Clinical Reasoning Guideline for Home Modification Interventions

Development of the Personal Factors Guideline.

Key informant interviews, a focus group, and field observations were conducted and analyzed to identify client personal factors that influence intervention decisions made by expert therapists.

Participants.

Clinicians with expertise in home modification intervention who lived in the St. Louis, Missouri, region were recruited using convenience sampling. Potential participants known to the research team were sent a study flyer by means of email. A snowball sampling method was used on a rolling basis to increase the sample size. Occupational therapists or certified occupational therapy assistants were invited to participate in the study if they had ≥2 yr of experience providing home modifications.

Procedures.

We used grounded theory to conceptualize the phenomenon of the clinical reasoning process used by expert occupational therapists in providing home modification interventions. This method uses constant comparative analysis of a variety of data sources to describe an existing phenomenon (Glaser & Strauss, 1967; Strauss, 1987). We conducted focus groups to yield insights through interaction with expert clinicians (Lindlof, 1995) and in-depth interviews and field observations of expert clinicians to explore the rationale for intervention choices by expert clinicians (Kusenbach, 2003). We (Susan L. Stark, Emily Somerville, and Aliza Smason) used the “go-along” method (Kusenbach, 2003) to observe the clinicians’ practice and to view and discuss the therapeutic interaction and intervention planning.

We developed a discussion guide containing a series of open-ended questions and prompts based on a review of the literature to reveal the clinical reasoning process that expert occupational therapists use when making recommendations for home modifications. Example questions from the discussion guide include “There are often many ways to overcome barriers in the home. How do you decide what modifications you will recommend to your clients?” and “Are there characteristics about your clients or their families or their environments that lead you to choose one solution over another?”

An expert clinician in home modification with experience leading focus groups facilitated the focus group (Stark), and a single researcher (Smason) conducted the key informant interviews. The 2-hr focus group and 75-min interviews were audiotaped and transcribed verbatim. Extensive field notes were taken during the go-along sessions. Transcripts and field notes were analyzed independently by four team members (authors Smason, Stark, Somerville, and Bigham) using constant comparative analysis (Hewitt-Taylor, 2001; Strauss & Corbin, 1990). The data were reviewed in detail and coded to form initial categories; this was followed by selective coding in which categories were examined to detect overlap, signifying the development of overarching themes. The process of data analysis was iterative, in which factors, conditions, and strategies were identified by comparing and contrasting the codes and through team discussion until consensus was reached. Descriptions of the themes were developed on the basis of supporting quotes from the original transcripts and field notes. Data collection (focus group, interviews, and go-along sessions) was completed on reaching saturation.

From the coding and thematic analysis, a personal factors guideline to support clinical reasoning in home modification interventions was developed; it included a factor, a set of conditions for that factor, intervention strategies to address the condition, and a clinical exemplar. The draft was presented to a subset of the original expert clinician participants for member check and revised on the basis of their feedback.

Multiple strategies were used to improve the trustworthiness (Krefting, 1991) of the data during Phase 1 of the study. We triangulated data collection approaches using both interview approaches (focus group, interview) and field observations (go-along method) to confirm the informants’ behaviors relative to their description of their behavior (thus avoiding a socially desirable response). In addition, use of a team of researchers to code using constant comparison, discuss, and interpret the findings assisted in the reflexivity and dependability of the analysis. Member check throughout the field observations and during the interviews, and a final formal member check of the draft guideline, increased the credibility of the data. The preliminary findings were examined in a second phase of the study in which a second, external group reviewed the findings.

Validation of the Personal Factors Guideline.

Content validity of the guideline was ascertained with a review by a second set of expert clinicians in home modification.

Participants.

Six occupational therapy scholars or clinicians were selected on the basis of their expertise in home modification intervention or record of publications in home modifications and recruited through convenience sampling methods. Each expert was invited to participate through email correspondence.

Procedures.

The experts independently rated each item on a 4-point relevance scale (i.e., the extent to which each item related to the clinical reasoning of expert home modification providers). A content validity index (CVI), or the proportion of experts who rated the item as content valid, was calculated for each item (Lynn, 1986). Experts rated each factor, condition, intervention strategy, and clinical exemplar on a scale ranging from 1 to 4 (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant but needs minor revisions, and 4 = highly relevant). Individual item CVI scores were calculated as the proportion of the 6 raters who scored the item as valid (rating of 3 or 4). The a priori cutoff to retain an item was .78 (Lynn, 1986). An overall scale-level CVI was calculated by averaging the factor-level CVI scores (Polit, Beck, & Owen, 2007). Experts provided extensive open-ended comments for each item and the instrument. The form was revised by the research team on the basis of the expert review.

Clinical Course of the Disease.

Expert occupational therapists conducted standardized assessments to measure the client’s capacity. These occupational therapists also used their knowledge of the clinical course of a health condition to predict their clients’ future capacity and to determine the optimal set of home modifications in the present and the future. One clinician stated that the modification plan “depends on their . . . functional abilities and capabilities. If they’re recovering from a hospitalization and they’re still a little weak, that’s different than somebody who has [a multiple sclerosis] exacerbation.” We observed that expert occupational therapists overcompensated for environmental barriers for clients with a progressive disease; they predicted future environmental barriers on the basis of the clinical course of the disease process to ensure that the intervention was effective for as long as possible.

Personal Assistance Preferences.

The occupational therapists ascertained client preferences for using personal support to perform their daily activities and varied the intervention plan accordingly. If a client stated a preference for and had access to human assistance, the occupational therapist recommended modifications and provided training that involved a caregiver. One therapist stated, “[Having a caregiver] makes me think of different solutions.” A preference for no personal assistance would result in a plan that included more architectural modifications or adaptive equipment.

Ability to Maintain Home Modifications.

Occupational therapists considered clients’ ability to care for and maintain the modification. If clients were physically, cognitively, or financially unable to maintain a device or product, alternative solutions were considered. One occupational therapist stated,

Readiness for Change and Compliance.

Occupational therapists noted that a client’s openness and willingness to make changes to the home influenced their therapeutic approach. This readiness for change was described by one occupational therapist as Prochaska and DiClemente’s (1982) Stages of Change model. A client’s readiness for change altered how occupational therapists presented intervention strategies to them. One occupational therapist noted that “it really . . . depends on the client as to how willing they are to make changes to stay in their homes.” Therapists indicated that readiness influences the choices clients make about home modifications and their approach to the intervention. One clinician noted a technique she uses with clients who are not ready to make changes: “I [say] things like, well, we can try it for this week and if you don’t like it we can take it off . . . or tweak it—just give it a week’s try.”

In addition to the readiness for modifications, in some cases the ability to follow through and implement changes influenced the recommendations occupational therapists made. Therapists noted that compliance could be affected by cognitive capacity or characteristics of the client’s personality versus a desire to make the changes.

Concern for Aesthetics.

The occupational therapists considered clients’ concern for the aesthetic appearance of the home when making recommendations. One therapist stated, “She [didn’t] like this idea about the toilet because it doesn’t match [the rest of her blue bathroom fixtures].” The therapist went on to say that despite the improved safety and function, the client would not consider making changes until her aesthetic priorities had first been met. Several therapists also noted that function rather than aesthetics might be the primary goal of other clients. The stigma of medical devices was also noted as a client concern. Thus, determining individual aesthetic preferences is an important factor in the clinical reasoning process.

Financial Resources.

Understanding the client’s financial situation and making appropriate recommendations based on the available resources was another theme therapists identified as important in the home modification process. One clinician described the process:

In addition, it is important that clinicians not undermine the trust and relationship that they have developed with their clients by making recommendations that are beyond the scope of what a client could realistically implement. As one therapist noted,

Therapists also noted that although some clients had the financial resources for home modifications, they might not have support from family members or friends to cover the full expenditure. One clinician stated, “If somebody is not expected to live more than a year . . . to spend thousands of dollars on [a new bathroom is hard]. . . . They might just do a bed bath instead.” Budgets influenced how occupational therapists prioritized solutions.

Personal Assistance Available and Social Support.

The occupational therapists discussed the importance and influence that personal assistance in the form of a caregiver has on the intervention process and outcome. The level of involvement of a caregiver influenced the type of modifications occupational therapists prescribed. One clinician shared that she would “try to include the caregiver in the whole process and [explain] the options [to] get their feedback.” Another clinician stated, “[I ask] how are the changes, the recommendations . . . affecting them, how are they experiencing the whole caregiver experience?” The caregiver’s approval or lack of approval was noted as an important factor in acceptance of home modifications. One therapist noted, “Sometimes the caregiver doesn’t want the client to be independent, or they don’t think that they need equipment.” In some cases, occupational therapists identified care providers from community groups as a linchpin in a successful intervention. The level of social support was also considered in determining the types of modifications needed. Social support ranged from installing the intervention to helping with daily activity performance and maintaining the intervention if needed.

Lives With Others.

The occupational therapists noted that clients often shared their home with other family members or pets and discussed the importance of ensuring that modifications work for all residents in the home. One clinician said, “I’m thinking of a person that we had whose husband has dementia, so some of the recommendations that we make could even be a safety hazard for him.” In one instance in the field, a bathroom modification resulted in use of a toilet riser instead of a comfort-height toilet because the home was shared with small children who would have had difficulty with a taller toilet.

Structural Condition of the Home, Housing Type, Weather Conditions, and Available Space and Layout.

Occupational therapists noted that factors such as type of housing, structural condition, ability to maintain one’s home, levels of the home, outside space availability and condition, and general floor plan were important characteristics to consider. One clinician noted, “I’m definitely looking at what type of housing it is. . . . Obviously . . . with apartments . . . they may not be allowed to [modify the home structurally without] some fights with landlords.” The occupational therapists discussed the challenge of providing home modifications when the structural integrity of the home was not sound. In other cases, the neighborhood conditions were important considerations in the clinical reasoning process. For example, weather conditions and neighborhood safety influenced choices, such as installing a ramp in a garage protected from the elements and out of sight of potential criminals who might perceive a person with a ramp as a vulnerable target. Modification plans were also influenced by the layout and flexibility of space. Available space to expand rooms or build additions was also discussed as an important consideration in developing intervention plans.

The initial guideline included a set of 14 personal factors and conditions derived from the nine themes: clinical course of the disease, personal assistance preferences, ability to maintain home modifications, readiness for change, compliance, concern for aesthetics, financial resources, personal assistance available, social support, living with others, structural condition of the home, housing type, weather conditions, and available space or layout. After a member check review by a subset of the Phase 1 experts, the guideline was refined to improve clarity and to develop clinical examples.

During this process, two additional factors were identified. Portability was described as the need for modifications to “travel” with clients who live in different homes seasonally or on the basis of caregiver availability. Literacy level was also identified as a consideration in selecting home modification interventions and in training clients to use and maintain interventions. The guideline was revised to reflect these two additional factors. Table 1 presents the factors and conditions.