Immediate action is required to address the crisis in occupational therapy fieldwork education caused by the COVID-19 pandemic.

Accreditation is a function that ensures quality in higher education.  Many accreditation functions in higher education are regional, and schools must engage those accreditation processes in order for students attending to be eligible for many forms of financial aid.

Many professional educational programs are also accredited by discipline specific organizations, which are in turn themselves monitored by national accreditors.  In sum, there are multiple layers to the educational accreditation process that all serve as a quasi-public protection to ensure quality.

 The occupational therapy profession has a discipline specific accreditor, named the Accreditation Council for Occupational Therapy Education (ACOTE).  This group has a statement on educational quality that can be found here.  This policy states that

a profession is distinguished by a variety of factors.  Among these are a set of recognized educational standards for professional preparation; a credentialing mechanism for certifying its members; and a degree of autonomy in making decisions which guide its future.

As such, ACOTE establishes standards that all occupational therapy professional educational programs must follow.  One key standard listed in ACOTE's statement on educational quality is to

Ensure the integration of fieldwork education into the educational program so that it is implemented and evaluated as a key component of the overall curriculum design.

In order to accomplish that requirement, the ACOTE occupational therapy education standards  include an entire section on Fieldwork Education (Section C).  Additionally, entry level doctoral programs have an additional section on Capstone Experiences (Section D), that also dictate requirements for that experience that can also involve some aspects of supervised internship in the field.

Most notably, Standard C.1.5 states that occupational therapy educational programs must ensure that "fieldwork agreements are sufficient in scope and number to allow completion of graduation requirements in a timely manner; in accordance with the policy adopted by the program as required by Standard A.4.7."

Directly related, Standard A.4.7 states that "The program must have a documented and published policy to ensure that students complete all graduation and fieldwork requirements in a timely manner.  This policy must include a statement that all Level II fieldwork [and Doctoral Capstone, as appropriate] must be completed within a time frame established by the program."

ACOTE places such a high value on the fieldwork function that as of August 2020, all candidacy applications require that a qualified fieldwork coordinator must be hired full-time and on-site 6 months prior to the submission of the Candidacy Application.

In order to comply with standards set out in Section C, ACOTE requires that candidacy programs provide evidence of signed letters of intent for two Level II fieldwork placements for each student in a variety of settings consistent with the curriculum design.  For example, if a program anticipates accepting 60 students, the program must provide letters of intent for 120 student placements in the Candidacy Application.

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Because of the COVID-19 pandemic, occupational therapy educational programs have experienced severe disruption with student fieldwork placements.  This difficulty became evident starting approximately March 10th.  A crowdsourced Google Sheets document that was populated with data from academic fieldwork coordinators across the country quickly filled up to over 400 placement cancellations.  After that time schools around the country closed, our country began social distancing processes, and fieldwork placements became an even more distal likelihood.  Primary schools are closed and teletherapy is only being provided to a fractional number of students, hospital systems sent students home because the training was not deemed 'essential' and there was a shortage of personal protective equipment.  Clinical fieldwork placements are simply on 'hold' across the United States in many contexts.  Efforts to collect data on that original sheet were suspended and ACOTE has started collecting the data in a more formal context.  I understand that their data indicates the scope of this problem is tremendous.

The issue was not restricted to the occupational therapy profession, but has been documented as heavily impacting the nursing profession and even medical students.

Health care professions responded to this crisis with varying levels of flexibility, in accordance with corresponding flexibility in state licensing laws.  According to the American Occupational Therapy Association, 21 states have statutes dictating that occupational therapy fieldwork requirements must occur over a specific number of weeks.  This causes some challenge, because if some states offer flexibility to meet the needs of students who had their clinical fieldwork cancelled with only weeks to go in the experience, the students might not be eligible for licensing in another state with stringent time requirements.  Accordingly, implementing a national solution is challenging in the absence of a centralized set of fieldwork requirements for licensing.

ACOTE has released a statement outlining the details of this challenge and at this time are pointing to their standards related to Fieldwork (Section C) and Capstones (Section D).  There are no concrete 'solutions' to the problem of student fieldwork cancellation, and now programs are faced with a complex set of concerns:

1. Some current students who were on the fieldwork have been sent home, they can't finish their fieldwork, and their graduations are delayed.  This has a downstream impact of ineligibility to sit for the certification examination, obtain licensing, and enter the workforce.  Many students are simply in limbo.

2. Students who had fieldwork scheduled for this Summer and Fall are now beginning to hear that their placements have also been cancelled.  That will cause a similar threat to their graduation timeline, with all the same downstream impacts that existing students are experiencing.

At some point in time we will see clinical sites willing to take students again, but we don't know when that will be.  That uncertainty adds significant stress into the educational and clinical placement system.  We require solutions, and the following suggestions are offered for the interim period of time:

• ACOTE must immediately place a MORATORIUM and HOLD on all new applicant and developing occupational therapy educational programs.  In accordance with ACOTE's own  standards, educational programs must be able to demonstrate that there is adequate availability of student fieldwork experiences to meet the needs of the numbers of students who are planned for enrollment.  It would be irresponsible to allow new programs to develop in this context when it is known that fieldwork placements are constricted.  Furthermore, ACOTE has an affirmative obligation to its existing accredited programs to ensure that students currently enrolled have the best chance of being able to secure fieldwork experiences and complete their educational programs.  Existing programs should not be forced to compete with developing programs for scarce fieldwork slots.

• ACOTE must immediately place a MORATORIUM and HOLD on all program transition of Masters level programs to the Doctoral level that would include Capstone Experiences that might compete with traditional fieldwork sites.  Some doctoral Capstone Experiences might be in educational or non-traditional contexts that would not strain the fieldwork system.  Those should be allowed to continue.  However, some of those experiences might be clinical in nature.  At this time, it would be irresponsible to allow new program development if those programs were going to create Capstone Experiences that would take away from the traditional fieldwork placement of existing Level II students.

• ACOTE should involve broad stakeholders in making decisions regarding flexibility in student fieldwork experiences.  Flexibility and problem solving is desired by all stakeholders; however, we must be cautious that flexibility does not threaten the integrity of the certification and licensing process.  Those stakeholders in particular need to be regularly consulted and involved in all decision making processes.

• AOTA and ACOTE should continue efforts to forge a national solution for the varying requirements that are present in the licensing laws of different states.  This may take some time, and is probably not a solution that will bear fruit in the short term - absent federal intervention and dictum.  However, this is such a unique and severe threat that appeal to federal level authorities should also be considered.

• Longer term reforms are required in the clinical training requirements for the occupational therapy profession.  This pandemic event has strained the system and demonstrates inherent weaknesses that can be better planned for in the future.  Specifically, fieldwork should be constructed around the demonstration of competence on specific learning objectives and outcomes.  It should NOT be simply a function of a designated length of time.  Furthermore, to better strengthen the pedagogic connection of these experiences to the occupational therapy curriculum, we should consider calling these experiences 'Practice Education' as opposed to 'Fieldwork.'  This kind of name change can drive a new philosophy and approach so that this system can be re-imagined and strengthened for the future.