Functional Evaluation and Management of Self-care and Other Activities of Daily Living
Charles H. Christiansen
Sandra L. Rogers
Kristine L. Haertl
INTRODUCTION
In this chapter, we discuss self-care and activities of daily living (ADL) from the standpoint of rehabilitation across a wide range of ages and conditions. We first describe the importance of this domain of human activity to illustrate why self-care and ADL performance are important rehabilitation goals. We then describe approaches to assessing an individual’s ADL skills, sampling the range and scope of assessments in this area that are supported by published research. We attempt to identify best practices and areas of philosophical and procedural controversies. Finally, we turn to the intervention strategies. A collaborative goal-setting process to guide intervention is emphasized. We summarize key intervention strategies across a sample of conditions, citing evidence in support of intervention strategies, where available.
Our objectives in this chapter include
To familiarize the reader with the central importance of self-care (ADL and IADL) in the life of the patient viewed from the perspective of discharge setting
To describe a range of approaches toward measuring self-care performance
To identify strengths and weaknesses of various ADL and IADL assessment instruments
To describe collaborative goal setting and development of a plan of care
To review various strategies and principles for intervention within the categories of adaptation, remediation, and compensatory strategies, health promotion, disability prevention, environmental modifications, use of assistive technology devices (ATDs), and use of personal care attendants (PCAs)
To summarize and research ADL-related interventions and plans of care
Enabling individuals to manage daily self-care is among the most important tasks undertaken by the rehabilitation team. This is because such tasks relate directly to the business of living and their performance signifies a return to participation in the routines of daily life. Self-care tasks include dressing, eating, bathing, grooming, use of the toilet, and mobility within the home. These are basic tasks included within the general category of ADL. Although able-bodied persons perform most self-care tasks routinely, such tasks can represent difficult challenges for persons with sensory, motor, and/or cognitive deficits.
Other important activities for living in the community are related to managing the requirements of daily life. These extended ADLs (EADLs) go beyond basic self-care and have been labeled by Lawton as instrumental ADL, or IADLs (1). These include food preparation, laundry, housekeeping, shopping, use of the telephone, use of transportation, use of medication, and financial management. Childcare is also an important responsibility in the daily routine of many people.
Unfortunately, there is no consensus on the classification of human activity. As a result, many terms with similar definitions used for ADL categories are used in the medical, health, and rehabilitation literature. Table 9-1 lists some of these. In this chapter, basic ADLs (BADL), such as eating, dressing, grooming, hygiene, and mobility, are described as personal or self-care tasks. Essential tasks for maintaining the living environment and residing in the community are described as IADLs or EADLs (see Table 9-1).
Self-care tasks may assume a symbolic meaning for the individual in a rehabilitation program, because attending to eating, dressing, and toileting tasks is basic part of the routine necessary for establishing a sense of identity (2) as well as for gaining acceptance in a social world (3). This is because appropriate dress, personal appearance, hygiene, and other expectations influence perceptions of the self and others (4).
In the developed nations, about 30% of a typical person’s waking hours is spent performing self-maintenance activities, including basic self-care and household maintenance (5, 6). For able-bodied persons, an average of more than 1 hour per day is spent in basic self-care activities (7). Research has shown that more than 70% of the variation in discharge decisions following stroke rehabilitation is determined by the ability to function independently self-care tasks necessary for bathing, toileting, social interaction, dressing, and eating (8, 9).
TABLE 9.1 Terminology of Functional Performance | |||||||||||||||||||||||
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In the United States, recognition of the importance of functional independence is reflected in population survey data collected by governmental agencies, such as the National Center for Health Statistics (10, 11). An individual’s functional ability is an important predictor of nursing home placement, with research showing a high correlation between the number of dependencies in ADL and the risk of institutional placement (10, 12).
Self-care and ADL in Context
Current international models of disability consider the multiple factors that influence daily life and the ability to perform necessary life tasks (13). These models recognize the importance of the physical and social settings in which an individual lives, and how these factors come together to support or limit task performance and participation as a member of society. Others with whom an individual regularly spends time constitute that individual’s social nucleus, providing important support and social interaction and influencing activity choices and role requirements as well as the level of independence (14, 15, 16). This nucleus typically includes friends, acquaintances, and members of the individual’s immediate and extended family.
It is within this social situation that the importance of self-care is most apparent, because meeting self-care needs is vital to success in meeting expectations for social interaction. Self-esteem, or the value accorded oneself, is determined by how well self-evaluation matches the values perceived as important in the social environment (17). Self-esteem is influenced by social acceptance and by one’s success in achieving a desired social identity (18, 19, 20, 21). Because the ability to perform self-care tasks contributes to both acceptance and identity, it can have a direct effect on self-esteem (19, 22). Importantly, social factors, including social support, are important predictors of rehabilitation outcome as shown by studies of amputation (23), stroke (24, 25), serious burn injury (26), spinal cord injury (20), hip fracture (27).
Typically, self-care activities are taken for granted by the person and society unless difficulties are encountered. Limitations in self-care tasks and dependency on others for their completion serve to diminish an individual’s self-concept and can lead to decreased morale and depression (28). A study of elderly patients found that a relationship existed between self-concept and functional independence, and that people who were dependent in ADL scored lower in measures of self-concept (19).
Research has shown a clear relationship among self-concept, morale, and level of functional independence. For example, Chang and MacKenzie found that self-esteem was a consistent and significant predictor of functional ability at various intervals following stroke (20). Chemerinski et al. found that improvements in ADL performance were associated with remission of poststroke depression (21). These studies and others (29) indicate that an important goal of rehabilitation should be to help patients learn to take control of decisions about daily living, since this may contribute positively to their sense of efficacy, morale, and overall sense of well-being. More important, it may also increase life expectancy, since loss of hope and feelings of helplessness during early rehabilitation phases have been shown to be associated with shorter survival rates following stroke (30).
Within living settings, the presence of an individual with needs for care-giving affects the entire family or social group (31, 32). When a member of the family can no longer perform expected activities, the daily routine may be upset, creating stress, diminished psychological well-being, and conflict (33). Family members must adjust their expectations of the individual who is disabled as well as adjust to changes in family routines and activities (34).
Family caregivers are important to the well-being of persons with disability and chronic illness (35). Over time families experience stages and time periods, each with characteristic issues. Important concerns related to self-care and care-giving needs must be considered in light of these stages, with recognition that needs change over time. The most significant change affecting caregiving is the number of family members who are available to provide support as a family life cycle matures.
Necessary adjustments made by families or caretakers confronted with rehabilitation challenges often include a reassignment of homemaking tasks or changes in priorities and may impose additional financial or social burdens due to the need to hire outside assistance or rely on volunteers (36). Studies have shown that levels of depression and anxiety, as well as somatic complaints, are more prevalent among caretakers and family members of disabled people living in the home environment than those typically found among members of the general population (33, 34). Yeung et al. found that self-confidence in Chinese family carers was an important factor in psychosocial well-being (32). Caregiver burden, a term given to the general strain, isolation, disappointment, and emotional demands of caring for a member of the household with a disability, seems to increase in proportion with ADL needs (37, 38, 39). A study of families involved in caring for survivors of stroke found that family adaptation after 1 year was related to family stresses and demands, family resources, and family perceptions. In particular, family functioning was poorer when the patient developed psychological morbidity, when the patient was less satisfied with the recovery, and when the health burden of the stroke was greater (40). In recognition of the increasing importance of the role of household caregivers, interventional strategies, including counseling, education and training, and social support, have been reported. Recent meta-analyses have indicated that such interventions are effective in improving well-being and mental health and reducing the “burden” of care among caregivers (41, 42).
During the rehabilitation process, the family can have a considerable influence on functional outcome (43). A stable and supportive family unit can be of great assistance, whereas families that are functioning poorly can impede rehabilitation. In some cases, poor outcomes can be traced to a lack of family involvement in the rehabilitation process (44). In other cases, too much support can encourage dependency (41). This indicates that the family should be involved in all aspects of rehabilitation, including evaluation and the setting of rehabilitation goals and treatment strategies before and after discharge (45).
A primary source of adjustment difficulties for people with physical disabilities comes from societal treatment of them as socially inferior (46). The common belief that strength, independence, and appearance are important aspects of self-worth is very damaging to people with disabilities. Interaction within a social group often depends on the ability to perform at the group’s expected level; otherwise, the person will not be included as a significant group member (18).
Self-care tasks are not publicly valued in the same manner as gainful employment (47, 48). Ironically, they assume importance principally when one’s inability to perform them leads to perceived disadvantage or social stigma (49). Self-reliance in ADL helps to refute the idea that a person with a disability may be a financial or social burden to society. It is important to realize that social participation and quality of life are often the ultimate goals of patients, and this endpoint should influence shared goal setting. Physical health is an enabler of well-being, and the capacity to accomplish self-care represents the beginning set of tasks necessary for participation. As noted by Hogan and Orme, ambulation and self-care mastery alone are insufficient for attaining desired goals related to social participation (50). A research synthesis reported by Bays concluded that independence with ADL, and social support were key variables in the quality of life experienced by survivors of stroke (51). Lund et al. determined that social participation in various activities of life, including self-care, contributed to perceived quality of life in survivors of spinal cord injury (52). Cardol et al. (53) asserted that ethical approaches to planning and implementing care in rehabilitation should place greater emphasis on the autonomy of the individual. This is exemplified by an attentive attitude, opportunities for informed choices by the patient, and consideration for each patient’s preferences, needs, and social contexts (53). In some cases, active participation in goal setting by persons receiving rehabilitation may require special efforts to overcome lack of familiarity, perceived indifference, and other barriers to involvement (54).
Self-care and Functional Performance
Traditionally, intervention for people who have difficulty performing self-care tasks has begun with training in the acute care or rehabilitation environment. Typically, such intervention includes instruction in procedures to regain dressing,
grooming, hygiene, and food preparation and eating skills. In pursuit of these goals, rehabilitation sessions have been conducted within the patient’s hospital room or in simulated ADL settings within the facility. Intervention strategies involve teaching the individual functional skills or the use of assistive technologies so that compensatory strategies can be performed in the postdischarge environment.
grooming, hygiene, and food preparation and eating skills. In pursuit of these goals, rehabilitation sessions have been conducted within the patient’s hospital room or in simulated ADL settings within the facility. Intervention strategies involve teaching the individual functional skills or the use of assistive technologies so that compensatory strategies can be performed in the postdischarge environment.
Unfortunately, as suggested earlier, ADL training in a rehabilitation facility does not guarantee skill generalization to the discharge location. Patients may perform well in a rehabilitation facility, but skills may not always transfer to the individual’s pre-admission or discharge living setting. Environmental and psychosocial factors that directly influence task performance may be too varied between settings for the person receiving rehabilitation to generalize the learned skills (55). In addition, the individual may become dependent on the staff for self-care performance (56) or lack the opportunity to practice new skills on a regular basis. Consequently, performance following discharge may reflect a lack of confidence or motivation.
Setting Rehabilitation Goals for the Discharge Environment
The growing cost of specialized rehabilitation care has led to a reduction in hospital lengths of stay and has resulted in more rapid discharge from special care facilities. More care is now provided in outpatient settings and in the home environment.
This has advantages, since intervention in the home can be beneficial in achieving certain self-care skills and community reintegration (57, 58, 59). Community-based intervention has the benefit that the environment can be evaluated in terms of architectural, transportation, and communication barriers and how these support or limit the individual’s daily living skills.
Collaboratively Planning Self-care and ADL Goals
Current standards in rehabilitation require the involvement of the person receiving care as well as family members or caregivers, as appropriate in planning intervention (60). Controlled studies have shown that active collaboration in rehabilitation goal setting increases client satisfaction with care (61).
When goals are set in collaboration with the individual receiving care, the motivation to learn and maintain a skill is better than if rehabilitation professionals or caregivers determine the goals. It also appears that agreement on goals may influence functional outcomes by establishing clearer and more realistic goals (62). Each self-care behavior should be evaluated to see if the individual is motivated to learn and maintain it. Some studies have shown differences in the extent to which professionals and persons receiving care have congruent views regarding rehabilitation goals (63) but generally support the value of client participation in decision-making about care (61, 64, 65, 66, 67). This underscores the need for close collaboration between providers and recipients of care when planning intervention.
One of the first options the professional and person receiving rehabilitation should explore concerning the performance of any self-care task is whether the task is necessary or desired. The individual may choose not to perform some self-care tasks that were done before his or her illness. For example, a woman with hemiplegia who formerly rolled her hair on rollers on a daily basis may decide to have it cut in an easierto-manage style rather than learn to use rollers with one hand. This type of decision should be based on individual preferences. Similarly, changes in societal styles and norms may also influence self-care goals, since greater diversity in clothing, hairstyle, and general appearance make it less likely that deviations from the norm will stand out.
In some instances, training procedures can be used to regain a desired skill. Following a cerebrovascular accident (CVA), for example, the therapist may be able to retrain the person to perform the task as it was performed before the CVA if there is sufficient return of voluntary movement. In some instances, the individual may no longer have the perceptual or physical capability to perform a task as before. However, he or she may be able to learn to accomplish the task using different movement patterns or with different body parts.
Environmental changes represent an additional array of intervention options that can be explored by the individual and his or her rehabilitation team as a means of gaining independence in self-care. In some instances, simply rearranging the physical environment may allow the disabled person to perform tasks independently. For example, moving dishes to lower shelves so that the patient can reach them from a wheelchair would represent a modification of the environment requiring only simple rearrangement. Structural changes in the physical environment also may be necessary. These can include major changes such as the architectural modification of rooms to accommodate wheelchair movement or less extensive improvements such as replacing round doorknobs with lever handles for a person who has weak grasp or installing bathroom rails and grab bars for persons with unsteady gait or balance difficulties.
The idea of universal design, which describes key principles for making environments, facilities, and objects useable for people regardless of their physical attributes or limitations, should have a positive impact on reducing barriers to activity and participation in the years ahead (68). This emerging environmental movement is broader than previous concepts of environmental accessibility (as described in the Americans with Disabilities Act and other legislation), yet highly relevant to rehabilitation and disability. Universal design emphasizes creating environments and objects that are simple and intuitive and that enable equitable and flexible use, have perceptible forms of information, require low physical effort, have tolerance for error, and have sizes and shapes appropriate for approach and use.
Assistive technology devices (ATDs) can be used to aid in the satisfactory performance of a desired task. These devices can range from simple, inexpensive articles, such as bathtub seats, to the use of expensive equipment such as computers for environmental control and communication (69). Many labor-saving devices are now widely available in catalogs and retail outlets catering to the general population. A line of fashionable apparel
designed for easy dressing and maintenance is now available for persons with limitations in range of motion. The rehabilitation professional’s role is to inform the patient of the existence and cost of these devices and to train the individual and caregiver in their use and maintenance.
designed for easy dressing and maintenance is now available for persons with limitations in range of motion. The rehabilitation professional’s role is to inform the patient of the existence and cost of these devices and to train the individual and caregiver in their use and maintenance.
Assistance from other people for the partial or total completion of a desired task is another option available to the individual receiving care (70). Assistance may come from spouses, friends, or paid PCAs. The role of the professional in this case must be to instruct the individual and/or the care attendant on optimal approaches to working together for the completion of identified self-care tasks (71). Figure 9-1 provides a decision chart that describes the process of goal setting summarized in this section.
Collectively, the personal and environmental intervention options described in this section form the basis for collaborative decision-making and treatment planning. It should be borne in mind that neither diagnosis alone nor the extent of impairment can serve as an adequate basis for planning self-care intervention. Together, the rehabilitation team and the individual receiving care must determine those approaches that represent the most realistic and achievable goals based on the abilities, values, and personal social circumstances of the recipient of care (61). Only in this way will optimal results be achieved after discharge.
 FIGURE 9-1. Decision-making process for self-care/ADL intervention. |
ISSUES IN ADL EVALUATION
Granger (72) defines functional assessment as “a method for describing abilities and limitations and to measure an individual’s use of the variety of skills included in performing tasks necessary to daily living, leisure activities, vocational pursuits, social interactions, and other required behaviors.” Assessment must take place within a conceptual framework. An early model for this purpose was the World Health Organization’s International Classification for Impairment, Disability, and Handicap (ICIDH) (73). The ICIDH was revised in 2001 after an international revision effort, and is now called the International Classification of Functioning, Disability, and Health, or ICF (13). The ICF and its revised classification broadens the overall scope of the structure to include categories that view limitations to activities and participation as functional
consequences that are influenced by environment, personal factors, and problems with body function or structure. The ICF also addresses concerns about terminology (such as use of the word handicap) and adopts terms and definitions that are global in application and reflect differences between developed and underdeveloped nations. The revised model for the ICF now has two parts, each with two components with defined domains and constructs as reflected in Table 9-2.
consequences that are influenced by environment, personal factors, and problems with body function or structure. The ICF also addresses concerns about terminology (such as use of the word handicap) and adopts terms and definitions that are global in application and reflect differences between developed and underdeveloped nations. The revised model for the ICF now has two parts, each with two components with defined domains and constructs as reflected in Table 9-2.
TABLE 9.2 International Classification of Functioning, Disability and Health, World Health Organization, 2001 | |||||||||||||||||||||||||
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As a conceptual framework for considering self-care, the ICF provides a means for recognizing that self-care tasks take place within particular living environments and may be performed differently based on an individual’s habits, culture, and social situation. This chapter attempts to emphasize that these contexts should be reflected in the functional assessment process, the determination of rehabilitation goals, and the type and location of interventions chosen.
Assessment has, as its ultimate purpose, the ability to make informed decisions. Scales and instruments designed to assess the ability of the individual to perform self-care tasks may assist in intervention or discharge planning by describing or documenting current abilities or monitoring changes in functional status. More global scales, which may include self-care components, are used to provide information on the effectiveness of rehabilitation programs, thus playing an important role in program evaluation.
Historical Development of Self-care Evaluation Tools
Assessment of the individual’s ability to function independently has been conducted in medical rehabilitation for nearly 50 years. In an early review of the problems of measurement and evaluation in rehabilitation published in 1962, Kelman and Willner found that poorly conceptualized outcome criteria, lack of standardization, disagreement about methods, multidimensional scales, and the influence of the setting on performance were barriers to effective management (74).
In the ensuing two decades, several published reviews of functional assessment from the standpoint of relevance, clinical utility, scale construction, standardization, reliability, and validity of scales concluded that the development of new scales should be curtailed, with greater effort devoted to the refinement and validation of existing scales (75, 76, 77, 78, 79). The challenges of functional assessment are summarized in the following sections.
Determining Capability Versus Characteristic Behavior
Current models of rehabilitation emphasize that function cannot be considered in isolation from its environmental context. This is made especially clear by the distinction between capability and actual behavior. Measures of capability represent what the person can do, whereas measures of actual behavior indicate what the person does.
Many self-care assessments in use during the past 30 years have been designed to measure what a patient is capable of doing within the care facility. An assessment of actual behavior, however, should ideally take place in the daily living environment in which the person will be performing the tasks. The setting influences actual performance that may differ from the individual’s capability. Awareness of the distinction between capability and actual behavior and their relationship to the patient’s environment has had an important impact on the development of new approaches to the assessment of self-care abilities. The ICF is based on a premise that disability is the result of an interaction between the person’s physical capabilities and the characteristics of a setting or environment. Environments have characteristics that can support or interfere with performance. It seems appropriate then that self-care performance assessment, if it is to be accurate and complete, should consider both the person’s physical capabilities and the characteristics of the environment.
As clients return home from hospitals, units, or residential facilities at an earlier stage, ease of administration becomes an
issue for determination of client progress. Although one way of determining ability is through observation of performance, another approach involves asking individuals themselves (or people living with them) to provide verbal reports. The literature is mixed about the validity of such reports. A study of stroke survivors by Knapp and Hewison found that caregivers generally perceived stroke survivors as more functionally impaired than did the survivors themselves (80). In contrast, a study by Wilz found that stroke survivors were able to accurately assess their level of impairment (81). Confusing the issue further, a study by Kwakkel et al. demonstrated that physical and occupational therapists consistently underestimated the degree of independence in ADL and level of recovery achieved by patients undergoing rehabilitation following stroke (82). The point here is that the most accurate way to measure self-care performance is through actual observation of the individual within the performance environment. Even then, however, the maintenance or consistency of the individual’s performance over time will be unknown.
issue for determination of client progress. Although one way of determining ability is through observation of performance, another approach involves asking individuals themselves (or people living with them) to provide verbal reports. The literature is mixed about the validity of such reports. A study of stroke survivors by Knapp and Hewison found that caregivers generally perceived stroke survivors as more functionally impaired than did the survivors themselves (80). In contrast, a study by Wilz found that stroke survivors were able to accurately assess their level of impairment (81). Confusing the issue further, a study by Kwakkel et al. demonstrated that physical and occupational therapists consistently underestimated the degree of independence in ADL and level of recovery achieved by patients undergoing rehabilitation following stroke (82). The point here is that the most accurate way to measure self-care performance is through actual observation of the individual within the performance environment. Even then, however, the maintenance or consistency of the individual’s performance over time will be unknown.
Contextual Factors in Self-care Evaluation
A complete assessment of self-care function should consider factors that include the patient’s ability to manage devices that extend independence through environmental control; the family resources available to the patient in the environment to which he or she is to be discharged; the amount of time or energy required to perform tasks independently; and the degree of safety with which patients are able to perform tasks.
Developments in high technology for independent living have made it possible to assess people with severe disability in terms of their available movements and physical resources for controlling switches to activate environmental control units. Paradoxically, these devices are more likely to extend the patient’s ability to perform IADL more proficiently than self-care tasks.
The inability to perform self-care tasks independently, of course, does not require discharge to institutional care if human resources are available in an alternative environment. Frequently, the client can, and does, rely extensively on the assistance of a partner, other family members, or friends, or PCA to assist with self-care tasks. It can be argued that the presence of these resources, although commonly determined by the social worker in planning discharge, should be given early consideration in planning rehabilitation intervention.
Additional contextual considerations include the amount of time and energy required to perform the task independently versus the value of the task as perceived by the patient. It cannot be assumed, given competing requirements for time and energy, that all patients assign the independent performance of all self-care tasks the same degree of importance. Thus, the motivation to complete the task independently after discharge is likely to be a function of the alternatives available for task completion, the importance of the task to the patient, and the amount of time and energy required to perform the task independently in the face of competing demands.
Weingarden and Martin reported on a study of ten postdischarge spinal cord-injured patients to determine if time was a factor in the decision to retain, modify, or completely delegate dressing activities (83). Although all ten patients were capable of dressing independently at home, none did so routinely. The authors concluded that the person’s concepts of appropriate time and energy expenditure are important considerations in postdischarge decisions on the use of functional skills. Another study by Pentland, Harvey, and Walker explored time use by 312 men with spinal cord injury living in the community. Their study showed that the level of the lesion, the level of functional independence, and the setting did not predict the amount of time spent in personal care, productivity, leisure, and sleep. Nor did the time spent in these activities predict outcomes such as life satisfaction, perceived health, or adjustment to disability (84).
The degree of safety with which a task is performed may be of obvious importance to the practitioner but may not be apparent to the patient or those caregivers in the environment who may be providing assistance with self-care tasks. It is, therefore, important that training in self-care assistance be provided as part of the rehabilitation effort and that the ability of helpers to render this assistance in a safe and effective manner be assessed before the patient is discharged (85).
Defining Functional Outcomes
Many observers have noted that increased emphasis on accountability and the need for determining the benefit-cost ratios of rehabilitation have revealed ambiguities and a lack of consensus regarding definitions of rehabilitation success. For example, gains in self-care ability, although important to the patient, may not be perceived as beneficial within a system that perceives employability as the sole criterion of success. This has created additional pressure for the development of evaluation tools that consider post-discharge function in the living setting.
Fortunately, increased attention to these issues has resulted in increased research, which has encouraged the refinement or development and validation of several scales that assess self-care performance. Some of these scales possess characteristics suitable for program evaluation and research as well as clinical decision-making. The need remains, however, for greater awareness of the problems associated with functional assessment, greater consensus on appropriate measurement items, and consistency in definitions and terminology. Although awareness of the importance of using instruments that possess necessary measurement characteristics has improved, a tendency to create ad hoc instrument modifications continues, making comparisons between studies more difficult.
Approaches to Obtaining Performance Data
Functional evaluation can be accomplished by direct and indirect means. Direct evaluation involves first-hand observation of skill performance. Judgment based on subjective observation, however, is not always an accurate predictor of outcome (82). Indirect evaluation can be done by using client report
(gathered through mailed surveys, face-to-face or telephone interviews) or reported by proxies, such as members of the family or household. Evidence of the validity of such indirect approaches is equivocal (80).
(gathered through mailed surveys, face-to-face or telephone interviews) or reported by proxies, such as members of the family or household. Evidence of the validity of such indirect approaches is equivocal (80).
In addition to creating threats to reliability, indirect reporting of functional performance can create threats to validity. A number of factors make it difficult to establish the validity of functional ability indices. These can include the impact of assistive technologies, environmental differences, and caregivers. Psychological factors, such as the patient’s level of motivation, the professional perspective of the rater, and the role expectations of the patient can compromise efforts at establishing the validity of these scales (86). There are also sources of error in observation, including the likelihood that the client’s performance is influenced by the evaluation process and therefore may not represent a typical or consistent performance.
Desirable Attributes of Self-care Scales
Reviews of functional status measures have identified several criteria for evaluating the quality or suitability of scales. These criteria derive both from psychometric standards and from expert opinion, and include psychometric properties of validity, reliability, sensitivity to change, and methods for assessing scaling properties, such as Rasch analysis (87, 88). Psychometric standards in the United States have been greatly influenced by the jointly developed standards of the American Psychological Association, the American Educational Research Association and the National Council on Measurement in Education (89). Within rehabilitation, the American Physical Therapy Association (APTA) (90, 91) published measurement standards in 1991, and the American Congress of Rehabilitation Medicine developed Measurement Standards for Interdisciplinary Medical Rehabilitation in 1992 (92). These standards provide important guidelines for the appropriate use and interpretation of measures, including self-care scales. They also provide definitions of important terms relevant to test development, and refer to technical problems that should be avoided by developers and users. Table 9-3 summarizes important characteristics that can be used in evaluating, comparing, and selecting rehabilitation measures.
TABLE 9.3 Desirable Criteria in Rehabilitation Measures of ADL Performance | |||||||||||
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