1. The Pool Activity Level (PAL) Instrument for Occupational Profiling in Dementia Care
Anae Dixon
Kia Ora,
My name is Anae Dixon. I am an Occupational Therapy student. I graduated last year and have spent this year completing my honours degree through Otago Polytechnic. As part of that, I have done a research project which was focussed on the Pool Activity Level, an instrument designed to promote occupation among people with dementia. I am here today to share those findings with you.

2. Overview The purpose of the PAL Purpose of study
Underpinning principles
Participants
The PAL Tools
Results and Findings
The PAL Levels
Conclusion
This presentation will be split into two parts.
Part of it will be based on the findings from my research study and part of it will be based on the Pool Activity Level instrument itself as it fits well with this section of the conference based on effective interventions for people with dementia. Also, the overall aim of my study was to increase awareness of its use in New Zealand.
I will start by explaining what the Pool Activity Level actually is. Then look at its overall purpose and why it was designed. Then we will have a look at the individual tools that make up the PAL instrument (life history profile, checklist, and activity profile). Then we will have a brief look at the individual activity levels (Planned, Exploratory, Sensory, and Reflex).
I will then go through the research process in this study (The lit review, method, data collection and analysis) with a main focus on the findings of the study and practice implications.

3. The Pool Activity Level (PAL)
Developed by Jackie Pool
A widely used framework in care settings across the UK
Proven reliability and validity (Wenborn et al., 2008)
Standardized assessment and outcome measure
Recommended for skills training and activity planning (NICE, 2006)
The Pal was designed by Jackie Pool, an occupational therapist specialised in dementia care.
It was first published in 1999 as part of the well respected Bradford Dementia Group Good Practice Guides.
The PAL is a practical resource for carers of people with cognitive impairments caused by conditions such as dementia, strokes and learning disabilities.
Has become a widely used framework in settings across the UK for providing activity-based care for people with dementia.
In 2005, a research study into the effectiveness of the PAL checklist was undertaken and the reliability and validity of the PAL Instrument was proved.
It then became of interest to strategic level providers and commissioners of health and social care services as a standardised assessment and outcome measure.
In the National Clinical Practice Guideline for Dementia, the PAL Instrument is recommended for daily living skills training and activity planning.

4. The purpose of the PAL instrument
Enable carers to engage people with dementia in meaningful activities
To be applicable in the home, day service or residential facility
To be integrated in to day-to-day care provision
Provide information on individual’s strengths and abilities
Ensure activities are meaningful and appropriate
The Pal was designed by Jackie Pool, an occupational therapist specialised in dementia care.
It was first published in 1999 as part of the well respected Bradford Dementia Group Good Practice Guides.
The PAL is a practical resource for carers of people with cognitive impairments caused by conditions such as dementia, strokes and learning disabilities.
Has become a widely used framework in settings across the UK for providing activity-based care for people with dementia.
In 2005, a research study into the effectiveness of the PAL checklist was undertaken and the reliability and validity of the PAL Instrument was proved.
It then became of interest to strategic level providers and commissioners of health and social care services as a standardised assessment and outcome measure.
In the National Clinical Practice Guideline for Dementia, the PAL Instrument is recommended for daily living skills training and activity planning.

5. Underpinning principles
People with cognitive impairment have abilities
In an enabling environment, these potential abilities can be realised
Activity is the key to unlocking this potential
The persons’ impairments and abilities must be understood
Activities must have personal significance.
The Pal was designed by Jackie Pool, an occupational therapist specialised in dementia care.
It was first published in 1999 as part of the well respected Bradford Dementia Group Good Practice Guides.
The PAL is a practical resource for carers of people with cognitive impairments caused by conditions such as dementia, strokes and learning disabilities.
Has become a widely used framework in settings across the UK for providing activity-based care for people with dementia.
In 2005, a research study into the effectiveness of the PAL checklist was undertaken and the reliability and validity of the PAL Instrument was proved.
It then became of interest to strategic level providers and commissioners of health and social care services as a standardised assessment and outcome measure.
In the National Clinical Practice Guideline for Dementia, the PAL Instrument is recommended for daily living skills training and activity planning.

6. The PAL Consists of:
Life History Profile - Gathers information on the persons life history, likes, dislikes, routines etc. PAL Checklist - Determines the persons current level of engagement PAL Activity Profile - Provides information on persons likely abilities, limitations, the caregivers role and suitable leisure activities Individual Action Plan – A record of information regarding the individuals current needs, preferences and routines in meaningful activities
Enables caregivers to recognise the person as a unique individual
Helps to understand peoples behaviours
Provides topic of conversation
Guides activity selection
Gathers information about the persons current level of engagement
Completed by someone who knows the person well
Based on observations from the past two weeks
A quick and easy to use 9 question checklist
Result indicates the persons activity level
General information for engaging the person in meaningful occupations
E.g. Dressing - Favourite garments, preferred routine, likes/dislikes, method
Encourages a consistent approach to care
Useful information for discharge
Based on the result of the PAL checklist 
There are four profiles, one for each activity level
Double-sided, A4 sheet of information
Information on likely abilities and limitations and the caregiver’s role
The Pal was designed by Jackie Pool, an occupational therapist specialised in dementia care.
It was first published in 1999 as part of the well respected Bradford Dementia Group Good Practice Guides.
The PAL is a practical resource for carers of people with cognitive impairments caused by conditions such as dementia, strokes and learning disabilities.
Has become a widely used framework in settings across the UK for providing activity-based care for people with dementia.
In 2005, a research study into the effectiveness of the PAL checklist was undertaken and the reliability and validity of the PAL Instrument was proved.
It then became of interest to strategic level providers and commissioners of health and social care services as a standardised assessment and outcome measure.
In the National Clinical Practice Guideline for Dementia, the PAL Instrument is recommended for daily living skills training and activity planning.

7. Ability to engage in activities:
Pool Activity Levels:
Planned
Exploratory
Sensory
Reflex
Ability to engage in activities:
The PAL consists of four activity levels; Planned, Exploratory, Sensory and Reflex.
The Planned level is the first activity level and represents the highest level of ability to participate in activities.
Reflex is the last or lowest level.
Although there are only four levels, people can move between these levels as the PAL can be done repeatedly over time. And often if staff members use the PAL in day to day practice, the persons ability to engage tends to improve as they become more independent and begin using their residual abilities.

8. Planned Activity Level
Can work towards goal directed activities with a tangible outcome, but may not be able to solve problems that arise in the process.
To facilitate participation:
Keep sentences short
Be present to help to solve problems that arise
Focus on activities that achieve a tangible result
So the highest level.

9. Exploratory Activity Level
Can carry out familiar activities in familiar surroundings, but is more concerned with the experience than the end result.
To facilitate participation:
Make first contact
Use simple, understandable instructions
Use a creative and spontaneous approach
Break the activity into manageable chunks
So the highest level.

10. Sensory Activity Level
Primarily concerned with experiencing the sensation of the activity and moving their body in response to those sensations.
To facilitate participation:
Guide to carry out single-step activities
Ensure the person experiences a wide variety of sensations
Give simple directions and reinforce with demonstrations
So the highest level.

11. R Reflex Activity Level
Maybe unaware of surrounding environment or own body. Movement is generally a sub-conscious, reflex response to direct sensory stimulation.
To facilitate participation:
Use direct sensory stimulation to raise self awareness
Don’t over-stimulate
Use single-word commands
Use facial expressions and tone of voice
So the highest level.

12. Example: Baking Activity
Planned: Able to carry out full task with some assistance solving problems
Exploratory: Can carry out 2-3 step parts of the process
Sensory: Can carry out single step activities. May require demonstration
Reflex: Can smell, taste and feel the individual ingredients and end product.
On example is doing baking with a group of people, which is something I have done on my placement. Knowing how to engage people at different functional levels was extremely rewarding as more people were able to be involved in the task and I could ensure that the task was achievable for their level of functioning.
Someone with planned level may be able to complete the full task, particularly if they have been a baker in the past, if they like baking and if they are in a familiar environment. If they are not in their own kitchen for example, they may struggle with finding items and need assistance with this. They are also likely to need assistance if any problems arise.
Someone at the Explanatory level is likely to be able to carry out 2-3 step tasks. So they may be able to crack the eggs in to the bowl and then beat them. They may also be able to roll up the mixture into balls and place them on the tray.
Someone at sensory level is likely to be able to carry out one step activities and may require prompts and demonstration. Someone at this level could perfrom tasks like stirring the mixture, squeezing lemons or kneading dough.
Baking is a great activity for someone at reflex level as there is lots of sensory stimulation. They are able to smell all the different aromas, see people performing various tasks, hear the different noises like the beater buzzing, they can be given some mixture to feel in their hands, and of course taste the end product.
In my experience, the baking was a great activity and could be adapted to suit all of the different ability levels so that everyone could be engaged. At the end, the biscuits were shared with other residents and staff members, and the people who participated were given lots of praise for their hard work. They felt a sense of accomplishment and seemed to really enjoy themselves.

13. Research Study:
The effectiveness of the Pool Activity Level (PAL) Instrument for Occupational Profiling: Clinician and Carer Perspectives
I did this study because I have always had a passion for working with older people and have a particular interest in dementia. I discovered the PAL tool on one of my fieldwork placements and it really appealed to me because I have worked as a caregiver for a number of years while on holiday from my studies and believed it had huge potential. I found out that it was being used very little throughout New Zealand and no one seemed to even know what it was, despite it being a reliable and valid tool and being used widely overseas. So I decided to research its effectiveness and spread awareness of its use. Ever since then I had been thinking about how the PAL is so applicable and more people need to know about it. When I decided to do honours I knew that I wanted to find a way to do that so that is why I chose to do this study.
The overall aim of this study was to explore the effectiveness of the Pool Activity Level (PAL) and gain an understanding of the potential for it to become more widely used in New Zealand. The researcher hoped that if the PAL instrument was found to be effective, the results of the study could be used to increase awareness and utilisation of the PAL within New Zealand.

14. Purpose Find out how it’s being used within this particular setting
Explore perspectives on the value of the PAL
Indicate potential for it to become more widely used

15. Participants Occupational Therapist Community Liaison Nurse Caregiver
Allied Health Assistant
x2 Inpatient Registered Nurses
Data was collected through six face to face, semi-structured interviews with clinicians and carers actively using the PAL in practice. I travelled to the research site and stayed for one week to conduct the interviews. Interviews were between 30 minutes and an hour long. The interviews were transcribed verbatim.
The participants included an occupational therapist, community liaison nurse, caregiver, allied health assistant and two inpatient nurses.

16. Use of the PAL Used with all dementia patients
PAL Checklist completed after two weeks
Checklist and Profile put in the notes
Useful when staff are struggling to work with the person
Educational tool
Outcome measure

17. Strengths of the PAL Instrument
Easy to use
Cost and time effective
Strengths-focused
Outcome measure
Assists with planning care
Facilitates person-centred care
“It is so simple to learn and quick to administer and use”
Occupational Therapist
“I find the tool very easy to understand, its easy to use, its short. Yeah, I like it.”
Community Liaison Nurse

18. Limitations of the PAL Instrument
Level of cultural sensitivity
Open to interpretation
Only four levels
Not relevant to all client groups
“On the one hand it is putting people into, you know, pigeon holes, but just the way its worded. It still gives you that range and it helps you think more clearly about why certain patients can’t do things”
Caregiver

19. Value of using the PAL for patients
Supports independence and individuality
Enhances wellbeing and quality of life
Maintains function
Reduces distress/agitation
Care is at the appropriate level
Feelings of satisfaction and achievement
“The benefit of it, oh amazing. Cause they, then they don’t get frustrated. They feel like they are getting instructions that they can comprehend. Not something that their not going to comprehend and you may as well be talking Japanese!”
Inpatient Nurse

20. Value of using the PAL for clinicians/carers
“So rather than treating them either below, which would be condescending, or above which would be confusing, its actually at their level so their response should be, positive, really.”
Inpatient Nurse
Changes the way they work
Sense of achievement/satisfaction
Enhances client-carer relationship
Involves the caregiver
Can show deterioration
Improves consistency with staff
“I love it! ….because its basically showing the caregivers, its all there in black and white. They are doing the assessment, they know the person, they are putting it on paper and they can see the outcomes. They can see how if you work differently with a person it works!”
Community Liaison Nurse
The caregivers change the way they work with the person, they have more positive outcomes and that gives them a sense of achievement as well.

21. Barriers to using the PAL
“My biggest challenge is to have the registered nurses accept that the caregivers can actually do that assessment. That’s my biggest challenge”
Community Liaison Nurse
People don’t know what it is
Not always receptive to new documentation
Remembering the levels
Time
Not enough follow up
Caregivers don’t look at the notes
Culture that nurses do the assessments
“Staff will say they've not got time to use it possibly. But, obviously once they understand it and if they are using it then ultimately they will save caregiver time because they have to give less assistance. But, until they are really familiar with it, people don't understand that.”
Occupational Therapist

22. Implementation of the PAL
Should be used more widely in NZ
Tipping effect
Basic training/education and follow up
Get everyone involved and on board
Effort needed to maintain it
Practical strategies
“Have a look at it, and give it a go! Try it. Don't be frightened to use something different ”
Community Liaison Nurse
“It’s one of the best things that I’ve found working in this sector and it seems such a simple to use tool that I find it really surprising that its not really widely used in New Zealand. It doesn’t take long to learn it and once you know it, it can just make such a difference.”
Occupational Therapist

23. Conclusion The PAL was valuable for those who used it
Barriers to using the PAL were noted
There is potential for it to be used more widely in NZ
In conclusion,
This study found that the participants who actively used the PAL found it to be a valuable tool for both themselves and the patients they worked with. Some participants found that there were barriers restricting them from using it, such as …
All of the participants, whether they used it daily or never, could see its value and thought it should be more widely used.

24. References
Wenborn, J., Challis, D., Pool, J., et al. (2008). Assessing the validity and reliability of the Pool Activity Level (PAL) checklist for use with older people with dementia. Aging and Mental Health, 12(2),
National Institute for Health and Clinical Excellence (NICE) Dementia, supporting people with dementia and their carers in health and social care, NICE clinical guideline 42. Retrieved from
Pool, J. (2012) The Pool Activity Level (PAL) instrument for occupational profiling: A practical resource for carers of people with cognitive impairment. Fourth Edition. London, Jessica Kingsley Publications