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. Author manuscript; available in PMC: 2014 Oct 6.
Published in final edited form as: Br J Occup Ther. 2014 Feb;77(2):59–63. doi: 10.4276/030802214X13916969447038

Evaluating capacity to live independently and safely in the community: Performance Assessment of Self-care Skills

Denise Chisholm 1, Pamela Toto 2, Ketki Raina 3, Margo Holm 4, Joan Rogers 5
PMCID: PMC4186770  NIHMSID: NIHMS561899  PMID: 25298616

Abstract

To determine clients’ capacity for community living, occupational therapists must use measures that capture the person–task–environment transaction and compare clients’ task performance to a performance standard. The Performance Assessment of Self-care Skills, a performance-based, criterion-referenced, observational tool, fulfills this purpose. In this practice analysis, using data from this tool from multiple clinical studies (N = 941), the authors describe tasks that clients from various diagnostic populations could and could not perform independently and safely. For clinicians, the Performance Assessment of Self-care Skills can be used to identify which daily tasks are compromised and the point of task breakdown, as well as to provide guidance about potential interventions.

Keywords: Occupational performance, activities of daily living, evaluation

Statement of context

Problems that limit occupational performance — that is, the ability to desire, plan and carry out roles, routines, and daily life tasks — may result in disability that limits participation in community life. The ability to perform daily occupations inclusive of basic activities of daily living (BADL) and instrumental activities of daily living (IADL) is a critical indicator of an individual’s capacity to live independently and safely in the community (Rogers et al 2001). Although there is no consensus among therapists and researchers about which tasks are required for independent community living, the list commonly includes functional mobility (for example, stair use), BADL (for example, dressing), and IADL (for example, shopping). Occupational therapists make unique contributions to the healthcare team’s decision-making process by identifying factors that support or hinder task performance requisite for community living. To determine if an individual is able to live independently and safely, evaluations must capture the person–task–environment transaction (Mallinson and Hammel 2010). The Performance Assessment of Self-care Skills (PASS, Rogers and Holm 1989) is a client-centred, performance-based, criterion-referenced, observational tool that assists occupational therapists to document occupational performance objectively and plan occupation-based interventions (Holm and Rogers 2008). It consists of 26 core tasks, categorized in four domains: five functional mobility (FM), three BADL, four IADL with a physical emphasis (IADL-P), and 14 IADL with a cognitive emphasis (IADL-C) (see Table 1). This paper explores the utility of the PASS in practice.

Table 1.

Performance Assessment of Self-care Skills (PASS) tasks

Functional mobility (FM)
  • ■

    Bed transfer (move from prone to supine position and rise from bed)

  • ■

    Stair use (ascend and descend stairs)

  • ■

    Toilet transfer (sit and rise from a toilet)

  • ■

    Bathtub/shower transfer (enter and exit bathtub and/or shower)

  • ■

    Indoor walking (walk indoors)

Basic activities of daily living (BADL)
  • ■

    Oral hygiene (clean teeth, dentures, and/or mouth)

  • ■

    Trim toenails (groom toenails)

  • ■

    Dress (don and doff upper body and lower body clothing)

Instrumental activities of daily living — physical (IADL-P)
  • ■

    Bend, lift, and carry garbage (lift and carry garbage sack)

  • ■

    Change bed linen

  • ■

    Sweep (clean spillage on the floor using a broom and a dust pan)

  • ■

    Clean up after meal preparation (perform clean-up tasks after meal preparation)

Instrumental activities of daily living — cognitive (IADL-C)
  • ■

    Shop (select and purchase grocery items)

  • ■

    Pay bills by cheque

  • ■

    Balance cheque book (balance a cheque book after writing cheques)

  • ■

    Mails bills and cheques (prepare envelopes for mailing cheques)

  • ■

    Telephone use (use telephone to obtain information)

  • ■

    Medication management (read medication information and organize medication according to prescription)

  • ■

    Obtain information: auditory (obtain information from a radio announcement)

  • ■

    Obtain information: visual (obtain information from a newspaper)

  • ■

    Small repairs (repair a flashlight)

  • ■

    Home safety (identify and correct hazards or problems in home safety situations)

  • ■

    Bingo (play bingo)

  • ■

    Oven use (cook muffins in an oven)

  • ■

    Stovetop use (cook soup on a stovetop)

  • ■

    Use sharp utensils (cut an apple with a sharp knife)

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Occupational performance measure

The PASS rates three occupational performance constructs: independence, safety, and adequacy; however, this paper is limited to independence and safety because these constructs were evaluated in all samples examined in this analysis. Independence is the ability to initiate, continue, and complete tasks without the assistance of another person. Safety accounts for risk to the client, therapist, task objects, or environment. The 26 PASS tasks consist of 163 criterion-referenced sub tasks, which are used to rate occupational performance. Tasks vary between two and twelve subtasks, depending on task complexity. Each subtask includes criteria for rating independence and safety.

PASS tasks are presented to clients in a standardized manner, including verbal instructions and placement of task objects. As a client attempts a task, the therapist provides assistance only when needed, with the least assistive prompt used first, followed by progressively more assistive prompts. The assistance levels, from least to most assistive are: (1) verbal supportive (encouragement); (2) verbal non-directive (cue to alert); (3) verbal directive (instruct); (4) gestures (point at object); (5) task/environment rearrangement (break task down); (6) demonstration (demonstrate task/subtask); (7) physical guidance (‘hands down’ — move body part needed); (8) physical support (‘hands up’ — lift body part/clothes/support); and (9) total assistance (do task/subtasks for the person).

Independence and safety are rated on four-point, ordinal scales. Independence summary scores are based on the frequency (for example, occasional or continuous) and level of assistance provided by the therapist (3 = complete independence; 2 = no level 7–9 assists, occasional level 1–6 assists; 1 = no level 9 assists, occasional level 7 or 8 assists, or continuous level 1–6 assists; 0 = dependence: that is, level 9 assist or continuous level 7 or 8 assists). The summary task independence score is the mean of the independence scores for related subtasks. For example, for ‘meal preparation with use of a sharp utensil’, scores are averaged for: (1) obtains correct fruit; (2) selects appropriate knife; (3) cuts fruit into eight parts; and (4) transports plate with fruit to table.

Safety scores are based on the extent to which unsafe performance was evident from task initiation to completion (3 = safe practices; 2 = minor risks but no assistance provided; 1 = risks to safety and assistance provided to prevent potential harm; 0 = risks to safety of such severity that task was stopped or taken over to prevent harm). Similar to independence scores, safety ratings are anchored to each subtask, however dissimilar to independence scoring, safety yields a single summary score that reflects safety for the total task. Safety is not rated for tasks which, being operationalized in the performance testing, do not present an immediate physical risk to persons, objects, or the environment (for example, telephone use).

The PASS has been used with cognitively, physically, and behaviourally impaired adults in a variety of client populations, and also with the well-elderly. It has been translated into Spanish, Hebrew, Mandarin, Farsi, Turkish, and Arabic, and there are versions for use in healthcare settings and clients’ homes, being identical save that clients use their own materials in their homes.

The PASS has good to excellent test–retest reliability (independence, r = .92 to .96; safety, 89% to 90% agreement) and inter-observer agreement (independence, 96%; safety, 97%) (Holm and Rogers 2008). Content validity of the PASS is based on the OARS Multidimensional Functional Assessment Questionnaire: Activities of Daily Living (Pfeiffer 1975), the Comprehensive Assessment and Referral Evaluation (Gurland et al 1977), the Physical Self-Maintenance and Instrumental Self-Maintenance Scale (Lawton et al 1982), and the Functional Assessment Questionnaire (Pfeffer 1987). Construct validity of the unidimensionality of the Independence and Safety scales of the PASS was established using exploratory factor analysis (Chisholm 2005).

Clinical research with multiple populations: namely bipolar disorder, congestive heart failure, dementia, depression, heart transplant, macular degeneration, osteoarthritis, and cerebrovascular accident (CVA), has enabled similarities and differences in the task independence and safety of community dwelling adults to be characterized. To illustrate occupational performance capacity across these diagnostic groups, data were culled from clinical methodological study databases (N = 941) that included PASS data, several of which have been published (Finlayson et al 2003, Gildengers et al 2012, Raina et al 2007, Rogers et al 2010, Rogers et al 2001, Skidmore et al 2006). All subjects for whom data were collected provided written informed consent, as required by the University of Pittsburgh Institutional Review Board. Data are missing for some items because the clinical protocols did not include them (for example, oral hygiene and trim toenails were not tested with the bipolar disorder clients because the focus was on IADL-C items). To explore and compare occupational performance across diagnostic groups, the percentage of individuals from each group who were independent and who were safe was calculated (see Table 2).

Table 2.

Percentage of individuals independent and safe in performing PASS items, across diagnostic groups

PASS Item BD
n = 85
I/S		 CHF
n = 110
I/S		 DEM
n = 26
I/S		 DEP
n = 349
I/S		 HT
n = 88
I/S		 MD
n = 61
I/S		 OA
n = 108
I/S		 CVA
n = 114
I/S
FM
Indoor walking 99/95 100/98 97/94 99/94 90/95 100/99 97/93 74/61
Bed transfer 99/99 85/94 77/97 89/95 56*/90* 62/94 88/97 68/56
Stair use 98/97 78/96 92/93 83/83 NT/NT 85/83 89/82 64/58
Toilet transfer NT/NT 94/98 65/94 95/90 77/91 90/97 92/95 67/59
Tub/shower 94*/93* 50*/64* 51*/50* 74*/65* NT/NT 44*/55* 35*/63* 58*/52*
BADL
Oral hygiene NT/NT 86/100 75/100 92/97 NT/NT 82/100 85/100 75/83
Dressing 99*/95* 66/98 28*/84 87/95 81*/90* 61/95 68/94 59/62
Trim toenails NT/NT 51*/97* 34/65* 54*/91* NT/NT 18*/81* 49*/90* 35*/33*
IADL-P
Garbage 91/91 77/97 35/100 83/92 NT/NT 49/100 83/96 45/48
Sweeping NT/NT 96/100 78/97 96/91 NT/NT 67/91 95/98 46/51
Bed linen 88*/89* 52*/93* 28*/70* 50*/75* NT/NT 33*/77* 63*/75* 38*/39*
Cleanup NT/NT 81/99 40/97 76/89 NT/NT 40/99 81/99 48/46
IADL-C
Sharps 90/93 67/99 20/93 70/88 NT/NT 20/83 70/95 43/41
Stovetop use 76/84* 63/92* 11/54* 58/77* 72/100 13/78* 69/94* 42/42
Oven use NT/NT 56/96 5/65 48/87 NT/NT 7/86 61/94* 40/29*
Bingo NT/--- 93/--- 49/--- 90/--- NT/--- 39/--- 94/--- 63/---
Telephone NT/--- 90/--- 18/--- 71/--- NT/--- 56/--- 91/--- 54/---
Auditory information 85/--- 93/--- 38/--- 80/--- 92/--- 93/--- 92/--- 71/---
Visual information 90/--- 92/--- 38/--- 76/--- 91/--- 10/--- 93/--- 66/---
Home safety 72/--- 62/--- 17/--- 63/--- NT/--- 5/--- 67/--- 61/---
Small repairs 68/99 54/100 3/100 61/97 85/97 26/100 63/99 58/70
Shopping 32*/--- 24*/--- 0*/--- 17*/--- 47*/--- 0*/--- 30*/--- 37/---
Pay bills 63/--- 33/--- 3/--- 41/--- 50/--- 2/--- 46/--- 37/---
Cheque book 45/--- 30/--- 3/--- 34/--- 50/--- 2/--- 35/--- 33/---
Mailing NT/--- 40/--- 3/--- 31/--- NT/--- 2/--- 44/--- 31*/---
Medications 48/96 33/99 3/97 32/96 58/96* 7/99 44/100 41/65
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Note: BD = bipolar disorder; CHF = congestive heart failure; DEM = dementia; DEP = depression; HT = heart transplant; MD = macular degeneration; OA = osteoarthritis; CVA = cerebrovascular accident; I = independence; S = safety; NT = not tested; --- = task does not include risk to safety.

*

lowest % of subjects independent/safe within a diagnostic group. FM = functional mobility; ADL = activities of daily living; IADL-P = instrumental activities of daily living with a physical emphasis; IADL-C = instrumental activities of daily living with a cognitive emphasis.

Critical reflection on practice

Our findings suggest that the complexity of some community living tasks is such that they are apt to be problematic. While all diagnostic groups demonstrated difficulties with one or more PASS tasks, no single population demonstrated consistently greater limitation than other populations across all four domains. For functional mobility, clients in the CVA group exhibited the lowest percentage of independence and safety. For the BADL domain, both the CVA and dementia groups demonstrated the most difficulty. The CVA, dementia, and macular degeneration groups demonstrated the lowest percentages for the IADL-P domain, with the latter two groups sharing lowest observed performance and safety percentages for the IADL-C domain. When conducting evaluations to determine competence to live independently, occupational therapists should give priority to those tasks that have the highest probability of resulting in questionable performance. Our analysis provides evidence supporting which tasks are most likely to be problematic for each diagnostic group.

The PASS is an efficient tool for measuring the complicated person–task–environment transactions associated with community living tasks. It is unique because it rates task safety and independence separately, whereas on most instruments clients must be safe to be rated as independent. The decision to separate the two constructs was driven by the need to help interprofessional colleagues, including legal professionals, understand how adults living independently in the community could be rated as ‘dependent’ because of risks to safety. As is apparent from Table 2, the proportion of each sample rated independent was seldom synonymous with the proportion rated safe. For example, for several tasks (stovetop use, oven use, small repairs, and medications) the percentage of clients who were independent was consistently lower than the percentage of clients who were safe. Across all diagnostic groups, clients tended to elect to be dependent over being unsafe. When all FM tasks were administered, the bathtub/shower transfer task revealed the lowest percentage of individuals with independent and safe performance across groups. For BADL tasks, when the trimming toenails task was administered, performance revealed greater dependence and safety risks, followed by dressing tasks, except for individuals with dementia whose performance of the dressing task was the most dependent. The IADL-P task of changing bed linens revealed the greatest dependence and unsafe performance across groups compared to the other IADL-P tasks. In IADL-C tasks there was a trend across groups for increased dependence in the shopping task, which requires the selection and purchase of grocery items. This task does not include a safety score because the tabletop simulated shopping task precludes risk to physical safety. The most unsafe performance of an IADL-C task was for stovetop use, for all groups with the exception of individuals with a CVA, who were most unsafe performing the oven use task.

Contributions of the PASS to occupational therapy practice

To further illustrate the utility of the PASS for intervention planning, Table 3 outlines the subtask sequence for tasks reflecting the most dependent performance in each domain across diagnostic groups: FM — Bathtub/shower transfer; BADL — Trim toenails; IADL-P — Bed linens; IADL-C — Shopping. The double underlined words/phrases indicate the action individuals are to perform; the single underlined words/phrases indicate the adequacy performance standard. By rating the subtasks that are involved in the task, rather than the task as a unit, therapists can identify the specific point(s) of task breakdown. Thus, the specific aspect(s) of performance where assistance is needed, or safety is at risk, can be readily identified, and can guide treatment planning. The bathtub transfer item (Table 3), for example, allows for the rating of five sequential subtasks. Subtask performance highlights typical differences between the groups. For clients with knee osteoarthritis, lowering oneself to the bathtub bottom is often the first subtask deficit; while for those with dementia, working out how to exit the bathtub is more problematic. The PASS, however, not only fosters problem identification, it also provides clues to potential, and feasible, occupation-based interventions. Through systematic application of the hierarchy of prompts — moving from verbal through manual prompts — the therapist gleans information about the type and degree of assistance needed to accomplish the task safely and with the least assistance. In turn, these data facilitate the development of targeted occupation-based intervention goals.

Table 3.

PASS subtasks with lowest percentage of clients rated independent/safe, by domain

Bathtub(T)/shower(S) transfer(FM)

  1. (S) Enters T in a controlled manner (lifts feet over T side; does not hit foot against T side; maintains balance standing on 1 leg)

  2. (S) Turns around (180 degrees and back) in a controlled manner (maintains balance; does not slip)

  3. (S) Exits T in a controlled manner (lifts feet over T side; does not hit foot against T side; maintains balance standing on 1 leg)

  4. (T) Enters T in a controlled manner (lifts feet over T side; does not hit foot against T side; maintains balance standing on 1 leg)

  5. (T) Lowers self to a seated position on T bottom in a controlled manner (does not ‘plop’ down)

  6. (T) Sits on T bottom and maintains balance (does not hold onto T sides or soap dish)

  7. (T) Raises self from T bottom in a controlled manner (does not ‘rock’ to gain momentum)

  8. (T) Exits T in a controlled manner (lifts feet over T side; does not hit foot against T side; maintains balance standing on 1 leg)

Trim toenails (BADL)

  1. Positions cutting tool correctly (grasps tool by handle; tool is in operating position — lock is released; lever of clipper is swiveled into position; grasps correct end of file)

  2. Reaches each foot (right and left) and maintains balance while trimming toenails (does not ‘chase’ moving foot; does not need to grasp sink or ‘catch’ self)

  3. Uses cutting tool in a controlled manner (inserts toenail into opening between blades of scissors, clipper, or nippers, or positions file at appropriate angle to nail; does not puncture or cut skin)

  4. Trims nails (two on each foot) adequately (trims off entire edge of nail, cut is reasonably smooth and even)

Bed linens (IADL-P)

  1. Removes all bed linens and maintains balance (removes everything except the mattress pad; does not ‘catch’ self on bed or other furniture; does not trip)

  2. Puts on bottom sheet with no edges touching floor (sheet tucked in under mattress) and maintains balance (does not ‘catch’ self on bed or other furniture; does not trip)

  3. Puts on and tucks in top sheet with no edges touching floor (edges of sheet hanging off bed do not reach shoe tops) and maintains balance (does not ‘catch’ self on bed or other furniture; does not trip)

  4. Puts on spread with no edges touching floor (edges of spread hanging off bed do not reach shoe tops) and maintains balance (does not ‘catch’ self on bed or other furniture; does not trip)

  5. Puts pillow into pillow case with no more than two tries to locate opening (no part of pillow remains outside of pillow case) and maintains balance (does not ‘catch’ self on bed or other furniture; does not trip)

  6. Places pillow at head of bed (end that top sheet is not tucked into) and maintains balance (does not ‘catch’ self on bed or other furniture)

Shopping (IADL-C)

  1. Selects all four items on the shopping list correctly (requires identification of items, followed by choice of items as indicated by client gathering items in one location, pointing to items etc.)

  2. Selects the correct cash for the four grocery items (cash given matches the receipt amount)

  3. Selects the correct coupon for the matching item (sets one coupon aside; gestures to matching item; places coupon on appropriate item)

  4. Gives correct coupon and cash to assessor (for example, Brand A Chopped Broccoli coupon)

  5. Identifies correctly that change returned is wrong amount (too much) and correctly identifies the amount that should have been returned (for example, 34 cents)

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Note: single underlined = adequacy performance standard (quality); double underlined = action client is to perform (process). FM = functional mobility; ADL = activities of daily living; IADL-P = instrumental activities of daily living with a physical emphasis; IADL-C = instrumental activities of daily living with a cognitive emphasis.

The PASS supports a dynamic assessment process (Vygotsky 1978). Unlike assessments where the therapist is discouraged from interacting with clients, interaction is encouraged when needed to facilitate task completion. When performance problems arise during the evaluation, the therapist introduces prompts systematically according to the prompt hierarchy (for example, verbal cues before physical cues) to enable performance. When clients do not demonstrate problems, the therapist refrains from offering assistance.

Lastly, each PASS item can stand alone. Thus, the therapist is able to administer only those tasks deemed relevant to the client’s daily life. Tasks that are not required by the client’s current or predicted living situation can be omitted. Additionally, if there are tasks that are essential to a client’s daily life that are not included in the 26 core PASS tasks, the therapist can use the item template to develop new PASS items. This task selection process supports a client-centred measurement strategy that is responsive to the needs of each client and can guide individualized interventions.

Limitations of this practice analysis include the wide-ranging number of subjects across diagnostic groups (26 to 349); missing data for select items due to variations in clinical protocols; and only the constructs of independence and safety being evaluated in all samples.

Summary

In summary, diminishment of clients’ occupational performance capacities through cognitive, physical, or behavioural impairments makes them more vulnerable to task demands and environmental influences. A performance-based, criterion-referenced tool, such as the PASS, can assist occupational therapists in determining the specific person, task, and/or environmental factors contributing to the occupational performance discrepancy. The results of the PASS assist therapists in determining which daily tasks are compromised, where the breakdown in performance occurs, and what interventions might be helpful to improve performance.

Key messages.

  • ■

    Valid and reliable occupation-based assessment is necessary for determining competence for community living in the least restrictive environment, which promotes health.

  • ■

    Independence and safety should be rated as separate constructs.

Acknowledgments

Funding: This research received NIH Grant support: R01 AG08947; P30 MH052247; R01 NR03624; P30 MH071944.

Footnotes

Conflict of interest: None declared.

Research ethics: Ethics approval was not required for this study.

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