Canadian Journal of Occupational Therapy 1-11 DOI: 10.1177/0008417416631773

Preparing for community development practice: A Delphi study of Canadian occupational therapists

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La pre´paration requise pour la pratique dans le domaine du de´veloppement communautaire : E´tude Delphi sur les ergothe´rapeutes canadiens

Leanne L. Leclair, Morgan L. Ashcroft, Tamara L. Canning, and Marla A. Lisowski

Key words: Capacity building; Clinical competency; Community practice; Education; Knowledge. Mots cle´s : compe´tence clinique; connaissances; e´ducation; pratique a` base communautaire; renforcement des compe´tences.

Abstract Background. Increasingly, community development is recognized as an important process for occupational therapy practice. However, occupational therapists working in community development report feeling unprepared. Purpose. This study aimed to identify the knowledge, skills, and experiences that occupational therapists need for practice in community development. Method. Using the Delphi technique, the researchers developed statements from the Round 1 (n ¼ 8) responses of occupational therapists involved in community development practice or scholarship. Rounds 2 (n ¼ 14) and 3 (n ¼ 12) sought to establish consensus among the occupational therapists on the areas of focus. Findings. Participants rated the importance of 64 statements grouped into 11 domains. After three rounds, researchers eliminated six statements by analyzing the median, interquartile range, and percentage of agreement. Participants reached consensus on 58 statements. Implications. Many of the competencies identified were relevant to all areas of practice, while others were specific to community development, suggesting a need for specialized education and training in this area. The results provide information that can be used to enhance the preparation of occupational therapists for practice in community development. Abre´ge´ Description. Le de´veloppement communautaire est de plus en plus reconnu comme un processus important pour la pratique de l’ergothe´rapie. Cependant, les ergothe´rapeutes qui travaillent en de´veloppement communautaire indiquent qu’ils se sentent mal pre´pare´s pour exercer dans ce domaine. But. Cette e´tude visait a` cibler les connaissances, les compe´tences et les expe´riences ` l’aide de la requises par les ergothe´rapeutes pour exercer dans le domaine du de´veloppement communautaire. Me´thodologie. A me´thode Delphi, les chercheurs ont formule´ des e´nonce´s a` partir des re´ponses du premier tour (n ¼ 8) des ergothe´rapeutes travaillant ou e´tudiant dans le domaine du de´veloppement communautaire. Le deuxie`me tour (n ¼ 14) et troisie`me tour (n ¼ 12) visaient a` atteindre un consensus parmi les ergothe´rapeutes face aux the`mes d’inte´reˆt. Re´sultats. Les participants ont attribue´ une cote d’importance aux 64 e´nonce´s regroupe´s en 11 domaines. Apre`s trois tours, les chercheurs ont e´limine´ six e´nonce´s en analysant la me´diane, l’intervalle interquartile et le pourcentage de concordance. Les participants ont atteint un consensus pour 58 e´nonce´s. Conse´quences. Bon nombre des compe´tences identifie´es e´taient pertinentes pour tous les domaines de pratique, alors que d’autres e´taient spe´cifiques au domaine du de´veloppement communautaire, ce qui sugge`re un besoin de formation spe´cialise´e et de formation pratique dans ce domaine. Les re´sultats fournissent de l’information pouvant eˆtre utilise´e en vue de mieux pre´parer les ergothe´rapeutes a` la pratique dans le domaine du de´veloppement communautaire. Funding: No funding was received to support this work. Corresponding author: Leanne Leclair, Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, R106-771 McDermot Ave., Winnipeg, MB, R3E 0T6, Canada. Telephone: 204-977-5631. E-mail: [email protected]

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nabling Occupation II (Townsend & Polatajko, 2013) specifies that communities—along with individuals, groups, organizations, and populations—can be occupational therapy clients. Increasingly, the occupational therapy literature has acknowledged community development as an important area of occupational therapy practice for working with communities (e.g., Lauckner, Krupa, & Paterson, 2011; Lauckner, Pentland, & Paterson, 2007; Leclair, 2010; Reitz, Scaffa, & Merryman, 2014; Restall & Ripat, 2008; Townsend & Polatajko, 2013; Trentham, Cockburn, & Shin, 2007). Yet, occupational therapists report not feeling prepared for practice in community development (Lauckner et al., 2011; Restall & Ripat, 2008). The purpose of this paper is to present the findings of a Delphi study of Canadian occupational therapists, which examined the knowledge, skills, and experiences that occupational therapists need in preparation for community development practice.

Background Almost 20 years ago, Thibeault and He´bert (1997) speculated that the amalgamation of occupational therapy and community development would yield new visions, new instruments, and new interventions, all of which could afford occupational therapy practice the capacity to influence social change. While the occupational therapy literature on community practice has grown exponentially over the past two decades, the literature on occupational therapy practice in community development represents only a small fraction and consists mostly of reflections (e.g., Leclair, 2010; Thibeault & He´bert, 1997), case reports (e.g., Packer, Spence, & Beare, 2002; Scaletti, 1999; Trentham et al., 2007), and a few qualitative studies (e.g., Lauckner et al., 2007, 2011; Wood, Fortune, & McKinstry, 2013). Not surprisingly, given the limited research in this area, the preparation of occupational therapists for community development roles has also been much less of a focus, and little information exists to provide guidance on the preparation of occupational therapists for practice in this area. Community development differs from community-based programming. Labonte (2012) described the community health continuum with community-based programming at one end and community development at the other. In community-based programming, occupational therapists provide programs in community settings targeted at individuals and families that focus on issues deemed by policy makers and/or program planners to be a concern for the community. The occupational therapists direct program planning or implementation and initiate interventions that are in keeping with the mandate of their organization and/or funder. Using this approach, the occupational therapist would seek out or intervene with individuals or groups who meet the criteria for their program. Examples of community-based programming are home care, school therapy, chronic disease management, and assertive community treatment.

Leclair et al. Community development involves working with, not just in, communities. In community development, the occupational therapist works with the community to identify and find solutions to their issues or concerns (Labonte, 2012). Many authors have proposed that communities are more than geography; communities are complex, dynamic, multidimensional systems that share interests, issues, or identities and evolve with their members (Green & Haines, 2008; Levin & Herbert, 2001; MacQueen et al., 2001). Occupational therapists engaged in community development practice involve the community in every aspect of planning and implementing community interventions that will meet the community’s needs as identified by the community. Community development is recognized as an important process for empowering and engaging communities in increasing control over and improving their health (World Health Organization [WHO], 1986). Labonte (2012) stated that community-based programs can lead to community development initiatives, and community development initiatives can lead to community-based programs. However, as outlined, the occupational therapist’s roles in community development differ from his or her roles in community-based programming. Lauckner et al. (2007) described community development as ‘‘a multi-layered, community-driven process in which relationships are developed and the community’s capacity is strengthened, in order to affect social change in their community that will promote the community’s access to and ability to engage in occupations’’ (p. 319). The principles of community development, such as collaborating with others, developing partnerships, empowering the community and power sharing, encouraging participation and community decision making, respecting diversity and self-determination, and practising in an ethical manner (Minkler, 2012), are in keeping with an occupational therapy client-centred approach, as defined by Law, Baptiste, and Mills (1995) and Sumsion (2000). The focus, however, is at a community level to broaden the effects of intervention, thus enabling the community to act together and implement changes (Thibeault & He´bert, 1997). Restall and Ripat (2008) sought occupational therapists’ perspectives on the use of client-centred strategies in community development. They found that occupational therapists reported that they lacked the knowledge and skills needed to implement client-centred strategies in community development, despite feeling that it was an important area of practice, and proposed that occupational therapists needed better preparation to work with communities. Scaffa and Sasse (2014) suggested that occupational therapy programs needed to facilitate the development of competencies for this area of practice. Occupational therapists working in community development have reported feeling unprepared for their role (Lauckner et al., 2007; Restall & Ripat, 2008). The existing literature provides some suggestions on ways that occupational therapists can prepare for practice in community development. For example, Lorenzo and Cloete (2004) recommended that therapists take management courses and development courses, and network with others to assist in developing the skills needed to

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Canadian Journal of Occupational Therapy perform the various roles involved in community development practice. Lauckner et al. (2007) suggested that previous experience working with communities, such as volunteering or completing fieldwork with community agencies or community groups, provides occupational therapists with the opportunity to develop their skills in community development. Fieldwork experiences can provide opportunities that prepare students for work in the community and can enhance self-confidence and the decision to work in community development (Derdall, Olson, Janzen, & Warren, 2002; Friedland, Polatajko, & Gage, 2001; Klinger & Bossers, 2009). Others have proposed the need for formal and informal continuing education opportunities for practicing therapists to prepare them for work in this field (see Lauckner et al., 2007; Restall & Ripat, 2008). There is, however, insufficient discussion and little consensus in the literature on the preparation needed for occupational therapy community development practice. Therefore, the purpose of this study was to gain consensus among occupational therapists with expertise in community development on the knowledge, skills, and experiences needed for practice in this area in an effort to help inform the preparation of occupational therapists for community development practice.

Method This study used the Delphi technique, which consists of several chronological questionnaires or rounds that seek to gain consensus among a panel of experts (Powell, 2003). The Delphi technique is particularly useful when seeking consensus in an area with a lack of agreement, an incomplete state of knowledge, or little empirical evidence (Delbecq, Van de Ven, & Gustafson, 1975; Powell, 2003; Thompson, 2009). The Delphi is a cost-effective way of gathering, structuring, and organizing communication around a particular topic among a geographically dispersed group of experts (Powell, 2003; Thompson, 2009). The technique has been applied in various contexts, including for the analysis of professional characteristics and competencies (Butterworth & Bishop, 1995; Duffield, 1993; Holmes & Scaffa, 2009; St. Pierre et al., 2012) and the development of educational programs (Gibson, 1998; Hartley, 1995). Each round builds on the results of the previous round. According to Delbecq et al. (1975), the number of iterations depends on the level of consensus required by the researchers and generally ranges from three to five rounds. Participants are anonymous to one another, allowing free expression of opinions (Campbell, Roland, & Buetow, 2000). The Delphi process took place over 2 years, with the first round consisting of a series of open-ended questions and the subsequent rounds comprising statements that participants were asked to rate for their importance to occupational therapy community development practice. Ethical approval was granted through the University of Manitoba Health Research Ethics Board (H2010:020, H2012:041). Written informed consent was obtained from all participants.

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Participants Round 1. The researchers obtained a list of occupational therapists who self-identified as working in community development from the Canadian Association of Occupational Therapists (CAOT). As well, the researchers cross-referenced the list with Canadian occupational therapists who had published or presented on community development and occupational therapy to develop a more comprehensive list. This process resulted in a total of 28 potential participants, all of whom were sent the questionnaire via e-mail. To ensure therapists had adequate experience related to community development, only therapists with at least 5 years’ experience working in community development were asked to respond. The researchers felt that occupational therapists needed at least 5 years’ experience to understand the breadth and depth of preparation that would be needed for this area of practice. In Round 1, eight (32%) occupational therapists responded to the open-ended questionnaire. The majority of participants had worked as an occupational therapist for over 20 years, and the number of years working in community development ranged from 5 to over 20 years. Participants reported having worked in a community development context with various populations: seniors, young adults, families and children, and individuals with physical disabilities or mental illness. Rounds 2 and 3. Using the same process for identifying occupational therapists working in community development as in Round 1, three additional individuals who had self-identified as working in community development on the CAOT membership list were added to the list of potential participants used in Round 1. A total of 31 Canadian occupational therapists were invited to participate in Rounds 2 and 3. Sixteen (52%) occupational therapists agreed to participate in the second round, but only 14 (45%) completed the survey. In the third round, 13 (42%) agreed to participate, but only 12 (39%) completed the survey. Most of the participants had worked more than 25 years as an occupational therapist. The number of years working in community development ranged from 5 to over 20 years. Similar to Round 1, participants reported having worked in a variety of community development contexts with various populations.

Data Collection Round 1. In keeping with the Delphi technique, the firstround questionnaire was unstructured and sought open responses to allow participants to elaborate on the topic area (Rowe, Wright, & Bolger, 1991; Thompson, 2009). An initial recruitment letter outlining the purpose of the study was sent via e-mail to all prospective participants. One week later, a second e-mail was sent that contained the questions. As part of the introduction to Round 1, participants were asked to review definitions of community development prior to responding to the questions. (The definitions used can be obtained from the first author and are in keeping with those described in the introduction.) If participants felt their work was in keeping with

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Revue canadienne d’ergothe´rapie

4 these definitions, participants were asked to respond to a series of open-ended questions: (a) What knowledge do you believe occupational therapists need to practise in community development? (b) What skills do you believe occupational therapists need to practise in community development? (c) What experience do you believe occupational therapists need to practise in community development? (d) Do you have any additional comments about occupational therapy and community development? Reminder e-mails were sent 2 and 4 weeks after the initial e-mail. Data collection occurred between April 2010 and June 2010. Rounds 2 and 3. Data collection for Rounds 2 and 3 occurred between March 2012 and June 2012. An initial recruitment letter outlining the purpose of the study was sent via e-mail to all prospective participants. One week later, a second e-mail was sent that contained a link to the survey on SurveyMonkey. Participants completed the online survey, which involved rating the importance of 64 statements on a 4-point Likert scale, and were given the opportunity to add statements that they felt were important. Participants had 2 weeks to respond to the second-round survey. A reminder e-mail was sent to the participants after 1 week. Once the second round closed, the researchers analyzed the data and reformulated the survey based on the results. This procedure took 2 weeks. An e-mail inviting participants to Round 3 of the survey was sent following completion of the analysis of Round 2 responses. The results of Round 2 were sent to all prospective participants. A reminder e-mail was sent after 1 week. When the third round was complete, the researchers analyzed the data. A fourth round of the survey was not required as consensus was reached after three rounds. Consensus is defined in the Data Analysis section.

Data Analysis Round 1. Following a process outlined by Hasson, Keeney, and McKenna (2000), the authors summarized, eliminated redundancies in, edited, and categorized responses using an inductive approach to analyze the data gathered in Round 1 of the Delphi. Using Microsoft Word, participants’ responses to each of the questions were collated. Each participant’s responses were colour coded to track responses during the analysis and determine if participants shared similar responses to a question. Three researchers reviewed the responses to the open-ended questions independently and combined similar responses for each of the questions related to knowledge, skills, and experiences needed for community development practice to eliminate redundancies. The three researchers then met to discuss their combined statements and worked together to refine the statements using the participants’ original wording as much as possible. Each of the researchers then independently categorized the statements into similar categories/ domains that captured the area of focus. The three researchers then met to discuss the categories/domains that emerged from the data and came to consensus. Subsequently, the first author

Leclair et al. compared the statements to the initial responses to ensure they remained true to the initial data. Rounds 2 and 3. Median, interquartile range (IQR), and percentiles were calculated for each statement. A single value for each of these statistics does not exist for the Delphi (Hasson et al., 2000). Therefore, the authors used values reported in other Delphi studies. Green (as cited in Hsu & Sandford, 2007) suggested that consensus is achieved when at least 70% of Delphi participants rate the statement 3 or higher on a 4-point Likert scale and the median is at 3 or higher. The IQR was used to provide a measure of the dispersion of the responses. The IQR is the absolute value of the difference between the 75th and 25th percentiles, with smaller values indicating higher degrees of consensus. Raskin (1994) identified an IQR of 1.00 or less as an indicator of consensus. For the purpose of this study, a statement was eliminated if 70% of participants did not rank it 3 or higher on a 4-point Likert scale, the median was not 3.00 or greater, and the IQR was not less than 1.00.

Findings Round 1 generated 11 categories with a total of 64 statements that were included in Round 2 of the Delphi technique. Table 1 presents the statements generated from Round 1 and participants’ responses to each statement in Rounds 2 and 3. Very few of the statements generated based on responses to the openended questionnaire were eliminated through the survey consensus process. In the second round, five of the 64 statements were eliminated, as consensus was not reached on those statements. Two of the eliminated statements were from the Advocacy/ Networking category. The Community Capacity Building/ Enablement category, Leadership and Conflict Management category, and Political Systems and Processes category each had one statement eliminated. In the third round, only the Knowledge of Occupation category had one statement eliminated: ‘‘the need to know how to perform task analysis with a community.’’ This statement had reached consensus in Round 2 but failed to reach consensus in Round 3, with the greatest percentage of change in participant agreement. Participant consensus shifted 26.6% from an agreement level of 93.3% to 66.7%. None of the participants provided a comment or explanation for their change in score. Between Rounds 2 and 3, participants shifted their choices on 36 of 56 statements. Nineteen of the 36 statements had a decrease in consensus between 26.6% and 1.6%. The remaining 17 statements had an increase in consensus between 13.3% and 5.0%. In the second round, 25 statements reached full (100%) consensus. In the third and final round, 36 statements reached full (100%) consensus. All of the statements in the Advocacy/Networking Partnerships, Evidence-Based Practice, and Political Processes and Systems categories reached full consensus in the final round. At the end of Round 3, experts

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Table 1 Consensus After Each Round on the Knowledge, Skills, and Experiences That Occupational Therapists Need for Practice in Community Development Round 1 Statement (Occupational therapists need to . . . ) Health 1. Have knowledge of the social determinants of health 2. Have knowledge of health promotion 3. Have knowledge of primary health care Knowledge of community 4. Have knowledge of power dynamics in communities 5. Have knowledge of community values 6. Have knowledge the social characteristics of the community 7. Have knowledge of the economic characteristics of the community 8. Have knowledge of the physical characteristics of the community 9. Have knowledge of how community agencies function 10. Have knowledge of how communities are influenced, formed, and shaped 11. Be able to work in under-resourced or rural areas Community development process 12. Have knowledge of the various definitions of community development 13. Have knowledge of community development models 14. Have knowledge of community development principles 15. Have knowledge of community-based rehabilitation 16. Be able to conduct community needs assessments to assist in the identification of community strengths and concerns 17. Be able to assist in the development of community goals Knowledge of occupation 18. Be able to apply occupational therapy frames of references to communities 19. Be able to apply occupation-based models to communities 20. Be able to perform task analysis with a community 21. Have knowledge of community occupations 22. Understand occupational justice as a community/population issue 23. Have knowledge of the relationship between an individual’s environments and their ability to engage and participate in occupations within the community Partnerships 24. Have knowledge of collaboration and collaborative practices 25. Be able to develop community partnerships 26. Have experience with team building 27. Be able to work with community organizations 28. Be culturally competent 29. Have knowledge about the cultural characteristics of communities 30. Be able to work with various cultural groups Community capacity building/enablement/empowerment 31. Have knowledge of community capacity building models 32. Be able to build capacity among community members 33. Have knowledge of adult education principles 34. Have knowledge of social inclusion 35. Be able to engage individuals in community activities 36. Have knowledge of the strategies involved in social action 37. Be able to employ enablement skills with communities and organizations 38. Be able to empower communities Advocacy and networking 39. Have knowledge of the strategies involved in advocacy 40. Be able to network with various individuals/groups/organizations

Round 2 Mdn IQR % Agreement Mdn

% Change in participant IQR % Agreement agreement

4.00 0.50 4.00 0.50 3.00 1.00

100 100 100

4.00 4.00 3.50

0.00 1.00 1.00

100 100 91.7

0 0 –8.3

4.00 4.00 3.00 4.00 4.00 4.00 4.00

100 100 93.3 93.3 93.3 86.7 93.3

4.00 4.00 4.00 3.50 3.00 4.00 4.00

1.00 0.25 1.00 1.00 1.00 1.00 1.00

100 100 100 100 100 91.7 91.7

0 0 þ6.7 þ6.7 þ6.7 þ5.0 –1.6

100

3.50

1.00

91.7

–8.3

93.3

4.00

1.00

91.7

–1.6

86.7 100 93.3 86.7

3.00 4.00 3.00 3.00

1.00 0.50 0.50 1.00

100 100 75 91.7

þ13.3 0 –18.3 –5.0

100

4.00

1.00

100

1.00 0.00 1.00 1.00 1.00 1.00 1.00

3.00 1.00 3.00 1.00 3.00 3.00 3.00 3.00

0.50 1.00 1.00 0.50

4.00 1.00

Round 3

0

3.00 1.00

86.7

3.00

1.00

91.7

þ5.0

3.00 4.00 3.00 3.00 4.00

1.00 1.00 1.00 1.00 1.00

86.7 93.3 86.7 86.7 93.3

3.50 3.00 3.00 3.50 4.00

1.00 2.00 1.00 1.00 0.00

91.7 66.7 91.7 83.3 90.9

þ5.0 –26.6 þ5.0 –3.4 –2.4

4.00 4.00 4.00 4.00 3.00 4.00 4.00

1.00 1.00 0.50 0.50 1.00 1.00 1.00

100 100 100 100 100 93.3 100

4.00 4.00 4.00 4.00 4.00 4.00 4.00

0.00 0.00 0.25 0.00 1.00 1.00 1.00

100 100 100 100 100 100 100

0 0 0 0 0 þ6.7 0

3.00 3.00 3.00 4.00 4.00 3.00 4.00

1.00 1.00 1.00 1.00 1.00 1.00 1.00

100 100 93.3 93.3 100 100 100

4.00 4.00 4.00 4.00 4.00 3.00 4.00

1.00 1.00 1.00 0.25 1.00 1.00 0.00

91.7 100 100 83.3 100 83.3 100

–8.3 0 þ6.7 –10.0 0 –16.7 0

3.00 1.50

73.3

—

–

3.00 1.00 4.00 1.00

93.3 93.3

100 100

þ6.7 þ6.7

— 4.00 4.00

— 1.00 0.00

(continued)

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Leclair et al.

Table 1 (continued) Round 1 Statement (Occupational therapists need to . . . ) 41. Be able to seek and obtain resources (i.e. funding) 42. Be able to write grant proposals 43. Have volunteer experience working with advocacy groups 44. Have effective communication skills 45. Have good writing skills 46. Be able to communicate their own strengths and limitations Leadership and conflict management 47. Have leadership skills 48. Have experience in the leadership role 49. Be able to assist in the development of local leaders 50. Have negotiation skills 51. Have problem-solving skills 52. Be able to effectively manage and resolve conflicts 53. Be able to organize volunteers 54. Have managerial and/or supervisory skills Group facilitation 55. Have knowledge of group processes 56. Be able to facilitate large groups 57. Be able to facilitate community committees or advisory boards 58. Have experience building legitimacy within a group Evidence-based practice 59. Be able to appraise evidence 60. Be able to translate evidence into action Political processes and systems 61. Have knowledge of political processes and systems that affect communities 62. Be able to navigate the various systems in which communities function 63. Be able to advocate for change within political systems 64. Have knowledge of current legislation and policies acting as barriers to occupational participation in communities

Round 2

Round 3

Mdn IQR % Agreement Mdn

% Change in participant IQR % Agreement agreement

3.00 3.00 2.00 4.00 4.00 4.00

1.00 2.00 1.00 0.00 1.00 1.00

86.7 66.7 46.6 100 93.3 100

3.00 0.25 — — — — 4.00 0.00 4.00 1.00 4.00 0.25

100 — — 100 100 100

þ13.3 – – 0 þ6.7 0

3.00 3.00 4.00 4.00 4.00 4.00 3.00 3.00

1.00 1.00 1.00 1.00 0.50 1.00 2.00 1.00

93.3 80 93.3 93.3 100 100 60 93.3

4.00 0.25 3.00 1.00 4.00 1.00 4.00 0.25 4.00 0.00 4.00 1.00 — — 3.00 0.00

91.7 91.7 91.7 100 100 91.7 — 83.3

–1.6 þ11.7 –1.6 þ6.7 0 –8.3 – –10.0

4.00 3.00 3.00 3.00

1.00 1.00 1.00 1.00

93.3 86.7 80.0 93.3

þ6.7 þ13.3 –5.0 –10.0

4.00 1.00 4.00 0.50

100 100

4.00 4.00 3.00 3.00

0.00 1.00 1.00 1.00

100 100 75.0 83.3

4.00 4.00

1.00 0.25

100 100

0 0

4.00 1.00

93.3

4.00

1.00

100

0

4.00 1.00

86.7

3.50

1.00

100

0

3.00 2.00 3.00 1.00

66.7 93.3

— — 4.00 1.00

— 100

— 0

Note. IQR¼ interquartile range.

reached consensus on 58 statements outlining the knowledge, skills, and experiences occupational therapists needed for practice in community development.

Discussion Over the past few decades, shifts in occupational therapy practice to community practice settings have prompted the emergence of new and exciting roles for occupational therapists. Community development is an emerging area of occupational therapy community practice that warrants further attention (Scaffa & Sasse, 2014). The European Network of Occupational Therapy Health Education (2011) highlighted community development approaches among the competencies occupational therapists needed for addressing poverty reduction and health inequalities. This study is the first to examine the knowledge, skills, and experiences occupational therapists need for practice in community development, thus providing some guidance on areas that require further development within the profession.

Study participants agreed that having knowledge of the determinants of health, health promotion, and primary health care is a vital part of occupational therapists’ preparation for community development practice. Community development is a strategy within health promotion (WHO, 1986). Primary health care also includes community development as an important component (WHO, 1978). Knowledge of the determinants of health is essential to both health promotion and primary health care. Student occupational therapists should be given opportunities to use this knowledge in the context of working with a community through, for example, fieldwork, service learning, or case studies. These experiences can help prepare occupational therapists for mobilizing the community to achieve their health promotion goals through community development. Having an understanding of community, community development principles, and models is also thought to be a critical aspect of preparation for community development practice. Literature provides support for the importance of knowledge of the community in general to community development practice (see Austin, 2005; Freudenberg, 2004; Klinger &

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Canadian Journal of Occupational Therapy Bossers, 2009; Lauckner, 2007; Lauckner et al., 2011; Laverack, 2006; Minkler, 1994, 2012; Slater, Knowles, & Lyon, 2008; Trentham et al., 2007; Wynn, Stewart, Law, BurkeGaffney, & Moning, 2006). The use of community profiles and existing data to build knowledge of a community (KU Work Group for Community Health and Development, 2014) and learn about the current resources available (Austin, 2005; Laverack, 2006; Trentham et al., 2007; Wynn et al., 2006) is an important tool for occupational therapists. Occupational therapists can use the resources within a community to strengthen public participation and promote health, thereby supporting engagement from all members of the community (Trentham et al., 2007). Community development principles are in keeping with occupational therapy client-centred practice principles and can be explored together with client-centred strategies at a community level (Restall & Ripat, 2008). In addition, understanding the application of community development models in conjunction with occupation-based models can further enhance occupational therapists’ understanding of their unique contributions to community development. Occupational therapy theories and occupation-based models are applied traditionally to individuals, and therapists may have difficulty applying them to communities (Leclair, 2010). Community occupational issues will differ from individual occupational issues; therefore, occupational therapists need to know how to identify both. Participants in this study agreed that a therapist needs to know how to apply occupational frames of reference and occupation-based models to communities. Providing student occupational therapists the opportunity to apply occupational therapy models within a community development process can enhance understanding of community occupations. Furthermore, occupational therapists working in community development should contribute to the development of theory that will support their current practice (Leclair, 2010). Barron and Taylor (2010) and Laverack (2006) recommended that being knowledgeable of the local politics of the community was important for individuals working in community development. Participants in this study concurred and reached consensus on statements regarding political processes. Restall and Ripat (2008) found that occupational therapists considered community organizing and coalition advocacy/ political action important; however, these client-centred strategies were not being implemented as frequently in practice. Understanding political processes within a community can foster acceptance of the community’s values, beliefs, and goals (Barron & Taylor, 2010). Occupational therapists with knowledge of political processes and strategies to navigate various systems can then incorporate this understanding into their practice. Community development, community empowerment, and community capacity building all describe a process that increases the assets and attributes a community can use to improve the well-being of the community (Gibbon, Labonte, & Laverack, 2002). Gibbon et al. (2002) reported that community capacity building is a useful and flexible approach to community work and can be used as a means and as an end

7 in community development. Congruent with this literature, participants from the current study agreed that community capacity building is a vital part of an occupational therapist’s preparation for community development practice. While many considered empowerment to be important, the participants in the current study did not come to consensus that occupational therapists needed to be able to empower communities. However, community empowerment is a key outcome of capacity building that enables a community to reach its self-identified goals (Laverack, 2006). Community development is often the means by which communities become empowered; community empowerment is an inherent outcome of the community development process (Bracht, Kingsbury, & Rissel, 1999). A definition of community empowerment was not provided as part of the Delphi process. Some clarification of the construct may have helped participants when considering this statement in relation to occupational therapy practice. The authors could also speculate that the lack of consensus related to community empowerment may relate to the limited discourse in the literature on the role of occupational therapists in empowering communities. Some authors have emphasized the importance of occupational therapists’ empowering individuals within communities, with the focus being on linking individuals to broader community collective efforts (Lauckner et al., 2011; Trentham et al., 2007). More recently, Reitz et al. (2014) outlined the principles and theoretical models that occupational therapists can use to develop empowered communities. This particular area warrants further exploration to understand if and how occupational therapists may be contributing to empowering communities. Study participants agreed that occupational therapists need leadership skills and experience in a leadership role. An effective leader helps to build and promote healthy communities. Leadership motivates and influences people to participate and be involved in an action, a critical element of community development (Minkler, 2012). Kouzes and Posner (2013) identified five effective leadership practices: ‘‘challenge the process, inspire a shared vision, enable others to act, model the way, and encourage the heart’’ (p. 43). Each of these practices could be applied at various points in the community development process. For example, occupational therapists working in community development may use their leadership skills to encourage the community to identify its needs, enable action to implement programs that address its needs, and inspire local leaders (Laverack, 2007). The development of leadership skills is essential for all areas of occupational therapy practice and is not unique to community development. However, the application of these skills at a community level will be quite different given the complex and dynamic nature of communities. The current study findings highlight that occupational therapists working in community development require conflict management and negotiation skills. Conflict is an inherent part of community development (Labonte, 2012; Zacharakis, 2006). Conflict within the community can occur given the diversity of individuals and agendas (Zacharakis, 2006). Understanding the diversity of the community and potential conflicts that may

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8 occur as a result are important for community development practice. Conflict can arise when diverse individuals/groups work together to develop a common agenda that addresses the needs of the community; conflict is part of collaboration. As well, recognizing and addressing a power differential among the various stakeholders is a recurrent theme in the community development literature (Barron & Taylor, 2010; Frank & Smith, 1999; Klinger & Bossers, 2009; Labonte, 2012; Laverack, 2007; Lauckner et al., 2011). An open attitude toward conflict can improve communication and facilitate the community development process (Frank & Smith, 1999). Occupational therapists need to be able to recognize points of conflict in communities and help seek resolutions.

Implications for Practice The results of the Delphi highlight several areas in which occupational therapists require preparation for practice in community development. Although many of the areas identified were specific to community development practice, others were relevant to all areas of occupational therapy. For example, statements included in the categories of Health, Partnerships, Advocacy and Networking, Group Facilitation, Leadership and Conflict Management, and Evidence-Based Practice relate to several areas of practice. Many of the statements contained in each of the categories are included in the Profile of Occupational Therapy Practice in Canada (CAOT, 2012) and The Essential Competencies of Practice for Occupational Therapists in Canada (Association of Canadian Occupational Therapy Regulatory Organizations, 2011). Currently, occupational therapy entry-level curriculum focuses on many of these areas; however, the emphasis is not necessarily on working with a community. The substantial overlap with many of the core competencies needed for occupational therapy practice indicates that community development roles are highly congruent with occupational therapy practice. The findings also suggest a need for specialized education and training in community development. Given the broad scope of occupational therapy practice, it is difficult to prepare student occupational therapists fully for all areas of practice. This level of preparation remains a challenge within occupational therapy curriculum, as not all knowledge, skills, and experience needed for a particular area of practice can be provided within an entry-to-practice program. Canadian occupational therapists are trained as generalists and are expected to gain additional knowledge, skills, and experience related to an area of practice ‘‘on the job’’ or through continuing education. As a result, similar to occupational therapists in other areas of practice, therapists working in community development will continue to develop their skill set beyond entry-level preparation. However, deciding on the amount of preparation offered specific to community development within an entry-level occupational therapy curriculum needs to be deliberated. Occupational therapy programs can use the information gathered from this study to make decisions around the areas that are not currently being offered in their curriculum,

Leclair et al. determine the methods of delivery that could be used to address these areas, and establish the level to which each area should be taught and integrated with other content within an entry-level curriculum. Additional research examining ways in which occupational therapy programs are integrating community development content into their curriculum would provide a better understanding of how occupational therapists are being prepared for this area of practice. Creating methods for sharing knowledge about community development practice, conducting research that provides evidence that supports occupational therapists’ effectiveness in community development, and supporting occupational therapists currently in community development roles and settings can further enhance this area of practice. Practicing occupational therapists have identified a need for ongoing professional development opportunities to address the knowledge and skills needed for this area of practice. Offering education specific to occupational community development and occupational justice, for example, can help ground occupational therapists in this work. Involving all facets of the occupational therapy profession, including students, educators, researchers, practitioners, and the provincial and national associations, will enrich the role of occupational therapy in community development.

Study Limitations This preliminary and exploratory study examined the knowledge, skills, and experiences that occupational therapists need for community development practice. The focus on Canadian participants limited the sample size and generalization of the findings to an international context. However, the principles of community development, regardless of the context, are similar (Minkler, 2012). Previous Delphi studies have made contributions to broaden the literature in a specific area, despite small sample sizes (e.g., Huang, Lin & Lin, 2008; St. Pierre et al., 2012). Moreover, research has shown that Delphi studies use a wide range of sample sizes (Campbell & Cantrill, 2001). Despite attempting to contact the same participants, the lengthy interruption between Round 1 and Rounds 2 and 3 may also limit the validity of the findings. As well, the Delphi technique was not supported by the use of other methods of data collection.

Conclusion This study provided an overview of the knowledge, skills, and experiences occupational therapists need to work in community development. While some of the statements are considered core occupational therapy skills, others are unique to community development practice. Research has shown that fieldwork experiences as well as academic exposure in this area help prepare students for community development practice. The findings from this Delphi study contribute to the occupational therapy literature on community development. Additionally, the results from this study could contribute to the development

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Canadian Journal of Occupational Therapy of resources used in the professional development of occupational therapists preparing for, or working in, community development practice and could be incorporated into student occupational therapists’ education and training to enhance their preparation for practice in community development. Continued research in community development and occupational therapy is needed to support current practice and encourage growth within the field.

Key Messages 

 

The knowledge, skills, and experiences identified are relevant to several areas of occupational therapy practice but require an emphasis on working with communities, not just in communities and with individuals. The areas identified overlapped substantially with the core competencies for occupational therapy practice. Occupational therapy programs can use the findings to determine areas that are not being addressed and consider the extent to which this content might be offered and/or integrated with existing content within the entry-level curriculum.

Acknowledgments We would like to thank the occupational therapists who participated in the Delphi survey for their valuable contributions and time in responding to the survey. We would also like to acknowledge Kim Giong and Britainee Whallen for their assistance with developing the statements used in the Delphi survey.

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Author Biographies Leanne L. Leclair, PhD, OT Reg. (MB), is Associate Professor, Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, MB, Canada.

11 Morgan L. Ashcroft, MOT, OT Reg. (MB), is Occupational Therapist, Prairie Mountain Health-Therapy Services, Russell, MB, Canada. At the time of the study, M. Ashcroft was a student in the Master of Occupational Therapy program at the University of Manitoba. Tamara L. Canning, MOT, OT Reg. (MB), is Occupational Therapist, Riverview Health Centre, Winnipeg, MB, Canada. At the time of the study, T. Canning was a student in the Master of Occupational Therapy program at the University of Manitoba. Marla A. Lisowski, MOT, OT Reg. (MB), Occupational Therapist, Brandon Regional Health Centre, Brandon, MB, Canada. At the time of the study, M. Lisowski was a student in the Master of Occupational Therapy program at the University of Manitoba.

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