The therapists interviewed are all expected by their institutions to administer standardized tests to all patients as part of their health assessment routines (Table
1). Test scores are entered into patients’ charts, and some test scores are also registered in hospital registers for research purposes. Overall, the administration of these tests was deemed to be time-consuming and some of the interviewed PTs and OTs stated that, at times, they felt that other rehabilitation-related activities were more important for the patients. This notion was strengthened by the fact that patients’ short stays at the wards seldom allowed for direct follow-up of test information. The findings that follow must be understood against the tension OT and PT test administrators experience in the test situation [
16] as they navigate between the standardized procedures and the holistic orientation characteristic of best practice in geriatric patient care.
The clinician’s gaze
OTs and PTs maintained that the test situation per se provided them with significant patient information. The test situation functioned as an arena for clinically observing the patient in action/interaction with the therapist. In addition to presenting the test’s stimuli (questions and tasks) and scoring the patient’s successive responses and performance, therapists explained that they would typically notice patients’ physical and cognitive functioning, coping strategies, emotional state, behavior, and ability to take instructions.
The therapists agreed that observing patients during testing provided them, as test administrators, with information on the patients’ functional status – a basic functional assessment:
PT2: (…) so, we observe basic functional ability: if they can sit, if they can stand, if they can walk, and if they can move about. That’s sort of what you observe in all (tests), also in BBS and TUG. (…). And something else that is common to be aware of is respiration. Then you’ll see … you’ll see how they breathe; heh-heh-heh (makes rapid breathing noises) high or if they do costal or abdominal breathing for example, or if they … because we often measure (oxygen) saturation on their finger. (…). Yes, (…) many need extra oxygen during activity. (Rows 541–549)
As implied in the quote above, the level of activity in physical testing was physically demanding for some patients. In fact, the level of physical activity in these tests was mentioned by several PTs as a beneficial by-product of testing, because the tests gave the patient a good workout. Thus, there was no need for the PT to treat the patient further on the test day. Another, and perhaps clinically more important, by-product of testing was that the functional ability of patients, observed while testing, could help therapists see what treatment measures the patient needed. Hence, observing patients’ impairments, such as potential respiration problems illustrated in the quote above, would trigger ideas for training schemes and aids needs. Another PT explained how observation of test performance was linked to training needs:
PT9: It gives me additional information, and it can also give me tips on what we should work with. (…). And you may see that he has troubles with the step (an elevated platform in BBS) and maybe we need to work a little more on that particular part of his balance, right? Or, I saw that the pace in TUG was much better when he used his walker than when he didn’t. So, that means that he’s able to increase his pace, but that he’s afraid to when he walks without support. (Rows 923–929)
This PT not only noticed what sort of balance training the patient needs, but also remarked the patient’s coping strategy, walking at a slower pace when walking without a walker. The therapists provided several similar examples of how patient strategies were observed in the test situation. The cognitive testing in MMSE offered an interesting example. The tenth question in MMSE is, “What floor of this building are you on?” Patients’ reasoning on this particular question was noticed:
OT10: Some are just so clever at this; “I arrived on the first floor and I cannot remember being wheeled up or down, no, I think I’ll go with the first floor.” And then, I consider them to be pretty clear-headed, but (of course, it is possible that upon admittance) they were placed in an elevator and just half-awake, and then you just don’t have a chance to keep track. (Rows 602–605)
Being attentive to patients’ strategies could also reveal their actual emotional state. Therapists remarked that some patients were insecure and scared upon entering the test situation, but that they played tough and defensive. This behavior was especially noticeable when testing cognitive abilities:
OT12: (…) the ones that have experienced loss of memory and have had some a-ha moments where they’ve forgotten things – almost (started) a fire and things like that, they can be very like … refuse and not wanting to take it (the test). Because they’re scared that we’ll find out that it’s become worse. Some are acting very “but I know this.” If we ever get to (the MMSE question), “What country are you in?” (They’ll say), “What a stupid question, right?” (I’ll say) “Yes, can you answer it?” Because we need them to answer, and then you understand that OK here is [the patient] trying to hide something because the right answer isn’t coming. (Rows 568–575)
Notice also how the therapist in this quote reasons about patients’ reluctance, but still justifies pressing for an answer.
Other test observations described by the therapists highlighted the patients’ physical behavior in test activities: Were patients fast or slow in their bodily movements? Examples of this were often visible in the physical testing; for example, the patient would finish the TUG quickly, but the therapist noticed that the patient almost fell several times during testing. In colleague communication, therapists often referred to such patients as “reckless”– not fully aware of their own physical limitations. Others were slow in their movements, and made sure they did not fall by walking slowly or checking that the chair was in the right position before sitting down. These patients were often referred to as “careful.” “Reckless” and “careful” indicated a mismatch between the patient’s capacity and behavior. Therapists also noted the cognitive aspect of patient behavior: for example, if the patient was adequate in conversation, or how well the patient comprehended test instructions.
Being a patient’s assigned therapist also entailed interaction (i.e., admission talk, training, and rehabilitation activities) with the patient outside the test situation. Therapists maintained that observations from outside the test situation often confirmed observations made in the test situation, but as one therapist pointed out, the opposite could also happen:
PT13: [Y]ou turn away for a moment and suddenly they may be trying to grab a magazine lying on the table or another typical activity – and then suddenly their arm is as good as new. But when you are testing – oh, no then it’s not any good. But these things are kind of discovered because we see the patient during the whole day, right? (Rows 733–737)
The OTs had an additional arena for observation because they habitually observed patients in morning care routines and kitchen safety training. These observations would typically serve as a backdrop for considering patient performance/behavior in the test situation.
The economy of test score communication
Test scores are objective measures, but therapists seemed reluctant to accept that quantification was a particularly important aspect of their assessment. Instead, test scores were described as only providing a black and white statement, unable to capture all aspects needed in assessing geriatric patients and, thus, tests were not considered informative enough from the clinicians’ perspective. However, end scores still played a key role in everyday clinical communication.
Therapists claimed that standardized testing functioned as
“an assurance of quality of what we do, really. That it’s not just a discretionary, subjective assessment of things, but, like, doing a standardized test is maybe making it a bit more reliable too”
(PT11 Rows 614–616). In this quote, the notion of standardized tests as an objective base in professional statements is highlighted. It appears that, objective-based statements are considered to be better than subjective-based statements. And, although a few therapists argued that there must be a balance between subjective and objective statements, most therapists emphasized the test scores’ ability to support professional statements:
PT11: I feel that, in many ways, if we’ve done that test I’ve more weight in my argument when I call the district needs assessment office and order further physiotherapy (for the patient). Then I can, sort of, say that it isn’t just that the patient has reduced balance – that you’ve observed it, but you’ve also taken a standardized test which shows … (Rows 594–598)
To further underline the ambiguity surrounding objectivity and subjectivity, one therapist started out comparing test scores to results from blood tests and computed tomography (CT) to illustrate that test scores are, in fact, as objective as results from blood tests or CTs, but ended the quote pondering the professional dilemma that follows standardized testing:
OT6: (…) they will take a blood test, they will take CTs of the head, [but] you will not see the cognitive impairments there. So, we need, sort of, something that can show that you do have cognitive impairments; that you have a problem conceptualizing time and then, the standardized tests are a good thing. (…) So, it’s somewhat the same thing, that these tests are important to provide the patient with the right treatment. At the same time, you cannot use them at random and you need to exercise professional judgment and be … understand that the patient is tired and sleepy – so, you need to consider that, and if the patient is unmotivated, then that may affect the result. (Rows 516–526)
So, despite being aware of the possible limitations, and being somewhat critical towards quantifiable results from testing, therapists maintained that such results carry weight. The weight was in part linked to a medical system in which the quantifiable and objective were considered superior to the qualitative and subjective:
OT8: That’s always, sort of, been the good and the bad of medicine – that they’ve demanded numbers to ensure that something is true or not, right? And if you cannot quantify … things concerning quality of life and pain and such, then it’s harder to research it. But, the doctors are fond of everything that can be quantified, and what the doctors like propagates downwards in the system. That’s the way it is. (Rows 712–717)
But, weight was also given to the meaning inherent in end scores, as these described a specific level of functional ability. When therapists had experience with a particular test and its scoring system, they could define level of functional ability by score information only. One therapist highlighted this ability and exemplified how end scores, as opposed to a subjective statement on functional ability, left neither room nor need for interpretation:
PT11: (…) sometimes you may read an assessment where it says that the patient has reduced balance, but, OK, what is reduced balance? Does that mean that he, sometimes, needs to take an extra step when walking, or is he like really unsteady and walks, sort of, like a drunken sailor? That’s when it’s useful to have that number, saying that … yes, maybe it’s 45 points or it’s 5. (Referring to BBS scores. Rows 640–645)
Comparably, the therapists would look up earlier test scores on readmitted patients and compare them to new test scores. Two score sets illustrated the patients’ functional development by indicating progress, or lack thereof, over time.
This ability to understand scores was also emphasized as positive because it was knowledge most clinicians on the ward had in common:
“So, if you were to talk about a benefit then you’ve got shared understanding” (OT8 Rows 731–732). In fact, it was the test scores’ position as objective and as a platform for shared professional understanding that made them function in communication with patients, colleagues, and districts’ needs assessment offices. A functional score may be used to assess patients’ needs for services and to allocate in-home aid equipment, placements in nursing homes, and other public health services in Norway. Thus, although we observed that OTs were somewhat reluctant to use scores in patient communication, in the interviews they stated that reluctance was mainly an issue if patients were frail or had low scores. PTs used test scores to communicate the age-appropriate function of patients or to illustrate fall risk. However, PTs communicated a score to patients with certain reservations well aware that:
PT1: It doesn’t mean anything to them, and I have to explain a little what it means. (…) Then I explain a little what the number means in relation to – in relation to the whole scale. And what the risk is, but then I’ll draw on … if I have seen the patient a lot I might know what the problem is.” (Refers to BBS. Rows 1104–1110).
Scores would be related to the patient in the following manner:
PT4: We talk a lot about the fact that “this test shows that you have a risk of falling and you have fallen, so this agrees well.” And we usually say something about the use of walking aids, and I say that “I see you’re good at using the walker and that you check that you sit down in the chair properly, because that’s what you need to do now. If you can (continue to) do that I’ll not worry.” (Rows 685–689)
As shown in the two quotes above, the quantifiable aspect of testing was not the main message to the patient. The few times therapists presented the end score as a main message seemed to be in communication with the district’s needs assessment office, because they knew that a low score could prompt allocation of public services. Still, therapists expressed reluctance toward this particular use of scores because it might entail testing patients who normally might be deemed unfit for testing:
OT8: I’ve had the district’s needs assessment office wanting MMSE to see if they can place the patient in a locked ward – and when you’re that impaired cognitively, then you’ll score down towards 15, 16. And then it’s a little … what’s the purpose of testing patients when we know that they’re pretty demented? (Rows 695–698)
Nevertheless, seeing that not all health care providers were familiar with tests’ scoring systems and that no end score could spell out the patient’s specific impairment, therapists habitually commented on the end score in writing:
“We never just write the end score in the chart. We always state what the problem is, because we are more concerned with the problem than with the actual end score” (OT6 Rows 514–516). Also in verbal communication, for example, with the multidisciplinary team, end scores were likely to be commented upon:
OT12: (…) it is important to me that you don’t say, in multidisciplinary meetings and reports, “27 of 30” and nothing more. You need to say what it is they scored poorly on and assess, that, yes, [the patient] was not oriented to place. (…). To me there is a difference between, like, you say one day wrong on date and day (questions) when you, like, are in a hospital and have been there for many weeks. Really, I’m not on top of dates and stuff every single day. You sort of need to consider this. But, if you say you’re in England when you’re in Norway, well, that’s a bit different. So, I think it is quite important to present what it was they scored poorly on, in order to get a more holistic impression of the patient. (Rows 443–453)
A clarification of test scores, such as the clarification presented above, could help other health professionals localize and assess the clinical significance of a patient’s impairment. Testing benefitted from clarifications when therapists found that the end score did not approximate the real-life person
– when there was a mismatch between observed behavior and end score.
OT14: (…) I had this patient who scored well on the MMSE, but when she was to brew a pot of coffee she didn’t have a clue how to do it. She didn’t understand why the water started to flow through and stuff. She’d turned the knob without noticing it. The same thing happened twice – and, like, according to the test score she should be pretty alert. (Rows 609–614)
Mismatches, such as this one, would typically be written down by the PT or OT as a caveat in the test form, communicated to the multidisciplinary team and, most likely, prompt further testing. Mismatches could, also, have an impact on how test results were communicated to the patient. For instance, if a patient scored high, but was considered reckless, the therapist would communicate the necessity of being more careful.