Occupational Analysis; activity analysis of toileting
What is activity analysis?
Activity analysis is the process of breaking down an activity into steps and examining its components. Activities, such as using a toilet, can be separated into constituent elements to analyse the skills required, as a means of understanding a person’s ability to undertake the task, or identify areas where the activity can be adapted to improve occupational performance (Creek, 2003).
Why do we need to undertake an activity analysis of toileting?
Being able to identify when toileting is necessary, access a toilet, and undertake all the component parts of the task such as adjusting clothing, attending to hygiene needs, washing and drying hands; are all required to facilitate autonomous and effective completion of toileting activities.
By understanding the difficulties, a person is experiencing, and some of the compensatory techniques they may have implemented, the steps in the sequence they may have removed and the risks they are taking, allows appropriate intervention to be recommended, realistic goals set and clinical reasoning to be both robust and defensible.
As Creek et al (2005) stated, occupational therapy cannot have a standardised intervention as each person is unique, with a distinctive history, culture, and occupational needs.
Therefore, activity analysis allows the delivery of a truly person-centred, problem solving approach in partnership with client goals.
There are multiple ways in which activity analysis can be undertaken, the table below is a guide for occupational therapists when undertaking an assessment and identifying barriers to occupational performance, in this case toilet activities.
Name of activity: using the toilet
- Timing – 6-8 times a day
- Length – 3-10 minutes
Physical demands
Component task | What is required | Possible consequences on occupational performance |
| Awareness of elimination | Neural feedback; Muscle tone. | Incontinence. |
| Getting to the toilet | Mobility; Balance; Gross body movements. | Urge incontinence. |
| Opening the door | Reaching out of base of support; Upper limb coordination; Fine finger movements; Grip strength. | Risk of falls and injury. |
| Adjusting clothing | Muscle tone; Balance; Gross & fine motor skills; Upper and lower limb coordination. | Restricted choice in clothing worn; Risk of over balancing. |
| Transfer on and off the toilet | Gross body coordination; Gross body equilibrium; Balance. | Falls; Not sitting centrally over the pan; Bodily fluids leaking onto the floor. |
| Reaching toilet roll | Manual dexterity; Control precision; Multi-limb coordination; Trunk strength; Static strength; Near and far vision; Depth perception. | Over balancing; Falls; Ineffective cleaning. |
| Wiping with toilet roll | Fine motor movement; Balance; Range of movement at shoulders; Bilateral coordination of upper limbs; Proprioception; Do they stand or sit? | Ineffective cleaning, leading to issues with skin integrity; Effect on personal hygiene. |
| Washing hands | Standing tolerance; Reaching out of base of support; Grip strength; Fine motor coordination; Balance; Upper limb coordination. | Risk of falls; Cross contamination; Infection risk increased if hand washing is ineffective or missed. |
Cognitive demands
Component task | What is required | Possible consequences on occupational performance |
| Awareness of elimination | Deductive reasoning; Working memory. | Incontinence. |
| Getting to the toilet | Short, long-term and working memory; Spatial awareness & orientation; Divided attention; Planning. | Dependence on others for prompts. |
| Opening the door | Problem solving; Cognitive flexibility. | Urge incontinence; Dependence on others. |
| Wiping with toilet roll | Planning; Self-monitoring; Organisation; Sequencing. | Problems with personal hygiene; Issues with skin integrity; Reliance on others for assistance. |
| Washing hands | Sequencing; Working memory. | Reliance upon others for prompting; Loss of independence. |
Intrapersonal demands
Component task | What is required | Possible consequences on occupational performance |
| Supervision from a carer | Oral expression; Oral comprehension; Selective attention; Cooperation. | Continence may be affected if the person cannot communicate needs to a carer, or a carer is not available. |
| Assistance from a carer | Following instruction; Risk awareness; Cooperation; Oral comprehension; Oral expression. | Risk of injury to carer and cared-for; If physical assistance is required; Issues with privacy and dignity; Blurring of life roles if assistance is given from a family member. |
Environmental features
Feature of the bathroom | Factors to consider | Possible consequences on occupational performance |
| Proximity of toilet to wall | How easy can the person access the toilet? | Effect on transfers; Ability to locate appropriate assistive equipment. |
| Height of toilet | Is the height of toilet suitable for the client, considering other household members? | Raising a toilet may affect occupational performance of other family members; Height adjustable equipment may be more appropriate. |
| Location of wash hand basin | Is the person using it to assist transfers? Is it hindering space? | Risk of injury with poor layout leading to further dependence. |
| Size of room | Turning space. | Increased risk of falls and injury. |
| Location of toilet roll | On a holder on the wall; On a free-standing holder or on the cistern? | Bending, twisting movements putting the person at risk of overreaching. |
| Type of flush | Is it a push button, or level handle? How does the person manage this? Do they remember to flush? | Issues with hygiene in the bathroom if the toilet cannot be flushed; Pain and discomfort in adopting various grip types. |
| Lighting/glare | Effect of this on visual perception. | Poor lighting can affect ability to locate items in the bathroom and affect all aspects of occupational performance. |
Appropriateness
Issue | Factors to consider | Possible consequences on occupational performance |
| Age | Can the person engage in age-appropriate toileting tasks? Dignity and privacy issues; What are their goals? | Complex assistive equipment can affect independence and autonomy. |
| Culture | A person’s toileting habits may not fit into this table; An individualised assessment is required; Awareness of self when discussing intimate hygiene is necessary; Understand what a person’s cultural norms are. | Failure to understand and account for cultural issues may lead to lack of trust and an ineffective assessment and recommendations. |
| Risk | Risks should be carefully assessed against a person’s goals, needs and wants. | The aim of eliminating risk completely can affect a person’s autonomy and independence. |
| Preparation | Equipment required; Toiletries required and located; Carers present and aware? | Inability to plan and prepare for toileting can affect continence and increase risk of falls and injury. |
References
- Creek, J. and Bullock, A., 2008. Planning and Implentation. In: Creek, J. and Lougher, L., 4th Edition. Occupational Therapy and Mental Health. Edinburgh: Churchill Livingstone, 109 – 131.
- Creek, J., Ilott, I., Cook, S. & Munday, C. (2005) Valuing occupational therapy as a complex intervention. British Journal of Occupational Therapy 68(6)
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