Kimberly Breeden, MS, OTR/L Founding Partner

Understanding Our Value as OT Practitioners

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In the first blog of this series we examined the extent to which occupational therapy is underrecognized by the public and other healthcare professionals.   

We also discussed how as OT practitioners we often fail to recognize our own value.  That is what I would like to discuss in this blog.  I would like to start with descriptions that I often read or hear other OTs and OTAs utilize to describe OT services.

 "OT addresses the upper body and physical therapy addresses the lower body."

"OT addresses self care or ADLs"

 "OT addresses bathing, dressing and fine motor coordination"

 "OT addresses handwriting and fine motor coordination"

 "OT addresses sensory integration and regulation" 

While these statements can be true of what OT may address in specific settings, I do not feel that they reflect the scope and breadth of our profession.  

Over 10 years ago, I had to submit an essay with my application for the Belmont University bridge program.  In that essay I wrote about the holistic scope and approach of occupational therapy.  I explained how throughout my career as an occupational therapy assistant and manager I could see the benefits of my occupational therapy training in my clinical and non-clinical roles.  I emphasized the value of our training in specific skills such as group dynamics, therapeutic use of self, and psychosocial assessment and interventions. I discussed that occupational therapy's training in the treatment of both physical as well as psychosocial conditions makes our profession unique from any other profession in healthcare.  I went on to state that there seemed to be a shift in healthcare delivery recognizing the value of holistic care and my belief was that OT practitioners were uniquely qualified to lead healthcare teams, departments, organizations, and systems in light of this transition. 

Ten years later,`` I can say that I continue to see a shift in healthcare toward more client-centered and holistic care that recognizes the importance of addressing health and wellness from a biopsychosocial perspective.  There is now more literature and discussions recognizing the gaps in healthcare include addressing mental health and the holistic aspects of health and wellness.  Unfortunately, I see most of these efforts being led by other healthcare professionals and  I see many disciplines expanding their practice to address these gaps.  

 Occupational therapy was founded on the recognition of the value of engagement in meaningful occupations in mental health settings.  During World War I, restorative aides began utilizing occupations with wounded soldiers to facilitate both a way to cope with their situation and pain as well as work toward recovery.  The benefits of the therapeutic use of occupations was recognized for both mental health as well as physical rehabilitation over 100 a years ago.   

Unfortunately since that time there were many changes that affected our profession, such as healthcare shifting to  the treatment of disease utilizing biomedical approaches such as  medication and surgery.  Changes in reimbursement for mental health services resulted in decreased OT job opportunities in mental health settings.  There was also a lack of evidence to support occupation-based treatments.  This seemed to result in occupational therapy interventions mostly focusing on occupational engagement indirectly by improving performance skills such as strength, coordination, cognition and activity tolerance. The problem with this is that it is difficult for most clients and healthcare professionals to identify the difference in occupational therapy and physical therapy.

I feel that as a profession we seem to not embrace the practice of utilizing occupations therapeutically as we did at our inception.  It seems to me that in most settings our focus is no longer on occupational engagement but rather on remediation of deficits.

To me occupation and occupational engagement are the 2 key concepts that make our profession so amazing and valuable.  Lets first look at occupation , AOTA states that "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. " (2020, p. 7).   Occupations are different than activities because occupations have specific meaning for individuals while activities are not associated with meaning.  When we consider this definition we have to recognize that our profession is focused on everyday activities that bring meaning and purpose to the lives of individuals.  This reflects our profession's client-centered approach.  In other words, we value each individual's experiences, preferences and goals.

The Occupational Therapy Practice Framework: Domain and Process, Fourth Edition identifies 9 distinct categories of occupation: activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation. This means that any of these categories of occupations are within the scope of occupational therapy to address.  I love the addition of the more recent categories of health management and rest and sleep because I feel that it helps me to be reminded that as an OT practitioner I should address these occupations equally as often as I address ADLs and IADLs.  

When I consider the 9 categories of occupation I am reminded of just how extensive our scope of practice really is. I think that what I find the most exciting about our profession is the realization that occupational therapy practice focuses not just on occupations as the goal but also uses occupation as the intervention.  This is what I mean by the therapeutic use of occupations.  I think this is amazing and means that no matter what the setting, my practice can and should include utilizing occupations, not activities, as a therapeutic intervention.  I feel like this very concept demonstrates our unique value apart from other disciplines such as physical and speech therapy.  I also feel that it sets us apart from other educational and behavioral professionals in pediatric and school settings.

There is growing research that indicates that improvements in coordination, strength, and ROM do not automatically translate into improved performance with occupations.  There is evidence that even indicates that utilizing the actual occupation as an intervention such as brushing teeth, completing actual buttons on a shirt, or opening bottles results in improvements in performance skills such as strength, coordination and ROM with less repetitions than exercise.  There is also growing evidence to support occupation-based practices.  The evidence is not inclusive to OT and other disciplines are also beginning to recognize the benefits of utilizing occupations as interventions. 

Occupational engagement focuses on a person's ability to participate in occupations that are meaningful to them; in other words what they want to do, need to do, or are expected to do.  Occupational therapy primarily addresses occupational engagement. This means that our focus is to support clients to return to or begin to participate in meaningful occupations and we do this by assessing and addressing the neuromuscular, sensory, visual, mental, psychosocial, cognitive, social , and environmental factors that impact participation in occupations including one's values, beliefs, and spirituality. We are uniquely trained to assess and consider how every one of these factors impact someone's occupational performance and engagement.  What other discipline is trained in this type of assessment and intervention?  Our profession is so complex and we do all of these things so well,  that we make it look simple.  This process has become so automatic for me, I often have to stop and remind myself to articulate and document these factors. 

I heard somewhere the other day that a majority of OTs and OTAs work in medical settings, and my own career illustrates this.  In my opinion our training as OT practitioners in addressing mental health as well as other psychosocial factors prepares us to address the biopsychosocial factors associated with disease and illness like no other discipline typically found on a healthcare team.  There are typically healthcare professionals who specialize in treating physical conditions and other's who specialize in treating psychosocial conditions, but we are the only ones who are equally trained to address both.  

Occupational therapy focuses on participation in occupations no matter what a person's abilities are and I love this because it means that we are not limited to working with individuals to restore or remediate function.  OTs and OTAs work to identify an individual's abilities and strengths and determine how task demands including environmental barriers can be addressed to support occupational engagement.   This is why we are so well suited to work in non-medical and non-traditional settings. Our value outside of healthcare is recognized in AOTA's Occupational Therapy Scope of Practice which states that "It is the position of AOTA that a referral is not required for the provision of occupational therapy services" they go on to say unless required by law, regulatory or payment requirements or AOTA documents (2021, p. 2). 

I am often puzzled by how often I have a tendency to limit my own practice to ADLs,  basic IADLs, and health management.  I am really not sure why, because I understand that addressing ADLs such as sex and intimacy, trimming toenails and fingernails, IADLs, health management, rest and sleep are all medically necessary services and reimbursable in my own practice setting. I also understand that engaging in these occupations can improve the quality of life for those individuals that I work with.  I think sometimes it is because there is not necessarily an expectation that occupational therapy should address these areas.  But I think the biggest factor is that I often forget to recognize the value that I can provide as an OT practitioner.   For me,  I have to be deliberate in remembering to address these issues. I have made significant improvements but I have a long way to go.

Occupational therapy is an amazing profession that focuses, addresses and celebrates occupational engagement which is the essence of one's humanity and individuality, it is what brings meaning and purpose to life.  I can't think of a better contribution that I would like to make as a professional.  The challenges we face as occupational therapy practitioners is to embrace our distinct value and equip ourselves with the information to support occupation focused services that allow us to support occupational engagement.  In order for our profession to be more recognized and understood, we as OT practitioners have to assert our value as experts in addressing occupational engagement and it's impact on health and wellness.  The secret is out, there is more and more focus on addressing the mind-body-spirit connection of health and wellness and the benefits of engaging in meaningful occupations.  It's time for us to clearly realize the value we bring utilizing these approaches. 
Written by: Kimberly Breeden, MS, OTR/L
Founding Partner of Aspire OT

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