Scoring a participant who declines a second demonstration

Question:

I have a question regarding scoring the lacing task.

The participant completed the running stitches and whipstitches following 1 demonstration. The participant then corrected both errors appropriately. 

Regarding the cordovan, the participant attempted the single cordovan stitch without demonstration. Participant completed 1 stitch whereby the lace was twisted. The therapist provided the participant the verbal cue; Does your stitch look like mine? Participant was then able to identify that the stitches were not the same. Participant continued ineffective problem-solving strategies to form a correct stitch before accepting the therapist’s offer of a demonstration. Participant made a secondary attempt at the task and completed 3 stitches. In Participant's second stitch, the lace was twisted. Participant stated "Mine is a bit messier than yours," and declined the therapist’s offer of a second demonstration.

Considering that the participant declined the offer of a second demonstration, does this put them back to a 4.4?

I have attached an image of the participant's stitch. Additionally, the participant scored 28/30 on the MoCA. 

Response:

Thanks for the photo and the detailed description. I’ll talk you through my clinical reasoning for the assigned score, which I hope will be helpful.

Starting at the RS and WS, we can confidently say the client met criteria for Level.Mode 4.4, as they corrected the twisted stitch in situ.

From there, we work backwards from Level.Mode 5.8:

5.8 – The client did not meet any criteria.

5.6 – The client did not benefit from a hint, and three correct single cord (SC) stitches in consecutive holes were not completed (including correct orientation/no twists).

5.4 – The client did not complete three correct SC stitches in consecutive holes after one demonstration.

5.2 – The client declined a demonstration. Clients at 5.2 usually accept a demonstration, so this suggests they do not have the functional cognitive skills to complete the stitch even if a demonstration were provided. Therefore, they did not meet criteria for Level.Mode 5.2.

We can then look at whether the client met criteria for any lower scores following one demonstration:

5.0 – The client did not complete any correct SC at any time after one demonstration. Although it is difficult to see clearly, I believe your thumb is on the front of the leather rectangle. Therefore, the client is not consistently going from back to front through the hole and loop. The client did not spontaneously recognise errors and required prompting. You noted that the client made problem-solving attempts, but these were not described. At 5.0, clients typically find a solution to the error but do not retain it, which is why you usually see at least one correct SC or some consistency in approach, even though they have to “find” the solution each time and correct one problem at a time. These skills were not demonstrated, so a score of 5.0 is not supported.

4.8 – The client did not go from front to back through the hole and loop and did not demonstrate correct needle directionality. Stitch performance appeared random. You did not describe attempts to tighten the stitch by pulling on the long lace with greater force or in different directions. Performance did not improve after the demonstration. Therefore, criteria for 4.8 were not met.

4.6 – Clients at this level usually accept a second demonstration. They go through the hole and loop from front to back (and may push the needle through the loop a second time), or they go from front to back through the hole and loop but get the directionality wrong. The stitch is not tightened. These skills were not demonstrated, so criteria for 4.6 were not met.

4.4 – The client may decline a second demonstration (meets criteria); makes a whip stitch and comes through the loop from the back i.e., front to back through the hole and back to front through the loop; (meets criteria). They also appear to have used the other method common at 4.4—going through the hole from front to back and immediately pushing the needle through the loop from the back as if it were one step. The client did not recognise an incorrect stitch (meets criteria).

Performance does not improve after a second demonstration below 5.2. The second demonstration is primarily for clients at 5.2. At  5.2 the 2nd demonstration improves our performance so we can do 3 correct SC. We accept a 2nd demonstration between 4.6 and 5.0. Refusal of a second demonstration is common at 4.4 and below. The client did not recognise that their stitch differed from yours, instead attributing it to “untidiness.”

In summary, assigning a score of Level.Mode 4.4 is appropriate for this client.

It is somewhat surprising that the client scored 28/30 on the MoCA; however, I have seen this in older adults who rely on procedural knowledge and two-dimensional problem-solving to answer questions. Given the MoCA score of 28, I would suggest putting a little more effort into verification of the screen score. If the client does not verify at 4.4, I would next look at 4.6, in case what we are seeing reflects personalisation of the task. Did she, by any chance, tell you that her stitch was better? If so, that would be evidence supporting 4.6. It would be very unlikely that you would verify at 4.2. If 4.6 does not fit, it would be valid to assign a verified score of 4.8. Unless she was just having a bad day (in pain, dehydrated, bad news, angry, etc.) it is unlikely she will verify at a higher level.mode than 4.8.