Background

The involvement of clients in the rehabilitation process is an important aspect in relation to the quality of rehabilitation in Denmark1,2 and internationally.3,4 Since 2013, this involvement has been described as an integral part of the Danish Model of Quality in the Healthcare System 2.5 It is also an aim of the Government of Canada6 to involve clients in the rehabilitation process, and this is generally a trend in the 2020 vision of many countries.7 In the recently concluded Health Agreement for the Metropolitan area in Denmark 2015-2018, clients' involvement is a vision in which "the client, including his or her relatives, is, and perceives to be, an active collaborator in his/her own rehabilitation process... and that clients are supported in mastering their illness using their own resources and needs".8^(p.3) However, it is well understood that there are difficulties in fulfilling this vision.9,10 A recent study involving Danish doctors and nurses (the Danish Knowledge Centre of User involvement in Healthcare [ViBIS])11 showed that the rehabilitation process is often done without evident reference to the client's perspectives or not done in a collaborative manner.12 Other studies of Danish cancer patients' experiences have documented unaddressed problems and inadequate rehabilitation.13,14 All of this illustrates the need for involving the clients in their rehabilitation process by allowing the client to identfy issues they themselves want to address.

A well known, efficient and recommended outcome measure to involve the client in the rehabilitation process is the Canadian occupational performance measure (COPM), which is an individualized measure designed to detect changes in a client's own perception of occupational performance over time.15-17 The COPM includes five steps. First, the clients assess and identify their occupational performance problems within the areas of self-care, productivity and leisure. Second, the clients rate the identified problems in terms of their importance to their lives on a scale of 1 (not important at all) to 10 (extremely important). Third, clients choose the five most urgent or important problems, which gives a basis for goal-setting, and this will then be focus of the rehabilitation. In the fourth step, the problems are rated by the clients in terms of performance (how the occupations are executed) and satisfaction (how satisfied the client is with the way he or she performs the occupations) on a scale of 1 to 10, with higher values indicating better performance and greater satisfaction, and conversely. Finally, after an appropriate interval, a re-assessment of the performance and satisfaction scores is done and can be calculated in order to measure changes in the client's perception of his/her occupational performance over the course of the rehabilitation.15 Thus, the COPM helps assess the client's perception of occupational performance through an interview about their priorities in their daily life. Occupational performance offers answers to: who the clients are (person), what the clients do (occupation) and where the occupations are conducted (the environment).18,19 Through the COPM interview, the clients identify issues concerning their significant occupations, the ones that define their lives and self-perception, and thereby prioritize their rehabilitation needs.

Several studies and two reviews support that the information obtained through the use of the COPM cannot be obtained through other measurements.20-25 In these studies, the COPM identified a wide range of issues which were not detected using other measurements. As the COPM is based on an individual's perspective, including their values, judgments and preferences regarding occupational performance, it can facilitate both clinical decision making and monitoring of functional progress.20 Similar results were found in a Danish study with cancer patients using the COPM and the 47-item Activity of Daily Living (ADL) Questionnaire (based on the ADL taxonomy).21 The study showed that the COPM revealed additional areas of difficulty, for example, hobbies (30%) and pets (5%).22 This supports the notion that the COPM is designed so clients can express their own perspectives and wishes in relation to the rehabilitation process and helps ensure the client's motivation and relevance of the aims in the rehabilitation process.23

A preliminary search of databases (PubMed and CINAHL) revealed up to 200 published scientific articles on the psychometric properties, applicability and use of the COPM. One literature review by Caswell et al. noted that the psychometric properties of the original version and validated translations of COPM were examined with a positive result.24 The review showed that the COPM has been validated against a variety of measures ranging from strict functional measures to measures of psychological and social functioning, and the validity (concurrent, criterion, convergent, divergent, construct and content validity) has consistently supported that the COPM measures occupational performance.24 Typically, 50-80% of the issues identified with the COPM are also identified using other measures; however, it is consistently noted that the COPM results in a larger number of identified issues.24 Internal consistency reliability has been shown to be within a reasonable range (0.81, P < 0.001), and test-retest reliability has consistently been found to be well above the acceptable range (0.89, P < 0.001).24 Studies of the COPM have included a broad spectrum of different clients who have found the COPM reliable.24 Studies of responsiveness all consistently report that the COPM is responsive to clinically relevant changes in occupational performance.15,24

Another qualitative systematic review by Parker and Sykes25 states some of the above mentioned positive outcomes. Furthermore, the COPM has demonstrated the ability to encourage engagement and motivation in the rehabilitation by cooperating with the client and allowing the client the ability to be an expert in their own life situation and thus define their goals.25 Nevertheless, the reviews identify some issues when using the COPM, for example, that the COPM is difficult to use in the acute phases of illness and in institutions that are not familiar with a client-centered approach, both of which have been found in Denmark.23,25 Despite the identified issues, the COPM is recommended for use in Danish rehabilitation practice16 and is used in studies conducted in Denmark.26,27 Moreover, the above-mentioned reviews are dated 10 and 12 years back, respectively, and do not include a thorough methodological description. This supports the importance of conducting a new systematic review of international research in order to provide recommendations based on current knowledge. To our knowledge, no current or systematic review in progress related to the use of the COPM during the client's rehabilitation phases has been identified. Thus, data obtained by conducting this systematic review can be used to develop a national clinical guideline with recommendations for use of the COPM in Danish practice.

Inclusion criteria

Types of participants

The review will include the following participants:

Professional(s): healthcare personnel who, across institutions, use the COPM throughout all phases of the clients' rehabilitation process. As the COPM is an outcome measure developed within the occupational therapy profession and is based on an explicit occupational therapy model, the COPM is often used by occupational therapists, but it has also been used by other healthcare professionals.

Client(s): any adult person, over 18 years, who has been referred to rehabilitation due to any kind of mental or physical illness.

Rehabilitation: a set of measures that assist individuals who experience or are likely to experience disability to achieve and maintain optimal functionality in interactions with their environments.28

Types of intervention(s)/phenomena of interest

The phenomena of interest for this review will be the experiences and perceptions of professionals and clients with the use of the COPM, and whether these enhance a client-centered approach in rehabilitation.

A client-centered approach is a process that focuses on involvement and partnership with the client in the process of their own rehabilitation or care, engaging them and encouraging them to take ownership of their own rehabilitation. Therefore, this review will consider studies that investigate the perspectives of clients and professionals in regards to using the COPM as an approach to facilitate client-centered practice in rehabilitation.

Context

The clients may receive rehabilitation services in any kind of institution (e.g. hospitals, rehabilitation centers, health centers and the like) or in their own homes. Therefore, this review will consider studies that include clients who receive rehabilitation in the following contexts:

* Hospitalized in acute or sub-acute settings (on hospital wards).

* Admitted to a rehabilitation or healthcare center (in the community).

* Receives outpatient service (in their own homes and environment) from a healthcare or rehabilitation centre in the municipality/or out-patient clinics.

Types of studies

The current review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and gender research.

Search strategy

The search strategy is aimed at finding both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the keywords contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Reference lists of all identified reports and articles will be searched for additional studies. Studies published in Danish, Swedish, Norwegian and English will be considered for inclusion in this review. Studies published from 1990 to 2016 will be considered for inclusion in this review, as the first version of COPM was published in 1990. Thus, in order to ensure all available material is covered, all materials related to the different versions of COPM from 1990 to the present will be included.

The databases to be searched include the following:

PubMed, CINAHL, OT-seeker, Pedro, Web of Science, SCOPUS, Cochrane Library, CRIStin, Swepub, DiVA, TRIP, NORA.

The search for unpublished studies will include the following:

MedNar, OpenGrey (which includes SIGLE and EAGLE).

Initial keywords to be used will be as follows:

COPM or "Canadian Occupational Performance Measure" AND Evaluat^* AND Rehab^*.

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or by including a third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review, using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes significant to the review question and specific objectives.

Data synthesis

The qualitative research findings related to clients' and health professionals' perceptions will, if possible, be pooled using JBI-QARI, as the overall aim of the review is to explore the use of the COPM as an instrument to enhance the client-centered approach in the rehabilitation process from the perspectives of both clients and professionals. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in a narrative form.

Acknowledgements

The current paper was supported by grants from Metropolitan University College, Copenhagen, Denmark, and from the Danish Association of Occupational Therapists. The authors would like to express their gratitude to Dr Palle Larsen from the Danish Centre of Systematic Reviews: a Joanna Briggs Institute Centre of Excellence, Aarhus, Denmark.

Appendix I: Appraisal instrument

QARI appraisal instrument

Appendix II: Data extraction instrument

QARI data extraction instrument

References