Occupational Therapists’ Cognitive Assessment Decision-Making in Acute Traumatic Brain Injury Care

Abstract

Background: Occupational therapists assess cognitive function in patients with traumatic brain injury (TBI) to determine the impact of impairments on occupational performance. In acute care settings, occupational therapists’ decision-making regarding the assessment of cognitive function is influenced by multiple factors. Aims: The aims of this study were to explore the perceived influences on choice of cognitive assessment by occupational therapists, the ways in which they incorporate observation of occupational performance in assessment, and their attitudes towards and experiences of implementing performance-based testing (PBT) in acute care. Methods: Fifteen occupational therapists with an average of 16.5 years of clinical experience working in acute care TBI management participated in an individual semi-structured interview. The interviews were conducted in person or online and consisted of six questions about which cognitive assessments they use in acute care, influences on this choice, and their experiences of assessing functional cognition using performance-based testing. Data were analysed using interpretive description. Results: The final four themes included (1) an emphasis on ‘functional observation of occupational performance’ and use of structured and tailored processes to make assessments, (2) ‘individualised and efficient’ assessment methods, (3) contextual influences on assessment choice, including the ‘occupational therapy department culture and hospital context’, and (4) ‘safety and management of risks’. Conclusions: Occupational therapy assessment of functional cognition in acute care depends on comprehensive understanding of individual patient-specific factors. Therapists are influenced by pragmatic factors when choosing assessments, which has led to the modification of standardised tests drawn from occupation-based approaches to fit within the time constraints of the acute care setting. The results indicate that therapists may benefit from guidance on how to safely assess patients’ functional cognition in an individualised way in the acute care setting.

1. Introduction

Traumatic brain injury (TBI) may result in ‘hidden’ cognitive deficits [1] that have an impact on the ability to complete everyday tasks independently [2]. On admission to hospital, or following neurosurgery, patients with TBI are typically transferred to an acute care ward for medical management prior to discharge home or transfer to rehabilitation [3]. Whilst in the acute stage of recovery, patients with TBI are often in a state of post-traumatic amnesia, causing confusion, agitation or drowsiness, and behavioural changes [4]. They may also have orthopaedic injuries or medical complications arising from multi-system trauma. One of the roles of the occupational therapist in acute care is to determine the impact of brain injury-related impairments on the ability to return to valued life roles and guide rehabilitation planning [3]. The ability to return to life roles is largely determined by the extent of the patient’s cognitive impairment [5] and subsequent recovery of cognitive function. Occupational therapists use information from assessments to identify cognitive impairments, commence early rehabilitation, predict functional outcomes, and support discharge recommendations [6].

Guidelines [7] recommend that cognitive rehabilitation should commence in acute care to increase overall active rehabilitation time and optimise rehabilitation outcomes. The accurate assessment of cognitive function as early as possible in acute care enables individualised rehabilitation planning and early rehabilitation to occur, maximising the potential benefits of neuroplasticity following TBI [8,9]. Without this, impairments may be missed, which can result in a lack of, or inadequate, rehabilitation [10,11]. It also ensures that the multi-disciplinary team, patients, and carers receive accurate information regarding current cognitive impairments [6]. However, there are potential constraints associated with assessing cognitive function in the busy acute care ward that are related to the patient’s status and ability to participate in assessment, the limited time available, and a lack of appropriate spaces to conduct assessments [12].

Clinical decision-making about which cognitive assessments or combination of assessments to use with patients in acute care with TBI is a complex area of clinical practice. A recent survey of occupational therapists indicated that this choice was dependent on therapists’ knowledge of evidence-based assessments, the availability of assessment resources, and the ability to implement them within the constraints of the acute care setting [12]. Survey respondents reported using a wide variety of standardised assessments in acute care, including pencil-and-paper based screening tests such as the Montreal Cognitive Assessment and Rivermead Behavioural Memory Test, as well as assessments of functional cognition.

In occupational therapy practice, functional cognition refers to the integration of cognitive skills in order to perform everyday activities in real-world environments [13]. Functional cognition is a dynamic concept [14] in which the patient’s performance sits on a continuum and varies depending on the task, the environment, and their motivation to complete the task. Over the past 10 years, occupational therapists have begun to use the term functional cognition in practice, highlighting the professions’ contribution with patients with cognitive impairments [15]. Assessments of functional cognition use direct observation of a person completing a challenging everyday task and inferring cognitive impairments from their performance [15,16]. In conjunction, there has been a focus on developing standardised performance-based tests that inform estimates of functional cognition. Performance-based testing involves a clinician observing actual performance of an everyday task in a simulated or real-world environment using a test with standardised methods of administration and norms [17].

When assessing functional cognition in this way, occupational therapists select tasks for patients to perform that are important to them or needed for return to their occupational roles [18], and are based on an individual’s unique occupational performance problems [19,20]. Performance-based tests provide a closer approximation of the ability to manage everyday tasks in real-world situations than pencil-and-paper screening tests or neuropsychological tests. They require the patient to respond to novel situations or interruptions and solve problems as required in real life [21]. By assessing everyday tasks, performance-based tests highlight errors made in task performance and may suggest areas for intervention in rehabilitation [2,22]. Performance-based testing of activities of daily living (ADL) is more accurate in predicting how an individual will manage on discharge compared with traditional forms of cognitive testing [6,23].

Performance-based tests include short screening assessments as well as lengthier comprehensive evaluations which assess a patient across a number of daily activities. Using a computer to order goods and services, using a new appliance, or managing an automated ticketing machine are examples of individual tasks used in tests [24,25]. The Multiple Errands Test [26], a comprehensive performance-based test, involves taking a patient to the shops and giving them a number of items to purchase and ‘rules’ to follow while performing these tasks. The Assessment of Motor and Process Skills (AMPS) [27] and the Perceive, Recall, Plan, Perform (PRPP) system of task analysis [28] are examples of performance-based tests in which the activities are selected on the basis of individual patients’ needs.

Most performance-based tests are designed for rehabilitation settings that have easy access to rehabilitation resources such as kitchens [11]. In acute care settings, occupational therapists usually work within a ward environment without easy access to ADL assessment spaces, which may make it difficult to use these tests. An acute ward setting has a different focus compared to a rehabilitation setting, with different pressures on staff [29], at times leading to therapists’ reliance on cognitive screening tests that are not performance-based [30]. Screening tests are quick, may cover multiple cognitive domains, usually require pencil and paper only, can be completed at the bedside, and require minimal interpretation of the results [31]. In contrast, performance-based tests require additional time to administer, ADL-specific environments, and experience from therapists to interpret results and predict performance in real-life following discharge [32]. Despite these challenges, standardised performance-based tests remain the recommended method to gather information to estimate a patient’s functional cognition [6,17]. Surveys of practice of Australian occupational therapists in 2012 [33] and in 2021 [12] showed that most occupational therapists prefer to use non-standardised observations of functional tasks and interviews in practice. In response to these challenges, some briefer performance-based screening tests [13,34] have been developed, which may be useful in acute care settings where time is limited. Whilst there are compelling practical and conceptual reasons for occupational therapists assessing cognitive function in acute care to use performance-based tests, they tend to be infrequently used.

Other survey results indicate that many factors impact occupational therapists’ choices of assessments for patients following TBI. In 2009, Alotaibi et al. surveyed occupational therapists working in varied areas of clinical practice in the USA and found that availability, clinical utility, and popularity in the workplace influenced use of assessments [35]. Similarly, a study of occupation-based assessment tools used in Sweden and Japan found that factors such as ready availability in the workplace and the impact of colleagues’ opinions influenced the choice of assessment, rather than patient-centred practice or published evidence [36]. An international study of 323 occupational therapists found that the cognitive assessments chosen varied widely between countries, as did the reason for their choice [37]. Findings from our recent Australian survey highlighted that many of the performance-based tests of cognition available for use by occupational therapists were not known to respondents and that the time constraints of the acute care ward impacted on their choice of assessments [12]. However, survey methodologies by nature provide only a broad description of factors and do not seek to understand the reasoning justifying assessment choice. Research on the decision-making of occupational therapists assessing real-world implications of cognition impairment is needed [20,38]. Given the potential constraints of using performance-based assessments in the acute care setting, it would be useful to know how occupational therapists assess functional cognition in acute care and what factors influence their choice of assessment method. Identification of these influences may assist with the removal of barriers to the use of performance-based testing in this setting and ultimately enhance the information available to the multidisciplinary team about the functional status of patients to inform decision-making. Therefore, we sought to develop a more in-depth understanding of occupational therapists’ perspectives of current practice regarding cognitive assessments used in acute care by using a qualitative approach. Accordingly, the research questions guiding this study were developed and are presented in

Table 1. Research questions.

1	What are the perceived influences on choice of cognitive assessment by occupational therapists in acute care?
2	How do occupational therapists incorporate observation of occupational performance into cognitive assessment in acute care?
3	What are occupational therapists’ perceptions of integrating performance-based testing into acute care practice?

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2. Methods

2.1. Design

A qualitative methodology incorporating an interpretive descriptive approach [39] was chosen in order to explore the perceptions of occupational therapists working in TBI management in acute care. Interpretive description was developed within the nursing field with the aim of providing practical recommendations from the analysis that assists with addressing a clinical question or problem [39]. As a qualitative methodology, interpretive description has a unique application for interventionist health disciplines where the aim is to elicit clinical knowledge from a group of interviewees with common experience (in this case, occupational therapists working with patients with TBI in acute care). Interpretive description provides clinically applicable research outcomes that may enhance occupational therapy assessment practice [39]. This project received ethical clearance from Queensland Health Metro North Human Research Ethics Committee (Ref# HREC/2019/QRBW/54305) and the University of Queensland’s Human Research Ethics Committee (clearance # 2020000751). The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [40] were followed for reporting.

2.2. Participants

The participants were a convenience sample of 15 registered Australian occupational therapists who were eligible to participate if they had clinical experience working with adults with TBI in acute care at any stage of their career. Participants were drawn from a sample of 81 respondents to an online survey about occupational assessment of cognition in acute care settings [12] which was distributed via links from professional association websites and via professional networks in TBI rehabilitation and research over a 3-month period from May to August 2020. Survey respondents were invited to provide their contact details to the first author if they wished to participate in an individual in-depth interview as follow up. The online survey’s data are reported elsewhere [12] and were not incorporated into this qualitative study. All participants who indicated willingness to participate were sent an email inviting them to participate in an interview and 15 responded. No participants refused or withdrew. Written informed consent was obtained from each interviewee prior to the interview. Preliminary analysis indicated that data saturation had been reached following the 15 interviews and further participants were not sought.

2.3. Data Collection

Interviews were conducted using a semi-structured interview schedule [41]. A list of potential questions was developed by the first author, following a scoping review of the literature [42] and based on the research questions. These were then reviewed and refined iteratively in a series of consensus discussions within the research team. See Supplementary File for the interview schedule. Questions were piloted with two clinical occupational therapists prior to data collection, resulting in minor changes to some questions to improve clarity. The interview sought to explore the clinical experience of the occupational therapist regarding their methods of assessment of cognitive function in patients with TBI and influences on their assessment choices. Therapists were asked to elaborate on how they currently assess functional cognition specifically and their perceptions of using PBTs in acute care and how they could be implemented under optimal conditions. Questions relating to assessment of functional cognition and PBT were purposely placed in the second half of the interview, after determining the participant’s current practice in their own words to reduce risk of social desirability bias when reporting their assessment choices. Interviews were conducted face-to-face, online, or by telephone depending on participant preference and geographic location and lasted 30–60 min. The first author conducted all interviews and was known to some interviewees through professional networks or workplaces. No one else was present at the interviews. The reasons for doing this research were explained at the beginning of the interviews. Field notes were recorded. Interviews were audio-recorded and transcribed verbatim using a professional transcription service, and then transcripts were returned to the interviewees and checked for accuracy.

2.4. Analysis

The interview transcripts were analysed using thematic analysis within an interpretive description approach [39,43]. Data were managed in Microsoft Word (2020, Microsoft Office 365). The first author commenced data analysis by reading all transcripts multiple times, highlighting key sections that related to the research questions. Meetings between the first and second authors led to an initial coding framework. Three representative interview transcripts were selected that included interviewees with a range of years of experience and work settings. There were 44 text segments of varying length, on average one sentence in length, relating to the research questions that were coded independently by the first and second authors, resulting in an 88% agreement rate. Further discussion resulted in some codes being merged and new codes formed; for example, nine different methods of assessment were collapsed into two major codes describing assessment as with or without functional observations. The revised coding framework was independently applied to two additional interviews. These interviews collectively included 37 text segments, and a coding agreement rate of 91% between the two authors was achieved. The first author then used this coding framework to code the remaining interviews.

Once coded, the first and second author met to group codes into preliminary themes. Further discussion amongst the research team resulted in preliminary themes being revised and condensed into four final themes. For example, the themes ‘knowledge of occupational therapy models and knowledge gained from research’ and ‘individual patient factors and context’ were collapsed into the overall theme of ‘professional judgement and experience’. This subsequently formed a final theme of ‘occupational therapy department culture and hospital context’.

The first author is a female occupational therapist with a bachelor’s degree in occupational therapy who was completing a masters research degree at the time of this study. With over 20 years of experience working in hospital settings, she held beliefs about the value of using performance-based tests in occupational therapy. The second and third authors are professors of occupational therapy working in academic positions with clinical backgrounds and established research portfolios in neurorehabilitation.

3. Results

Fifteen occupational therapists (14 female, 1 male, age range 27–53 years) from around Australia completed interviews. Their average years of experience working as an occupational therapist was 16.5 years (range 6–29 years). Nine were currently working in acute care and six in rehabilitation but had experience working in acute TBI assessment and rehabilitation. Fourteen participants worked in hospital settings and one was in community rehabilitation at the time of interview. Of those in hospital settings, 13 worked in public state government funded hospital settings and one in a private hospital. Most interviewees currently worked in metropolitan settings, which is representative of where the majority of patients with TBI receive acute hospital care in the Australian context. Due to the nature of mixed diagnosis acute care wards, participants’ caseloads included a variable mixture of patients with neurological and non-neurological conditions. The final sample size was determined primarily by thematic saturation [41], as determined by the research team. A second pragmatic consideration was that interviews occurred during COVID-19, with added burdens acknowledged to frontline healthcare staff, possibly impacting the rate of volunteering for interview participation.

Findings were represented by four major themes derived from the data. The first theme, ‘functional observation of occupational performance’, related to the methods of assessment chosen by therapists. The second theme highlighted that interviewees structured and tailored the assessment processes used in order to be ‘individualised and efficient.’ The third theme related to contextual influences on assessments chosen and the contribution of professional knowledge, clinical skills, and practical experience influencing cognitive assessment choices, specifically the ‘occupational therapy department culture and hospital context’. The fourth theme, ‘risk and safety management’, included physical safety risks to patients when completing assessments in addition to risk management at the organisational level. Each theme has a number of sub-themes, as shown in

Table 2. Themes and sub-themes.

Themes and Sub-Themes	Definition
Theme 1: Functional observation of occupational performance	Methods of cognitive assessment chosen by occupational therapists in acute care
1.1 Reasons for choice of assessment	Explanations about choice of pen-and-paper/kit-based assessments or performance-based assessments and observations
1.2 Observations of functional tasks	Descriptions of the types of tasks used in observations of occupational performance
1.3 Environmental constraints	Influence of acute care setting on choice of assessment, e.g., space and facilities available
1.4 Modifications to assessment	Adaptation to standardised assessments to suit administration in acute care
Theme 2: Individualised and efficient assessment	Ways of structuring the assessment process to be efficient while also tailoring assessments to meet individual patient needs
2.1 Purpose of assessment	Understanding the person and the cognitive demands of their occupations to inform cognitive assessment
2.2 Real-life approximations	The use of individualised assessment tasks which simulate tasks relevant to the person’s life and with similar levels of support
2.3 Maximising efficiency	Choice or modification of assessments to maximise efficiency within the time constraints of the acute care setting, including interweaving treatment with assessment.
Theme 3: Occupational therapy departments and hospital context	Contextual influences on assessments chosen and the contribution of professional knowledge, clinical skills, and practical experience influencing cognitive assessment choices
3.1 Supportive ‘whole of department’ approach	Influence of a culture of occupation-based practice including use of occupation-based language and occupational therapy practice models as a facilitator of use of performance-based assessments
3.2 Hospital policies and procedures	Constraints to performance-based assessment of cognition arising from hospital pressure to discharge, caseload demands, time pressure, or access to appropriate spaces and facilities
Theme 4: Risk and safety management	Consideration of physical safety risks to patients when completing assessments and risk management at the organisational level
4.1 Patient safety	Concerns about acute care patients being injured or exacerbation of symptoms when engaging in functional tasks on or off the ward as part of a functional cognitive assessment
4.2 Risk management	The need for cognitive assessments to inform discharge planning by assessing the level of risk to patients on returning home

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Theme 1. Functional Observation of Occupational Performance. Most interviewees reported that their assessment commenced with an initial interview with the patient, the ward nurses, and caregivers. Following these interviews, assessment practices diverge to either include observation of occupational performance or not. Assessment without observing occupation reportedly included a range of pencil-and-paper tests, kit-based assessments of specific cognitive domains, and standardised scales where appropriate, such as post-traumatic amnesia (PTA) scales. Many interviewees reported choosing pencil-and paper screening tests or kit-based assessments as they were perceived as quick to administer and could be completed at the bedside. Some used these as screening tests then proceeded to further assessment if warranted. Their choice of kit-based assessments also reflected preferred local practice and assessment availability in their hospital: ‘I use the CAM [Cognitive Assessment of Minnesota], or the Rivermead [Rivermead Behavioural Memory Test], or sometimes the BADS [Behavioural Assessment of Dysexecutive Functioning]—because that is what we have’ (P7). Although the assessment tools and methods chosen varied widely, almost all interviewees stated that they used functional observation of occupational tasks, but to varying degrees, while in acute care.

Most interviewees described the observation of occupational performance as generally involving observing a patient completing an everyday task within the hospital environment in a non-standardised way without using a published assessment. A range of tasks were reported as commonly observed by therapists, including grooming activities, making a basic meal, or ordering a coffee from a shop within the hospital grounds. The tasks were chosen based on convenience and relevance to the patient at that time. As one therapist described, ‘Well if they needed to buy a card because they wanted to give it to their wife because it was their birthday, we’d go to the hospital newsagency’ (P1). Some tasks were pre-planned by the occupational therapists, but others were described as being opportunistic, capturing real-life situations as they occurred on the ward and documenting interpretation of these observations. For example, ‘You’ve got all these things to organise for your Christmas shopping… can you show me’ (P9). Similarly, therapists used objects at the bedside to observe a patient’s performance and interpret cognitive function from that observation: ‘People are sitting on their phones, texting their family… That’s an observation that you can add into your assessment’ (P11). Using items easily obtained in the hospital context at the patient’s bedside was raised as a possible concern by several interviewees. They felt that this non-standardised observation of occupational performance could be biased as the interpretation was subjective and depended on the skills of the therapist in choosing an appropriately challenging activity and analysing performance. As one participant commented, ‘The whole grooming task’s really useful, but sometimes it’s not going to show you anything as it’s too easy’ (P8). This raised the importance of choosing tasks that were appropriately challenging but also able to be completed within the acute care environment.

The acute care setting environment influenced the type of assessment that was possible, with some interviewees indicating that their ability to arrange opportunities to observe relevant or appropriately challenging occupational tasks was restricted; for example, ‘A kitchen based assessment on the ward is very, very difficult… we don’t have that environment or space’ (P3). However, some interviewees indicated that they had overcome environmental constraints, with one therapist reporting, ‘I’d do a kitchen assessment, in an informal kitchen set up’ (P5), or ‘The kitchen was further away from the ward… so [I] use the kitchenette’ (P14). These therapists conveyed that they believed assessing cognitive function via observation of occupational performance was important, and so they devised different ways to achieve this aim. However, practical suitability for the acute setting was reported as a barrier to using available performance-based tests due to their need for specific spaces and equipment; for example, ‘In terms of executive function tasks and the Multiple Errands Test, I just don’t think the existing one is really sustainable and useful for an acute care setting… it involves taking someone downstairs (P12)’. Non-standardised approaches and modifications to existing performance-based tests relied on the therapist’s clinical experience in selecting appropriate tasks and interpreting results with more experienced therapists reporting adapting assessments to suit the acute setting.

Another barrier to conducting performance-based tests in the acute setting was related to patient factors in the early post-injury phase such as agitation. Some therapists indicated that their assessment practice was to limit performance-based test use in response to safety concerns: ‘If they’re really aggressive and agitated… I don’t want to do risky things like take them to make a cup of tea’ (P9).

Theme 2. Individualised and Efficient Assessment. This theme reflects the tension between designing an individualised assessment tailored to the cognitive demands of patient’s occupational profile, which requires more planning and time, and completing cognitive assessment in an efficient and timely manner given the constraints of the acute environment. Ways that they achieved efficiency while maintaining a degree of individualisation including combining assessment and intervention within the one therapy session in an interwoven manner and modifying existing assessments to be shorter or more specific to the patient’s needs.

A dominant issue raised by interviewees that their decision-making for assessment involved having a clearly defined purpose for the cognitive assessment itself, based on individual patient-specific factors. For example, the complexity of tasks they chose depended on the patient’s pre-morbid presentation and occupational profile: ‘if I’ve got somebody who is a high-flying executive, I would be doing a much higher level task’ (P1). Or ‘If they were 85 and had some memory problems before, then my perspective would be really different, then you’re starting to think about safety and discharge’ (P15). Determining the individualised purpose for assessment was seen as an important first step to ensure they conducted the type of assessment that would allow them to recommend whether the patient could return home, or return to work, or if they required rehabilitation. ‘In return to home and bigger-level life tasks which also includes work and driving, managing one’s life,… [I] need to be aware of doing enough [assessment] to provide some input into that decision making’ (P1).

Some interviewees stated that they preferred to use assessments that were individualised to closely approximate ‘real-life’ situations, for example to enable patients to use supports similar to those they had previously used in the community or having family members present if they will be regularly assisting with more complex tasks on discharge. In doing so, they minimised irrelevant or unnecessary assessments and assessed only those issues that directly impacted on the patient’s individual situation and ability to return home. One therapist commented that the aim was to simulate real-life situations as closely as possible, stating ‘assessments should take into account and involve those care supports and whatever level of scaffolding that a person might previously have had’ (P13). Some interviewees discussed hesitancy using standardised assessments as they had limited capacity to be individualised, such as allowing prompts for patients or accommodating input from caregivers, as occurs in real-life. ‘As soon as someone asks or talks, they lose marks, I think, that’s not right’ (P8). The flexibility of assessments in order to individualise them to suit a patient’s real-life situation was highly regarded by the majority of interviewees. In contrast, some felt that kit-based tests or performance-based tests were difficult to keep updated and contained prescribed tasks that were not always relevant to the patient’s situation. For example, some kit-based tests contain cheque books to assess financial management: ‘I don’t like the cheque book idea… really out of date’ (P8).

With regards to efficiency, speed of administration was the reason some therapists chose pen-and-paper or kit-based assessments. Most interviewees described how limited time to complete assessments often led to choosing a shorter assessment of cognitive function, such as a pencil-and-paper test, although longer assessments may have been clinically indicated. ‘I think it’s the time… I’ve got maximum 45 min [to assess and complete documentation for a patient]’ (P14). However, others described ways to use performance-based tests efficiently. Therapists with more clinical experience commonly referred to using an individualised approach where assessment and rehabilitation strategies were intentionally interwoven within one session. These therapists commonly reported combining an initial interview and observation with trialling rehabilitation strategies all in one session, increasing time efficiency from initial interview to commencing early rehabilitation in acute care. As one therapist commented, ‘I will do a standardised assessment, but I’ll do a functional first… treatment mixed with assessment to be more time efficient’ (P14). As a benefit of this approach, interviewees reported that patients were often unaware that they were being formally assessed, for example (P10).

A few interviewees reported modifying standardised performance-based tests so that they could use the underlying principles but complete an assessment within the time and environmental limitations of acute care. Modified versions of the Multiple Errands Test [28] to save time were mentioned by different therapists. One therapist described ‘I use ‘my’ “modified Multiple Errands Test”… so, taking them down to the cafeteria area of the hospital, setting them a few tasks to do’ (P4). Or ‘Go to the newsagent… I want you to find me a fishing magazine’ (P15).

Theme 3. Occupational Therapy Department Culture and Hospital Context. In this theme, some interviewees described the importance of a supportive culture within the occupational therapy department to form a consistent department-wide approach to the assessment of cognition and support therapists to align assessment practices with occupation-based principles. Having a ‘whole of department’ approach commenced with consistent terminology: ‘If we’re universally as a team using [the term] functional cognition it makes us credible… we’re experts in this [functional cognition] and we’re using this language’ (P6). Another interviewee stated ‘We’re trying to badge ourselves as being [functional]… our expertise, our scope is to look at functional cognition’ (P1). Throughout the interviews, interviewees rarely used the term performance-based tests until after it was described. Similarly, few used the term functional cognition until prompted by interview questions. However most agreed that a focus on the use of ‘occupational performance’ and ‘functional cognition’ language provides a supportive environment promoting practice change and use of performance-based tests. ‘We’ve had a real focus on integrating occupational language into our work… at the end of the day our core business is occupational performance’ (P2). Interviewees from occupational therapy departments where performance-based tests were integrated into practice stated that department managers active in strategic planning were successful in sustaining practice change. As one of these interviewees commented, ‘Functional cognition’s been on the OT business plan for quite a while’ (P1).

Similarly, these interviewees reported that clear direction and structure from leaders of the occupational therapy department facilitated clarity for them in terms of their role and scope regarding cognitive assessment within the multidisciplinary team. The importance of the occupational therapist using their profession-specific knowledge to actively choose how to assess was emphasised. This was described by one of the more senior participating therapists as ‘We have worked to give the OTs some phrases and some concepts to use… to present a united front to describe a functional cognition approach where the OT will decide whether a [functional cognitive] assessment is indicated and the OT will choose which assessment’s most appropriate for the client’ (P2).

Profession-specific occupational therapy knowledge, such as knowledge of models and frameworks and the use of goal-setting, were described by some as shaping their cognitive assessment. ‘They’re the foundations, without them, nothing happens… whatever assessments I use it’s with a goal or purpose and it’s on a particular framework’ (P14). One interviewee shared the importance of an overarching frame of reference to base assessment on, ‘I think a frame of reference is more beneficial than discrete assessment tools’ (P15), preferring the flexibility of having a profession-specific approach that aligned with professional identity when assessing functional cognition rather than being limited to using individual performance-based tests consisting of prescribed sub-tasks. Regarding the impact of occupational therapy theoretical models on practice, often adopted at a department level, multiple interviewees referred to the Person Environment Occupation (PEO) model and applied this when assessing functional cognition [42]. In relation to performance-based tests, interviewees reported knowledge of more commonly known tests such as the Multiple Errands Test [26].

The hospital policies and procedures were also seen as influencing assessment choice as therapists needed to work within parameters such as the acute care length of stay and any defined care pathways for TBI patients. The short length of stay for patients with TBI in acute care was described as a major issue; for example, ‘Time is of the essence and some assessments do take time… we have a short timeline in order to be able to assess and make a decision about a patient… meanwhile “we want discharge” due to hospital bed pressures’ (P11) and ‘Time [with patients] is always a problem in acute care, what are you going to pick to use’ (P1). A small number of interviewees referred to using short standardised tests, such as the Kettle Test [42], in response to both safety concerns and time constraints in acute care.

Interviewees expressed concern regarding a lack of appropriate spaces and resources for the observation of patients’ occupational performance. However, some described that the hospital had recognised this need and allocated appropriate facilities to the occupational therapy department. Therapists who had worked in purpose-built facilities with dedicated ADL assessment spaces (such as full ADL assessment kitchens) reported that this positively influenced assessment choice: ‘When neurosciences unit came to be… [with a full kitchen and a laundry], the number of kitchen assessments skyrocketed’ (P10).

Theme 4. Risk and Safety Management. A core issue in the decision-making process for the majority of interviewees was the need to monitor and manage safety risks for the patient and the therapist throughout the process of cognitive assessment. This related to two different aspects of safety—managing the patient’s safety while performing cognitive assessment at the hospital and ensuring that the chosen cognitive assessment was robust enough to identify any risks associated with the patient returning home.

A small number of interviewees felt that safety issues needlessly dominated decision-making processes in the hospital and this could at times adversely influence assessment choice. ‘Everything in hospital is about discharge and being safe, hospital organisations are inherently risk averse’ (P8). When safety issues dominated, the interviewees felt that their ability to apply suitably challenging instrumental ADL tasks which required, for example, a kitchen or leaving the ward to access hospital shops, was limited. Potential safety concerns with moving medically unstable acute patients off the ward was raised by multiple interviewees. For example, ‘That physical barrier of having to move the patient, for particularly a more inexperienced therapist, taking them off that safe ward environment’ (P13).

Managing the risk and safety of patients prior to discharge from acute care was complicated by the need to offer sufficiently challenging and appropriate tasks in order to assess their occupational performance in context and evaluate their functional cognition. Interviewees with more years of clinical experience reported greater confidence in managing the safety issues when taking the patient off the ward and assessing risk during activities. Experienced therapists also described assessing the risks of the patients’ cognitive status in relation to discharge as their responsibility: ‘My job as an OT is to see if somebody is safe and independent enough to go home and return to their usual activities’ (P10). Similarly, a key purpose for completing assessments was described as gathering enough information to estimate a patient’s functional cognition.

4. Discussion

In response to the first research question, ‘what are the perceived influences on choice of cognitive assessment in acute care’, this study found that choice of assessment was shaped by a detailed understanding of multiple individual patient factors and the interplay of those factors. An individualised yet non-standardised approach to assessment emerged and was commonly used, with therapists tending to rely on functional observation of occupational performance. Some interviewees were hesitant to use standardised performance-based tests as they felt the prescribed subtasks limited their ability to individualise assessment to suit specific patient needs. When they did use standardised assessments, they preferred those that could be individualised by choosing tasks that suit the individual, for example the PRPP [28] or the AMPS [27]. However, the costs for training in these assessments and the time required to administer them may prohibit widespread use in acute care. Key performance indicators such as length of hospital stay which reduce the amount of time available for patient assessment [29] may underpin the sub-theme of ‘maximising efficiency’. Therefore, the lack time available to occupational therapists was a key influence on choice of cognitive assessment.

Many interviewees reported they were unable to find suitable standardised performance-based tests to meet the needs of their patients and the acute hospital system. Some described modifying standardised assessments, sometimes with support from the assessment authors, to reduce their length or adapt the nature of activities so they could be conducted in the patient’s room or the acute ward environment. In addition to modifying performance-based tests, some used tests designed for other populations without TBI, despite having no published data. This has been referred to as using ‘off-label’ assessments and, although observation may still be clinically useful, the modification of assessments makes collected data invalid [11]. This points to the need for the development and standardisation of modified versions of performance-based tests of functional cognition that can be easily and efficiently applied at the bedside or in acute care settings.

For some therapists, assessment choice was heavily influenced by what was available to them. For example, where use of kit-based assessments was the dominant practice in the occupational therapy department, therapists were more inclined to them. This was similar to findings from a previous study that described how pragmatic factors impacted assessment choice, such as what assessments are readily available or what their co-workers chose [35]. Other therapists had hospitals with purpose-built ADL therapy spaces which made completion of performance-based tests easier. Some therapists also described how a supportive department culture focussed on an occupation-centred practice provided a common framework for assessing cognition, with therapists choosing to use performance-based tests in preference to pencil-and-paper based tests. The culture of the occupational therapy department can be an important factor in defining the occupational therapy role and assessment choice in assessing functional cognition [20] via a ‘whole of department’ approach. Some therapists had hospitals with purpose-built ADL therapy spaces which made completion of performance-based tests easier. Although individual patient factors largely determined which assessments were initially identified as suitable, the results suggest that the hospital context and occupational therapy department culture determined the final assessments chosen.

How patient risks are managed by hospitals and occupational therapy departments also influenced assessment choices, as they determined the risks therapists were prepared to take when assessing cognitive function in acute care. Therapists were constantly assessing risk when working with patients with TBI yet balancing this with the need to offer performance-based tests with sufficient complexity and cognitive demands while also taking into account the patient’s current cognitive and medical status. Findings from this study suggest that occupational therapy department policies and procedures relating to risk management play a pivotal role in practice decisions in acute care settings.

The second research question was ‘how do occupational therapists incorporate observation of occupational performance into assessment of cognitive function in acute care’. An overarching thread running through the themes was that the short length of stay in acute care [29] made it difficult to focus on occupational performance and observe suitably cognitively demanding tasks. Additionally, therapists described the challenges of balancing the needs of the patients with the acute care hospital context constraints, where patients may not be able to leave the ward environment, leading to increased use of observation of occupational tasks on the ward. They stated they used non-standardised observation of occupational tasks, for example by using items in a patient’s immediate surroundings, interpreting occupational performance using their core occupational therapy skills in activity analysis. This highlights how observational assessments by occupational therapists, which are often conducted opportunistically using activities relevant to hospital patients (such as making a phone call), may provide valuable insights into functional cognition to inform clinical decisions. In a time-constrained environment, information gained from the observation of occupational tasks may complement or even reduce the need for pen-and-paper or kit-based assessments of cognition.

A further challenge faced by therapists working in acute care TBI when using observational assessments was the risk of missing cognitive impairments when providing tasks that were too easy for the patient [44]. Missing impairments may lead to incorrect interpretation of a patient’s performance and adverse outcomes for patient care if a rehabilitation plan was formed on inaccurate information. The extent to which therapists include occupational performance in their assessment in acute care remains directed by the individual therapist and their determination to integrate evidence-based assessment from the many approaches and assessment methods available to them [36,37]. Therapists working in a supportive occupational therapy department culture stated having a common ‘whole of department’ approach supported integration of performance-based tests and occupational performance to a greater degree.

In response to the third research question, ‘what are occupational therapists’ perceptions of using performance-based testing in acute care’, few interviewees mentioned the term performance-based tests unprompted. However, the majority supported use of occupational performance as a means to assess functional cognition once the concept was raised. A large number of interviewees stated that limited access to performance-based tests was the main barrier to using standardised tests in their workplace, similar to the results of the survey of Australian occupational therapists [12]. However, some studies have shown that occupational therapists may overcome challenges such as limited access to assessment resources [36] with support from research evidence and by advocating for the spaces, training, and resources they require.

Interviewees’ preferences for terms such as ‘function’ and ‘functional assessment’ as opposed to the term performance-based tests may reflect the fact that functional cognition and performance-based tests are still emerging terms in Australian occupational therapy practice. Intentional use of functional cognition terminology by occupational therapists is important to increase clarity, consistency, and repeatability between therapists as well as promote occupational therapists’ specialist skills in this area of practice [20,45]. In acute care, intentional use of ‘occupation’ and ‘occupational performance’ terminology may assist therapists to further define occupational therapy’s role and scope [46].

This study raises some implications for clinical practice. An interesting finding was the extent to which therapists relied on the assessments that were readily available in their workplace. Easy access to assessments and ease of implementation into practice are known to be important factors influencing assessment choice [22,35]. Even in cases where their use of terminology related to functional cognition and their access to formal performance-based tests in the workplace was limited, most therapists in this study placed emphasis on including occupational performance in assessment of patients with TBI. This suggests a readiness and clinical need for occupational therapists in acute to have access to more formal training on the assessment of functional cognition and the use of performance-based tests in this context. Further implementation research on how best to provide training to this group of clinicians and increase knowledge and skills in functional cognitive assessment is needed.

Occupational therapists working in acute care highlighted that cognitive assessment of people with TBI is highly individualised and the choice of assessment requires complex clinical reasoning. Decision-making in other areas of clinical practice with high levels of complexity such as upper limb rehabilitation [47,48] have benefited from formal decision-making aids. Decision-making aids allow for patterns to be identified by the user, patient characteristics to be categorised, and, through focussing on a number of decision points, likely outcomes to be predicted [48]. Decision-making aids have been developed for choosing general cognitive assessments and include an inventory of assessments, clinical reasoning algorithms, and guidelines for choosing between assessment alternatives [49]. Considering the complexity of patients with TBI, decision-making aids specifically focussing on the assessment of functional cognition may support therapists with varied levels of experience to understand and choose between the assessments available to them in an evidence-based way [48].

Another interesting finding was that experienced therapists in this study emphasised how they commenced intervention alongside the assessment of cognitive function in acute care. Newer models of care in use internationally [50] challenge the existing model in which acute care and rehabilitation are separate entities and patients have separate admissions to each stage, often in different buildings. There is evidence that, in addition to economic cost savings [45], early and continuous rehabilitation following TBI leads to improvements in patients’ functional outcomes, especially when rehabilitation is commenced as soon as possible, even in acute care [50]. The results suggest that occupational therapists use a range of approaches to understand the impact of a patient’s functional cognitive status on their occupational performance and simultaneously use this information to commence intervention in the acute stages after TBI. However, time and resource constraints present barriers to this practice, which need to be addressed to facilitate earlier more comprehensive cognitive assessment and rehabilitation.

5. Limitations

There are some limitations to this study. Data collection occurred in 2020–2021 and interview participation rates were likely impacted by COVID-19, with disproportionate effects on the southern states of Australia, which were more impacted by lockdowns at this time. Interviewees initially volunteered to complete the survey and this may have biased the sample to those with a specific interest in TBI rehabilitation and cognitive assessments. Due to the nature of occupational therapy practice and acute care caseloads, it was not possible to determine an average number of years that participants had spent working in acute care TBI exclusive of other diagnostic groups.

Questions used in the interview were from a semi-structured interview guide. The way some questions were formulated, such as ‘can you think of times you have assessed functional cognition’, or ‘how do you think performance-based tests could be implemented in acute care’, could be seen as statements biased in support of use of performance-based testing. The first author is a clinical occupational therapist currently working in a rehabilitation hospital setting with prior experience and beliefs about the value of occupational therapists using performance-based tests, and therefore they reflected on the potential bias and influence this may have had throughout data collection and analysis. To increase credibility, the second author, who has extensive qualitative research experience, analysed parts of the data independently and all members of the research team were involved in reviewing qualitative data codes, forming categories, and forming coding frameworks and subsequent themes from the data.

Although transcripts from the interviews were reviewed for accuracy by all interview interviewees within two weeks, data analysis may have been strengthened further by sharing preliminary themes from the interviews with interviewees for feedback. This study focused solely on clinician perceptions; however, investigation of patient and caregiver perspectives would have added valuable information both at the study design and data analysis stages.

6. Conclusions

The results of this study provide some insights regarding decision-making about the choice of cognitive assessments based on qualitative interviews with 15 Australian occupational therapists with experience in assessing patients with TBI in acute care. Individual therapists approached decision-making about assessment in many different ways; however, they most commonly chose informal non-standardised observation of occupational performance. Some therapists chose to modify existing assessments, shortening them for use in acute care, where time is limited, yet retaining the underlying concepts of performance-based tests. Having a clear purpose for assessment provided a reference point for choosing individualised assessments for each patient and ensured assessments incorporated occupational performance whilst managing any risks to patient safety. Being a highly complex area of clinical practice that requires assessment choice to be individualised, the assessment of functional cognition following TBI may benefit from decision-making aids to support clinical reasoning. Further research is required to understand the best methods to support the implementation of performance-based tests, investigate barriers for their use, and increase use of evidence-based assessment practice.

7. Significance

Occupational therapy cognitive assessment within the acute care hospital context predicts real-life implications of cognitive impairments for patients with TBI. The assessment of functional cognition in acute care remains influenced by largely pragmatic factors, including the hospital context, some of which may be modifiable by occupational therapists striving to complete evidence-based assessments. Therapists reported using short versions of performance-based tests, limiting the information gained as this approach lacks validity. Modifying tests may be a response to a lack of suitable performance-based tests with clinical applicability for acute care. The foundations for facilitating change include a planned occupational therapy department-wide approach to support uptake of existing evidence-based assessments of functional cognition.