Future Directions in Employment, Occupational Rehabilitation, and Disability: Introduction to the Special Section

Purpose From an array of disciplinary perspectives, the articles in this special section examine opportunities and challenges in the economic, social, and civic participation of individuals across the spectrum of disabilities. Methods At multiple levels of analysis, the contributors consider employment law and policy frameworks, occupational and vocational rehabilitation strategies, and corporate practices in support of the full and equal inclusion of people with disabilities in society. Results and Conclusions The implications for policymakers, public and private sector stakeholders, and occupational rehabilitation professional are presented to help inform future policies, practices, and strategies to improve employment outcomes for people with disabilities.

Reflection as a Means to Foster Client-Centred Practice

Background. Client-centred practice embraces important concepts about partnership and justice that promote client participation in meaningful occupations. It is important to understand how occupational therapists can engage in and continue to develop client-centred practice within the constraints of everyday settings. Purpose and Methods. An action research study was undertaken by a group of four occupational therapists to describe insights gained, and to show the effectiveness of participation in reflective education to help foster client-centred practice. Results. The six main insights generated by the group involve: congruence, understanding the potential, environmental factors, personal factors, expectations, and lifelong learning. Practice Implications. Although actual change to daily practice was limited, group members felt the reflective group discussion provided them with a launch pad to start a journey toward more client-centred practice. This may be the key to moving beyond simply changing the face and language of occupational therapy practice toward a deeper understanding and implementation of client-centred practice to improve client outcomes. Suggestions are provided for implementing reflection to help continue to develop your own practice.

National Perspective

The future holds great promise for occupational therapists. Our success in utilizing the opportunities afforded by continuing changes in health care depend on our ability to recognize and act on potential beneficial trends as well as effectively address our challenges. Development of effective partnerships, obtaining required new knowledge and skills, ongoing commitment to evidence-based practice and quality service and demonstrating personal and collective responsibility for advocacy and promotion are key factors for our ability to prosper in these changing times.

The Recovery Paradigm: Should Occupational Therapists be Interested?

Background. The mental health literature attests to a paradigm shift from an emphasis on treatment towards a focus on fostering recovery. This paradigm emphasizes many constructs familiar to occupational therapists, including quality of life, empowerment, hope, meaningful activities and work. Occupational therapists are not only familiar with these terms, but have addressed recovery-related constructs in both research and practice. Method and Purpose. Literature on the recovery paradigm, mental health and occupational therapy was reviewed to gain an understanding of this paradigm and its relationship to occupational therapy in mental health. Result. Core occupational therapy beliefs and assumptions are strikingly similar to those purported to be important to fostering recovery. Implications. Occupational therapists should consider taking a keen interest in the construct of recovery. By virtue of professional beliefs and assumptions, occupational therapists are uniquely positioned to assume a leadership role in the area of recovery—related research and practice.

Developing Agentic Learners for 21st Century Practice: A Pedagogic Approach in Occupational Therapy

In this paper, an approach to teaching occupational therapy students how to create orthoses, whilst at the same time developing higher-order critical thinking, reflective, and clinical reasoning skills is described. The scaffolded nature of the learning activities, incorporating Kolb's reflective learning cycle, was used to support students' capacity for clinical reasoning and better prepare them for clinical placement. The peer-assessment element was also designed to support the experiential learning by allowing students to test their evaluation of hand orthoses, compare their assessment with an expert's, and identify areas for improvement. Students who demonstrated higher grades for the written reflection assessment showed better agreement with the experts (smaller bias, p<0.01). This study concluded there was a correlation between students' capacity for reflective thinking and the development of clinical reasoning. Furthermore, the reflective writing exercise encouraged students to generalise their skills beyond the classroom. The approach and findings of this study are relevant to a range of allied health professions through providing a process to support the development of higher-order critical thinking, reflection, and reasoning skills. Furthermore, the study provides an evidence base to demonstrate that higher reflective skill capacity and critical thinking are crucial to creating agentic learners.

[Occupational therapy: achievements and problems]

Occupational therapy is topical and attracts attention of various medical specialists, for being on junction between clinical, hygienic, social and economical sciences. The authors present major directions of research and practical work of the Institute from its foundation till nowadays.

Occupational rehabilitation in Hong Kong: current status and future needs

INTRODUCTION

This paper reviews the development of occupational rehabilitation in Hong Kong, both in terms of the science as well as the service for injured workers. Besides, it also reviews the existing Employees' Compensation Ordinance for work injury to illustrate how the policy could influence the success and development of the discipline.

METHODS

Five experienced occupational rehabilitation providers, including 1 occupational medicine specialist, 3 occupational therapists, and 1 physiotherapist critically reviewed the past and current development of occupational rehabilitation in Hong Kong as well as the local contextual factors, which could influence its future development.

RESULTS

Since the enactment of the Employees' Compensation Ordinance in the 1950s, there have been progressive improvements in the field of occupational rehabilitation in Hong Kong. Services in the early years were mostly based on the biomedical model, where doctors and patients tended to focus on clinical symptoms and physical pathology when making clinical decisions. Since then, remarkable academic achievements have been made in the field locally, from the validation of clinical instruments for assessment of work capacity, assessment of employment readiness to the evaluation of efficacy of interventional programs for injured workers focusing on work related outcomes. However, there has been a relatively lack of progress in the development of related policies and implementation of related programs for occupational rehabilitation. There is no built in linkage between rehabilitation, compensation and prevention in the current system in Hong Kong, and there is no rehabilitation policy specific to those workers with occupational diseases and injuries.

CONCLUSIONS

There are still deficiencies in the development and provision of occupational rehabilitation services in Hong Kong. Incorporation of requirements for occupational rehabilitation at the legislation and policy levels should be seriously considered in the future. Besides, the development of the Occupational Medicine subspecialty in the public hospital system in Hong Kong is considered a facilitator to the future development of occupational rehabilitation in Hong Kong.

An emerging occupational rehabilitation system in the People's Republic of China

INTRODUCTION

China has become a major economic influence in Asia and globally. The country is in the position to further develop its workers' insurance and compensation system. This paper aims to introduce the existing workers' compensation policies, explain how these policies guide the operation of the occupational rehabilitation system for injured workers, and suggest ways to further develop an effective and sustainable system for the country.

METHODS

Major government policies and initiative documents and existing literature on occupational rehabilitation were critically reviewed. Shortfalls in our current system were identified and potential further development regimes were propose.

RESULTS

Since 2004, China has implemented its national policy on providing timely and comprehensive rehabilitation and return-to-work interventions for workers who are injured at work. The three-tier medical and occupational rehabilitation system appears effective for enabling injured workers to access these services. Such a system is regarded as the most optimal for the country in spearheading the development of quality occupational rehabilitation services, and at the same time incorporating the existing expertise in acute medical care and rehabilitation within the public medical and health system. Problems encountered in the system can be classified under the culture, system and competence building aspects.

CONCLUSION

The future workers' insurance and compensation system can probably put more emphasis on using bio-psychosocial and work disability prevention models in guiding its service development and delivery. Efforts need to be placed on building the competence of professionals in the system who provide services for injured workers. The empowerment of important stakeholders in the workers' insurance and compensation system and their inclusion in the planning of service delivery are crucial for developing a sustainable and effective system for China.

Occupational therapy - meeting the needs of older adult workers?

OBJECTIVE

The purpose of this phenomenological study was to explore and better understand (a) why aging workers continue to work past retirement age, (b) how aware occupational therapists are of the needs of the growing demographic of the aging worker, and (c) potential occupational therapy interventions that could better help this population.

METHOD

This study was conducted with a mixed method design approach, specifically the parallel/simultaneous design, which consisted of both qualitative and quantitative investigation. The quantitative portion of the study focused on data obtained from the surveys and the qualitative portion was based on phenomenological interviews of aging workers.

RESULTS

Themes emerging from the interviews demonstrate the importance of health promoting habits and family support in providing the critical foundation to maintain employment past age 55. Financial stability was a key motivator which compelled the interviewees to continue working. The older workers had no planned date for retirement and felt confident that the knowledge and life experience they offered were important qualities they brought to the workplace. The survey showed a need for occupational therapists to become more responsive to the growing demographic of older adult workers as they reported limited service enhancement and expansion for this group.

CONCLUSION

Aging workers are prime candidates for occupational therapy. However, the profession appears to be overlooking opportunities to meet the needs of these productive community members. Occupational therapists need to better respond to the physical, social, psychological, cognitive, and environmental challenges faced by this well population. The authors challenge occupational therapists to alter services, seek funding and obtain continuing education so they are better equipped to establish and enhance effective programs for this growing population.

The growth of the profession of occupational therapy

Occupational therapy is a frequently unknown and misunderstood profession. However, occupational therapy practitioners have a rich history in the US Army, from the inception of the profession to current challenges. The article is a chronicle of historical highlights of occupational therapy which discusses how this history is harmonious with that of occupational therapy in the US Army. In researching this topic, several concepts emerged: (1) occupational therapy grew from a belief that people need occupation, or activity, to remain healthy; (2) people learn the best through purposeful activity; (3) the number of occupational therapists in the US Army decreases during peacetime, but in time of war the benefit of this profession is recognized and its numbers increase; (4) although models of health care change, the primary focus of occupational therapy remains constant; and (5) there is a direct correlation between the philosophy of occupational therapy and the philosophy of treating Soldiers with combat stress reactions, a "go-to-war" mission of Army occupational therapy practitioners. As such, the management of these Soldiers is enhanced by the unique skills offered by this profession.

The use of craft activities as an occupational therapy treatment modality in Norway during 1952–1960

The purpose of the present study was to explore the use of craft activities as occupational therapy treatment modalities in Norway during the period 1952-1960. Data were obtained through in-depth interviews with six retired occupational therapists on their experiences in using crafts. Data were analysed through textual analysis and this resulted in four themes: craft activities identified as a therapeutic tool; ambivalence in how to frame the intervention; practice relative to power relationships; and occupational therapists and patients as equals. A limitation of the present study was that participants drew on their screened memories in the context of contemporary practice, which may omit or distort the historical truth. Further research is needed to document the effect of contemporary therapeutic use of craft activities, and to bring forward how occupational therapists and clients value the craft activities of today in the context of their lives.

Changing practice patterns of school-based occupational therapists in Israel

Following the enactment of the Special Education Law in Israel in 1988, school-based occupational therapists (OTs) were expected to modify their practice patterns by, providing services within the classroom or other educational settings, increasing collaboration with other team members, and implementing indirect intervention models such as monitoring and consultation. The purpose of this study was to examine the intervention patterns of school-based OTs in Israel. The study sample included 77 school-based OTs. The survey was carried out through a questionnaire which included: (1) background information, (2) implementation and perceptions towards intervention models, and (3) team-work practices of the OTs. The findings indicated that most of the time (76.9%) OTs still implement the 'direct therapy' model, working outside the classroom and focusing on improving performance components. These findings imply that school-based OTs in Israel are still in the process of changing their practice patterns, and are mostly applying the medical model. However, due to the relatively small sample, it is important to repeat this survey using a larger sample of OTs who work in different settings and with various age groups.

Time, Space, and the Kaleidoscopes of Occupation

Our daily round of occupations occurs within time and space. Our understanding of occupation has traditionally viewed time and space as part of the external environment. Patterns of the “when?” and “where?” of occupations can be described. But relating time and space to the internal experience of occupation reflects more of the meaning to individuals and more complex patterns arise. Like the varied bits of glass in the object case of an art kaleidoscope, the multiple elements of occupation interact. Reflected in mirrors of our choice, we find always-changing, complex patterns of daily occupation. The elements of occupation most important for maintaining or regaining health and the mirrors and lens through which we view occupation historically have formed shifting patterns in occupational therapy, patterns of how we view ourselves, our practice, and those to whom we provide our services. We must combine the science and the art of occupational therapy as the metaphor of the kaleidoscope combines both, producing awe and wonder at the result.

Challenges and Strategic Solutions for a Research Emergent Profession

This paper explores some of the truisms associated with evidence-based practice. The intention is to remind the reader that evidence-based practice is a decision-making tool and not a rule; and to propose a strategic approach to overcoming the challenges we face as a research emergent profession.

Recent advances in physical and occupational therapy for children with cerebral palsy

Recent research and conceptual frameworks that emphasize family centered care and participation in family, school, and community life have contributed to advances in provision of health care by physical therapists and occupational therapists to children with cerebral palsy (CP) and their families. This article provides a contemporary perspective on physical and occupational therapy for children with CP. Topics include conceptual frameworks, early identification, prognosis for gross motor function, implications of impairment in motor control and muscle performance, and physical fitness and secondary prevention. Case scenarios and examples illustrate how current knowledge and research is applied to decision making within the context of the individual child and family.

Occupation reconsidered

The current article delineates the need for the profession of occupational therapy to maintain relevance and be responsive to current trends. As part of such responsivity, this article proposes a reconsideration of the concept of occupation as an 'adaptive response' to the current societal need for clarification regarding occupational therapy. Reconsideration of what is meant by occupation for general use is discussed and illustrated by the ambiguous use of the term occupation as both a means and an end. Although occupational therapists are comfortable with such ambiguous use because of their apparent ease with complexity, use of the term in an ambiguous manner makes it harder for society to understand what is meant by occupation. Related to this, an annotation of literature on the definitions of occupation is presented in summary form. Furthermore, the political need to reconsider the term occupation is argued in light of the revision of International Classification of Functioning, Disability and Health (ICF), which includes the use of the word activity. Finally, this article proposes that occupation should be considered as the process of doing with meaning, and that activity should be the outcome. Such reconsideration renders us consistent with ICF and paves the way to reduce ambiguity in the use of the term occupation with the general public.

Weighted Wrist Cuffs for Tremor Reduction During Eating in Adults With Static Brain Lesions

OBJECTIVE. This study examined whether weighting the forearm during feeding decreased tremors and increased functional feeding in adults with intention tremor caused by static brain lesions.

METHOD. Five individuals with various diagnoses, ages 30–81, were videotaped during 8 or 16 meal sessions, alternating treatment and control conditions within each meal. In this single-case design, treatment consisted of application of a weighted fabric wrist cuff and the baseline (control) condition employed an identical cuff with the weights removed. Dependent variables studied were time to acquire and deliver a bite, grams of food eaten, number of times food was spilled, number of times a compensatory technique was used, participant self-rating, and investigator rating of the severity of the tremor.

RESULTS. All five participants demonstrated improvement during treatment in one or more of the dependent variables. t Tests of the means of baseline and treatment half-sessions incorporating conservative control of Type I error revealed the following statistically significant improvements under the weighted condition: Participants 3, 4, and 5 took less time to acquire a bite; Participants 4 and 5 made fewer spills; Participants 3 and 5 showed a diminished tremor. There were no statistically significant decreases in function on any variable for any participants during the weighted condition.

CONCLUSION. The application of weight to the wrist of a person with upper-extremity tremor is accompanied by some functional improvement in self-feeding for some individuals. The size of benefit seems to be sensitive to the amount of weight used.

Changing times: trials and tribulations of the move to Master's entry-level education in Canada

BACKGROUND

Most health care professions are reviewing issues related to the changing nature of professional education and practice. Social work, physical therapy, speech-language pathology, audiology, and recently occupational therapy, have raised the entry-level training requirements to the graduate level to enhance formal education programs.

PURPOSE AND SCOPE

In the past few years, this trend has generated considerable debate and discussion within the occupational therapy profession both in Canada and internationally. In November, 2001 the Canadian Association of Occupational Therapists (CAOT) announced that Canadian universities must convert to entry-level Master's programs by 2008 to receive re-accreditation (CAOT, 2002a). This paper describes the historical evolution of Canadian occupational therapy education, outlines several issues within occupational therapy that are impacting the move, and discusses benefits and challenges to Master's level training.

PRACTICE IMPLICATIONS

Recommendations are presented for the development of Master's entry-level occupational therapy training programs in Canada.

Professional tensions in client-centered practice: using institutional ethnography to generate understanding and transformation

For almost 20 years, occupational therapists have advocated client-centered practice. Yet client-centered practice is fraught with tensions that arise outside the practice of individual occupational therapists. This paper is guided by two questions: What produces professional tensions in client-centered practice? and What understanding and change might be generated using institutional ethnography? The sociological theory and method of institutional ethnography are described using data from an ongoing investigation of mental health services as a social institution. Illustrated are the research aim, research questions, and institutional analysis that distinguish institutional ethnography from conventional ethnography. Two professional tensions are associated with attempts to fulfill client-centered practice in mental health. One is that of working at cross-purposes with the prevailing hierarchical structure; the other tension is that of being celebrated yet subordinated in the medical and management hierarchies of health services. Although client-centered practice is difficult to do, the authors recommend institutional ethnography as a research approach to generate understanding and transformation of the context and practice of occupational therapy.

Professional accountability in restructured contexts of occupational therapy practice

Professional standards for accountability establish essential competencies for clinical practices and provide strategies for professional advancement. This study examines the perspectives of a sample of occupational therapists on their capacity to engage in continuing education, to provide evidence-based practices and to have confidence in the effectiveness of available quality assurance mechanisms within restructured contexts of occupational therapy practice. The analysis of in-depth interviews with participants from program management, managed competition and private practice suggested three urgent needs: the development of strategies to assist therapists' translation of research evidence into clinical practices, research to determine the effectiveness of models of professional leadership within the workplace that promote professional accountability and alliances to advance policies that eliminate workplace barriers to professional accountability.

Reclaiming the vision of reaching for heart as well as hands

Although infrequently discussed in the professional literature, visionary language and visual imagery are identifiable elements within occupational therapy's culture. They seem part of the profession's desire to characterize, affirm, and renew itself. One early vision of practice, that of reaching for heart as well as hands, is the subject of this inquiry that extends a prior discussion of visions in occupational therapy. Central to the inquiry are the early vision's (a) origin, exemplification, and clarity of meaning within one autobiographical text and (b) merits for the profession's characterization, affirmation, and renewal. The early vision of reaching for heart as well as hands may benefit the profession today by characterizing the ethos of occupational therapy as integrative, affirming its practice as occupational, and inspiring its practitioners to renew a commitment to caring.

Shifts in Parent–Therapist Partnerships: Twelve Years of Change

OBJECTIVE. A national survey was conducted to identify occupational therapists’ current attitudes and values in their working relationships with parents of preschool children with developmental disabilities. This study replicated a 1987 national survey that examined therapists’ relationships with parents of preschool children with cerebral palsy.

METHOD. Surveys were sent to a random sample of 400 therapists, with 199 returned from respondents who identified themselves as working with preschool children with developmental disabilities. After calculating descriptive statistics for each item in the survey, a one-way analysis of variance was performed to test for differences based on four demographic variables.

RESULTS. Respondents reported that working with parents, more than any other aspect of intervention, had the greatest impact on the progress of a child with disabilities. Consistent with the 1987 survey, respondents believed that parents focus on their own adjustment to their child’s disability as well as on their child’s progress more than any other issues. Therapists continue to report satisfaction when generating positive change for child and parent through education and use of clinical knowledge and skill.

CONCLUSION. Results suggest that efforts to foster family-centered intervention in occupational therapy educational programs are increasing therapists’ confidence and skills in working with parents of children with disabilities. Implications for occupational therapy practice and education include a need for therapists to expand their knowledge and expertise in working effectively with vulnerable families. Educators need to focus on teaching strategies not only to refine the role of occupational therapy as a direct treatment provider, but also to incorporate creative ways to deal with the psychosocial issues of parents and families.

Occupational Therapy and Achievement of Self-Identified Goals by Adults With Acquired Brain Injury: Phase II

OBJECTIVE

The purpose of this study was to investigate the association between participation in goal-specific outpatient occupational therapy and improvement in self-identified goals in adults with acquired brain injury.

METHOD

Thirty-one persons with traumatic brain injury of mixed chronicity participated at three sites located in different regions of the United States. Using a repeated-measures design, therapy that usually was offered at each site to achieve specific goals was followed by a no-treatment period. Participants completed the Canadian Occupational PerFormance Measure Performance subscale (COPM-P) and Satisfaction subscale (COPM-S), and the Community Integration Questionnaire (CIQ) at admission, discharge, and 1 to 18 weeks after discharge. Goal attainment scales were developed at admission and scored at discharge; the differences for each site were tested, using dependent t tests. Gains for the treatment period (admission to discharge) in COPM subscales and the CIQ were compared with gains during the no-treatment period (discharge to follow-up) for each site, using dependent t tests. The results were synthesized meta-analytically across the sites.

RESULTS

The participants identified a total of 149 goals, 81% of which were achieved. Goal attainment T scores improved significantly (Z = 7.52, p < .001), and the combined effect size was large (r = .94). The COPM-P (Z = 4.13, p < .001) and COPM-S (Z = 4.25, p < .001) showed significantly greater gains during the treatment (average 15.3 weeks) versus the no-treatment (average 9.9 weeks) period. Effect size estimates were large: .71 and .76, respectively. Gain scores of the CIQ did not differ significantly (Z = .75, p = .22, r = .29) between periods.

CONCLUSION

Participation in goal-specific outpatient occupational therapy that focused on teaching compensatory strategies was strongly associated with achievement of self-identified goals and reduction of disability in adults with mild to moderate brain injury.

Pragmatism and structuralism in occupational therapy: the long conversation

The history of occupational therapy may be understood as a continual transaction between two cultural discourses: pragmatism and structuralism. Pragmatism is a way of thinking that presupposes humans are agentic by nature and knowledge is tentative and created within particular contexts. Structuralism is a way of thinking that assumes humans are composites of recurring general frameworks and that knowledge is objective and can be generalized to multiple contexts. Early in the field's history, both pragmatist and structuralist assumptions about the human and knowledge produced different readings, or interpretations, of what constituted the appropriate tools, methods, and outcomes for occupational therapy. Consequently, occupational therapy adopted an interesting mix of pragmatist language regarding the human and structuralist approaches to knowledge, resulting in professional identity problems still experienced today. However, recent developments offer an opportunity for occupational therapists to correct old identity problems through critically evaluating incompatible assumptions and carefully reading the prevailing cultural ethos.