Why students will be making elevator speeches to define OT for another 100 years

A new day, a new document, a new definition for the profession:

For many years, the American Occupational Therapy Association has stated that students need to promote the profession by developing an effective 'elevator speech' explaining occupational therapy. This essay explains that the reason why students will be making elevator speeches for the next 100 years is because the leaders of the profession keep changing definitions about what OT is and who it serves.

+++

There is a new draft document on The Philosophical Base of OT Education that is going to be debated and voted on by the Representative Assembly.  The current document was published in 2007.

There are contrasting statements in the two documents.  From the 2007 document:

Occupational therapy education promotes integration of philosophical and theoretical knowledge, values, beliefs, ethics, and technical skills for broad application to practice in order to improve human participation and quality of life for those individuals with and without impairments and limitations.

And from the proposed document:

Occupational therapy (OT) education prepares occupational therapy practitioners to address the occupational needs of individuals, institutions, communities, and populations. The education process includes both academic and fieldwork components. The philosophy of occupational therapy education parallels the philosophy of occupational therapy, yet remains distinctly concerned with beliefs about knowledge, learning and teaching.

+++

The new document seems to suggest that in the last seven years there has been a consensus paradigm shift in that the profession of occupational therapy has a professional scope of practice that now includes addressing the occupational needs of individuals, institutions, communities, and populations.

I understand that there are some members of our Academy who believe this to be true, and I also understand that there have been some successful efforts to get this kind of wording into Model Practice acts, but I would like to know the practical and field evidence that supports this kind of wording, outside of what some people are wishing to be true.

This kind of language takes us out of sync with many state practice acts that still identify OT as a health related profession.  Most state practice acts do not support the notion that OTs are licensed to solve the occupational problems of entire communities and populations.

At some level, I suggest that we need to have congruence between what we say we teach and what the field actually does.  If our leadership fails in this, then they place our entire profession in peril.

Many states primarily define occupational therapy around treatment of individuals.  The word 'client' is used but generally refers to human clients, and the regulations supporting the practice act are all oriented around 'client factors' that are typically addressed.  Additionally, practice requires involvement of the MD to provide referrals in most cases.

The newer definition of ‘client’ is individuals, institutions, communities, and populations.   There is no consistency in how we have defined 'client' over time.  Rather, there is a steady stream of incrementalism in our professional documents that continues to drift away from our philosophical core.

The ongoing changes to the Practice Framework provides prima facie evidence of incrementalism.

There is a new focus in the OTPF 3rd ed. in that "Clients are now defined as persons, groups, and populations." (p.S2.).  The document itself lists this as a "MAJOR REVISION" (p. S2).  Use of the term "MAJOR REVISION" is taken directly from the document and makes a claim of consistency difficult to understand.  The OTPF 2nd edition made some reference to 'broader definitions of client' including populations of people but the OTPF 3rd edition is more explicit.  Furthermore, additional MAJOR REVISIONS include "The relationship of occupational therapy to organizations has been further defined." (p. S2).

In fact, the document now more boldly states "Services are provided directly with clients using a collaborative approach or on behalf of clients through advocacy or consultation processes." (p.S3).  The extension of the definition of occupational therapy goes even further: "Finally, organizations employ occupational therapy practitioners in roles in which they use their knowledge of occupation and the profession of occupational therapy indirectly.  Practitioners can serve in positions of dean, administrator, and corporate leader.  These positions support and enhance the organization but do not provide client care in the traditional sense." (p.S3).

The Practice Framework states that it "builds on a set of values that the profession has held since its founding in 1917."  (p.S3).  This is outright revisionism.  I would like to see some citation from the founders of the profession that would support calling a college dean or an administrator an 'occupational therapist' as they function in their non occupational therapy jobs.

This is all just evidence of severe drift from our purpose as a profession.  100 years ago we started as a health and perhaps social service profession that directs its efforts toward individuals so that they can function more independently for the benefit of themselves and the benefit of society.    Now we are stating that occupational therapy promotes social and occupational justice, advocates for laws and social policies, and has an expanded view of client that now includes institutions so that being a dean can now be practicing OT, if you are using your OT knowledge.

The failure of the Practice Framework, and the potential failure of this new document on the philosophy of education, is that the reality of what most OTs actually do in their jobs is lost.  It is replaced by this expanded conceptualization of OT.  I will again state that there is absolutely nothing wrong with occupational therapists using their knowledge and skills in service of many different job functions.  That does not make everything that an OT can do 'occupational therapy.'

Professions have a social contract, and the public has an expectation of what services a profession will provide.  The OTPF and this new Philosophy of Education document includes an incremental redefinition of our profession.

Presenting ourselves as occupational therapists is not the same as claiming that everything we do is 'occupational therapy.'  When we fail to make this distinction, we are breaching our social contract.

++

 Why we need to have a defined scope of practice that comports with reality

Aside from any definition that may or may not be included in any practice act, it would be helpful to know how much of what people are identifying as OT intervention is being carried out on buildings and oppressed communities and populations of people.  It is a big world and I don't doubt that there may be a few people who are providing occupational therapy to buildings, but before we change the definition of our profession any further we should probably consider evidence.

It is my belief that we should be protecting our actual scope of practice with actual language that reflects what most people do.  We should not be populating our definitions and our practice acts with erroneous ideas about what constitutes occupational therapy.

We need to start making distinctions between THE WAYS THAT PEOPLE USE THEIR OT SKILLS and WHAT CONSTITUTES OT PRACTICE.

When a lawyer enters politics, they become a politician and they cease being a lawyer.  They use their law skills but it is NOT PRACTICING LAW.

The same is true for occupational therapy.  When you design an accessible playground you are using your OT skills, but you are not PRACTICING OCCUPATIONAL THERAPY.   LOTS of other people can do that job too, and they are not PRACTICING OCCUPATIONAL THERAPY.  If we define our practice as things that many other people can do, we no longer have a profession that is worthy of licensing!

That does not make designing accessible playgrounds an unimportant task.  If we want to survive in the health care arena we need to start distinguishing between what actual 'therapy' is and what 'use of OT skills in related tasks' is.

A core need in a regulated profession is to have congruence between what its Academy says it does and what its professionals do on a daily basis when they are practicing their profession.

As a part of regulation, State practice acts tend to spell out the specifics of intervention in terms that are labeled 'scope of practice.'  This 'scope of practice' defines the legal activities that the public can expect from the licensed professional.  This list protects the public and prevents professionals from engaging in activities that are beyond its legal scope.

In all professions, there are MANY ancillary activities that professionals may engage in that don't precisely represent 'practice' of the profession.  Many of those ancillary activities draw upon the related knowledge of the professional.  However, since those activities might be reasonably completed by a number of people with a number of different skill sets, engaging in those tasks can't be considered a unique scope of practice of any particular discipline.

As an exercise that demonstrates this, consider which professional is most appropriate for the job:

1. Consulting to planners on ADA requirement for bathroom accessibility in a new office complex
2. Leading a community group that investigates universal design elements in a playground
3. Developing a falls prevention program and presenting to a senior citizen group
4. Promoting a clubhouse model when developing a community mental health program
5. Providing a bullying awareness program in an elementary school
6. Advocating at a common council meeting for curb cuts in a downtown shopping area
7. Participating on a design team in developing powered mobility devices for toddlers
8. Raising awareness of human sexual trafficking and suggesting alternate policing strategies
9. Developing an after-program fitness event for parents and children in a local Head Start
10. Writing a grant to obtain funding for more library materials for people with visual impairments

In these ten examples, you might expect that different people would write in OT, PT, nurses, doctors, architects, engaged citizens, social workers, generic human service workers, grant writers, civil engineers, and an almost endless list of other people who might be qualified.

The point is that this kind of systems consultation, or service to populations, or whatever it may be called - does not represent a unique practice role for occupational therapists.  That does not diminish the importance of these tasks.  It just does not make them unique to the OT Scope of Practice.

When we conflate the profession of occupational therapy with the ancillary good things that an occupational therapist might do with their skills we WEAKEN our ability to express a cogent message to the public about what the profession is.

Many practitioners struggle with reimbursement in a health care context.  What messages are we sending when we say that the practice of OT also involves ancillary consultative activities that might be carried out by any number of professionals?

What kind of unnecessary resource drains and legal challenges do we expose ourselves to by conflating our ancillary activities with our actual professional practice?

+++

How do we solve this problem?  

We solve this problem by distinguishing "OT Practice" from "Fun things you might do with your OT credentials someday."  I strongly speak against the continued push to put this language in our official documents.  We can respect the good work that OTs do in these areas without continuing to confuse our public about what our profession is licensed to do in a therapy context.

As there has been a call for fact-based information, I offer the following for consideration by the RA when they discuss the proposed document:

The NBCOT Practice Analysis is a useful tool to help determine level of frequency of occupational therapy tasks engaged in by new practitioners.  The activities of new practitioners should be a good point of critical reflection for educators when they are considering documents about the philosophy of education.  Hopefully, there is some congruence between the way that educators are preparing students and the tasks that those students engage in once they are in the field.

Dunn and Cada (1998) reported the results of the 1998 NBCOT Practice Analysis and in this article they identified population-based services as a practice area of new emphasis.  That Practice Analysis included a survey of over 3000 occupational therapy practitioners.  Validated knowledge and skill statements were rated for frequency.  Population based services were rated at a low frequency of 4% to 5% but this was adequate frequency that it was included in the analysis report.

In the subsequent Practice Analysis (NBCOT, 2008) services to populations was no longer a separate domain as it did not reach the level of frequency that was evident in the previous analysis.  Instead, services to populations had diminished frequency and was reflected only as an isolated point of knowledge, underneath the larger domain of "Selecting and implementing evidence based interventions."  Accordingly, a much smaller percentage of items on the exam reflected this area.

The most recent NBCOT Practice Analysis (2012) surveyed nearly 3000 practitioners and there was again very low frequency of population based services.  In the most recent analysis such services are reflected at the task and knowledge level related to overall program development and advocacy.  There was not a high enough frequency that this would be listed at a domain level.

I have significant personal and institutional knowledge of all these Practice Analyses as a function of my volunteer record with NBCOT.  I recall with specificity the issue of population based services when it appeared in the analysis.  As a member of the Exam Development Committee, and later as a leader of that group, I recall item writers struggling because so few people had any direct experience with population based services at that time and there was a paucity of reference materials that could support an item on the certification examination.

I have very specific and direct recollection and validated my recollections by discussing this issue with other people who were deeply involved at that time.  At that time of that 1998 Practice Analysis we had conversations wondering why population based services appeared as a validated domain.  People have mused that it may have been related to the BBA of 1997 changes at the time that left so many OTs unemployed and looking for 'ancillary' work where they could use their OT skills.  It was notable that the reported frequency of those activities dropped in the 2008 and 2012 Practice Analyses, once the immediate BBA crisis subsided.

Frequency of task engagement is a functional metric that should be used by the profession when it is defining its activities and scope of practice.  Services to populations or whole communities are a low frequency activity and do not represent a common area of occupational therapy practice.

When combined with the other pragmatic challenge of determining if such activities even represent a unique occupational therapy role, it remains rather puzzling that this is a continued point of emphasis in our professional documents.  When we are creating broad-reaching documents about the philosophy of the occupational therapy profession and how we are educating future clinicians, it is difficult to understand why there would be an extensive focus on such a constricted area of actual practice.

Bottom line questions for the RA: 

1. Should we define our profession in such terms that only represent the activities of a fractional portion of our membership as has been verified by Practice Analysis?

2. With stipulation that ancillary activities are valuable in their own right, on what justification do we define our practice by minority activity, particularly when there is not evident consensus that these activities even represent a unique role of occupational therapy?

3. Just because we have a history of shifting definitions that don't make good sense, is it adequate justification to continue down a path once we have facts that should cause us to stop and pause?

References:

American Occupational Therapy Association (2008). Occupational Therapy Practice Framework: Domain & Process 2nd Edition.  American Journal of Occupational Therapy, 62(6), 625-683.

American Occupational Therapy Association (2014). Occupational Therapy Practice Framework: Domain & Process 3rd Edition.  American Journal of Occupational Therapy, 68, S1-S48.

Cada, E. and Dunn, W. The National Occupational Therapy Practice Analysis: Findings and Implications for Competence.  American Journal of Occupational Therapy, 52, 721-728.

NBCOT (2008). Executive Summary for the Practice Analysis Study. Registered Occupational Therapist OTR®. Retrieved Oct 30, 2014, from http://www.nbcot.org

NBCOT (2012). Practice Analysis of the Occupational Therapist Registered OTR®. Retrieved Oct 30, 2014, from http://www.nbcot.org