The Concept of Function

The Concept of Function carolyn A Unsworth

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Introduction Our ability to function is something that is assumed until it is impaired in some way, usually because of a change in health status. Therefore, throughout the literature, function often appears to be explored in the context of health and illness. 6·9 An individual's ability to function is the basis for most occupational therapy practice and this information directs clinical decisions.w However, if we seek to facilitate the restoration of function, we must have a clear idea of its dimensions. In the current economic climate where therapists must be able to demonstrate their effectiveness, the need to describe and measure function accurately is lncreastng.u This article reviews the ways in which function has been defined by the literature, and by the assessments that have evolved to measure it. It argues that, as a profession, occupational therapy needs to consolidate its concept of function, and then work towards measuring it.

Denning function A great deal of attention has been devoted to establishing assessments that can capture or represent an individual's functional status. The first section of this article examines a selection of assessment tools in an attempt to examine how researchers have encapsulated function in their assessments. In many cases, function is inappropriately defined as being what the functional assessments measure.

Defining function through assessments Smith 5 recently reviewed the area of functional assessment in occupational therapy. Smith's article presented an excellent overview and included innovative and scientific ways in which functional assessment findings can be validated (for example, Rasch analysis) and used to aid clinical decision making (for example, decision analysis techniques).e Although this article focused on functional assessment, function was not defined to any extent. Functional assessment was defined by Grangert-' as 'a method for describing abilities and limitations in order to measure an individual's use of the variety of skills included in per-

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forming tasks necessary to daily living, vocational pursuits, social interactions and other required behaviours'. Determining a patient's functional status through formal assessment is important for treatment planning and measuring rehabilitation outcornes.n However, the literature definitions offered above do not operationalise this concept, that is, convert the theoretical idea of function into a defined statement regarding the way in which it should be measured. 13 Therefore, functional assessments appear to be poorly linked to theory. If functional assessments are semantically and conceptually confused,s they may offer the health team a dangerously inadequate decision-making tool. Several authors have presented charts indicating items included in various activities of daily living (ADL) assessments (for example, McDowell and Newell,14 Donaldson et al 15 and McAvoy41. Reviews of the content and scoring procedures of assessments are useful for therapists because they indicate the items included and the psychometric strengths and weaknesses of the assessments. However, reviews to date have not discussed the fact that item inclusion reflects the author's beliefs concerning the concept of function, nor have these reviews been thorough in representing all the tasks covered by these assessments.

Review of a sample of functional assessments Purpose Examination of functional assessments provides insight into the assumptions implicitly held by the authors about the nature of the construct. Therefore, the purpose of this review was to examine if the items measured and the type of measurement procedure used reflect a consistent view of function.

Selection criteria Over 200 daily living or functional assessments have been published. Many of these scales are presented and reviewed by authors such as Israel et al,16,17 Asher,1s McDowell and Newell14 and Kane and Kane.19 The majority of functional or ADL assessments have been developed to ascertain the skill level of older people who experience difficulties in daily func-

Carolyn Unsworth, BAppSc(OccTher), PhD Student, Department of Behavioural Health Sciences, La Trobe University, Bundoora 3083, Australia.

British Journal of Occupational Therapy, August 1993, 56(8)

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tion associated with advancing age and associated health problems. The following criteria were therefore adopted to select assessments for review: 1. Suitable for use with an elderly population (but application may be wider) 2. Suitable for people without a psychiatric condition 3. Developed for use in rehabilitation as opposed to extended care 4. Most items involve performance rather than simulation 5. The assessment is published. From a large number of assessments examined (approximately 150), 22 assessments met the criteria outlined above and were reviewed. A content analysis was performed by two independent raters: the author and an experienced psychologist. Items were grouped according to broad categories and, in part, reflect the assumptions of the raters about the construction of assessments. Table 1 presents an assessment content and scoring summary of the assessments reviewed. Assessment items were not included in Table 1 if they did not appear in two or more assessments; for example, items such as ladder climbing and motivation were omitted on the basis of this requirement. The final two rows in Table 1 indicate the total number of assessment items listed by the assessment authors as opposed to the number of items reported by the raters. Discrepancies indicate where categories have been condensed or expanded by the raters. For example, while an assessment may include five dressing items such as underwear, shirt, trousers, socks and shoes, Table 1 presents this as one item: dressing.

Review findings The review indicated that assessment authors conceptualise function quite differently. This is evidenced by the fact that so many assessments met the review criteria. In particular, the review highlighted inconsistencies in what researchers believe ought to be measured, confusion between measuring skills and tasks, and different approaches to scale construction.

1. Inconsistencies in items measured Smith 5 stated that, as a profession, we have not yet determined what we should measure in a functional assessment. The content analysis revealed substantial disagreement over the items that ought to be included in an assessment. Table 1 indicates that over 47 items may be used to assess function. Items included range from dressing to attending social events but, as Nichols 2o pointed out, the majority of scales include items relating to 10 major activities: bathing, getting into and out of bed, transferring, negotiating stairs, mobility, dressing, continence, using the toilet and feeding. This is supported by the high percentage of assessments including these items, as indicated in Table 1, column 23. Of the assessments reviewed, 95% included one or more aspects of mobility and 91% included dressing and eating. The Barthel Index21 includes all the central assessment tasks listed above and is upheld as the 'gold standard' with which other daily living assessments are compared. Table 1 provides the reader with a clear indication of authors who conceptualise function as being confined to personal care tasks and those who see function more broadly. Lawton and Brody22 were the first researchers to divide a standardised functional assessment into basic and instrumental items, where the former refers to personal care items and the latter refers to an individual's ability to adapt to his/her environment, that is, to shop, travel, cook and handle money. The substantial differences between assessments looking only at personal care and those assessing a variety of daily liVing items reflect a lack of clarity concerning the construct under examination. 288

The method of choosing items on assessments of function is rarely reported in the literature. As Reed23 suggested, it appears that the majority of functional assessment items are chosen on intuition or face validity rather than on construct validity. The majority of assessments are criterion-referenced, where 'normality' is determined a priori by judgement of what the population does. Norms may be defined as shared expectations about behavtour.> Therefore, functional assessments compare an individual's performance with the author's ideals of normal. Many of the items included in these assessments were not clearly defined. This lack of operational definitions limits comparability of scores between patients, and patient scores over time. Another problem is that, when items are defined, definitions offer quite different interpretations of the task. For example, terms such as bathing are defined quite differently by the Barthel lndex.st the Katz ADL Index,25 the Instrumental ADL Scale,22 the Rivermead ADL Assessmentss and the Functional Life Scale.27 Does bathing include bath transfers, washing and drying? One of the greatest difficulties with the assessments reviewed is the extent to which the information is condensed, and the quality of the information lost as it is transposed from specific details to broad activity categories such as bathing.

2. Confusion between measuring skills and tasks Some of the assessments reviewed confuse the measurement of tasks or activities with skills and abilities. For example, the Functional Life Scale 27 examines an individual's ability to perform activities such as bathing and eating as well as measuring some of the motor and cognitive skills that enable the task to occur. This raises another issue for debate: is the assessment of function about skills or tasks?

3. Different approaches to scale construction A variety of approaches to measuring function have been adopted. Finally, the assessment review leads us to question: is function best measured by a score or a profile of scores or no score at all (that is, qualitatively)? Substantial variation was noted in the administration and scoring procedures of these assessments. The structure of a living skills or functional assessment is also indicative of the assumptions held by its designer. There are three main types of quantitative measurement scale: a single index, consisting of a single score generated by summating the information from one or more items; a muttipart index based on the summation of information obtained from a number of sets of items; and a profile consisting of the scores or values of individual items. Table 1, row 59, indicates how each assessment may be classified. The construction of a single index in this field is based on the assumption that function can be adequately represented by a single score. It is implicitly assumed that the summated items are essentially replications of each other. The reason for their inclusion is a sampling issue, that is, to ensure that a valid and reliable measure is obtained. A single index assumes that the concept being measured is urndimensional.17 An index will also rate the person with a lower score if a task is not applicable and, therefore, not rated. Popular summed indexes include the Barthel Index21 and the Australian ADL Index.28 On the other hand, a profile or multipart index is based on the assumption that the concept being measured cannot be adequately represented by a single score or measure. In the language of test theory, the assumption is that function is a multidimensional concept.17 Of course, some occupational therapists reject the use of a quantitative approach in the assessment of living skills, preferring the use of qualitative concepts such as thick description 29 in their representation of livlng skills. Checklists offer British Journal of Occupational Therapy, August 1993, 56(8)


Table 1. Content analysis of assessments of function

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yet another method of describing patient function. Checklists simply provide clinicians with an exhaustive list of tasks for the patient to perform. A checklist is not a measurement tool. Checklists have no operational definitions and cannot be used to measure change over time or to compare individuals. 1 All measurement, whether quantitative or qualitative, involves an abstraction of the individual being measured along the dimensions the assessor believes to be relevant to the problem or question under consideration. The measurement is not the individual but a representation of the individual. Measurement is inherently a reductionist activity where complex systems such as function are summarised and simplified in the measures generated, whether the elements of the description are verbal or numeric in character. Once again, however, it is the users of the measures who determine which information is pertinent. The information they collect reveals, in part, the conceptualisation they hold of the system under study and, in part, the extent of their desire to simplify it. Given these variations in assessment content, administration and scoring, are researchers measuring the same thing? Examination of functional assessments clearly leads us to question the nature of function. However, literature definitions and discussions on function also present quite disparate ideas about what function actually is. While the growth of assessment tools designed to capture and represent function has been prolific, theory development in this field has been comparatively limited.

literature definitions of function In occupational therapy literature, the term function is explored in relation to the role of activity in maintaining health and wellbeing. Mosey30 stated that to function is to carry out the tasks that the environment demands of us. This includes the demands placed on us by society and individuals within this, and also our self-expectations. In order to function, we must have certain characteristics: we must have skills and specific abilities; we require knowledge; and, often, we require specific or general assistance.w Mosey defined function as 'the ability to engage comfortably at an age-appropriate level in performance components and the areas of occupational performance within the context of one's cultural, social and non-human environment' .30 From this definition, the issue of examining the qualitative aspects of function is raised. This includes the independence, the competence and the wellbeing of the individual carrying out the function. The relationships of these concepts with function are similarly ill-defined in the literature. The medical rehabilitation literature has also attempted to define this abstract concept. One definition offered stated that function is 'the activity appropriate to the nature or position of a person or thing - the normal and specific contribution of any bodily part ... to the economy of a liVing organism'.6 Furthermore, function may be defined as 'relating directly to everyday needs and interests - concerned with application in activity'.6 However, in much of the health and rehabilitation literature, function may be discussed and measured without defining it at all. For example, while the World Health organtsatton's» definitions of impairment, disability and handicap defined and organised the levels of intervention that a health system can offer a patient, restoration of function is discussed without reference to what function represents.

Inconsistencies in the language of function Lack of clarity in the literature concerning function has led most occupational therapists to use the terms function and

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ADL interchangeably; after all, as Cynkin and Robinson pointed out, 'activities that are woven into the fabric of our everyday lives ... ultimately express and define function' .10 Such inconsistencies were identified in a study by Thornton and Rennie.32 The study reported that the most common ways that therapists expressed activities of daily living were selfcare activities, showering and dressing, general mobility, feeding, personal hygiene, home management, meal preparation and activities of daily living (ADL). Other less frequently used terms included functional activities, functioning at an independent level, personal care, daily liVing skills, vocational/avocational factors, community living skills and usual daily activities. Problems with the use of such a mixture of terms extend beyond the resulting communication problems with staff and patients. This study clearly illustrates fundamental problems in the categorisation of the components of function. In an attempt to reduce the confusion surrounding the terminology commonly used by occupational therapists, the American Occupational Therapy Association produced a guide entitled 'Uriiform Terminology for Occupational Therapy'.33 While this guide provides a useful method of categorising tasks and skills, it does not place these within the context of function.

Summary of deflnitlons of function From the definitions presented, function does not appear to be conceptualised or defined consistently. Compounding this problem is the fact that the terminology of function (such as activities of daily living and living skills) is not used uniformly. Mosey34 suggested that this area has been neglected by researchers for two related reasons: firstly because function or ADL has traditionally been the domain of women and, therefore, not of concern to the predominantly male research community, and secondly because the activities that comprise function are largely taken for granted.

Directions for the future Having reviewed several functional assessments, it is proposed that function is in danger of being defined inductively, that is, by assembling a list of tasks and then assembling the construct. It is advocated that the work is done deductively, where the construct of function is defined from theory and a list of tasks is then deduced. In order to achieve this, further debate and research needs to be conducted in three primary areas: examination of the concept from a theoretical perspective; through this, clarify the relationship between skills and tasks; and based on theory and knowledge of people's activity patterns, determine the items that ought to be used to assess an individual's functional status.

Debate and explore the concept of function from a theoretical stance To provide a firm base for practice in this area, conceptual models from which to work need to be identified. Reed and Sanderson35 and MoseyJO both offered interpretations of function that provide a framework for clinicians. Similarly, the model of human occupationv- offered therapists a valuable model for practice in which occupational function forms a base for assessment and treatment of patients. This model24 operates within an open systems frame to explore function as a component of human adaptation. Human function is presented as consisting of three interdependent subsystems: volition, habituation and performance. Optimal function is dependent on the interaction of these three subsystems. There is no speedy solution to defining function through these approaches; however, such issues must be debated more rigorously in the occupational therapy literature. British Journal of Occupational Therapy, August 1993. 56(8)


clarify relationship between tasks and skills Therapists also need to clarify the relationship between tasks and skills. It is proposed that their relationship may be conceptualised as in Fig.1, where tasks form activities, and skills and activities together make up function. Although simplistic, it is important that relationships such as the one offered in Rg.1 are made explicit. Function, however, occurs within one's wider contextual envlronrnent.w Future conceptualisations of the relationships between the constituents of function need to reflect this belief. Rg.1. Conceptualisation of the relationship between skills, tasks and function. FUNCTION SKILLS/ABILITIES

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Establish normative patterns of function In order to define function or daily living activities, it would be expected that the majority of the literature and the assessments would be based on research conducted with community groups to ascertain the nature of activity involvement, and the amount of time individuals spend in activity; that is, to have a collection of normative data. However, this is clearly not the case. It is only quite recently that time budget research has begun to provide us with data on individuals' involvement in activity.36-38 The limited research in this area may be, in part, due to the fact that in studying members of the community, the very factor that is to be studied, independence, limits us from doing this if it is to be preserved and maintained. However, the information collected to date needs to be utilised in the construction of functional assessments. Several authors have also explored the daily activity patterns of populations with a health impairment. These include Taylor,39 who studied daily living activities with spinal injury patients, and Belcher et al,40 who examined the activity patterns of married and single stroke patients. Furthermore, Chiou and Bumett-t revealed that the therapist's judgements of important life activities (theoretically the. ones chosen as assessment items) were value laden, were not always representative of the client's needs, and often did not accurately represent the activities that the client was required to perform from day to day. Functional assessments tend to focus on the tasks patients need to perform in hospital, and ignore the function that might exist for patients outside these institutions. Yerxa42 stated: ' ... the occupational therapist does not force his value system upon the client. But rather through using his skills and knowledge, exposes the client to a range of possibilities which constitute his external reality. The client is the one who makes the choice.' This statement must also apply to occupational therapy measurement tools. Further research needs to be conducted to identify the functions that are sufficiently important to the client to warrant assessment.

Summary and conclusions This review presented some of the definitions of function offered by theoretical and 'assessment literature, and found that a consistent view of function and how it ought to be measured is not provided. It is concluded that more theoretical work is required to ensure that theory drives the measurement of function. Parallels between the measurement of intelligence and function are apparent. Psychologists face the

adage that intelligence is what intelligence tests measure.ss Is function what functional assessments measure or something else? Only greater theoretical exploration can prevent function from being defined by functional assessments. There is no speedy or simple solution to this problem. Consolidating the concept is essential before the assessments that are continually developed accurately indicate an individual's function. Acknowledgements This article is based on a paper written by Carolyn Unsworth and Dr Shane Thomas for presentation at the 16th Federal Conference of the Australian Association of Occupational Therapists, Adelaide. The assistance of Dr Thomas in preparing the original manuscript is gratefully acknowledged. References

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Ethics in Practice: Cruelty

In this case, it may be difficult for you to be objective about the incident because you have bunt up a good relationship with this lady and you feel that she trusts you. You also know that her mental condition may cause her to fabricate incidents and to feel that people are against her. The nursing staff and doctor may consider that you are inexperienced and do not know Mrs 8 as well as they do, and you already have reason to suppose that they may not share your concerns about what might have happened. If a patient has sustained an injury whilst on the ward, an accident form should have been filled in and this would normally include details of how the accident occurred. If, in your professional judgement, you feel that there is a possibility, however slight, that Mrs 8 was telling the truth, and the injury was not accidental, you have an obligation to record and report your concerns. You should produce a written report. which must be as objective as possible, noting that you observed the bruising and recording what Mrs 8 said to you. You should not pass any opinion as to whether or not the injury was inflicted by a nurse, but report that Mrs 8 alleged that the nurse had hit her. Your head occupational therapist should advise you about the format of your report. The report should then be given to the ward sister or service manager and it is his/her responsibility to investigate the matter further. You should be careful not to discuss the incident with the patient, or in any way appear to be supporting her allegation. If you do not report the incident, you are failing in your professional duty. If the allegation is correct, the member of staff concerned needs to be disciplined; if it is not correct, your report will give written evidence of Mrs 8's paranoid ideas, which will be important in her future management. Ethics Committee, COT. 1. BAOT. Codeof Professional Conduct. Br J OccupTher 1990; 53(4): 143.

Dear Ethics Committee, I am a basic grade occupational therapist working on a ward for elderly mentally ill patients. One of the patients, Mrs 8, has severe depression which makes her very difficult to motivate, and she also suffers from paranoid delusions. I have a good relationship with this lady and can usually persuade her to do things for herself. She has some degree of insight into her condition and often asks me whether or not she is imagining things. Her doctor feels that she has a manipulative personality and is keen to get her well enough with medication to return to the private residential home where she has lived for the past year. Apparently, the staff at the home are not keen to have her back, because she has upset the other residents by accusing them of stealing. One morning on the ward, I was helping Mrs 8 to dress when I noticed a large bruise on her upper arm. I remarked upon this and Mrs 8 told me that one of the night staff, Nurse X, had hit her because she was slow in getting to bed. One of the nursing assistants overheard our conversation and said that Mrs 8 was not telling the truth; she had, in fact, stumbled and hit her arm on the bedside locker. She also remarked that Mrs 8 was a troublemaker and that I should not believe everything she said. Mrs 8 did not mention the incident again, so I did not take any further action because I did not wish to jeopardise my relationship with the nursing staff. They also seemed to have a different view of Mrs 8 and her behaviour. However, I am still worried about the incident.

Principle 2, Cruelty The 8AOT's Code of Professional Conduct. Principle 2, advises members who witness or have evidence of ill-treatment to patients to report this to their head occupational therapist.!

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The Concept of Function

The Concept of Function

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