 

games, journal, money management tool, camera, calculator, 

music, and phone. The variety of memory aid functions available 

increases the potential of effectively matching a memory device 

to an individual’s unique needs 3 . 

6. Outcomes: An improvement in daily functioning and 

increased independence were common outcomes in many studies 

involving task-completion, accompanied with increased selfesteem, 

self-confidence, and improved emotional stability. 

Discussion 

The identified themes were supported by the key informants. 

Although the literature reviewed for this study was drawn from 

multiple disciplines, the findings are relevant to occupational 

therapy because all studies focus on enabling function. In fact, 

the themes identified were consistent with the process that OTs 

undertake when engaging in a therapeutic relationship with any 

client, as reflected in the Canadian Practice Process Framework 

(CPPF) 9 . In using the CPPF, the societal context/practice context 

would apply to theme 1, clinician knowledge/confidence. Prior 

to initiating a therapeutic relationship, the clinician can reflect 

on their personal knowledge, perceptions, and attitudes toward 

the use of a mobile device as a therapeutic tool. Throughout the 

first three stages of the CPPF (‘enter/initiate’, ‘set the stage’, and 

‘assess/evaluate’), the clinician assesses the client’s needs, 

strengths, supports, and goals, which corresponds to theme 2, 

assessing client needs. The third theme, hardware and software 

considerations, applies to the ‘assess/evaluate’ and ‘agree on 

objectives/plan’ stages of the CPPF. Here, the clinician has 

determined that a mobile device is appropriate for the client, and 

considers the accessibility features and customizes the device to 

match the client’s needs. The fourth theme, client training and 

support, corresponds to the ‘Implement plan’ and 

‘Monitor/Modify’ stages of the CPPF. As described by the adult 

learning theory, it is critical for the individual to understand the 

benefits associated with learning the new task in order for 

learning to be successful. The fifth theme, memory aid 

functions, corresponds to the ‘Implement plan’ and 

‘Monitor/modify’ stages of the CPPF. The sixth and final theme, 

‘outcomes’, corresponds to the ‘evaluate outcomes’ and 

‘conclude/exit’ stages of the CPPF. The clinician can measure 

the success of mobile devices based on functional outcomes, 

such as greater independence or improved quality of life, among 

many others. 

Gaps in the literature: Several articles highlighted the need for 

both cross-disciplinary and OT-specific practice guidelines in 

order to increase confidence and satisfaction in performing a 

needs assessment and creating a treatment plan that would 

include the use of a mobile device for cognitive impairment. 

There is also limited information available for troubleshooting 

when device malfunctions occur. The lack of high-level 

evidence directly affects clinician recommendations, and 

funding for clinician training or devices. 

Strengths/Limitations of the study: The strengths of this study 

include a systematic and comprehensive search. The authors 

completed an audit trail of the search, data extraction, and 

thematic analysis so as to facilitate the ability to replicate the 

research and verify the findings. The inclusion of key informants 

provided valuable information and verification of themes. The 

key limitation of the study was that all four key informants were 

OTs, which may have limited the generalizability of the findings 

to other disciplines. However, the range in areas of practice and 

clinical settings was varied which limits the potential bias. 

Conclusions/ Future Directions 

The following recommendations were made: 1) Set practice 

guidelines to improve clinician competence and confidence in 

recommending mobile devices. 2) Promote and support the 

completion of high level evidence-based research, while 

recognizing that high level evidence may be difficult to achieve 

with technology constantly evolving, and the complexity of 

brain injury. 3) Advocate for funding to increase availability of 

continuing education opportunities. 4) Promote selfdetermination, 

self-efficacy, and self-management amongst 

clients, and 5) Engage in interprofessional collaboration, both by 

using devices as a tool for communication and by providing 

interprofessional education and training in the field. 

As the popularity of mobile devices continues to increase, 

mHealth strategies allow individuals to participate in selfmanagement 

and prevention of chronic conditions. OTs play a 

critical role in ensuring the successful use of individualized 

mobile devices as cognitive aids as they are able to identify 

individual strengths and needs that support participation in 

occupation. 


We are grateful to our supervisor, Christy Taberner, for her 

support and encouragement throughout the research process. We 

also extend thanks to the clinicians who graciously gave their 

time for consultation on the topic. 

References 

1 Wade, T. K., & Troy, J. C. (2001). Mobile phones as a new memory aid: A 

preliminary study using case studies. Brain Injury, 15, 305-320. 

2 Klasnja, P. & Pratt, W. (2011). Healthcare in the pocket: Mapping the 

space of mobile-phone health interventions. Journal of Biomedical 

Informatics, doi:10.1016/j.jbi.2011.08.017. 

3 Cramm, H., Seguin, J., & Adler, R. (2011). iDevices and occupational 

therapy. Occupational Therapy Now, 13.3. 

4 Arskey, H., O’Malley, L. (2005). Scoping studies: Towards a 

methodological framework. International Journal Social Research 

Methodology, 8, 19-32. 

5 O’Neil-Pirozzi, T. M., Kendrick, H., Goldstein, R., & Glenn, Mel. (2004). 

Clinician influences on use of portable electronic memory devices in 

traumatic brain injury rehabilitation. Brain Injury, 18, 179-189. 

6 DePompei, R., Gillette, Y., Goetz, E., Xenopoulos-Oddson, A., Bryen, D., 

& Dowds M. (2008). Practical applications for use of PDAs and 

smartphones with children and adolescents who have traumatic brain 

injury. NeuroRehabilitation, 23, 487-499. 

7 Inglis, E. A., Symkowiak. A., Gregor, P., Newell, A. F., Hine, N., Wilson, 

B. A., Evans, J., & Shah, P. (2004). Usable technology? Challenges in 

designing a memory aid with current electronic devices. 

Neuropsychological rehabilitation, 14, 77-87. 

8 LoPresti, E. F., Mihailidis, A., & Kirsch, N. (2008). Assistive technology 

for cognitive rehabilitation: State of the art. Neuropsychological 

Rehabilitation, 14(1/2), 5-39. 

9 Townsend, E. A. & Polatajko, H. J. (2007). Enabling occupation II: 

Advancing an occupational therapy vision for health, well-being, & 

justice through occupation. Ottawa, ON: CAOT Publications ACE.

THE USE OF SOCIAL MEDIA BY OCCUPATIONAL THERAPISTS: 

Recommendations for the College of Occupational Therapists of Ontario 

Students: Jessica Yu & Leanne Fernandez Supervisors: Elinor Larney, Anita Jacobson & Bonny Jung 

ABSTRACT 

An evidence based practice project was developed with the College of Occupational Therapists of Ontario 

(COTO) to obtain occupational therapists’ (OTs) perspective on their use of social media in their personal and 

professional lives. An electronic survey was sent to all registered OTs in Ontario (4926 members) on their use of social 

media. The results of the survey highlighted respondents’ beliefs and attitudes on social media and how they currently use 

social media either personally and/or professionally. The survey found that respondents (n=892) felt the risks of using 

social media outweighed the benefits; yet most respondents used social media in their lives. Overall, 61% of respondents 

used social media, more for personal reasons as opposed to professional use. The majority of all respondents indicated 

their concern on protecting personal privacy. Most respondents felt confident or proficient in their ability to navigate 

privacy settings; however, some respondents felt either unsure or had never tried to use privacy settings. Therefore, the 

authors recommended to the COTO that all OTs should be aware of the risks and benefits to using social media regardless 

of whether it was used for personal or professional reasons. Two categories of suggestions were recommended: The 

COTO should (1) develop guidelines on the use of social media and (2) conduct further research on specified topics. In 

conclusion, this study identified the need for all OTs to be informed on the risks and benefits to using social media, how 

to protect personal privacy on social media and how to use social media in a safe and professional manner. 

INTRODUCTION 

In Canada, 80% of individuals age 16 or older report using the Internet for personal reasons (Statistics Canada, 

2010). According to Ipsos Reid (2011), the majority of Canadians who use the Internet (60%) have a social networking 

profile. Many Canadians who have a social networking profile are persons aged 18 to 23 (86%); however, other age 

groups are also joining the social networking scene. Also, the use of social media in the healthcare field is rising (Change 

foundation, 2011; National Research Corporation, 2011). Based on the popularity of social media used by many 

individuals in Canada and in the healthcare field, the COTO wanted to examine how members used social media both 

personally and professionally in order to potentially develop future guidelines on the use of social media. (Central East 

Ontario Community Information Database, 2009). For this study, social media was defined as “online technologies and 

practices that are used to share opinions and information, promote discussion and build relationships” (Central Office of 

Information, 2009). Social media sites included in this survey were Google+, Facebook, Twitter, LinkedIn, YouTube, and 

dating sites. The study report outlines the results and recommendations from a survey on social media that was 

administered to the COTO members. 

LITERATURE REVIEW 

Currently, there is a gap between the increasing use of social media in the healthcare field and the lack of clear 

guidelines for OTs’ use of social media. This study aimed to address this gap by obtaining OTs’ opinions on their use of 

social media to aid in the potential development of the COTO guidelines. Several colleges and associations in other 

healthcare disciplines nationally and across the world have guidelines on social media; however, none of the colleges of 

OTs across Canada have such a guideline. Since the mandate of the COTO is to protect public safety, the implications of 

using social media are of concern. Some concerns include: crossing of professional-client boundaries; concerns of privacy 

and confidentiality; lack of clarity in payment for services; increased OT workload; and the potential for damage to 

reputations (Change Foundation, 2011; Grant, D., 2011; Wainer, L, 2011b; Wong. A, 2011). OTs are obligated to comply 

with the COTO standards in all practice situations. Some standards that may address the drawbacks to using social media 

include professionalism through the Code of Ethics (COTO, 2011); Standards for Consent (COTO, 2008a); privacy in the 

Standards for Record Keeping (COTO, 2008b); and Standards for Professional Boundaries (COTO, 2009). Additionally, 

under the Personal Health Information Protection Act, 2004 (PHIPA), there are rules for the collection, use and 

disclosure of personal health information and as such, OTs are required to be diligent in their role as health information 

custodians or agents (Government of Ontario, 2004). By using social media where a third party controls the site 

information (such as Facebook, Twitter, YouTube, etc.), OTs cannot control the theft, or unauthorized use of any client 

health information; therefore, it does not meet the legislation outlined in PHIPA. 

METHODOLOGY 

This study aimed to address the following study question: “What are occupational therapists’ beliefs and 

attitudes on social media and what is their current usage of social media personally and professionally?”. A survey 

methodology was used, as it was the best method to elicit reported responses from a specific population, it ensured 

anonymity of responses and it was cost and time effective (Forsyth & Kviz, 2006). A web based survey designed 

specifically for this study was sent to all OTs electronically via Survey Monkey (2011). The survey was emailed to all 

OTs registered with the COTO for the 2011-2012 practice year and they were given 17 days (~2.5 weeks) to complete the 

survey. The sample size included 4926 COTO members. The survey was comprised of one open-ended question and 23 

close-ended questions with multiple-choice answers, and with an “other, please specify” category as appropriate to the

THE USE OF SOCIAL MEDIA BY OCCUPATIONAL THERAPISTS 2 

question. A total of 892 members completed the survey, which was approximately 18% of the COTO membership. The 

data was exported into Microsoft Excel for basic data analysis. There were no ethical concerns for this study as 

participation in the survey was voluntary and there were no requests for private health information. 

KEY FINDINGS 

Respondent Demographics: Overall, 61% of respondents had been practicing OT for 10 years or more, and it was 

hypothesized that these respondents were over 30 years of age based on their completion of their Bachelors or Masters of 

OT degree at a Canadian school. Furthermore, most of the respondents were employed in workplaces that were funded by 

the public sector and worked in a clinical role. The demographic information of the respondents was found to be 

representative of the Canadian OT workforce trends in terms of age, area of practice and practice funding source (CIHI, 

2010). 

Use of Social Media: Most respondents reported using social media (69%) in their lives, more so for personal reasons 

(72%) as opposed to professionally in OT practice (25%). Moreover, most respondents reported not advertising (92%) on 

social media sites. Many respondents who used social media for personal reasons wanted to stay in touch with friends and 

family, receive others’ updates, post pictures and videos and follow others. Of the respondents who did use social media 

in OT practice, most of them used it for continuing education/professional development purposes as well as to network 

with other OTs. 

Privacy and Confidentiality for Social Media Use: Most respondents (82%) felt either reasonably confident or 

proficient to navigate privacy settings on social media sites. However, 11% of respondents were unsure how to navigate 

privacy settings and 7% of respondents had never tried to use privacy settings. Although most members reported being 

reasonably confident or proficient in navigating and using privacy settings, it was found that many respondents were still 

concerned about protecting their personal privacy when using social media. 

Using Social Media in the Future: Respondents who were not using social media in their personal or professional lives 

were split in their decision to use social media in the future. Guidelines on social media that listed the advantages and 

disadvantages of use along with strategies to protect members and the public could help respondents to make an informed 

decision on continued or future use. 

IMPLICATIONS FOR PRACTICE 

The findings of this study found that the majority of respondents in the survey used social media whether it was 

for personal or professional reasons. Therefore, it was hypothesized that there might be opportunities for OTs and clients 

to interact on social media sites, whether it was intentionally or inadvertently. If clients were to contact OTs through 

social media, then OTs should be aware and knowledgeable on how to address this issue while minimizing any 

repercussions to client rapport. Moreover, it is in the best interest for OTs to be aware and up to date on the PHIPA 

legislation and any privacy settings or controls to ensure that they are protecting their personal privacy on social media 

sites. In addition, the risks to using social media in practice include potential implications on professional boundaries, 

reputation management, privacy, confidentiality, and professionalism (Wainer, 2011a). Therefore, it is important for OTs 

to be aware of the benefits and risks of using social media, especially if using social media professionally. 

RECOMMENDATIONS 

Based on the findings, two categories of suggestions were recommended: The COTO should (1) develop 

guidelines on using social media and (2) conduct further research on specified topics. To ensure all OTs in Ontario are 

informed on the risks and benefits of using social media in their personal or professional lives, the authors recommended 

that guidelines on social media be developed; the guidelines would be suggestive in nature as opposed to prescriptive. 

Suggested topics for the social media guideline would include: describing how standards of practice apply to social media 

use, key considerations for members to be aware of, and general strategies to protect OTs and the public when using 

social media. The developed guidelines would be a tool that OTs could use to become more familiar with how to protect 

their personal privacy and use social media in a safe and professional manner. Additionally, it was recommended that 

more research is needed to better understand members’ opinions on selected topics including how social media is being 

used in OT practice and OTs’ concerns regarding privacy. Focus groups or interviews could be possible methods to 

explore selected topics further. 

KEY REFERENCES* 

Canadian Institute for Health Information. (2010). Occupational therapists in Canada, 2010 [PDF]. Retrieved from 

http://www.cihi.ca/CIHI-ext-portal/pdf/internet/OT_10_infosheet_EN 

Cavoukian, A. (2012). The Personal Health Information Protection Act and your privacy. Retrieved April 1, 2012 from 

http://www.ipc.on.ca/images/Resources/up-health_e.pdf 

Change Foundation. (2011). Using social media to improve healthcare quality: a guide to current practice and future 

premise. Retrieved on March 16, 2012 from http://www.changefoundation.ca/docs/socialmediatoolkit.pdf 

Forsyth, K. & Kviz, F.J. (2006). Survey research Design. In Kielhofner, G. (Ed.). Research in occupational therapy: 

Methods of inquiry for enhancing practice. Philadelphia: F.A. Davis. 

Wainer, L. (2011a). Analysis of environmental scan for social media in OT practice. [COTO document]. 

*The complete reference list can be found in the PowerPoint presentation or is available upon request

Title: Identifying and Overcoming Barriers to Accessible Education for University Students with Disabilities 

Authors: Beth Marquis, Educational Consultant, Centre for Leadership in Learning 

Kanishka Baduge, MSc OT Student, School of Rehabilitation Science 

Csilla Gresku, MSc OT Student, School of Rehabilitation Science 

Kait Hammel, MSc OT Student, School of Rehabilitation Science 

Katie Rincker, MSc OT Student, School of Rehabilitation Science 

Abstract: The authors are currently undertaking a study designed to collect qualitative data about the effects of the AODA 

legislation on the teaching and learning environment at McMaster University. A component of the first phase of this research, 

conducted by occupational therapy students, explores the ways in which students with disabilities perceive the relative accessibility 

and inclusiveness of teaching and learning at this institution. 

The current study involved interviewing participants with a mental or physical disability, who are enrolled in undergraduate or 

graduate programs, to gain insight into their experiences of the teaching and learning environment at McMaster University. The 

research questions addressed were as follows: 

1) How do students with disabilities experience the accessibility and inclusiveness of the teaching and learning environment 

at McMaster University? 

2) How do students with disabilities perceive the effect of the AODA on the teaching and learning environment at McMaster 

University? 

Six participants were interviewed. Interviews were transcribed, coded, and used to create a structure of salient themes which included 

1) barriers to the accessibility of the teaching and learning environment, 2) supports to the accessibility of the teaching and learning 

environment, and 3) perceptions of the AODA legislation. 

Introduction: Statistics show that persons with disabilities are less likely to attend post-secondary institutions (Human Resources 

and Skills Development Canada [HRSDC], 2011). The importance of creating inclusive and equitable educational experiences for all 

college and university students has been widely recognized (Burgstahler & Cory, 2009; Scott, McGuire & Foley, 2003). Recent 

teaching and learning scholarship, for example, documents the necessity of acknowledging the increasing diversity of the student 

population (Pliner & Johnson, 2004), and of uncovering and removing barriers to learning experienced by students with disabilities 

in particular (Cook, Rumrill & Tankersley, 2009). At the same time, in Ontario, new legislation is making these issues especially 

pronounced. The Accessibility for Ontarians with Disabilities Act (AODA), which became law in 2005, mandates universal access 

for persons with disabilities, requiring the removal of barriers to their full participation in all aspects of society, including higher 

education. It is designed to break down barriers to accessibility in Ontario by the year 2025 (Beer, 2010). 

Literature Review: A number of studies have examined the existing supports and barriers to higher education for students with 

disabilities. There is a trend moving in the direction of universal instructional design (UID) which has the potential to remove all 

existing barriers and in turn benefit all individuals regardless of their ability (Foley, McGuire, & Scott, 2003; Pliner & Johnson, 

2004; Scott et al., 2003).There are many factors that have been identified in the existing literature that influence the experience of 

students with disabilities in post-secondary education. These include lecture/teaching style and delivery, assessment/testing style, 

opportunity for class participation and interaction, access to information regarding available supports and services, availability of 

resources and services, staff understanding of student needs, staff knowledge of disability characteristics, attitudes, willingness to 

accommodate, and the amount and quality of support provided (Cook et al., 2009; Fuller et al., 2004a; Fuller et al., 2004b; Jacklin, 

Robinson, O’Meara, & Harris, 2007). The current available evidence suggests a need for further study into these existing supports 

and barriers in order to effectively act upon the voices of students with disabilities and make higher education more inclusive (Fuller 

et al., 2004b). 

Methods: Students at McMaster University with both visible and invisible disabilities participating in either undergraduate or 

graduate programs were recruited for this study. A recruitment letter was sent via email to administrative staff at 

Departmental/Faculty offices and other units across campus. These individuals were asked in turn to distribute the letter (via email) 

to all students in their departments. Interested volunteers contacted a research assistant directly through email. Open-ended questions 

were used in order to collect data regarding the lived experiences of students with disabilities at McMaster University. All six 

participant interviews were audio recorded and transcribed verbatim. Member-checking was completed and triangulation methods 

were then used to analyze the data. This data was then coded and a theme structure was created to capture all core ideas. 

Results/Discussion: Three main themes emerged from the data that were related to the accessibility of the teaching and learning 

environment at McMaster: 1) barriers to accessible teaching and learning, 2) supports to accessible teaching and learning, and 3) 

perceptions of the AODA legislation. The result of the project was the creation of a theme structure with sub-themes and dimensions, 

as seen on back of page. 

Conclusions/Future Directions: With the onset of the new AODA standards, the findings of this study are especially important to 

inform inclusive policy and practice at McMaster University and across post-secondary institutions in Ontario. The current study is 

part of a larger longitudinal study that will serve to track change during the implementation process of the Harmonized AODA 

Standard which mandates universal accessibility for students with disabilities. The next phases of the study will include ongoing 

journal reflection during the implementation period and follow up interviews post implementation of the Harmonized AODA 

Standard. By building on the current supports and minimizing the barriers to an accessible teaching and learning environment at 

McMaster University, there is the potential to create an inclusive environment that promotes success for all students.

References: 

Fuller, M., Bradley, A., & Healey, M. (2004a). Incorporating disabled students 

within an inclusive higher education environment. Disability & Society, 

19(5), 455-468. 

Fuller, M., Healey, M., Bradley, A. & Hall, T. (2004b). Barriers to learning: A 

systematic study of the experience of disabled students in one university. 

Studies in Higher Education 29(3), 303-318. 

Jacklin, A., Robinson, C., O’Meara, L., & Harris, A. (2007). Improving the 

experiences of disabled students in higher education. York: Higher 

Education Academy. Retrieved from http://www.heacademy.ac.uk/assets 

/York/documents/ourwork/research/jacklin.pdf 

Acknowledgements: The OT research team would like to thank Beth Marquis, 

project supervisor and Bonny Jung, academic supervisor, for their support and 

encouragement throughout the EBP process. Thank you!

Learning Together to Work Together: Professionalism & Patient Safety 

Evaluating an Interprofessional Event: Are We Making a Difference at McMaster? 

Ashlen Kain & Kait Toohey MSc OT Candidates 2012, McMaster University 

Bonny Jung PhD, OT Reg (Ont), Jenn Salfi RN, PhD, Alison Cook, RN, MSc & Margaret Shkimba 

Abstract 

Background: In support of the government’s emphasis on Interprofessional education (IPE) and to prepare health science students for 

interprofessional practice, IPE is a staple within the curriculums of health sciences programs, including occupational therapy, offered at 

McMaster University. McMaster’s Program for Interprofessional Practice, Education and Research (PIPER) successfully implements 

several annual IPE events for students within all health care programs to attend in order to meet IPE graduation requirements (PIPER, 

2012). The Learning Together to Work Together: Professionalism and Patient Safety workshop held on January 27, 2012 was the largest 

event PIPER has organized to date with approximately 650 students and 70 faculty in attendance; it is the hope that this large-scale 

workshop becomes an annual event. Purpose: To evaluate the effectiveness of this workshop in contributing to students’ knowledge, 

skills, and attitudes. Methods & Design: A Sequential Explanatory Mixed Methods Design was used (Kielhofner, 2006). Before and 

after attending the workshop, students were invited to complete the Readiness for Interprofessional Learning Scale (RIPLS) 

Questionnaire (McFadyen, Webster & Maclaren, 2006) and a series of open-ended questions (included in the post-workshop survey 

only). Students were also invited to participate in one of three focus groups. Results: Pre- and post- questionnaires indicated some 

change in student readiness, particularly in the area of teamwork collaboration. Seven key qualitative themes were also identified through 

analysis of focus group discussions and open-ended online questionnaires. 

Introduction 

Within the healthcare field, professional behaviours, team 

respect, and collaboration are strongly linked to patient 

satisfaction and safety (DuPree, Anderson, McEvoy & 

Brodman, 2011). However, there are barriers within the health 

care system that are contributing to poor interprofessional 

collaboration and professionalism. Interprofessional education 

(IPE), which is an initiative involving two or more professions 

learning alongside one another, is being used more extensively 

to address these barriers (Sargeant, 2009; Mueller et al., 2008). 

For years, the federal and provincial governments have 

emphasized the importance of IPE for new learners and 

practicing clinicians by allocating money to various IPE 

initiatives and designating IPE as a primary pillar within 

Ontario’s Health Human Resources Strategy (School of 

Rehabilitation Sciences, 2008; CAOT, 2006). In response to 

the government’s focus on IPE, the Canadian Association of 

Occupational Therapists (CAOT) has also recognized the 

importance for occupational therapists (OTs) to engage in IPE 

opportunities that promote effective interprofessional 

collaboration, communication and patient safety (CAOT, 

2011). IPE has been recognized by the CAOT as a primary 

initiative to enhance the services OTs provide within the 

primary health care, and home and community care settings 

(CAOT, 2008; CAOT, 2006). Mueller et al (2008) found that 

97% of OTs practicing in Ontario have also recognized the 

importance of IPE in promoting effective clinical practice; 

however only 50% of these therapists believe they had 

received an appropriate amount of IPE training prior to 

entering practice. 

In support of the government’s emphasis on IPE and to 

adequately prepare health science students for 

interprofessional practice, McMaster’s PIPER successfully 

implements several annual IPE events for students and faculty 

to attend (PIPER, 2012). On January 27, 2012, PIPER 

organized their largest workshop to date, Learning Together to 

Work Together: Professionalism and Patient Safety. This IPE 

workshop brought together students from several programs 

including medicine, nursing, occupational therapy, 

physiotherapy, child-life specialist, physician assistant, and 

midwifery. It is PIPER’s hope that this will become an annual 

event. 

Purpose 

The purpose of this report is to present a program 

evaluation of the Learning Together to Work Together: 

Professionalism and Patient Safety workshop. This event was 

evaluated on its effectiveness in contributing to students’ 

knowledge, skills, and attitudes about professionalism and 

interprofessional collaboration. 

Methodology 

Design: A sequential explanatory mixed methods study 

design was chosen for this study based on Kirkpatrick’s four 

level evaluation model (Kirkpatrick & Kirkpatrick, 2006). This 

model includes a sequence of four levels used to evaluate 

program effectiveness: Level 1) Reaction; Level 2) Learning; 

Level 3) Behaviour; and Level 4) Results. According to 

Kirkpatrick & Kirkpatrick (2006), each level impacts the next 

level to provide valuable information about a program. As 

typical with the sequential explanatory mixed methods study 

design, quantitative and qualitative data were analyzed 

separately (Kielhofner, 2006). 

Quantitative: Quantitative data was collected using a 

before and after study design. Readiness for Interprofessional 

Learning Scale (RIPLS) Questionnaire data was collected from 

347 students before and after attending the workshop, to 

measure changes in student readiness for interprofessional 

learning and collaboration that occurred as a result of attending 

the workshop (McFadyen, Webster & Maclaren, 2006). 

Statistical analysis of the pre- and post- workshop scores was 

completed using SPSS computer software, and changes in 

RIPLS scores were measured between programs.

Qualitative: Qualitative data was collected from two 

primary sources: open-ended survey questions that 

accompanied the online post-survey, and through the 

facilitation of three focus groups. Using stratified random 

sampling, 18 students were chosen to participate in the focus 

groups; these participants included four medical students, four 

nursing students, four occupational therapy students, three 

physician assistant students, two midwifery students, and one 

child life specialist student. No physiotherapy students were 

able to attend these groups. Each focus group was cofacilitated 

by two student researchers and audio recorded for 

later transcription. Focus group recordings were transcribed 

verbatim using a denaturalized transcription technique. Focus 

group transcriptions and the qualitative questions from the 

online questionnaire data were coded manually by two student 

researchers individually and later compared for agreement. 

Qualitative data was then coded electronically using NVivo 9 

computer software (Basit, 2003). Student researchers 

performed a content/narrative analysis of the data from which 

seven primary themes emerged (Taylor-Powell & Renner, 

2003). 

To establish trustworthiness throughout the data collection 

and analysis process, triangulation, member checking, peer 

debriefing, and reflection were used and an audit trail was 

maintained (Kielhofner, 2006). 

Results & Discussion 

Quantitative: Analysis of the RIPLS pre- and post- 

questionnaires revealed that the teamwork and collaboration 

subscale was statistically significant (p=0.01). 

Qualitative: Seven key themes emerged from the 

qualitative data collected from online surveys and the focus 

group discussions. These themes are as follows: 

1) Students learned about the importance of interprofessional 

collaboration and communication for patient safety; 

2) Students became somewhat more familiar with roles of 

other professions however, they wanted additional 

clarification; 

3) Students appreciated the opportunity to meet students from 

other programs; 

4) Some students felt the scenarios and examples were very 

medically focused; 

5) Students found the keynote speaker most enjoyable; 

6) Students found the small group discussions to be the most 

useful; and 

7) Students enjoyed the IPE workshop overall and recommend 

it continuing in the future. 

Statistically significant change within the “teamwork and 

collaboration” subscale of the RIPLS echoed the qualitative 

themes of opportunity for networking and usefulness of small 

group learning. Collaborative experiences at the workshop 

may have provided students with the opportunity to recognize 

the implications of collaboration for patient safety and to 

further develop these skills among their interprofessional 

small groups. This may have contributed to the statistically 

significant change in this subscale. 

Relevance to OT: Since IPE is recognized by CAOT as a 

primary initiative to enhance the services provided by 

occupational therapists, this workshop has provided an 

opportunity for occupational therapy students to engage in 

interprofessional collaboration and communication to further 

develop these competencies. In particular, this event allowed 

occupational therapy students to understand the importance of 

explaining the role of OT and advocating for the profession to 

enhance patient safety. 

Limitations & Future Direction 

Within the quantitative data set, not all students completed 

both the pre- and post- RIPLS online survey, therefore results 

were analyzed as a whole, rather than identifying change 

among individuals. Completion of the RIPLS survey was 

optional so some student experiences and viewpoints may not 

have been equally represented. 

Further, students who volunteered to participate in the three 

focus groups were those who enjoyed the workshop and found 

value in attending. Thus, a volunteer bias was present in the 

focus groups which may not accurately represent all student 

views and opinions. Also, despite efforts to represent all 

faculties within the focus groups, no physiotherapy students 

were available to participate. 

Further research should more closely examine the 

qualitative themes within student responses from each program. 

Examining the responses from each program in isolation will 

help determine if there were any experiences or thoughts that 

are more common, or even unique to, students from any 

specific program. 

Conclusion 

PIPER’s first large-scale workshop entitled Learning 

Together to Work Together: Professionalism and Patient Safety 

was evaluated using Kirkpatrick’s four-level evaluation model 

as a theoretical basis (Kirkpatrick & Kirkpatrick, 2006). The 

RIPLS questionnaire was used to statistically measure changes 

in student learning and readiness for interprofessional 

collaboration that occurred as a result of attending this event 

(McFadyen, Webster & Maclaren, 2006). Qualitative measures 

included open-ended survey questions and focus groups were 

used to capture student experiences of the workshop. While 

many students across programs reported that the IPE workshop 

was beneficial for their learning, recommendations were also 

captured to improve this event for future student cohorts. 


We would like to thank all student participations for sharing 

their experiences. We would also like to thank Bonny Jung, 

Jenn Salfi, Alison Cook, and Margaret Shkimba for all of their 

support and guidance throughout this project. 


Canadian Association of Occupational Therapists (2011). CAOT position 

statement: Occupational therapy and client safety. Retrieved from 

http://www.caot.ca/pdfs/positionstate/PS_ClientSafety.pdf 

Kielhofner, G. (Ed.). (2006). Research in occupational therapy: Methods of 

inquiry for enhancing practice. Philadelphia: F. A. Davis. 

Kirkpatrick, D. L., & Kirkpatrick, J. D. (2006). Evaluating training programs: 

The four levels (3rd ed.). San Francisco: Berrett-Koehler Publishers Inc. 

McFadyen, A.K., Webster, V.S., & Maclaren, W.M. (2006). The test-retest 

reliability of a revised version of the readiness for interprofessional 

learning scale (RIPLS). Journal of Interprofessional Care, 20(6), 633-639. 

Mueller, D., Klingler, R., Paterson, M., & Chapman, C. (2008). Entry-level 

interprofessional education: Perceptions of physical and occupational 

therapists currently practicing in Ontario. Journal of Allied Health, 37(4), 

189-195. 

Sargeant, J. (2009). Theories to aid understanding and implementation of 

interprofessional education. Journal of Continuing Education in the Health 

Professions, 29(3), 178-184. 

*A full reference list is available upon request*

Reflection and Reflective Journaling in Occupational Therapy 

Authors: Jacqueline Bull, Katelin Wakefield, MScOT Candidates 2012; Supervisors: Lorie Shimmell MSc, OT Reg. (Ont.), 

Bonny Jung PhD, OT Reg. (Ont) 

McMaster University 

Abstract 

Reflective journaling (RJ) throughout clinical placements is a component of Canadian occupational therapy programs. However, 

there is a lack of evidence describing its implementation and supporting its use in clinical practice. Purpose. To explore the 

experiences of reflective journaling among student occupational therapists and preceptors and to develop implementation 

recommendations for clinical placements. Methods. 20 students and 10 preceptors from the McMaster occupational therapy 

program were interviewed. Data was analyzed using phenomenological methods. Findings. Using qualitative analysis five 

themes were identified describing student and preceptor perspectives relevant to the use of reflection and RJ during clinical 

practice. Implications. RJ is valued by both students and preceptors, however to enhance both personal and professional 

development and optimize use in clinical practice, some modifications are necessary. 

_______________________________________________________________________________________________________ 

Introduction 

Reflection describes the exploration and analysis of 

experiences in order to increase knowledge and awareness 

(Schon, 1983). As an iterative process, reflection within 

clinical practice furthers learning and promotes integration of 

new knowledge (Buckley et al., 2009; Hubbs & Brand, 2005). 

Reflective activities can also be used for personal development 

such as to increase self-awareness, develop emotional 

intelligence, and to achieve further insight (Moon, 2004). 

Mann, Gordon, & MacLeod (2009) describe three types of 

reflection: reflection-in-action, knowing-in-action and surprise, 

and reflection-on-action. Within clinical environments, 

reflective journaling (RJ) can be used to enhance professional 

development and clinical reasoning and has the capacity to 

enable transformative change (Buckley et al., 2009). 

An environmental scan of Canadian occupational therapy 

programs revealed there is no standardized approach to the 

implementation of reflective practices across occupational 

therapy education; however, all programs in Canada implement 

reflective activities through academic or placement experiences 

(Shimmell, 2010). 

Using a phenomenological approach, this study aims to 

explore the subjective realities of current occupational therapy 

students and preceptors with regards to RJ. The findings of this 

study will be used to develop recommendations for the use of 

RJ in the McMaster occupational therapy clinical education 

curriculum. 

Methods 

Procedure and Participants 

• Approval granted by McMaster University/Hamilton 

Health Sciences Research Ethics Board 

• Purposive sampling via email used to recruit McMaster 

student occupational therapists and preceptors 

• 20 student participants, 10 preceptor participants 


• Semi-structured interviews, 15 to 45 minutes in length 

• Recorded and transcribed verbatim 

Data Analysis 

• Results were collected and entered into NVIVO 9 

• To maximize reflexivity and data triangulation, paired 

debriefs and routine team discussions were held 

• One student and one preceptor codebook developed. 

Differences in coding were reconciled through discussion 

and revision 

• Query methods within NVIVO 9 were used to ensure 

development of accurate themes 

Results 

Student implementation of journaling 

Student participants were divided in their preferences for 

methods of reflection. Some student participants discussed 

struggling with the reflective writing process, whereas others 

discussed using written reflections to better articulate 

themselves. Verbal reflection was viewed as less timeconsuming 

with immediate validation. Overall, students 

expressed the importance of using a reflective method that is 

suited to them. Additionally, most preceptors discussed that it 

is important to support the reflective style of the student. 

Most student and preceptor participants discussed an 

increase in depth of journals over time, describing an increased 

understanding of occupational therapy, development of 

practice knowledge and increased understanding of RJ. Many 

student participants stated that reflection became easier and 

progressed into more practice-based reflections grounded in 

professional development. Alternatively, some student 

participants indicated that the depth remained unchanged or 

regressed due to time constraints, privacy concerns and 

perceived preceptor disinterest. 

How do student and preceptor participants value reflection 

and reflective journaling? 

Student participants spoke highly of the benefits of 

reflection for the purposes of both professional and personal 

development. However, only half of the students anticipated 

using written journaling in future practice, most of whom 

identified prior academic or personal experience with 

journaling. The remainder of students anticipated use of nonwritten 

forms of reflection in practice. 

Perceived quality and quantity of feedback from preceptor 

participants is closely linked with student participants’ 

expressed value of RJ. A majority of the student participants 

who received meaningful feedback on their journals were more 

positive about the value of RJ and anticipated future use in 

practice. 

Preceptor participants valued reflection for personal 

development of clinical reasoning, efficient and effective 

assessment and intervention, enhanced self-awareness and 

lifelong learning. One preceptor stated, “you have to be 

reflective or you don’t make any positive changes, you don’t 

improve your learning... if you’re not reflective, then you’re

not really a conscious competent clinician” (P03). 

All preceptor participants engaged in verbal reflection with 

their students, whereas only four preceptors provide written 

feedback on journals. 

Reflection as a tool for professional development 

Participants were prompted to describe how RJ has 

influenced professional development. Participant descriptions 

were assigned to one of the seven competencies as outlined in 

the Profile of occupational therapy practice in Canada 

(Canadian Association of Occupational Therapists (CAOT), 

2007). When removed from the antecedent context, majority of 

student participants stating using reflection to “put some of the 

pieces together” (S08) and “connect the dots” (S11). In other 

words, “you’re making what’s implicit, you’re making it 

explicit” (S05). 

Over the course of interviews, student and preceptor 

participants described the use of RJ in the development of all 

seven occupational therapy competencies. 

Challenges using reflective journaling 

Over half of the student participants commented that lack 

of time was a challenge. Student participants discussed 

competing priorities, length of time required to write a journal, 

fast-paced nature of the placement and the added challenge of 

commuting. Preceptor participants stated that it comes down to 

what is the priority in your day. Student participant discussed 

feeling that there were too many requirements for RJ leading to 

reflections that are disingenuous, “meaningless and empty” 

(S06). 

Student participants also discussed that censoring or editing 

their RJ reduced both authenticity and overall benefit of the 

journaling process. Student participants who were negative 

about sharing reflections with faculty still discussed the value 

of having faculty feedback. However, in general, their 

comments highlighted that journals would be edited for content 

and style. 


Student participants made recommendations for RJ 

preparation, requirements and feedback. To clarify RJ 

expectations, student participants suggested providing an 

evaluation guideline or rubric and more meaningful feedback 

from faculty, specifically recommending the academic advisor. 

Discussion 

This study provides an understanding of the experiences of 

student occupational therapists and preceptors with reflection 

and RJ. The findings of this study are supported by literature in 

this area. As reflective practice is individualized, supporting 

the student’s reflective style is essential. In order to facilitate 

deeper reflection, Hubbs & Brand (2005) highlight the 

importance of providing feedback on both the content and 

process of RJ. Students discussed feeling uneasy with the 

power difference between faculty and students, however, they 

also discussed the importance of receiving meaningful faculty 

feedback. 

In order for RJ to be an effective tool, students must have a 

clear understanding of its value (Mann et al., 2009). As the 

findings from this study demonstrate, those students with more 

preparation, including a solid understanding of RJ, were more 

likely to use it in future practice. The challenges of RJ 

addressed by participants, such as writing articulating, being 

time consuming and disingenuous, were echoed in the 

literature (Buckley et al., 2009; Harris, 2007). 

Limitations of this study include volunteer bias, probing 

participants around the theme of clinical reasoning. 

Conclusion 

The findings outline five key areas arising from 

participants’ journeys through the reflection and RJ process: 

student implementation, value, professional development, 

challenges and recommendations. These findings support the 

need for an approach to RJ that incorporates peer to peer 

sharing of RJ, structured evaluation, verbal faculty feedback 

and an awareness of challenges. 

Program Recommendation 

• Year one and year two student, who share the same 

academic advisor, paired for mutual submission and 

review of written journals 

• Academic advisor will meet with pair to provide verbal 

feedback and facilitate dialogue on content and process 

of RJ 

Subsequent research will be required to implement and 

evaluate the effectiveness of this recommendation. 

References 

Buckley, S., Coleman, J., Davison, I., Khan, K., Zamora, J., Malick, 

S., et al. (2009). The educational effects of portfolios on 

undergraduate student learning: a Best Evidence Medical 

Education (BEME) systematic review. Medical Teacher, 31, 

282-98. 

Canadian Association of Occupational Therapists (2007). Profile of 

Occupational Therapy in Canada. Ottawa, ON: CAOT 

Publications. 

Harris, M. (2007). Scaffolding reflective journal writing – Negotiating 

power, play and position. Nurse Education Today, 28, 314- 

326. 

Hubbs, D.L. & Brand, C.F. (2005). The Paper Mirror: Understanding 

Reflective Journaling. Journal of Experiential Education, 

28, 60-71. 

Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and 

reflective practice in health professions education: A 

systematic review. Advances in health sciences education: 

Theory and practice, 14, 595-621. 

Moon, J. (2004). A handbook of reflective and experiential learning: 

Theory and practice. London: Routledge Falmer. 

Schon, D. (1983). The reflective practitioner: How professional think 

in action. London: Temple Smith. 

Shimmell, L. (2010). [Canadian University OT program use of 

reflection, n=7 schools]. Unpublished raw data. 

The authors gratefully acknowledge the support of the McMaster 

School of Rehabilitation Sciences Educational Research Grant and 

the research contributions of Emma Graham and Anna Goulding, 

BHSc.

Male Motivations to study a formal education in the Occupational Therapy field 

Patrick Whalen & Gawain Tang M. Sc. Candidates 2012, McMaster University. 

Project Supervisors: Bonny Jung Ph.D., OT Reg. (Ont. ) & Michael W. K. Chan, MBA, OTR/L, OT Reg. (Ont.) 

Supporting Agencies & Funding: Mohawk College 

ABSTRACT: Despite a lack of recent literature, Occupational therapy (OT) has traditionally been a female dominated profession 

and males made up only 7.6% of the OT workforce in Canada in 2009. This gender disparity impacts the way males 

are represented in OT as a minority group of practicing therapists. Purpose: To investigate the reasons that males enter the 

OT & OTA/PTA programs at McMaster and Mohawk. Methods: In March 2012, an email was sent to all male students 

enrolled in the OT or OTA/PTA programs at McMaster and Mohawk. Semi-structured interviews were completed with 5 

student OTs and 5 student OTA/PTAs resulting in an 83% participation rate. Interview data (n=10) was transcribed and 

coded into themes using NVivo 9. Findings: Four key themes were congruent among participants in choosing OT as their 

area of study: Implications: Prior knowledge and influences, benefits as a male in the program, challenges as a male in the 

program, and perceptions on recruitment should be taken into consideration to increasing male representation in the OT 

field. 

Introduction 

Ever since its inception in the 1900s, occupational therapy (OT) 

has traditionally been a female dominated profession (Brown, 

1998b). In a recent study conducted by the Canadian Institute for 

Health Information, it was found that females make up 92% of 

the occupational therapy (OT) workforce in Canada (CIHI, 

2009). Thus, it is clear that the gender disparity between working 

males and females continues to persist today. While there 

has been a lack of literature in the last ten years regarding male 

OT recruitment practices, in the past, occupational therapy education 

programs have had difficulty in recruiting male students, 

and keeping them enrolled in the program (Posthuma, 1983). 

Given the lack of focused research towards the male attitudes 

and perceptions of OT, the purpose of this study was to understand 

why males currently choose to pursue an education in OT. 

Identifying the reasons for males entering the OT & OTA/PTA 

programs at McMaster and Mohawk can provide insight into the 

male perspective on the OT focused professions and is a necessary 

step towards increasing male representation within the profession. 


For professions where there is a large gender disparity it is important 

to understand the nature of how gender structure influences 

the decisions of the minority gender to pursue the area of 

study. The World Health Organization defines ‘gender’ as referring 

to the “the socially constructed roles, behaviours, activities, 

and attributes that a given society considers appropriate for men 

and women” (WHO, 2012). Gender Structure theory (Risman, 

2004), considers that gender is an intrinsic quality which differentiates 

personalities, cultural rules, or institutions in complex 

ways. The Prominence of OT came about during WWI (Townsend 

&Polatajko, 2007) where women were recruited for the 

position secondary to the beliefs that women possessed the 

compassionate and sensitive nature needed to be a therapist (Readman, 

1992). Past evidence has found males to be apprehensive 

about joining female dominated professions, and the majority of 

those who do join tend to depart the profession (Turgeon & Hay, 

1994). 

Male recruitment in OT in North America has been historically 

low and there have been several studies completed since the early 

1970’s on why recruitment and retention of male therapists 

has been low. Christiansen (1970) also found that men were 

likely to leave the OT profession as low salary levels affected the 

desire to stay in the profession. Lack of advancement, salary 

levels and recognition/prestige of the profession were also noted 

by Brown (1998) indicating that two decades later similar barriers 

to male retention are still being seen. Males in OT educational 

programs have met with adversity completing certain 

tasks such as dressing assessments, and been exposed to client 

embarrassment (Readman, 1992, Parish, Carr, Suwinski, & 

Rees, 1990). Readman (1992) suggested that sexism and the 

assumption that all occupational therapists were female was a 

primary issue for retaining male therapists. Christensen (1970) 

indicated that many males entered the profession because they 

were enticed to do so by other males practicing as occupational 

therapists. When altruism was compared between 510 male and 

female allied health students it was found that all joined their 

respective professions in order to help people (Byrne, 2008). 

However, when a group of male and females were interviewed 

from this study it was discovered that females wished to help 

people on an individual level, while males wished to help people 

on a societal or group level (Byrne, 2008). 

Methods 

Design: A qualitative phenomenological study design was used 

to gain information about the experiences of male students enrolled 

in the OT program at McMaster University and the 

OTA/PTA program at Mohawk College. Ethics: Ethics approval 

was obtained from the McMaster University student research 

ethics board and the Mohawk College research ethics board prior 

to the commencement of data collection. Participants: Purposeful 

sampling was conducted on students currently enrolled 

as OT students at McMaster University and OTA/PTA students 

at Mohawk College in Hamilton, Ontario. Recruitment was 

completed during the month of February and March of 2012. 5 

McMaster Student OTs answered the call for recruitment and 7 

Mohawk Student OTA/PTAs. The sample size was 12 but, two 

student OTA/PTAs dropped out of the study prior to completion 

of an interview. Therefore our study had 10 participants, 5 student 

OTs and 5 student OTA/PTAs, resulting in an 83% participation 

rate. Data Collection: Data was collected through the 

completion of 10 semi-structured interviews which were audio 

recorded. These raw data audio recordings were transcribed into 

text. The interviews were conducted by two male McMaster student 

OTs. Data Analysis: The 10 transcriptions were entered 

into NVivo 9 software and coded. Interview data was clustered 

into descriptive categories resulting in the identification of four 

general themes. 

Results 

Recruitment emails were sent to all male OT (5) and OTA/PTA 

(7) students enrolled at McMaster or Mohawk and a total of 10

interviews were completed. Thus a participation rate of 83% was 

achieved. The following four main themes emerged from the 

study: Benefits to being a male in the OT field. Challenges of 

being a male in the OT field. Prior knowledge and influences 

towards the OT field. Perceptions on recruitment and retention. 

The results are presented from both the congruent and 

unique perspectives of the male student OTs and OTA/PTAs. 

Discussion 

Benefits to being a male in the OT field 

The male bond shared between a male therapist and a male client 

was a common theme among the participants and has not 

been seen in the OT literature in relation to male attitudes about 

the benefits of males in practice. For patients transitioning to 

adulthood participants indicated that adolescent male patients 

could relate better to male therapists because they have been 

through similar developmental stages. With rapport building 

and client-centred practice as cornerstones in OT practice 

(Townsend, & Polatajko, 2007), participants are suggesting that 

males can enhance rapport building through the shared male 

experience . Participants also indicated that the typically larger 

musculature stature they bring is an added benefit during transfers 

in contrast to Parish et.al (1990), who found that males perceived 

muscular stature as stereotyping them into being needed 

for brute force and strength based positions, rather than the holistic 

skill set they bring. When considering patient safety and 

acquiring future employment, this suggests that male strength in 

the OT field is no longer seen as a deterrent to entering the profession. 

Participants felt a clear benefit of being a male in both 

the classroom and workforce was the different perspective they 

brought to practice. 

Challenges 

Many of the challenges indicated by SOTs and student 

OTA/PTAs were similar to the themes that came up in previous 

studies. Dressing assessments have traditionally been indicated 

as a barrier to practice by male OTs ( Parish et.al, 2008; Readman, 

1992). Participants also echoed uncomfortable experiences 

during dressing assessments on placements where patients preferred 

a female rather than a male due to modesty and handling 

comfort involved with self-care activities. Thus, the therapeutic 

comfort level during personal care related treatment continues to 

persist. Several past studies have indicated that role strain and 

female dominance were reasons for males leaving the profession 

(Parish et al., 2008; Brown, 1998; Readman, 1992). Some 

participants describe similar feelings around social isolation as a 

challenge in their environment. Participants often felt they could 

not relate to the female dominated social discussions and felt 

that extracurricular activities catered to female interests. Parish, 

et al. (2008) also elaborates on feeling isolated within the profession 

being a deterrent to continuing practice because facilities 

and meetings were usually directed towards females. 

Prior knowledge and influences towards the OT field. 

Personal influences from family and friends in the health care 

setting had a significant impact on participant decisions. Many 

individuals also learned about OT from volunteering or working 

in rehabilitation or health care setting and realizing that fit their 

ideals. Most participants indicated that they also researched the 

OT profession or found out about OT from government websites. 

Participants felt that enhanced advocacy by male occupational 

therapists within the profession would be a good way to entice 

more males to pursue OT as a career. Another recruitment strategy 

suggested was to increase student awareness of the OT profession 

at the high school and undergraduate levels. In addition, 

participants suggested the use of assisted devices technology be 

advertised or included in the profession descriptions, to cater to 

the male interest in technology. In contrast to past studies 

(Brown, 1998; Posthuma, 1983), prestige and pay scales were 

seen as a benefit of the profession and aided participants' decision 

to enroll in the OT field of practice. 

Perceptions on Recruitment and Retention 

Cracknell (1989), suggested a fear by current therapists to recruit 

more males into the OT profession because males did not 

emphasis the qualities of the profession such as sensitivity and 

nurturing. However, each participant indicated that they felt a 

good OT or OTA/PTA required attributes such as sensitivity, 

nurturing, person-focused, empathy. In contrast to Cracknell 

(1989), it can be inferred that participants feel males do possess 

these qualities. One participant spoke about the changing urban 

gender roles and how role for men and women are altering as 

parents allow their children to not be defined by classical gender 

roles. Using Risman's Gender Structure theory it can be theorized 

that the change in social gender roles may in fact be a subtle 

rebellion where males in the OT and the OTA/PTA programs 

may be doing gender differently by forging alternative masculinities 

(Risman, 2004). It was hypothesized that the OT profession 

required an ideological shift to attract more males to the profession. 

Participant responses could be reflective of their ability to 

embrace or conform to present ideologies taught in the female 

dominated profession. One might ask, should male students be 

conforming to the ideals OT programs, or should the OT programs 

be more accommodating to fit the needs of the male minority? 

Conclusions/Future Directions 

As gender roles in urban society change so do the reasons why 

males pursue a career in health care professions of the OT and 

OTA/PTA programs. Based on the current motivating influences 

it is evident that the past trends guiding males into the OT field 

maybe changing. Given the relatively even ratio between males 

and females in Canada, having a better balance between male 

and female OT practitioners would fit the current demographic. 

A more even gender distribution in the workforce could mean a 

more diverse perspective provided for the therapeutic benefit of 

the male patient/client. Limitations of the study were that it was 

only conducted in Hamilton, ON with students at McMaster 

University and Mohawk College which makes the results difficult 

to generalize. As well, it is the first qualitative study conducted 

on male OTs in the literature and thus it is difficult to 

complete a comparison to other studies. It is our hope that this 

study will generate dialogue from male and female members of 

the profession, employers, and members of faculty to enhance 

male recruitment and retention practices in future studies. 


We would like to thank our supervisors Bonny and Michael for 

their unwavering support, and to Mohawk for their generous 

funding. 

References 

Brown, G.T. (1998). Male occupational therapy in Canada: A demographic profile. British Journal of 


Byrne, N. (2008). Difference in types and levels of altruism bases on gender and program. Journal of Allied 

Health, 37, 22-29. 

Canadian Institute for Health Information.(2009). Occupational Therapists in Canada, 2009. Ottawa, ON 

Christiansen, C.H. (1970). The male occupational therapist: Attitudes and trends. American Journal of 


Cracknell, E. (1989). Conflicts for the female therapist: Some Reflections. British Journal of OT 52, 386-88 

Parish, J., Carr, D., Suwinski, M., & Rees, C. (1990).Undressing the facts: The problems encountered by male occupational 

therapists. British Journal of Occupational Therapy, 53, 67-70. 

Posthuma, B.W. (1983). Males in occupational therapy. Canadian Journal of Occupational Therapy, 50, 133 -135. 

Readman, T. (1992). Recruitment of men in occupational therapy: Past, present and future. Canadian Journal of 


Risman, B. J. (2004) Gender as a Social Structure: Theory Wrestling with Activism. Gender and Society 

18(4), 429–50. 

Townsend, E.A, & Polatajko, H.J. (2007). Enabling occupation II: Advancing an occupational therapy vision for 

health, well-being, & justice though occupation. Ottawa, ON: CAOT Publications. 

Turgeon, J., & Hay, J.A. (1994). Male occupational therapists in Ontario: A survey of work-related issues. Canadian 

Journal of Occupational Therapy, 61, 277-284. 

World Health Organization.(2012). Gender, Women, and Health. Retrieved March 2, 2012 from: 

http://www.who.int/gender/whatisgender/en/

Abstract 

This research project proposes a working 

definition of occupational community to 

enhance our understanding of occupation as 

shared experience and facilitate further 

study of this concept. Occupational community 

is a unique concept that is not yet 

defined in the literature. The definition was 

developed by performing a literature review 

on the individual concepts of occupation 

and community and placing them into a two 

separate concept maps. Overlapping concepts 

were identified and relationships were 

established between these concepts to develop 

a concept map for occupational community. 

Our definition of occupational community 

is as follows: occupational community 

describes a community that is defined 

by its shared occupation which occurs in a 

shared space among individuals with a common 

identity thereby producing network of 

meaningful relations and emotions. 

“loosely connected and activity-based groups that the 

best hopes exist for bringing some of the virtues of 

community to the modern world” Brint (2001) 

Occupational Community 

Authors—Erich Bogensberger, Kent Tsui, Joyce Tryssenaar 

McMaster University School of Rehabilitation Science 

Introduction 

This research project proposes a working definition of occupation community as a foundation for a future research 

project to study this concept. The authors feel that occupational community is a unique concept that warrants further study. 

Occupation has regularly been studied as an individualized concept, specific to the individual participating with factors such 

as culture, social, and physical environment influencing the occupation. However, a recently published article in The Journal 

of Occupational Science has highlighted that occupation is rarely individual in nature and relies on the relationships 

between multiple people to contribute to its meaning (Fogelberg & Frauwirth, 2010). The concept of occupational community 

attempts to enhance our understanding of occupation as a shared experience. The proposed definition of occupational 

community is as follows: occupational community describes a community that is defined by its shared occupation (cooccupation) 

which occurs in a shared space among individuals with a common identity, thereby producing a network of 

meaningful relations and emotional connection 


Occupation— The Canadian Association of Occupational Therapists (1997) has defined occupation as: 

“...groups of activities and tasks of everyday life, named, organized, and given value and meaning by individuals 

and a culture. Occupation is everything people do to occupy themselves, including looking after themselves (selfcare), 

enjoying life (leisure), and contributing to the social and economic fabric of their communities 

(productivity)” (p.34). 

The bulk of the literature available from occupational science and occupational therapy domains echo aspects of this definition. 

There are two salient concepts that are discussed in the Occupational Science literature that are not included in the 

above definition. The concept of co-occupation and occupational systems has been introduced in an effort to move away 

from the individualistic nature that occupation has been previously studied (Fogelberg & Frauwirth, 2010). Co-occupation 

has been introduced as a form of occupation that is shared between people and recognizes that occupation is rarely individual 

and almost always in the context of the social environment and/or relationships (Fogelberg & Frauwirth, 2010). These 

shared occupations are organized at different levels (individual, group, community, and population) by occupational systems 

(Fogelberg & Frauwirth, 2010). The elements in this system interact to produce occupations at each level and as more 

people become involved the social distribution becomes more evident. 

Community— Community in the literature is an ambiguous concept that is not consistently defined (Amit, 2010; Brint, 

2001). The definition of community has been a source of contention among varying disciplines such as psychology, sociology, 

and anthropology, each with their unique understanding of community. The author’s understanding of community was 

developed following a review and thematic analysis of community in the literature. Community exists in a shared space 

where members can interact with each other, have a structure and are guided by common values and beliefs. These characteristics 

interact to produce meaningful relations between members 

“Occupation is rarely, if ever, individual in nature” 

Dickie, Cutchin, & Humphry (2006)

The “Occupational Community” Framework 

Figure 1 is a concept map developed for occupational 

community. Four key concepts 

were identified to be fundamental in understanding 

occupational community. 

Network of meaningful relations 

The network of meaningful relations is the 

concept that emphasizes the quality of relationships 

between members as the defining 

feature of the community. Network of 

meaningful relations builds on the common 

identity of members to develop these meaningful 

relations, allowing for shared goals 

and experiences, effectively enabling occupation/co-occupation. 

In addition, the network 

of meaningful relations emphasizes the 

emotional connection felt between members 

that may not be present in common identity. 

Co-occupation 

The concept of co-occupation is fundamental 

to the understanding of occupational community. 

Co-occupation is the mechanism in 

which members share experiences, emotions, 

physicality, relationships, and goals. Sharing 

these factors allow members to build an 

emotional connection with each other beyond 

a functional interdependent relationship. 

In this way co-occupation generates 

and is embedded in the common identity, 

which is essential for occupational community. 

Common identity 

This is the identity that members of the community 

share with each other and is used to 

distinguish them from other groups. Common 

identity distinguishes itself from network 

of meaningful relations as it does not 

emphasis the emotional connection between 

members. 

Shared space 

Occupational community also occurs in a 

shared space. This refers to the space in 

which community interactions and occupation 

take place. The shared space makes 

engagement in occupation possible and interactions 

between people easier. The shared 

space can indirectly influence the common 

identity and network of meaningful relations. 

Occupational Community 

When you’re writing a flyer, write it so that 

someone who has never heard of your company 

can understand what you’re offering as quickly 

as possible. Stay away from using jargon, acronyms, 

or complicated terms. If you’re not sure 

what to write, make a list of “what we do” and 

then a list of “why our products or services are 

the best.” Use that information to create your 

brochure. Consider including customer testimonials 

or 

SUB-HEAD 

information about awards you’ve won. 

Consider including customer testimonials or 

information about awards you’ve won. Continue 

flyer text here. Continue flyer text here. Continue 

flyer text here. Continue flyer text here. 

Continue flyer text here. Continue flyer text 

here. Continue flyer text here. Continue flyer 

text here. Continue flyer text here. Continue 

flyer text here. Continue flyer text here. Continue 

flyer text here. Continue flyer text here. 

Continue flyer text here. Continue flyer text here. Continue flyer text here. Continue flyer text 

here. Continue flyer text here. Continue flyer text here. Continue flyer text here. Continue flyer 

text here. Continue flyer text here. Continue flyer text here. Continue flyer text here. Continue 

flyer text here. Continue flyer text here. Continue flyer text here. Continue flyer text here. Continue 

flyer text here. Continue flyer text here. Continue flyer text here. Continue flyer text here. 

Continue flyer text here. 

Figure 1 - Occupational Community concept map 

Future Direction—The results of our research has found occupational community to be a unique concept yet to be studied in 

the literature. The framework proposed for this concept builds on the constantly evolving definition of community and will 

provide a new lens for occupational therapists and scientists to study occupation and the communities that form around it. The 

proposed research grounded in this definition will seek to enhance our understanding of this concept, the impact occupation 

can have on the community, and may potentially enhance service delivery by Occupational Therapists. 

References 

Amit, V. (2010). Community as good to think with: The productiveness of strategic ambiguities. Anthropolgica, 52, 357-375. 

Brint, S. (2001). Gemeinschaft revisited: A critique and reconstruction of the community concept. Sociological Theory, 19, 1-21. 

Canadian Association of Occupational Therapists. (1997). Enabling occupation: An occupational therapy perspective. Ottawa, ON: CAOT 

Publications ACE. 

Dickie, V., Cutchin, M.P., & Humphry, R. (2006). Occupation as transactional experience: A critique of individualism in occupational science. 

Journal of Occupational Science, 13, 83-83. doi: 10.1080/14427591.2006.9686573 

Fogelberg, D., & Frauwirth, S. (2010). A complexity science approach to occupation: Moving beyond the individual. Journal of Occupational 

Science, 17, 131-139. doi: 10.1080/14427591.2010.9686687

Evidence Based Practice Symposium - McMaster University

Create successful ePaper yourself

Delete template?

Save as template?