Reimagining Occupation 2020-2022: Perspectives of Occupational Therapists (Sandra Kirkwood)
‘Reimaging Doing,’ the theme for the celebration of World Occupational Therapy Day in October 2020, championed the call to re-imagine occupational therapy in each therapist’s practice and worldwide.
‘Overall, I invite and challenge occupational scientists to be imaginative in moving forward with a transformative agenda that addresses issues of occupational rights, equity and justice as “every great advance in science has issued from a new audacity of imagination” (Dewey, 1929/1984, p. 247).’
The
concept of re-imagining occupation was developed by occupational therapy
scholars (Hyett et al., 2019; Kinsella & Durocher 2016; Rudman 2019;
Townsend et al., 2012). The
purpose of this article is to review the relevant literature on ‘re-imagining
occupation,’ and to apply the knowledge to reflect on our 2020 experiences of
re-imagining occupation in adult rehabilitation services in Australia. During the 2020 COVID-19 pandemic, practice
as an occupational therapist shifted dramatically. There was upheaval in healthcare
employment and new initiatives in Telehealth by Medicare. Life as we knew it changed in many ways with requirements for isolation during the pandemic lockdown. This
resulted in greater opportunities for re-imaging occupation in adult
rehabilitation in 2020. Australia was different in some respects, particularly in bringing the outbreak under control so there were fewer deaths and less disability resulting.
The key questions are:
What does re-imagining occupation mean?
How is this concept expressed through our rehabilitation practice in Australia?
What is our vision for the future?
What Does Re-imagining Occupation Mean?
Definition of Occupational Therapy
Before 1994, the American Occupational Therapy Association (AOTA) defined Occupational Therapy as: “the art and science of directing man’s involvement in selected task to reinstate, reinforce and enhance performance, to facilitate learning of the skills and functions essential for adaptation and productivity, diminish or correct pathology and to promote and maintain health.” This definition recognised both ‘art and science,’ but did not use the term ‘occupation.’
Focus on Occupation
The focus on ‘occupation’ became clearer in 2012 through the World Federation of Occupational Therapists (WFOT) definition:
Occupational therapy is a client-centred health profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement (World Federation of Occupational Therapists 2012).
The WFOT definition expressed the need for occupational therapists to use occupational terminology in all aspects of service delivery. Practice was reconceptualised through assessments that focused on understanding the meaning of occupation for individuals within their unique, social and physical environments. This established new directions in therapy of working towards enabling occupation, rather than using a deficit-approach to remediating individual skills. Therapists supported service users to self-manage their own health by providing education and carer support services. However, there was a lag in understanding the philosophy of occupation within the multi-disciplinary team. In many cases, occupational therapists were expected to undertake discrete tasks that were assigned to them based on what they had always done. New vocabulary was needed to explain concepts of function in terms of occupation.
The World Health Organisation, International
Classification of Functioning, Disability, and Health (2012) placed
‘participation’ at the forefront in rehabilitation. Therapists used the
language of ‘enablers’ and ‘barriers’ to describe ways of facilitating daily living
activities, work and recreation. The new ICF vocabulary was more supportive of
empowerment of clients as they became partners in rehabilitation. The National
Disability Insurance Scheme (NDIS) used World Health Organisation terminology,
such as ‘assistive equipment,’ to re-shape how therapy services and equipment were
delivered. Service users may request internal review of decisions made.
The World Health Organisation (2001) International Classification of Functioning (ICF) has potential to stimulate community-based rehabilitation. However, funding models have not yet evolved to point of sustaining community-based occupational therapy rehabilitation. Medicare provides minimal financial stimulus for occupational therapy in primary health care, which is reliant on local doctor’s awareness of the need for services. The national My Aged Care (MAC) program directed government funding to support of elderly people living in their own homes. However, funding provided aged care packages to individuals without a strong occupational orientation to enabling function in daily living tasks and recreation. Occupational therapy became controlled and directed by national funding regimes (NDIS, MAC, Medicare), with little appreciation of the value of an occupational perspective, and how this would play out to enabling better function in people’s lives. Home modification funding was used to install grab rails and ramps in homes, but there was no population-based scheme to strategically plan accessible, adaptable housing for people with a disability nationally.
Occupation-Focused Models
Various models have emerged to foreground people's occupational performance, environmental context, participation and engagement. Sue Ren Wong and Gail Fisher (2015) compare and contrast three models that are commonly used by Occupational Therapists.
Canadian Model of Occupational Performance and Engagement (CMOP-E): Townsend & Polatajko, 2007; OT theory.
Model of Human Occupation (MOHO): Keilhofner, 2008. MOHO website.
The Person-Environment-Occupational Performance (PEOP) Model: Christiansen et al., 2005; OT theory.
Each model has different emphasis on concepts such as: enabling function, removing barriers, and advocacy for social justice. Various assessments and tools have been developed for practice and research which are based on each model's explanation of occupational performance. It is important to understand the frame of reference and evaluate which approaches and resources are most useful for re-imagining occupation in various contexts. The conceptual foundations are grounded in understanding of relationships with dynamic interactions between people-environment-occupational performance. People's habits, social roles, physical and political environments vary. Technology has risen in prominence as a context and modality for practice. The common theme is occupation.
How is Re-imagining Occupation Expressed Through Our Practice?
'In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do (WFOT 2012).' As an occupational therapist with 40-year experience in healthcare, education, aged care and disability services, I am aware of the potential for occupational therapists to take action in: scoping the assessment tools they use; undertaking consultation, planning and advocacy; developing a vision for the future; research and evaluation. This requires a radical re-thinking of the philosophy underpinning occupational therapy. A continuous, critical reflexivity is needed to question our habitual ways of being and doing. This collective re-imaging may occur through this process:
1. Scoping Assessment Tools
Firstly, scoping the choice of assessment tools that support re-imagining occupation, brings new insights. The WHO Disability Assessment Schedule 2 (WHODAS 2), the Model of Human Occupation assessment tools (MOHOST / OCAIRS), and the Community Integration Questionnaire Revised (CIQ-R) are planned for review to analyse the congruence with occupational performance approaches.
2. Consultation, Planning and Advocacy
Secondly, there are is potential for working at the population level through community consultation, strategic planning, and advocacy. This requires service planning initiatives that release occupational therapists from the limitations of their current duties.
3. Research Evaluation and Outcome Measurement
Thirdly, occupational therapists need to be able to demonstrate through research and outcome measurement, a shift toward re-imagining occupation, and the benefits this brings. Traditional outcome measurement tools such as the commonly used, Functional Independence Measure (FIM), for example fails to consider factors outside of the individual (Ferrucci et al., 2007). Analysis of outcome measurement tools is recommended, to identify those tools that best support occupational approaches in adult rehabilitation.
What is Our Vision for the Future?
There is growing awareness of the need to address inequities in healthcare and workforce planning. Health is understood in a holistic way, as the interaction of many factors, not just internal to the individual. Our occupational goals, environment, and performance result in varying level of health that can be modified by our own actions. This translates into an occupational perspective of health by considering people’s values and beliefs within an environmental context.
Occupational therapists bring new perspectives as they re-imagine occupation in diverse adult rehabilitation settings. In Australia, Aboriginal perspectives of health are holistic. Occupational therapists collaborate with Aboriginal-controlled community services on social determinants of health as they work on housing, systemic advocacy, and advocacy for supporting access and equity. There is potential for occupational therapists to work at all levels of healthcare and in community-based rehabilitation in new ways, to facilitate systemic social change. Occupational understandings open opportunities in emerging areas for rehabilitation. Examples of case studies which promote changes in traditional practices can be located in the Australian Journal of Occupational Therapy.
Further research and reports of practice are needed. Karen Whalley Hammell challenges occupational therapists in 'Building back better: Imagining an occupational therapy for
a post-COVID-19 world.' Whalley Hammell describes social inequities and structural injustice in healthcare that were exacerbated by the Covid-19 pandemic. She argues for 'Building Back Better,' by recognising colonial neo-liberal ableist ideology at the core of occupational therapy theory and practice, and making adjustments to prioritise well-being, equity, and social inclusion. This involves moving beyond the traditional areas of self-care, productivity that have been the focus of occupational therapy for generations. The call is to re-imagine a renewed occupational therapy for the post-pandemic world.
A Call to Action
What is needed in the future is diligence in questioning and applying occupational perspectives to current and emerging needs of society. For example, the COVID-19 pandemic raised the need for people’s engagement in meaningful occupations while they were in isolation. Occupational therapists adapted their usual methods and used telehealth platforms when they were unable to see people face-to-face. Creativity and well-informed adaptation of strategies underlie occupational activity analysis—a process of tailoring intervention to occupational goals by providing graded levels of support over time. The knowledge of occupational performance and level of support required can be applied to all areas of living.
Recommendations
Therefore, it is essential to consider employment of occupational therapists as assessors for funding and support services, to inform a renewed conceptualisation of directions for rehabilitation initiatives. Provision of support services and assistive equipment will not necessarily result in changes in people’s functional ability, unless there is an occupational rehabilitation agenda that is negotiated with service users and service providers. Monitoring and evaluation of rehabilitation services by occupational therapists determines if occupational goals are on track for being met in a timely way. This requires strategic planning and service renewal.
Education is required to ensure better understanding of occupational perspectives in health. Occupational therapists are uniquely equipped to provide education and training in occupational performance approaches to the multi-disciplinary team, services users and their significant others.
Changes to workforce planning and funding is required to accommodate the re-imaging occupation process. If occupational therapists are to take on consultancy, advocacy, and education roles, then economic stimulus is needed to establish referral pathways and more strategic utilisation of occupational therapists in community and hospital-based rehabilitation services. Further research is required on tools for occupational performance outcome measurement once changes in service direction are established. The shift to a more occupational approach is measured through attainment of occupational goals by the individual, and at the societal level.
References
Callaway
L, Winkler D, Tippett A, Migliorini C, Herd N, & Willer B (2014) The community integration questionnaire--revised (CIQ-R).
Summer Foundation, Ltd.
https://www.summerfoundation.org.au/wp-content/uploads/CIQ-R-Normative-Data-Report-2014.pdf
Christiansen C, Baum C, & Bass-Haugen J (Eds) (2005). Occupational therapy: Performance, participation and well-being (3rd edition). SLACK Incorporated.
Ferrucci L, Koh C, Bandinelli S, & Guralnik J (2007) Disability, functional status, and activities of daily living. Encyclopedia of Gerontology, 427-436. https://doi.org/10.1016/B0-12-370870-2/00075-5
Hyett N, Kenny A, & Dickson-Swift, V. (2019) Re-imagining occupational therapy clients as communities: Presenting the community-centred practice framework, Scandinavian Journal of Occupational Therapy, 26(4), 246-260, https://doi.org/10.1080/11038128.2017.1423374
Kinsella EA, Durocher E. (2016). Occupational justice: Moral imagination, critical reflection, and political praxis. OTJR: Occupation, Participation and Health. 36(4):163-166. https://doi.org/10.1177/1539449216669458
Kielhofner G. (2008) Model of human occupation (MOHO): Theory and application (4th ed.). Lippincott Williams & Wilkins.
Model of human occupation (MOHO) website. https://www.moho.uic.edu/
OT theory CMOP-E. https://ottheory.com/therapy-model/canadian-model-occupational-performance-and-engagement-cmop-e
OT theory PEOP-E. https://ottheory.com/therapy-model/person-environment-occupation-performance-model-peop
Rudman, D. (2014) Embracing and enacting an ‘occupational imagination’: Occupational science as transformative, Journal of Occupational Science, 21(4), 373-388, DOI: https://doi.org/10.1080/14427591.2014.888970
. (2019) Engaging the occupational imagination: Meeting in diversity. Journal of Occupational Science. 26(2), 165-172. https://doi.org/10.1080/14427591.2019.1577443Townsend E, & Polatajko, H. (2007) Enabling occupation II: Advancing an occupational therapy vision for health, well-being, and justice through occupation. Canadian Association Occupational Therapy CAOT-ACE.
Townsend E, Wicks A, van Bruggen H, Clair V. (2012) Imagining occupational therapy. British Journal of Occupational Therapy. 75(1), 42-44. https://doi.org/10.4276/030802212X13261082051490
Whalley Hammell, K. (2021) Building back better: Imagining an occupational therapy for
a post-COVID-19 world. Australian Occupational Therapy Journal, July, pp. 444-453. https://doi.org/10.1111/1440-1630.12760
Wong S, Fisher G. (2015) Comparing and using occupation-focused models. Occupational Therapy In Health Care, 29(3), 297-315.
World Federation of Occupational Therapists. (2012). About occupational therapy: Definition of occupation. https://wfot.org/about/about-occupational-therapy
World Health Organisation. (2001). International classification of functioning, disability, and health. https://www.who.int/classifications/international-classification-of-functioning-disability-and-health
World Health Organisation. Disability assessment schedule 2 (WHODAS 2). https://www.who.int/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule
Comments
Post a Comment