Action is defined as ‘the exertion of drive, or mental and physical effort which results in the creation of a tangible or intangible product’ (du Toit 2009, p. 43). Like motivation, action can also be organised into levels. These levels describe the sequential differences in the nature and quality of the individual’s engagement in activities that is described in terms of ability to form relational contact with others, events, materials and objects in the environment, as well as the characteristics of engagement (see Table 1.1).

During the course of both the levels of motivation and action, the individual accomplishes a wide range of skills and occupational behaviours. It is important therefore to be able to distinguish where the patient is at within a particular level, namely, the beginning, the middle or moving towards the next level. The following phases are used to describe this and can be applied at each level of both motivation and action:

• Therapist-directed phase indicates that the individual is demonstrating skills and occupational behaviour characteristics of both the previous and current levels. However, without support, structure and encouragement, he is not able to maintain the functioning characteristic of this current level, and occupational behaviour will easily regress to that of an earlier level. Thus, the patient needs the support of the therapist to produce the occupational behaviour consistent with the beginning of the current level.
• Patient-directed phase indicates that the individual’s occupational behaviour is generally characteristic of the requirements of that level. He can maintain this occupational behaviour relatively independently provided the context is supportive.
• Transitional phase indicates that the individual is demonstrating occupational behaviour consistent with the current level but is able to demonstrate some occupational behaviour and characteristics of the next level under optimal conditions.

Assessing the level of creative ability and recording the levels of creative ability

The determining of a patient’s level of creative ability does not require a special assessment. The patient’s level of creative ability can be determined from any comprehensive occupational therapy assessment but involves three sequential steps which relate to the clinical reasoning or interpretation of the assessment information.

Step 1: Evaluation of occupational skills and behaviour. This should be included in the client’s initial and comprehensive assessment prior to commencement of treatment. It should also be part of the ongoing monitoring of his condition, so that the developmental momentum of creative ability can be maintained in all facets of intervention.

The assessment of the patient’s current level of creative ability should be based on observation and clinical evaluation of his occupational skills and behaviour in as wide a variety of situations as possible. This assessment should not be based on what the patient’s reports he can do, but on a practical evaluation of his current behaviour and skill in all areas of OP. While the patient’s occupational history is pertinent in trying to establish treatment outcomes and goals, it is what the patient is currently able to do that is relevant in this assessment. This can only be achieved by involving the patient in an activity to determine his current OP. The nature of his engagement and the quality of performance will determine his level of action. In consultation with the patient, and considering his interests and aptitudes, the occupational therapist will select an activity which has purpose, relevance and meaning to the patient but also has the opportunity to elicit satisfactory assessment information. The activity should preferably be unfamiliar yet within his frame of reference so that the occupational therapist is not accessing a habituated skill or routine. The activity should create a challenge for the patient so that he has to think and process the activity, but it should be able to be completed within approximately 45 minutes. It should have a concrete end product and encourage active participation to facilitate the task concept assessment.

Understanding the level of creative ability is facilitated by taking careful note of the following:

• The patient’s attitude and ability to make relational contact with materials, objects, people and events in the environment
• His ability to plan, initiate and sustain effort until the activity is complete or to continue at the same level of performance over time if the activity or task is repetitive
• His quality of performance and the ability to evaluate what has been done and the standard set for himself
• The ability to do activities with or without supervision, the amount of environmental structure required for adequate participation and the ability to read cues and meet norms that are both overt and covert
• The ability to control anxiety when faced with obstacles and new challenges
• The ability to act with originality, to solve problems and to act on decisions made
• Finally, the response to engagement and emotional response to performance and the end product (See Table 1.2.)

Step 2: Establishing the level of action. As each level of action defines the occupational skills and behaviour characteristics of that level, it is possible to categorise the patient’s behaviour and skill in the OPAs according to the levels of action. Using the information gathered about the patient’s occupational skills and behaviour, analyse his level of action in each OPA. Make a cross in the grid in the appropriate column, positioning it to indicate the phase of the action. If there are marked variations, review the assessment data to ensure that it represents the patient’s overall pattern of OP, rather than his habituated skills.

This is most commonly done on a grid system, such as the one in Table 1.3.

Where the level of action is clustered in all OPAs, determining the overall level of action is straightforward, as the example in Table 1.3. Table 1.3 shows that the client’s occupational skills and behaviours are on a level of constructive exploration in all OPAs but in the patient-directed phase in three areas (social, work and free time). In one OPA (personal management), the phase has been rated as being transitional. This indicates that although occupational behaviour and skills are all characteristic of the constructive explorative level, there are some skills and behaviours that are associated with the norm awareness experimental level of action under optimal circumstances. Thus, using the principle of majority rules, the patient’s overall level of action is constructive explorative patient-directed phase.

Table 1.4 indicates that although all OPAs are within the norm awareness experimental level, personal management and social ability fall within the patient-directed phase, while work and leisure fall within the therapist-directed phase. When there are two OPAs in one phase and two in another, the following principles can be applied: social ability has the most impact on OP, followed by work ability. Since the social OPA has a governing influence, the overall level of action would be constructive explorative patient directed.

Where there is variation in the patient’s level of action in the four OPAs, determining the level of action is more complicated. Table 1.5 indicates a variation in the level of occupational skills and behaviours in four OPAs: the social ability is constructive exploration on the patient-directed phase; in both the work and constructive use of free time areas, skills are characteristic of the norm awareness experimental action level, but in the work area, there are a few indications of skill and behaviours of the imitative norm-compliant level (transitional phase); in the personal management area, although skill and behaviour are predominantly imitative norm-compliant in nature, some norm awareness experimental behaviour is still evident (therapist directed).

Thus, the client’s overall level of action is norm awareness experimental – fluctuating between therapist-directed and transitional phases. Clustering usually occurs within the level or across two levels, so the example in Table 1.5 would be unusual. As stated earlier, when marked variations occur, the occupational therapist should review the assessment data to ensure that the current OP has been assessed correctly, at the same time taking note of habituated skills.

Variations in the level of action between the different OPAs must always be accounted for in planning the programme as the levels of action are used when planning treatment by using the action grid. The occupational therapist therefore mixes and matches the principles and guidelines of treatment so that they fit the patient’s needs and reflect the variation in the action grid.

Step 3: Establishing the level of motivation. As motivation is difficult to observe and measure directly, the occupational therapist must presume the patient’s level of motivation from the quality and nature of his observable occupational skills and behaviour. It has already been discussed that there is a stable relationship between the levels of motivation and the levels of action (see Table 1.1). Using the data recorded on the level of action grid completed in Step 2, a presumption can be made about the patient’s level of motivation.

Additional recording tools have been developed to record outcomes in regard to the level of activity participation and functioning. These tools are the Activity Participation Outcome Measure (APOM) (Casteleijn 2010) and the Functional Levels Outcome Measure (FLOM) (Zietsman 2011) and complement the VdTMoCA. The APOM and FLOM are used to indicate the baseline functioning before intervention commences. Measurements are taken again during or after intervention to track and record change in activity participation or functioning in the client (see Chapter 10 by Zietsman and Casteleijn).

Description of the levels

Group 1

Tone

Motivation on this level is directed at establishing and maintaining the will to live, which du Toit (1980) called ‘positive tone’. This includes the biological tone, which is the starting point for development of all human systems that are required to enable OP.

Purposeless and unplanned action

Action on this level is purposeless and unplanned and patients have no OP skills. They are defenceless, dependent and incapable of caring for themselves. They have to be protected, cared for and nurtured. They lack awareness of themselves and their bodies as being separate from the world around them. Their ‘actions’ are mainly automatic, appear purposeless and are not goal directed, but these actions contribute to the development of the internal human systems so as to achieve ‘biological tone’.

These patients are unable to care for, provide for, or defend themselves in any way. They have very little or no control over their bodies and bodily functions. They need to be washed, dressed, toileted, fed, cared for and protected. They have little awareness of others. They attempt to communicate their basic needs of discomfort, hunger or thirst, but this is non-specific, for example, they may grunt or shout, but this seldom identifies the problem or the extent of their distress. Language is frequently absent or, if present, is often only monosyllabic and is mostly incoherent. They usually respond positively to nurturing and are usually able to recognise daily caregivers. They appear to be unable to identify different situations, other than a momentary awareness of strangeness or familiarity, but are distressed by changes in routine and daily patterns.

These patients are totally non-productive in an occupational sense and have no concept of ‘doing’. There is little evidence of intention or effort. They can focus their attention momentarily on stimuli. Their physical movements are uncoordinated, often reflexive and haphazard. They are unable to demonstrate any constructive occupational behaviour. They have no concept of free time.

Patients with psychiatric illness, who regress to this level, are usually severely disordered. They are disorientated and severely impaired in all the psychosocial client factors and performance skills, which incapacitate them.

The treatment outcomes on the purposeless and unplanned level of action are:

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