The Just Right Challenge JIM HINOJOSA Department oj Occupational Therapy, New York University, New York, New York
This paper is based on a keynote address "The Just R!~t;ht Challenge" given on October 14, 1993, at Massachusetts Associationjor Occupational Therapy Annual Conjerence in Marlborough, MA. The occupational therapy projession is accountable to the society it serves. This paper outlines some key internal and external influences affecting the projession as it prepares jor the next decade. Internal influences include the sphere oj expertise, role clarification, and competencies. External influences include the use of service extenders, cross training, and practice parameters. Keywords: Occupational therapy; Practice parameters; Cross training; Service ex-
tenders
CHALLENGES Occupational therapists have always been concerned with the "just right challenge" to enable individuals to engage in the activities that give meaning to their lives. However, as a theme for a conference, "the just right challenge" goes beyond the traditional view of ensuring success during intervention. This paper challenges practitioners to expand their horizons; it challenges practitioners to open their eyes to innovations; and, it challenges practitioners to examine themselves in this world of social change. This paper presents a view of the world of occupational therapy that supports the statement made by Dr. Mary Reilly that "occupational therapy can be one of the great ideas of the 20th century medicine" (Reilly, 1962). From the author's perspective, occupational therapy is a great idea for society.
OCCUPATIONAL THERAPY'S MANDATE A profession is a group of individuals recognized by society to perform specific functions because of their specialized training. Kie1hofner (1992) and
Mosey(1981, 1992) maintain that a primary function of a profession is the application of knowledge for the benefit of society. The predominant concerns of a profession evolve and shift over time in response to changes in society. These continuous changes ensure that a profession remains viable and is responsive to the needs of the society it serves. Since its founding, occupational therapy's mandate has been to enable people to engage and participate in their own daily activities. In order to meet its obligation, occupational therapy has responded to numerous internal influences (e.g., growth in knowledge, advances in technology) and external influences (e.g., social and government policy, payment practices). As a health care profession, occupational therapy has been particularly influenced by the trends and concerns of medicine (Christiansen, 1991). While medicine continues to affect the evolution of the profession, other changes in society seem to have a greater influence. Responsive to societal change, occupational therapy has moved into education and community-based service-delivery models. For example, pediatric occupational therapists in the early seventies, supported by federal education laws, WORK 1994; 4(4):253-258 Copyright © 1994 by Butterworth-Heinemann
254
WORK / OCTOBER 1994
provided occupational therapy as a related service in education-based systems. During the 1980s occupational therapy became a primary service as society focused on the unique needs of infants and toddlers with disabilities and their families. This change in society's priorities led to an increase in the number of therapists working in educationbased practices and to a change in the site ofpractice from clinics and hospitals to schools and community settings (Hinojosa and Kramer, 1993). This shift in the site of practice and servicedelivery models is also evident in other areas of practice. Occupational therapy continues to evolve to meet the needs of society by shifting its priorities. The strength of occupational therapy is its ability to adapt and change in response to society. However, if occupational therapy is to continue to be viable, it must examine its priorities relative to the current needs of society. What is happening in society? What is happening in occupational therapy? And what is influencing practice today?
Count Data Book" in the Washington Post, March 24, 1992.) 3. HIVIAIDS concerns. One million Americans are estimated to be infected with the HIV virus. (Source: Center for Disease Control, reported in the Washington Post. December 29, 1992.) 4. Elderly concerns. In 1991, 12 % of the U.S. population was over 65 years of age, totaling over 31.5 million people. (Source: National Council on Aging in OT Week, June 27, 1991.)
WHAT IS HAPPENING IN OCCUPATIONAL THERAPY? Trends in the Environment (American Occupational Therapy Association, 1993) identified seven occupational therapy practice concerns:
Each year, the American Occupational Therapy Association (AOTA) prepares a report called Trends in the Environment (American Occupational Therapy Association, 1993), which identifies societal and practice concerns. The 1993 report identified that societal change was evident in political shifts, expansion of information , and technological innovations. The report further identified four specific concerns for society:
1. The demand for occupational therapy services continues to grow and shortages of occupational therapy practitioners persist. 2. The trend in hospitals is for the length of stay to decrease for both acute care and rehabilitation. 3. Home health services continue to increase. 4. Pressures are to increase the use of noncertified personnel to provide occupational therapy serVIces. 5. The use of physical agent modalities remains a divisive issue in the profession. 6. Interdisciplinary competition continues to cause friction among health care providers. 7. Some attempts are being made to restrict the types of disabilities occupational therapy practitioners can treat in education-based systems.
1. Minority concerns. Minorities compose 25 % of the population of the United States, with African Americans making up 12 % of the population and Hispanic Americans 9 %. (Source: Crispell, 1991.) 2. Family concerns. The number of children born to unwed mothers reached 8.6% of all births. An estimated 24% of children in the United States live in single-parent families, and 20 % of all children live below the poverty line. (Source: The Annie E. Casey Foundation and Center for the Study of Social Policy "Kids
N one of these concerns reflect changes in society and the need to deal with minority issues, issues of the health care for the poor, the AIDS epidemic, and/or the elderly. Instead, these concerns focus on the profession; they are essentially concerned with how the profession provides services and protects its territory. Changes in society and the challenges facing occupational therapy practice must be examined together. Occupational therapy's mandate to serve society means that it must address the needs of minorities, the poor, the chronically ill, and the
WHAT IS HAPPENING IN SOCIETY?
The Just Right Challenge
elderly. If, and how, occupational therapy addresses these issues may determine how viable occupational therapy will be into the next decade.
WHAT IS INFLUENCING PRACTICE TODAY? Occupational therapy needs to examine the internal and external factors that are influencing practice. If occupational therapy practitioners recognize some of these influences, perhaps they can make changes to ensure that occupational therapy continues to meet its contract with society.
Internal Influences A profession determines its own internal priorities and the actions it will engage in. Often, these priorities are established to deal with issues that are important for the profession's practitioners. For occupational therapy, these internal influences stem from what the profession's leaders believe is needed to support the profession's significance and value in the current society. As occupational therapy prepares itself for the future, it must deal with three practice concerns: 1) sphere of expertise; 2) role clarification; and 3) competency. Sphere of expertise. Defining occupational therapy's unique body of knowledge and domain of concern has become increasingly important in this complex, technologically advanced society. Occupational therapy practitioners are concerned with how individuals function in their natural environments. They strive to facilitate individuals' abilities to take control of their lives and to allow them to live and function within their own social and cultural groups. This means that practitioners must attend to what the term function means to the people they serve: people who come from single-parent families or who are chronically ill, poor, HIV-infected, or elderly; people from different races and cultures; people with different sexual orientations, traditions, beliefs, values, and patterns of behaviors. It is clear that occupational therapy practitioners must be proactive in dealing with what function means to these individuals; if they are not, other professionals will step in. All practitioners share the responsibility of
255
clearly documenting occupational therapy's contributions to an individual's ability to function. This documentation must be sensitive to the individual's age, culture, disability status, and resources. Who is better able to understand function relative to a person's sociocultural background? Who can better understand the changes of the elderly, the HIV-infected, or the ill and poor? Finally, occupational therapy research efforts must be more clearly directed at substantiating the functional outcomes of interventions relative to a person's individual situation, including sociocultural status and resources. In response to this need to more clearly define occupational therapy's sphere of expertise, AOTA continually revises uniform terminology to define the domain of concern of occupational therapy. In Uniform Terminologyfor Occupational Therapy (3rd Edition) (American Occupational Therapy Association, in press), the domain of concern is expanded beyond performance components and performance areas to include the performance context. Performance context clarifies the ways in which occupational therapy practitioners use context (e.g., sociocultural and physical features, other people in the environment, objects in the environment, the structure of the environment) in the provision of their services. It highlights the importance that occupational therapy practitioners give to age (developmental status), culture, resources, and the situation within which the person lives. Role clarification. During the past 20 years, the role delineation between registered occupational therapists (OTRs) and certified occupational therapy assistants (COTAs) has been an issue for many practitioners. Typically, the role delineation has been made on the first year of practice and consists of tasks an OTR could perform versus tasks a COTA could not perform. However, this approach does not work. Stereotypical categorization of specific tasks is inappropriate, and it is not sensitive to the skills of the practitioner or the requirements of service-delivery systems. Rather than focusing on tasks practitioners perform, it is more useful to consider the many roles that practitioners assume. "Occupational Therapy Roles" (Crist, Halom, Hinojosa, et al.,
256
WORK / OCTOBER 1994
1993) provided support for this approach by identifying 12 roles assumed by OTRs and COTAs, key performance areas, relevant qualifications, and supervision requirements for different levels of expertise. Many employment situations require that an individual perform several roles simultaneously. Use of this approach frees practitioners to consider ind~vidual skill and expertise. By changing and adjusting their views of the ways in which occupational therapy practitioners work together, OTRs and COTAs will be better able to meet the expanding demand for services. Further, a clear understanding of the role of occupational therapy practitioners seems fundamental to the establishment of guidelines for the use of service extenders. Competency. Competency standards modify over time as practitioners deal with people from different cultures, as setting and service-delivery patterns change, as knowledge expands, and as technology changes. As practitioners provide services to minorities, families of different configurations, HIV-infected patients and the elderly, they must develop and substantiate their specific competencies to work with these populations. Competence is a critically important ethical requirement for all professionals. When a practitioner is competent in an area of practice , society and the recipient of intervention are assured that the person providing the service has the appropriate knowledge and skills to intervene in a safe and effective manner. Competence for the professional extends to the individual's ability to assess his or her attitude, knowledge, and skills related to the use of a specific intervention strategy. One difficulty inherent in determining whether someone is competent is that a practitioner often cannot be categorized as simply competent or incompetent. Instead, a continuum exists. A practitioner may be either more or less competent in the use of a specific modality, technique, or practice. It is possible that one could be competent in a modality today and less competent tomorrow due to lack of use or change in technology. In addition, a practitioner may have prerequisite knowledge and skills but still not be competent. For example, the therapist may be an expert in the use of a specific tool but not have sufficient
theoretical knowledge to develop a theory-based approach to intervention. When an occupational therapy practitioner chooses to use a specific therapeutic tool, he or she must establish and maintain competence. That is, each practitioner has the professional obligation to establish and monitor his or her competency for the tools used. Through continual monitoring, practitioners can verify that they are competent and can use a therapeutic tool properly and safely. As the tools of occupational therapy expand through technological advancements, each practitioner is responsible for ensuring his or her competency. In order to meet its obligation to society, occupational therapy must continue to ensure that its practitioners are competent. Competence in the next decade means that practitioners establish and monitor their attitudes, knowledge, skills, and behaviors, These competencies will ensure that occupational therapy practitioners are seen as the leaders in the delivery of effective, relevant services.
External Influences External factors that influence professions are more complicated as they are defined by external political, economic, or social forces. As with internal influences, a profession determines the external influences to which it will respond. Occupational therapy responds to three external factors influencing practice: 1) use of service extenders; 2) cross training; and 3) practice parameters. Use of service extenders. Occupational therapy practitioners have always used other personnel to assist in the delivery of occupational therapy services. The use of service extenders (personnel not formally trained in a particular health profession) has recently become a critical issue as a result of the manpower shortage, the need for more specialized services, the high cost of occupational therapy services, and the need for cost containment. Occupational therapy practitioners are defining how service extenders are appropriately used during the intervention process. Part of this process is identifying when it is appropriate to use a service extender with a particular client, not just because it may be the most cost-effective method of providing intervention. At the heart of occupa-
The Just Right Challenge
tional therapy is the relationship that practitioners develop with their clients around their occupational lives. Occupational therapy practitioners should not risk losing this relationship by extensive use of cost-,effective service extenders. AOTA is currently developing a statement that clarifies the use of service extenders during the intervention component of service provision. With the current focus on the delivery of quality, costeffective occupational therapy, practitioners must develop and test alternative service-delivery models that include service extenders. Cross training. The issue of cross training has emerged as a result of the manpower shortage, the high cost of occupational therapy services, and. the need for cost containment. Several state legislators, agencies, and health care facilities are studyingways to cross train professionals. For example, in Florida the Health Care and Insurance Reform Act of 1993 (Chapter 93-129, Laws of Florida) established an agency to develop cross-training programs that allow flexibility in using occupational therapists; nurses; radiologic technologies, clinical laboratory, multiphasic health testing, and cholesterol screening personnel; and respiratory therapists. Currently, they are still examining the issue of cross training, but it is doubtful that a program will be implemented. Florida is not alone, however. In Kentucky the legislature has had considerable activity related to the cross training of occupational therapists, physical therapists, and clinical laboratory and radiologic technicians. Further, facilities in California, Minnesota, and New York have been exploring cross-training proposals for occupational therapists and other health care professions. Crossing training already takes place in many specialized areas of practice. Numerous opportunities exist for cross training among professionals. For example, occupational therapists, physical therapists, and speech-language pathologists all may become trained in neurodevelopmental treatment (NDT). However, this type of cross training is considered by many professionals to be different from training specific to professional qualification. In preparation for the future, occupational therapy must carefully consider the implications and consequences of cross training at all levels of practice.
257
What should occupational therapy do to prepare itself for cross training? First, occupational therapy must articulate its uniqueness and clearly define its body of knowledge, acknowledging the points at which overlap exists among professions. Second, occupational therapy practitioners must develop collaborative relationships with other professionals. Interdisciplinary collaboration fosters support and understanding of one another's contributions. With increased inter~isciplinary cooperation, occupational therapy practitioners may appreciate that professions overlap in some areas. This overlap is healthy; it is an not an example of one profession attempting to "take something" that belongs to another profession. Third, occupational therapy practitioners must continue to engage in outcome research that supports the effectiveness of interventions. Without this research support it is impossible for occupational therapy to support its efficacy. Practice parameters. Subsequent to the crosstraining situation in Florida, the Florida occupational therapy association has been asked to provide practice parameters. This request for practice parameters may lead to similar requests in several other states. When developing practice parameters, practitioners should capture the broad scope of occupational therapy practice. The parameters should be written in a way that does not restrict the development of new practice areas. Practice parameters, like state scope of practice statements, will vary from state to state and possibly from facility to facility. Obviously, this may lead to differences in occupational therapy practice from region to region. Occupational therapy practitioners must give up the idea that occupational therapy is the same everywhere. They must become comfortable with the fact that occupational therapy practice varies to meet the unique needs of the community and service-delivery model within which it is applied.
CONCLUSION As a viable profession, occupational therapy is continually evolving to respond to society's needs. The strength of occupational therapy is its ability
258
WORK / OCTOBER 1994
to adapt to a changing world. Clearly, occupational therapy practice is changing in response to increasing demands for access to quality, costeffective services. Changes in society require that occupational therapy address the needs of minorities, the poor, the chronically ill, and the elderly. Occupational therapy addresses these concerns by responding to both internal and external influences. By responding to the changing needs of society, occupational therapy sets internal priorities that support the profession's significance and value. To this end, the profession is clarifying its sphere of expertise, developing new role definitions for its practitioners, and maintaining that practitioners must establish and monitor their competency. Political, economic, or social forces
determine the external factors that influence occupational therapy. Occupational therapy currently responds to the external issues of the use of service extenders, cross training, and practice parameters. The ways in which the profession responds to these external influences will determine how service delivery looks in the future. This paper should challenge some of the ideas about occupational therapy. It may even lead practitioners to question why they do what they do. This is an exciting time to be an occupational therapy practitioner. Occupational therapy practitioners are in demand - and what occupational therapy does makes a difference in people's lives. Occupational therapy has many challenges, but with each challenge comes another opportunity.
REFERENOES American Occupational Therapy Association. (in press). Uniform terminology for occupational therapy (3rd Edition). Rockville, MD: American Occupational Therapy Association. American Occupational Therapy Association. (1993). Trends in the environment. Rockville, MD: Research Information and Evaluation Department, American Occupational Therapy Association. Christiansen, C. (1991). Occupational therapy intervention for life performance. In C. Christiansen and C. Baum, (Eds.), Occupational therapy: Overcoming human performance deficits (pp. 3-43). Thorofare, Nj: Slack. Crispell, D. (April, 1991). War and a question of black and white. The Numbers News, Ithaca, NY. Crist, P., Halom,j., Hinojosa,j., et al. (1993). Occu-
pational therapy roles. Am] Occup Ther, 47, 10871099. Kielhofner, G. (1992). Concepts andfoundations of occupational therapy. Philadelphia, PA: F. A. Davis. Kramer, P., and Hinojosa, j. (1993). Domain of concern of occupational therapy relevant to pediatric practice. In P. Kramer and j. Hinojosa (Eds.), Frame of references in pediatric occupational therapy. Baltimore, MD: Williams and Wilkins. Mosey, A. C. (1981): Occupational therapy: Configuration of a profession. New York: Raven Press. ___ . (1992). Applied scientific inquiry in the health professions: An epistemological orientation. Rockville, MD: American Occupational Therapy Association. Reilly, M. (1962). Occupational therapy can be one of the great ideas of the 20th century medicine. Am ] Occup Ther, 16, 1-9.
This paper is based on a keynote address "The Just R!~t;ht Challenge" given on October 14, 1993, at Massachusetts Associationjor Occupational Therapy Annual Conjerence in Marlborough, MA. The occupational therapy projession is accountable to the society it serves. This paper outlines some key internal and external influences affecting the projession as it prepares jor the next decade. Internal influences include the sphere oj expertise, role clarification, and competencies. External influences include the use of service extenders, cross training, and practice parameters. Keywords: Occupational therapy; Practice parameters; Cross training; Service ex-
tenders
CHALLENGES Occupational therapists have always been concerned with the "just right challenge" to enable individuals to engage in the activities that give meaning to their lives. However, as a theme for a conference, "the just right challenge" goes beyond the traditional view of ensuring success during intervention. This paper challenges practitioners to expand their horizons; it challenges practitioners to open their eyes to innovations; and, it challenges practitioners to examine themselves in this world of social change. This paper presents a view of the world of occupational therapy that supports the statement made by Dr. Mary Reilly that "occupational therapy can be one of the great ideas of the 20th century medicine" (Reilly, 1962). From the author's perspective, occupational therapy is a great idea for society.
OCCUPATIONAL THERAPY'S MANDATE A profession is a group of individuals recognized by society to perform specific functions because of their specialized training. Kie1hofner (1992) and
Mosey(1981, 1992) maintain that a primary function of a profession is the application of knowledge for the benefit of society. The predominant concerns of a profession evolve and shift over time in response to changes in society. These continuous changes ensure that a profession remains viable and is responsive to the needs of the society it serves. Since its founding, occupational therapy's mandate has been to enable people to engage and participate in their own daily activities. In order to meet its obligation, occupational therapy has responded to numerous internal influences (e.g., growth in knowledge, advances in technology) and external influences (e.g., social and government policy, payment practices). As a health care profession, occupational therapy has been particularly influenced by the trends and concerns of medicine (Christiansen, 1991). While medicine continues to affect the evolution of the profession, other changes in society seem to have a greater influence. Responsive to societal change, occupational therapy has moved into education and community-based service-delivery models. For example, pediatric occupational therapists in the early seventies, supported by federal education laws, WORK 1994; 4(4):253-258 Copyright © 1994 by Butterworth-Heinemann
254
WORK / OCTOBER 1994
provided occupational therapy as a related service in education-based systems. During the 1980s occupational therapy became a primary service as society focused on the unique needs of infants and toddlers with disabilities and their families. This change in society's priorities led to an increase in the number of therapists working in educationbased practices and to a change in the site ofpractice from clinics and hospitals to schools and community settings (Hinojosa and Kramer, 1993). This shift in the site of practice and servicedelivery models is also evident in other areas of practice. Occupational therapy continues to evolve to meet the needs of society by shifting its priorities. The strength of occupational therapy is its ability to adapt and change in response to society. However, if occupational therapy is to continue to be viable, it must examine its priorities relative to the current needs of society. What is happening in society? What is happening in occupational therapy? And what is influencing practice today?
Count Data Book" in the Washington Post, March 24, 1992.) 3. HIVIAIDS concerns. One million Americans are estimated to be infected with the HIV virus. (Source: Center for Disease Control, reported in the Washington Post. December 29, 1992.) 4. Elderly concerns. In 1991, 12 % of the U.S. population was over 65 years of age, totaling over 31.5 million people. (Source: National Council on Aging in OT Week, June 27, 1991.)
WHAT IS HAPPENING IN OCCUPATIONAL THERAPY? Trends in the Environment (American Occupational Therapy Association, 1993) identified seven occupational therapy practice concerns:
Each year, the American Occupational Therapy Association (AOTA) prepares a report called Trends in the Environment (American Occupational Therapy Association, 1993), which identifies societal and practice concerns. The 1993 report identified that societal change was evident in political shifts, expansion of information , and technological innovations. The report further identified four specific concerns for society:
1. The demand for occupational therapy services continues to grow and shortages of occupational therapy practitioners persist. 2. The trend in hospitals is for the length of stay to decrease for both acute care and rehabilitation. 3. Home health services continue to increase. 4. Pressures are to increase the use of noncertified personnel to provide occupational therapy serVIces. 5. The use of physical agent modalities remains a divisive issue in the profession. 6. Interdisciplinary competition continues to cause friction among health care providers. 7. Some attempts are being made to restrict the types of disabilities occupational therapy practitioners can treat in education-based systems.
1. Minority concerns. Minorities compose 25 % of the population of the United States, with African Americans making up 12 % of the population and Hispanic Americans 9 %. (Source: Crispell, 1991.) 2. Family concerns. The number of children born to unwed mothers reached 8.6% of all births. An estimated 24% of children in the United States live in single-parent families, and 20 % of all children live below the poverty line. (Source: The Annie E. Casey Foundation and Center for the Study of Social Policy "Kids
N one of these concerns reflect changes in society and the need to deal with minority issues, issues of the health care for the poor, the AIDS epidemic, and/or the elderly. Instead, these concerns focus on the profession; they are essentially concerned with how the profession provides services and protects its territory. Changes in society and the challenges facing occupational therapy practice must be examined together. Occupational therapy's mandate to serve society means that it must address the needs of minorities, the poor, the chronically ill, and the
WHAT IS HAPPENING IN SOCIETY?
The Just Right Challenge
elderly. If, and how, occupational therapy addresses these issues may determine how viable occupational therapy will be into the next decade.
WHAT IS INFLUENCING PRACTICE TODAY? Occupational therapy needs to examine the internal and external factors that are influencing practice. If occupational therapy practitioners recognize some of these influences, perhaps they can make changes to ensure that occupational therapy continues to meet its contract with society.
Internal Influences A profession determines its own internal priorities and the actions it will engage in. Often, these priorities are established to deal with issues that are important for the profession's practitioners. For occupational therapy, these internal influences stem from what the profession's leaders believe is needed to support the profession's significance and value in the current society. As occupational therapy prepares itself for the future, it must deal with three practice concerns: 1) sphere of expertise; 2) role clarification; and 3) competency. Sphere of expertise. Defining occupational therapy's unique body of knowledge and domain of concern has become increasingly important in this complex, technologically advanced society. Occupational therapy practitioners are concerned with how individuals function in their natural environments. They strive to facilitate individuals' abilities to take control of their lives and to allow them to live and function within their own social and cultural groups. This means that practitioners must attend to what the term function means to the people they serve: people who come from single-parent families or who are chronically ill, poor, HIV-infected, or elderly; people from different races and cultures; people with different sexual orientations, traditions, beliefs, values, and patterns of behaviors. It is clear that occupational therapy practitioners must be proactive in dealing with what function means to these individuals; if they are not, other professionals will step in. All practitioners share the responsibility of
255
clearly documenting occupational therapy's contributions to an individual's ability to function. This documentation must be sensitive to the individual's age, culture, disability status, and resources. Who is better able to understand function relative to a person's sociocultural background? Who can better understand the changes of the elderly, the HIV-infected, or the ill and poor? Finally, occupational therapy research efforts must be more clearly directed at substantiating the functional outcomes of interventions relative to a person's individual situation, including sociocultural status and resources. In response to this need to more clearly define occupational therapy's sphere of expertise, AOTA continually revises uniform terminology to define the domain of concern of occupational therapy. In Uniform Terminologyfor Occupational Therapy (3rd Edition) (American Occupational Therapy Association, in press), the domain of concern is expanded beyond performance components and performance areas to include the performance context. Performance context clarifies the ways in which occupational therapy practitioners use context (e.g., sociocultural and physical features, other people in the environment, objects in the environment, the structure of the environment) in the provision of their services. It highlights the importance that occupational therapy practitioners give to age (developmental status), culture, resources, and the situation within which the person lives. Role clarification. During the past 20 years, the role delineation between registered occupational therapists (OTRs) and certified occupational therapy assistants (COTAs) has been an issue for many practitioners. Typically, the role delineation has been made on the first year of practice and consists of tasks an OTR could perform versus tasks a COTA could not perform. However, this approach does not work. Stereotypical categorization of specific tasks is inappropriate, and it is not sensitive to the skills of the practitioner or the requirements of service-delivery systems. Rather than focusing on tasks practitioners perform, it is more useful to consider the many roles that practitioners assume. "Occupational Therapy Roles" (Crist, Halom, Hinojosa, et al.,
256
WORK / OCTOBER 1994
1993) provided support for this approach by identifying 12 roles assumed by OTRs and COTAs, key performance areas, relevant qualifications, and supervision requirements for different levels of expertise. Many employment situations require that an individual perform several roles simultaneously. Use of this approach frees practitioners to consider ind~vidual skill and expertise. By changing and adjusting their views of the ways in which occupational therapy practitioners work together, OTRs and COTAs will be better able to meet the expanding demand for services. Further, a clear understanding of the role of occupational therapy practitioners seems fundamental to the establishment of guidelines for the use of service extenders. Competency. Competency standards modify over time as practitioners deal with people from different cultures, as setting and service-delivery patterns change, as knowledge expands, and as technology changes. As practitioners provide services to minorities, families of different configurations, HIV-infected patients and the elderly, they must develop and substantiate their specific competencies to work with these populations. Competence is a critically important ethical requirement for all professionals. When a practitioner is competent in an area of practice , society and the recipient of intervention are assured that the person providing the service has the appropriate knowledge and skills to intervene in a safe and effective manner. Competence for the professional extends to the individual's ability to assess his or her attitude, knowledge, and skills related to the use of a specific intervention strategy. One difficulty inherent in determining whether someone is competent is that a practitioner often cannot be categorized as simply competent or incompetent. Instead, a continuum exists. A practitioner may be either more or less competent in the use of a specific modality, technique, or practice. It is possible that one could be competent in a modality today and less competent tomorrow due to lack of use or change in technology. In addition, a practitioner may have prerequisite knowledge and skills but still not be competent. For example, the therapist may be an expert in the use of a specific tool but not have sufficient
theoretical knowledge to develop a theory-based approach to intervention. When an occupational therapy practitioner chooses to use a specific therapeutic tool, he or she must establish and maintain competence. That is, each practitioner has the professional obligation to establish and monitor his or her competency for the tools used. Through continual monitoring, practitioners can verify that they are competent and can use a therapeutic tool properly and safely. As the tools of occupational therapy expand through technological advancements, each practitioner is responsible for ensuring his or her competency. In order to meet its obligation to society, occupational therapy must continue to ensure that its practitioners are competent. Competence in the next decade means that practitioners establish and monitor their attitudes, knowledge, skills, and behaviors, These competencies will ensure that occupational therapy practitioners are seen as the leaders in the delivery of effective, relevant services.
External Influences External factors that influence professions are more complicated as they are defined by external political, economic, or social forces. As with internal influences, a profession determines the external influences to which it will respond. Occupational therapy responds to three external factors influencing practice: 1) use of service extenders; 2) cross training; and 3) practice parameters. Use of service extenders. Occupational therapy practitioners have always used other personnel to assist in the delivery of occupational therapy services. The use of service extenders (personnel not formally trained in a particular health profession) has recently become a critical issue as a result of the manpower shortage, the need for more specialized services, the high cost of occupational therapy services, and the need for cost containment. Occupational therapy practitioners are defining how service extenders are appropriately used during the intervention process. Part of this process is identifying when it is appropriate to use a service extender with a particular client, not just because it may be the most cost-effective method of providing intervention. At the heart of occupa-
The Just Right Challenge
tional therapy is the relationship that practitioners develop with their clients around their occupational lives. Occupational therapy practitioners should not risk losing this relationship by extensive use of cost-,effective service extenders. AOTA is currently developing a statement that clarifies the use of service extenders during the intervention component of service provision. With the current focus on the delivery of quality, costeffective occupational therapy, practitioners must develop and test alternative service-delivery models that include service extenders. Cross training. The issue of cross training has emerged as a result of the manpower shortage, the high cost of occupational therapy services, and. the need for cost containment. Several state legislators, agencies, and health care facilities are studyingways to cross train professionals. For example, in Florida the Health Care and Insurance Reform Act of 1993 (Chapter 93-129, Laws of Florida) established an agency to develop cross-training programs that allow flexibility in using occupational therapists; nurses; radiologic technologies, clinical laboratory, multiphasic health testing, and cholesterol screening personnel; and respiratory therapists. Currently, they are still examining the issue of cross training, but it is doubtful that a program will be implemented. Florida is not alone, however. In Kentucky the legislature has had considerable activity related to the cross training of occupational therapists, physical therapists, and clinical laboratory and radiologic technicians. Further, facilities in California, Minnesota, and New York have been exploring cross-training proposals for occupational therapists and other health care professions. Crossing training already takes place in many specialized areas of practice. Numerous opportunities exist for cross training among professionals. For example, occupational therapists, physical therapists, and speech-language pathologists all may become trained in neurodevelopmental treatment (NDT). However, this type of cross training is considered by many professionals to be different from training specific to professional qualification. In preparation for the future, occupational therapy must carefully consider the implications and consequences of cross training at all levels of practice.
257
What should occupational therapy do to prepare itself for cross training? First, occupational therapy must articulate its uniqueness and clearly define its body of knowledge, acknowledging the points at which overlap exists among professions. Second, occupational therapy practitioners must develop collaborative relationships with other professionals. Interdisciplinary collaboration fosters support and understanding of one another's contributions. With increased inter~isciplinary cooperation, occupational therapy practitioners may appreciate that professions overlap in some areas. This overlap is healthy; it is an not an example of one profession attempting to "take something" that belongs to another profession. Third, occupational therapy practitioners must continue to engage in outcome research that supports the effectiveness of interventions. Without this research support it is impossible for occupational therapy to support its efficacy. Practice parameters. Subsequent to the crosstraining situation in Florida, the Florida occupational therapy association has been asked to provide practice parameters. This request for practice parameters may lead to similar requests in several other states. When developing practice parameters, practitioners should capture the broad scope of occupational therapy practice. The parameters should be written in a way that does not restrict the development of new practice areas. Practice parameters, like state scope of practice statements, will vary from state to state and possibly from facility to facility. Obviously, this may lead to differences in occupational therapy practice from region to region. Occupational therapy practitioners must give up the idea that occupational therapy is the same everywhere. They must become comfortable with the fact that occupational therapy practice varies to meet the unique needs of the community and service-delivery model within which it is applied.
CONCLUSION As a viable profession, occupational therapy is continually evolving to respond to society's needs. The strength of occupational therapy is its ability
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to adapt to a changing world. Clearly, occupational therapy practice is changing in response to increasing demands for access to quality, costeffective services. Changes in society require that occupational therapy address the needs of minorities, the poor, the chronically ill, and the elderly. Occupational therapy addresses these concerns by responding to both internal and external influences. By responding to the changing needs of society, occupational therapy sets internal priorities that support the profession's significance and value. To this end, the profession is clarifying its sphere of expertise, developing new role definitions for its practitioners, and maintaining that practitioners must establish and monitor their competency. Political, economic, or social forces
determine the external factors that influence occupational therapy. Occupational therapy currently responds to the external issues of the use of service extenders, cross training, and practice parameters. The ways in which the profession responds to these external influences will determine how service delivery looks in the future. This paper should challenge some of the ideas about occupational therapy. It may even lead practitioners to question why they do what they do. This is an exciting time to be an occupational therapy practitioner. Occupational therapy practitioners are in demand - and what occupational therapy does makes a difference in people's lives. Occupational therapy has many challenges, but with each challenge comes another opportunity.
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pational therapy roles. Am] Occup Ther, 47, 10871099. Kielhofner, G. (1992). Concepts andfoundations of occupational therapy. Philadelphia, PA: F. A. Davis. Kramer, P., and Hinojosa, j. (1993). Domain of concern of occupational therapy relevant to pediatric practice. In P. Kramer and j. Hinojosa (Eds.), Frame of references in pediatric occupational therapy. Baltimore, MD: Williams and Wilkins. Mosey, A. C. (1981): Occupational therapy: Configuration of a profession. New York: Raven Press. ___ . (1992). Applied scientific inquiry in the health professions: An epistemological orientation. Rockville, MD: American Occupational Therapy Association. Reilly, M. (1962). Occupational therapy can be one of the great ideas of the 20th century medicine. Am ] Occup Ther, 16, 1-9.
