Clinical Rehabilitation
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The UK FIM+FAM: development and evaluation
Lynne Turner-Stokes, Kyaw Nyein, Tabitha Turner-Stokes and Claire Gatehouse
Clin Rehabil 1999; 13; 277
DOI: 10.1191/026921599676896799
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Clinical Rehabilitation 1999; 13: 277–287
The UK FIM+FAM: development and evaluation
Lynne Turner-Stokes, Kyaw Nyein, Tabitha Turner-Stokes and Claire Gatehouse Regional Rehabilitation Unit,
Northwick Park Hospital, London, UK
Received 20th October 1998; returned for revisions 6th December 1998; revised manuscript accepted 30th January
1999.
Background and aims: The aim of this study was to develop and evaluate
the UK version of the Functional Assessment Measure (UK FIM+FAM).
Design: Before and after evaluation of inter-rater reliability.
Development: Ten ‘troublesome’ items in the original FIM+FAM were
identified as being particularly difficult to score reliably. Revised decision trees
were developed and tested for these items over a period of two years to
produce the UK FIM+FAM.
Evaluation: A multicentre study was undertaken to test agreement between
raters for the UK FIM+FAM, in comparison with the original version, by
assessing accuracy of scoring for standard vignettes.
Methods: Baseline testing of the original FIM+FAM was undertaken at the
start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams)
each rated the same three sets of vignettes – first individually and then as
part of a multidisciplinary team. Accuracy was assessed in relation to the
agreed ‘correct’ answers, both for individual and for team scores. Following
development of the UK version, the same vignettes (with minimal
adaptation to place them in context with the revised version) were rated by
28 individuals (nine teams).
Results: Taking all 30 items together, the accuracy for scoring by individuals
improved from 74.7% to 77.1% with the UK version, and team scores
improved from 83.7% to 86.5%. When the 10 troublesome items were taken
together, accuracy of individual raters improved from 69.5% to 74.6% with
the UK version (p <0.001), and team scores improved from 78.2% to 84.1%
(N/S). For both versions, team ratings were significantly more accurate than
individual ratings (p <0.01). Kappa values for team scoring of the troublesome
items were all above 0.65 in the UK version.
Conclusion: The UK FIM+FAM compares favourably with the original version
for scoring accuracy and ease of use, and is now sufficiently well-developed
for wider dissemination.
Address for correspondence: Lynne Turner-Stokes, Regional
Rehabilitation Unit, Northwick Park Hospital, Watford Road,
Harrow, Middlesex HA1 3UJ, UK. e-mail: [email protected]
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© Arnold 1999
0269–2155(99)CR257OA
278
L Turner-Stokes et al.
Introduction and background
Method
The measurement of outcome in rehabilitation
following brain injury poses a number of difficulties. Patients often have complex disabilities,
and cognitive and communicative problems not
only impede progress in therapy, but are often
the major factors limiting return to independence. Measures need to take account of these
areas, as well as assessing physical disability.
The Barthel Index1 and the Functional Independence Measure (FIM)2 are widely used global
measures of disability.3 However, they have
failed to gain universal acclaim as outcome measures for brain injury, partly because they are
dominated by physical disability and offer only
crude assessment for cognitive and psychosocial
disability.
The FIM+FAM was developed specifically for
use in brain injury.4 It does not stand alone, but
adds a further 12 items to the FIM which specifically address cognitive and psychosocial issues,
while applying the same seven-level scoring system. The latter are inevitably more subjective
and difficult to score,5 to the extent that they can
undermine the reliability of the scale as a whole.6
It is recommended that the FIM+FAM is scored
by a multidisciplinary team. This may help to
improve reliability, but makes it somewhat cumbersome for use in routine clinical practice.
The UK FIM+FAM Users Group was set up
in 1995 to bring together those units who were
using the scale in the UK, to ensure consistent
scoring between the different centres in order to
facilitate sharing of data. The group is co-ordinated by the Regional Rehabilitation Unit at
Northwick Park Hospital, and currently includes
representative members from over 25 units in the
UK.
The aims of the group were to explore how the
FIM+FAM may be adapted for use as an outcome measure for brain injury rehabilitation in
the UK, and to evaluate the UK version of the
FIM+FAM in comparison to the original version,
prior to dissemination. The group also considered
methods of data collation and analysis, and systems for training and updating users which are
described elsewhere.7 The UK FIM+FAM is
shown in Appendix 1. A brief description of
changes to each item is given in Appendix 2.
In the development of the UK FIM+FAM, the
group sought ways to improve consistency of
scoring, especially for the more subjective items.
It considered whether any of the FAM items
should be modified and if so, which and how.
An initial poll of 10 user teams indicated a high
level of agreement in identifying items that were
particularly subjective and difficult to score in
day-to day clinical use. When asked to rank the
six items they found most difficult to score, only
10 ‘troublesome’ items were mentioned at all.
These are given in rank order in Table 1, and the
first five were mentioned by over 80% of users.
It was agreed that FIM items could not be
changed structurally, as this would compromise
the integrity of the UK FIM data, and preclude
comparison with colleagues elsewhere in the
world. Problem solving and Social interaction are
FIM items and so may not themselves be
changed. However, the group has identified ‘task
batteries’ to improve objectivity of scoring (see
Appendix 2). The FAM items are at an earlier
stage of development and currently there is no
worldwide database. Liaison with the originators
of the FAM at Santa Clara Valley Medical Center, USA, confirmed that if changes were shown
to improve the reliability/validity of the data,
these would be considered for adoption and dissemination at source.
The identified troublesome FAM items were
reviewed individually by the group and changes
initiated to reduce subjectivity. The FIM applies
a uniform seven-level scoring system across all 18
items (see Appendix 1). There are undoubtedly
problems in extrapolating this concept of an indiTable 1 The 10 ‘troublesome’ items of the FIM+FAM
placed in rank order
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Problem solvinga
Adjustment to limitations
Emotion
Employability
Social interactiona
Community mobility
Safety judgement
Attention
Speech intelligibility
Comprehensiona
a
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FIM London
items.
The UK FIM+FAM: development and evaluation
279
vidual performing 25%, 50% and 75% of the FAM items required that some vignettes were
task, when the ‘task’ is an area of psychosocial modified to reflect those changes. However only
function. For some of these items the group rede- the minimum adaptation was made to reach the
fined cut-off points between levels in terms of fre- same correct score so that vignettes remained as
quency of intervention, rather than percentage of comparable as possible.
In all, 65 raters took part in the study (18
the task performed independently, and this was
felt to be easier for staff to rate. Language was nurses (28%), 16 occupational therapists (25%),
improved to avoid terms which were poorly 15 physiotherapists (23%), 9 speech and language
understood, such as ‘general life functioning’ and therapists (14%), 4 psychologists (6%) and 3 doc‘poseyed’. Decision trees were laid out in a con- tors (4%)). The distribution of disciplines was
sistent pattern, with the descriptions of each level simliar for the two rounds, and only five individat the bottom of the page, making it easier to uals took part in both. FIM+FAM rating experirefer to both the decision tree and scoring man- ence ranged from 0 to 54 months (mean 19
months) in the first round and 0–60 months
ual during rating.
These changes have been systematically (mean 24 months) in the second and was also not
piloted and reviewed over a period of two significantly different.
Each set of vignettes includes 30 items, so
years, and the final UK FIM+FAM was completed in June 1997. Teams reported that they three sets produce 90 item scores. Thirty-seven
found the UK version easier to understand and individuals scoring three sets thus produced 3330
use, but formal evaluation of the UK FIM+FAM (37 × 90) item ratings and 11 teams produced 990
was required to demonstrate that the changes item ratings in the first round. In the second
had indeed led to an improvement in scoring round there were 2520 individual item ratings
and 810 team ratings. Data were collated in
accuracy.
Wide geographic separation precluded the use Microsoft Excel, and transferred to SPSS for staof real patients for a multicentre inter-reliability tistical analyisis.
study, so ‘vignettes’ were used to test accuracy of
scoring. The vignettes have been developed by
Results
the originators of the FAM (Santa Clara Valley
Medical Center, USA) for training and testing
Overall accuracy (assessed in terms of percentnew users. Each set consists of 30 minicase studage ‘correct’ scores) for individuals and teams for
ies (one for each item) leading to agreed ‘correct’
both versions are shown in Table 3. The accuracy
or ‘best’ scores determined by an independent for individual ratings improved from 75% to 77%
panel of experienced raters.
with the UK version, and team accuracy
Using these vignettes, eight centres (Table 2) improved from 84% to 86%. In this study, scores
from the user group undertook a multicentre
evaluation of inter-rater agreement of the UK
FIM+FAM, in comparison with the original Table 2 Rehabilitation centres contributing to the
multicentre vignette study
version.
In the first round of evaluation, baseline test- 1) Alderbourne Rehabilitation Unit, Hillingdon Hospital,
ing of the original FIM+FAM was undertaken at
Uxbridge UB8 3NN
the start of the project in 1995. Thirty-seven reha- 2) Astley Ainslie Hospital, Edinburgh, Scotland EH9 2HL
Staffs Rehabilitation Unit, The Haywood, Stoke
bilitation professionals (11 teams) each rated the 3) North
on Trent ST6 7AG
same three sets of vignettes – first individually 4) Poole Brain Injury Service, Poole Hospital, Dorset
and then as part of a multidisciplinary team.
BH15 2JB
Accuracy was assessed in relation to the agreed 5) RAF Headley Court, Epsom, Surrey KT18 6JN
Brain Injury Centre, Rathbone Hospital, Liverpool
‘correct’ answers, both for individual and for 6) The
LI3 4AW
team scores.
7) Regional Rehabilitation Unit, Northwick Park Hospital,
Following development of the UK FIM+FAM,
Middlesex HA1 3UJ
the same vignettes were rated by 28 individuals 8) St Michael’s Rehabilitation Centre, Aylsham, Norfolk
NR11 6NA
(nine teams). Structural changes
tohttp://cre.sagepub.com
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L Turner-Stokes et al.
Table 3
Overall scoring accuracy for individuals and teams: the UK version compared with the original FIM+FAM
Original version of FIM+FAM
For all 30 items
Accuracy of individual raters
Accuracy of team scores
For 10 troublesome items
Accuracy of individual raters
Accuracy of team scores
UK version of FIM+FAM
For all 30 items
Accuracy of individual raters
Accuracy of team scores
For 10 troublesome items
Accuracy of individual raters
Accuracy of team scores
Number of
raters
Correct scores/
Total no. of item scores
% accuracy
37
11
2488/3330
829/990
74.7
83.7
37
11
771/1110
258/330
69.5
78.2
28
9
1943/2520
701/810
77.1
86.5
28
9
627/840
227/270
74.6
84.1
for the original version are already quite accept- considered an acceptable target in this context.6
able so, when taken as a whole, the differences Figure 1 shows the medians, quartiles and ranges
are not significant. When the 10 troublesome for kappa values for the two versions across all
items only were analysed, the individual rating items. Figure 2 shows the distribution of kappa
accuracy improved from 70% to 75% with the values across the 10 troublesome items. In each
UK version, and team accuracy improved from case agreement is generally better for the UK
78% to 84%.
version than for the original, and the benefits of
A breakdown analysis of the 10 troublesome multidisciplinary team scoring are also evident.
items is shown in Table 4. The accuracy of indi- Kappa values for team ratings across the trouvidual rating was improved in the UK version in blesome items were all 0.65 or above for the UK
all 10 items, although in some the difference was version.
very small – range 1–12% (mean 5.3%). Accuracy of the team scores improved in 7/10 items,
and improvements ranged from 3 to 29%. Analy- Discussion
sis of summary measures across these 10 items
showed that improvement in percentage accuracy In our evaluation methodology, we recognize the
was significant for individual scores (T-test: p limitations of using vignettes, which provide an
<0.001) but not for team scores. For both the assessment of scoring accuracy, and not strictly
original and the UK version team scoring pro- reliability. Ideally, reliability testing should
duced significantly higher percentage accuracy involve assessment of the same group of real
than individual scoring (p <0.001 and <0.01 patients by a large number of individuals and
respectively).
teams. However, this design is rendered unfeasiTaking the 10 items individually, the greatest ble by geographic separation, and the impossibilimprovements were seen in Safety awareness ity of so large a number of raters being able to
(+29%), Adjustment to limitations (15%) and familiarize themselves with each patient suffiEmployability/use of leisure time (10%), but only ciently to score them reliably. Vignettes similar
reached statistical significance for Safety aware- to those used here are routinely used by UDS
ness (chi-squared: p = 0.004).
(Uniform Data Systems) to assess scoring accuAgreement with correct scores for each indi- racy of raters before enrolling them as accredited
vidual and each team was tested using Cohen’s FIM users and to identify aspects of the scale that
kappa statistic. Kappas above 0.65, representing are difficult to score.8 In future studies, the use
a very good level of agreement,
have been
of recorded
videos
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2, 2010may go some way towards
The UK FIM+FAM: development and evaluation
Table 4
281
Scoring accuracy: differences between the two versions for the 10 troublesome items
Individual scores
Team scores
Item
Original
accuracy
(n = 111)
UK version
accuracy
(n = 84)
Difference
Original
accuracy
(n = 33)
UK version
accuracy
(n= 27)
Problem solving
Adjustment to limitations
Emotion
Employability/use of leisure
Social interaction
Community mobility
Safety judgement
Attention
Speech intelligibility
Comprehension
71
74
81
79
75
87
65
92
68
78
55
66
64
66
61
72
53
74
52
63
+2%
+12%
+3%
+8%
+5%
+8%
+4%
+5%
+1%
+5%
25
23
27
26
27
30
22
30
23
25
19
23
23
24
20
24
26
26
20
22
Mean
95% confidence interval
t-test
69.4%
(66%)
(79%)
(76%)
(79%)
(73%)
(86%)
(63%)
(88%)
(62%)
(75%)
74.7%
5.3%
2.96–7.64
p <0.001
(76%)
(70%)
(82%)
(79%)
(82%)
(91%)
(67%)
(91%)
(70%)
(76%)
83.9%
(70%)
(85%)
(85%)
(89%)
(74%)
(89%)
(96%)
(96%)
(74%)
(81%)
78.4%
–6%
+15%
+3%
+10%
–8%
–2%
+29%
+5%
+4%
+5%
5.5%
–2.20–13.20
N/S
Kappa values
(64%)
(67%)
(73%)
(71%)
(68%)
(78%)
(59%)
(83%)
(61%)
(70%)
Difference
Figure 1 Distribution of kappa values across all 30 items. Individual and team
agreement with correct scores is shown for the original and UK FIM+FAM
versions.
overcoming this problem, but even so are not a pants 1–2 hours to rate individually and at least
full substitute for genuine cases. Further in vivo one hour as a team. It was considered that a
reliability studies will still be required.
larger number of vignettes would reduce rater
Kappa statistics must be viewed with some compliance. Cohen’s kappa has gained accepcaution in small sample numbers, and for this tance as a standard for testing agreement in interreason results are also given in terms of the rater reliability studies, although strictly
percentage ‘correct’ scores. The three sets of speaking, it requires a sample size of 2κ2. In the
vignettes used in this study
took
most particiof the
FIM+FAM
this would be 98, which is
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L Turner-Stokes et al.
Kappa values
282
Figure 2 Distribution of kappa values across the 10 troublesome items.
Individual and team agreement with correct scores is shown for the original
and UK FIM+FAM versions.
rarely possible to achieve. Other studies have below 80% in the first round evaluation. Problem
also tended to use suboptimal numbers.6
solving and Social interaction remain weak items,
In spite of these reservations, in this prelimi- but having agreed to maintain the integrity of the
nary evaluation the UK FIM+FAM compared FIM, these cannot be changed unless this is inifavourably with the original version. Although tiated by UDS.
Since the first and second rounds of evaluation
the difference between the two versions in percent accuracy was small when items were taken were undertaken two years apart, it might be
overall, analysis of the 10 troublesome items argued that improvement in accuracy resulted
revealed more marked improvement in the areas from increased rater experience in use of the
that had been targeted for change. The small but FIM+FAM. However, except for five individuals,
consistent improvements on scoring accuracy the two studies were undertaken by different
reached significance, however, when rated by raters and the overall FIM+FAM experience
among the raters was similar on both occasions.
individuals.
It might further be argued that the changes
Improvement in scoring accuracy by teams did
not reach statistical significance over the 10 items, made to the vignettes themselves between the
and this was felt to reflect the relatively higher two versions could have rendered them easier to
level of team scoring accuracy overall for the score in the second round. However, only the
original version, which left less room for minimum necessary changes were made to bring
improvement. Nevertheless, taking items individ- vignettes into line with the new wording in deciually, there was significant improvement team sion trees and manual. Care was taken to ensure
scoring accuracy in Safety awareness (+29% p = that only the equivalent information was given,
0.004). Although not reaching significance, and the correct scores for each item were kept
notable improvements were also seen in Adjust- the same.
For both versions, accuracy was significantly
ment to limitations (+15%), Employability/
leisure activities (+10%), both of which had improved when raters scored the vignettes as a
ranked highly among the offending items in the team. This underlines the desirability of multidisciplinary
team2, 2010
rating, whichever version is
original version and wereDownloaded
scored
with accuracy
from http://cre.sagepub.com
at King's College
London - ISS on February
The UK FIM+FAM: development and evaluation
used, and does therefore restrict the use of the
FIM+FAM to settings in which staff availability
and time allow this method of scoring.
In summary, development of the UK
FIM+FAM has led to revision of the decision
trees and manual for 10 items previously identified as particularly difficult to score. The UK
FIM+FAM appears to compare favourably with
the original version for scoring accuracy and ease
of use, and is now sufficiently well-developed for
wider dissemination.
Acknowledgements
The authors would like to thank all participating members of the UK FIM+FAM Users
Group, and in particular Kath McPherson, representing Astley Ainslie Unit, Edinburgh; Ann
Hunter, representing Hunter’s Moor Rehabilitation Unit, Newcastle; and Elspeth Novice, representing Northwick Park Hospital for their
contributions to the UK version. We are indebted
to Karyl Hall of Santa Clara Valley Medical Center, San Jose, USA, for collaborative support; to
Keith Sephton and Stephen Jeaco for help with
the computer package; to Caroline Dore of the
Department of Medical Statistics and Evaluation,
Imperial College School of Medicine for statistical advice; and to the Luff Foundation for financial support.
Note: Copies of the UK FIM+FAM are available
from: Dr Lynne Turner-Stokes, Regional Reha-
283
bilitation Unit, Northwick Park Hospital, Watford
Road, Harrow, Middlesex HA1 3UJ, UK.
References
1 Mahoney FI, Barthel DW. Functional evaluation: the
Barthel Index. Md State Med J 1965; 14: 61–65.
2 Hamilton BB, Granger CV, Sherwin FS, Zielezny M,
Tashman JS. A uniform national data system for
medical rehabilitation. In: Fuhrer JM ed.
Rehabilitation outcomes: analysis and measurement.
Baltimore: Brookes, 1987: 137–47.
3 Turner-Stokes L, Turner-Stokes T. The use of
standardized outcome measures in rehabilitation
centres in the UK. Clin Rehabil 1997; 11: 306–13.
4 Hall KM, Hamilton BB, Gordon WA, Zasler ND.
Characteristics and comparisons of functional
assessment indices: disability rating scale, functional
independence measure, and functional assessment
measure. J Head Trauma Rehabil 1993; 8: 60–74.
5 Alcott D, Dixon K, Swann R. The reliability of the
items of the functional assessment measure (FAM):
differences in abstractness between FAM items.
Disabil Rehabil 1997; 19: 355–58.
6 McPherson KM, Pentland B, Cudmore SF, Prescott
RJ. An inter-rater reliability study of the functional
assessment measure (FIM + FAM). Disabil Rehabil
1996; 18: 341–47.
7 Turner-Stokes L. Outcome measures for in-patient
neurorehabilitation settings – a commentary.
Neuropsychol Rehabil 1999; in press.
8 Granger CV, Deutsch A, Linn RT. Rasch analysis
of the functional independence measure (FIM(TM))
mastery test. Arch Phys Med Rehabil 1998; 79:
52–57.
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Appendix1 – The UK version of the FIM+FAM
Self-care
1) Eating
2) Grooming
3) Bath/showering
4) Dressing upper body
5) Dressing lower body
6) Toileting
7) Swallowinga
Sphincters
8) Bladder management
9) Bowel management
Mobility
10) Transfers: bed/chair/wheelchair
11) Transfers: toilet
12) Transfers: tub/shower
13) Transfers: cara
14) Locomotion: walking/wheelchair
15) Locomotion: stairs
16) Community mobilitya
Communication
17) Expression
18) Comprehension
19) Readinga
20) Writinga
21) Speech intelligibilitya
Psychosocial
22) Social interaction
23) Emotional statusa
24) Adjustment to limitationsa
25) Use of leisure time (replaces ‘Employability’ in original version)a
Cognition
26) Problem solving
27) Memory
28) Orientationa
29) Concentration (replaces ‘Attention’ in original version)a
30) Safety awareness (replaces ‘Safety Judgement’ in original version)a
a
FAM items
Seven
Level
7
6
5
4
3
2
1
levels for each item
Description
Fully independent
Requiring the use of a device, but no physical help
Requiring only stand-by assistance or verbal prompting or just help
with set-up
Minimal assistance
Requiring incidental hands-on help only (performs >75% of the task)
Moderate assistance
Subject still performs more than half the task (50–74%)
Maximal assistance
Subject provides less than half of the effort of the task (25–49%)
Total assistance Downloaded from
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Complete independence
Modified independence
Supervision/set-up
The UK FIM+FAM: development and evaluation
285
Appendix 2 – Details of the UK version of the FIM+FAM
This appendix briefly describes the changes to the original FIM+FAM that have been made to
produce the UK version. Further details and full manual are available on request from the
authors.
General changes
1) Reorganize tree structure to same layout as FIM items.
2) Inclusion of brief description of each level on the same page as the tree structure to aid cross
reference to the scoring manual.
3) Removal of broad terms, such as ‘General life function’.
4) Removal of poorly understood words, such as ‘poseyed’.
5) Restore emphasis on what subject does do, not what they would or could do.
6) Define levels in terms of frequency of help or intervention required, rather than percentage
of task.
Changes to specific items
16) Community mobility
Community mobility might be considered a handicap item, but is such a crucial limiting factor
for community integration that many units address it actively as a problem in the course of
rehabilitation.
‘Personal transportation’ is redefined as ‘getting about in the community’.
The decision tree prompts the rater to indicate the mode of transport used, and on which the
subject is rated, and is reminded that car transfers are assessed separately.
‘Incidental help’ is defined and cut-off points for lower levels are determined by the need for
help just at the start of the journey, at both ends, or during the course of the journey.
21) Speech intelligibility
Speech intelligibility includes the articulation, rate, volume and quality of vocal communication,
but not the ability to express ideas or accurate information, which is covered by expression.
Above the help line, the use of compensatory strategies (including rate of self-correction) to
produce intelligible speech is included. Below the line, help is reflected in listener effort, and cutoff points determined by the subject’s ability to produce intelligible syllables, words, phrases or
sentences and requirement for familiarity on the part of the listener.
22) Social interaction
Social interaction is an FIM item which cannot be changed. An abbreviated version of the manual
was included at the bottom of the decision tree, which teams found helpful in confirming the
correct level.
23) Emotion
Emotion includes not only the frequency and severity of mood disturbance but also the ability to
take responsibility for their emotional behaviour.
‘Structured’ and ‘unstructured’ setting is removed since the subject should be scored in the
setting in which they are.
Use of medication to control mood is included above the help line, providing the subject takes
this themselves and without prompting.
Below the help line, cut-off points for levels are determined by the frequency of intervention
required to control and manage emotional behaviour.
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L Turner-Stokes et al.
24) Adjustment to limitations
Adjustment to limitations was considered to have two components.
•
•
Above the ‘help’ line, a mental set with regard to coming to terms with their disability and
having realistic expectations for the future.
Below the line more practical adjustments and the use of coping strategies and alternative
techniques to overcome their disabilities and operate at the maximum level of safe
independence.
Cut-off points for levels 1–4 are based on the amount of help required to employ use of
alternative strategies.
25) Employability
Employability was considered to be a handicap item. In most rehabilitation settings it can only be
scored in terms of what the subject would or could do, not what they do do. It was therefore
replaced with an alternative item ‘Use of leisure time’.
Use of leisure time involves three components: choosing the activity, making the necessary
arrangements to take part in it, and performing the activity. Cut-off points for levels 2–4 are
dictated by the number of these steps for which help is required.
26) Problem solving
Problem solving is an FIM item, so no change was made to the decision tree or manual. However,
scoring above and below the ‘help’ line requires the identification of ability to solve complex and
simple problems. Task batteries were suggested on which subjects might be tested to improve
objectivity of scoring.
Simple problems were identified as routine everyday tasks, requiring familiar strategies for
problems that have arisen and been tackled before.
Complex problems may be new or unfamiliar tasks which have several stages or require
qualified judgement and forward planning.
Examples of simple and complex problems are given below. These are not intended to be
exhaustive but illustrative of the sort of task on which the subject might be assessed, which can
feasibly be used in a hospital rehabilitation setting.
•
•
•
•
•
•
Simple problem
Given a meal tray with no cutlery
Asked to put on a shirt – given it inside out
Asked to write – given unsharpened pencil
Getting something out of reach
Negotiating obstacles in a wheelchair
Preparing for a transfer
•
•
•
•
•
•
Complex problem
Planning a three-course meal
Planning a multistage journey
Planning a group activity
Self-medicating
Dealing with a broken piece of equipment
Being given the wrong change
29) Attention
Attention is renamed ‘Concentration’.
Concentration is defined in terms of the length of time the subject is able to concentrate on a
purposeful (nonautomatic) activity.
Some activities can be either automatic or nonautomatic. For example, eating may be an
automatic activity if it poses no problem for a subject, but nonautomatic if it requires
concentration to use adapted cutlery or overcome ataxia.
Cut-off points for the lower levels are defined in terms of the length of time for which they
concentrate on such an activity, e.g. <5 minutes, 5–15 minutes, 15–30 minutes, etc., and also on the
amount of help required to get back on track once distracted.
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The UK FIM+FAM: development and evaluation
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30) Safety judgement
Safety judgement reflects both physical and cognitive abilities and is renamed Safety awareness to
avoid the implication that subjects with severe physical disability have more limited opportunity
for being unsafe.
In Safety awareness, ‘be safe’ is replaced with ‘help to maintain personal safety’, placing
responsibility on the subject rather than the carer. Again, the wording emphasizes what the
subject does do, not what they would and could do and cut-off points for the lower levels are
defined in terms of the length of time for which they are safe to be left alone.
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