Annals of International Occupational Therapy

Position Paper 

Enhancing Professionalism and Quality of Service by Establishing an Occupational Therapy Association in the People's Republic of China

Yun Shi, MA; Tsu-Hsin Howe, PhD, OTR, FAOTA; Jim Hinojosa, PhD, OT, FAOTA; James Y. Wang, BA

Abstract

We propose that the establishment of a national occupational therapy professional association in the People's Republic of China would support the development of high-quality occupational therapy and address the current shortage of competent occupational therapists with unique knowledge and skills grounded in and of Chinese culture. We argue that establishing a national occupational therapy association will require sensitivity to the unique political and structural setting of the People's Republic of China. We discuss specific challenges to founding an association and offer recommendations. Chinese occupational therapists are encouraged to work closely with the government of the People's Republic of China to establish a national professional occupational therapy association. Simultaneously, occupational therapists at local levels can support the establishment of an association. Together, the central and local associations can work to establish educational, practice, and ethical standards and to ensure best practices for the benefit of occupational therapy consumers. [Annals of International Occupational Therapy. 2018;1(1):41–48.]

Abstract

We propose that the establishment of a national occupational therapy professional association in the People's Republic of China would support the development of high-quality occupational therapy and address the current shortage of competent occupational therapists with unique knowledge and skills grounded in and of Chinese culture. We argue that establishing a national occupational therapy association will require sensitivity to the unique political and structural setting of the People's Republic of China. We discuss specific challenges to founding an association and offer recommendations. Chinese occupational therapists are encouraged to work closely with the government of the People's Republic of China to establish a national professional occupational therapy association. Simultaneously, occupational therapists at local levels can support the establishment of an association. Together, the central and local associations can work to establish educational, practice, and ethical standards and to ensure best practices for the benefit of occupational therapy consumers. [Annals of International Occupational Therapy. 2018;1(1):41–48.]

During the past three decades, the central government of the People's Republic of China has made significant efforts to promote quality rehabilitation services (Lin, n.d.; Zhang & Shen, 2014). However, there is a severe shortage of personnel qualified to deliver rehabilitation services, including occupational therapy (Lee, 2014). In 2009, according to national survey data released by the Chinese Association of Rehabilitation Medicine, the total number of occupational therapists in China was 2,400, and the number of Chinese citizens living with a disability was estimated to be 85.02 million—roughly one occupational therapist per 100,000 citizens (Zhang & Shen, 2014). A temporary solution to this shortage was to recruit personnel with educational backgrounds in health care, such as nursing, traditional Chinese medicine, or chiropractic, to provide occupational therapy without formal occupational therapy training (Li, 2011; Zhang & Shen, 2014). In general, these practitioners, working as occupational therapists, do not have adequate knowledge or skills in occupational therapy. Consequently, the quality of rehabilitation service may be compromised, even though many practitioners have expressed a desire for additional training to improve their knowledge and skills (Shi & Howe, 2016). In this article, we argue that establishing a national occupational therapy professional association in China will promote and ensure the delivery of quality occupational therapy for Chinese citizens. We believe that there are personal and societal benefits associated with the establishment of a professional association, and we propose that a professional association is essential for promoting professionalism and improving the quality of rehabilitation services. We also offer suggestions for possible routes to establishing a Chinese occupational therapy association.

Currently, there is no national professional association for occupational therapy recognized by the central government or the public in the People's Republic of China. Research reports indicate that highly skilled, ethical, and competent professionals increase the likelihood of desired health outcomes (Mosadeghrad, 2014; Schneiderman et al., 2003). We propose that an association will assist occupational therapists in becoming such professionals and in meeting their obligation to society to provide high-quality rehabilitation services. Both society collectively and individual recipients of services will directly benefit. Specifically, establishing a Chinese occupational therapy association will support the Chinese government's goals under the policy “rehabilitation for all” (General Office of the State Council of the People's Republic of China, 2002). The association would develop and enforce standards of practice and a code of ethics. The association would then be able to support the mission of the Chinese government as well as the common goal of occupational therapists to provide quality rehabilitation services to every person with a disability, regardless of region, income, gender, social status, or age. Critically important, the association would facilitate the delivery of occupational therapy that reflects Chinese culture and values.

Advancing the Practice of Occupational Therapy

All professions have a unique body of knowledge that is acquired through systematic, formal education (Hooper et al., 2014; Sabari, 1985). During their education, occupational therapists acquire the values, knowledge, skills, and attitudes essential for competent practice. This unique expertise is the foundation for the distinct services that each profession provides. The creation of a professional occupational therapy association in the People's Republic of China would promote the specific contextual knowledge needed to practice occupational therapy in China. Further, a national association would support occupational therapists in delivering efficacious care and also promote research in occupational therapy, establishing the validity and efficacy of occupational therapy in China. These types of accomplishments are evident in the activities of the professional associations of Canada, the United States, and Japan. Each association strategically supports evidence-based research by providing resources for awareness and advocacy of occupational therapy. Through their publications, conferences, and continuing education programs, these associations continually foster best practices (American Occupational Therapy Association, n.d.; Canadian Association of Occupational Therapists, n.d.; Japanese Association of Occupational Therapists, n.d.). A Chinese occupational therapy association would continually expand the knowledge base of the profession and keep Chinese occupational therapists informed through education, conferences, and publications.

Facilitating Professionalism

A professional association would facilitate professional practice by emphasizing the unique characteristics of occupational therapy. Professions share common characteristics and have four foundational features. Flexner (1910) identified the characteristics of a profession when he studied medicine in the United States, and these characteristics are still used to define professions (Crowe, 2017; Cruess, Johnston, & Cruess, 2004; Lawlor & Morley, 2017): (a) members of a profession have a unique body of knowledge that is acquired through systematic training; (b) practitioners provide services that are consistent with an articulated code of ethics; (c) the expertise and knowledge of the members must be recognized by society; and (d) there is a professional association that promotes the competence of members and the profession as a whole.

Without a national association, occupational therapy in China does not satisfy these criteria. Additionally, the larger evolution of medical practice in China underlines the importance of establishing a national occupational therapy association. Medicine was one of the first Chinese health care professions. After government economic reform in the 1980s, Chinese medicine became a profit-seeking entity (Xu, 2013). In the years that followed, to generate higher incomes, physicians began overprescribing medications and requesting expensive tests (Xu, 2013). These unethical actions had serious, far-reaching consequences, including the abuse of antibiotics (Currie, Lin, & Meng, 2014). In 2002, the Chinese Medical Doctor Association (CMDA) was established (Cao, 2011; Chinese Medical Doctor Association, n.d.a) in response to this situation. The CMDA is a national, voluntary, not-for-profit professional association that regulates the Chinese medical profession (Cao, 2011; Chinese Medical Doctor Association, n.d.a). After its establishment, the CMDA adopted a national code of ethics to address unethical conduct (Chinese Medical Doctor Association, 2014). It also developed standards and guidelines for practice, began assisting with licensure examinations, and established national journals to facilitate communication with the international medical community (Chinese Medical Doctor Association, n.d.b). Further, the CMDA outlined strategies to improve doctor–patient relationships. Likewise, with the support of the Chinese Association of Rehabilitation Medicine, physical therapists in China are engaged in establishing a professional association (Jones & Skinner, 2013). Therefore, to ensure professionalism, occupational therapists must undertake the same process of forming a national association.

Establishing Professional Standards

Currently, there are no written standards for practicing occupational therapists in China. A Chinese occupational therapy association has the potential to serve as the organization to establish, implement, and monitor standards in China. It is a fundamental responsibility of professional associations to develop and enforce standards for ethics, practice, education, and research (Carr-Saunders & Wilson, 1964; Foote, 1953; Greenwood, 1957; Meintjes & Niemann-Struweg, 2009; Mosey, 1992). Such standards set a baseline for services and ensure that professionals maintain and enhance the quality of their practice. Professional practice standards guide behaviors and actions and protect the public from unethical, incompetent, and questionable services (Lester, 2014; Spielthenner, 2015).

A Chinese occupational therapy association will facilitate the professionalization of occupational therapy through the development of a formal qualification process that includes education, apprenticeship, and examinations. Further, the association can establish regulatory bodies with powers to admit and discipline members (Bullock & Trombley, 2000). Association standards for education will establish criteria for admitting new members, and practice standards will provide norms for members who want to remain active in the profession (Australian Education Union, n.d.). Practice standards and a code of ethics will serve as the basis for rejecting or removing incompetent members and promoting best practices (American Occupational Therapy Association, 2015a, 2015c). These standards will help occupational therapists to maintain and enhance the quality of their services and ensure that they meet their obligation to society. When practitioners do not meet established standards, an association will provide a method for excluding them from practice.

We recognize that Chinese occupational therapists have unique values, beliefs, and behaviors that must be stated in any standards for occupational therapy in China. The Chinese occupational therapy association would be the appropriate organization to establish ethical, practice, and educational standards that reflect core Chinese values and to guide occupational therapists in professional conduct consistent with China's distinctive issues. For example, in China, occupational therapy is strongly associated with medicine. Most occupational therapists practice in hospital settings and are trained at medical universities (Li, 2011). Currently, nine occupational therapy programs in China have been approved by the World Federation of Occupational Therapists (WFOT) (World Federation of Occupational Therapists, n.d.a). Seven programs offer entry-level baccalaureate degrees, and the other two award entry-level master's degrees. All of the programs are established within medical schools or universities. In contrast to most Western countries, Western medicine is not the only choice of remedy in China. According to the Chinese Ministry of Health, traditional Chinese medical institutions account for 5% of all health care institutions in China (Ministry of Health, P. R. China, 2015). Approximately 9% of these traditional Chinese medical institutions are hospitals, and some are required to provide occupational therapy services (Ministry of Health, P. R. China, 1989). As a result, researchers, educators, and practitioners have been working to establish therapeutic methods that combine Western medicine and traditional Chinese medicine (Huang et al., 2015; Tian & Zhang, 2014). A Chinese occupational therapy association would need to develop culturally relevant standards that address and support unique facets of occupational therapy in China.

Establishing Ethical Standards

A code of ethics is both a practical document that outlines professional conduct and an aspirational document that sets standards for conduct. It is also a public statement that delineates the behaviors and actions that consumers can expect from a profession. A Chinese occupational therapy association will create a code of ethics that stipulates that all occupational therapists will be held accountable for their actions, consistent with Chinese societal values and beliefs (Kyler, 2014).

The WFOT Code of Ethics (World Federation of Occupational Therapists, 2016a) provides a general framework for minimum ethical requirements for all members of the Federation (World Federation of Occupational Therapists, n.d.b). These requirements are designed to be, at best, general rather than specific, and they are not culturally or situationally relevant for every nation. Most countries with well-developed occupational therapy associations, such as the United States, Canada, Japan, Australia, and Israel, have adopted their own sets of ethical standards (American Occupational Therapy Association, 2015c; Canadian Association of Occupational Therapists, 2007; Israeli Society of Occupational Therapy, 2015; Japanese Association of Occupational Therapists, 2005; Occupational Therapy Australia, 2014). For example, the Japanese Association of Occupational Therapists Code of Ethics (Japanese Association of Occupational Therapists, 2005) prohibits occupational therapists from receiving bribes or illegal commissions from clients or others. The Israeli Society of Occupational Therapy Code of Ethics expands and defines the scope of the “promotion and development” rule of the WFOT. The expanded ethical standard requires all members to adopt the role of educator, highlighting the importance of training and mentoring students and peers (Israeli Society of Occupational Therapy, 2015). Similar to the other countries with established occupational therapy practices, a Chinese occupational therapy association would need to develop a culturally relevant code of ethics.

Establishing Educational and Accreditation Standards

Educational standards set minimum requirements for all educational programs and define specific competencies that occupational therapists must meet to practice (American Occupational Therapy Association, 2006; World Federation of Occupational Therapists, 2016b). These educational standards identify the criteria used to admit new occupational therapists into the profession (Penelope & Hinojosa, 2011). These standards also could be used to evaluate and promote first-class educational programs (Accreditation Council for Occupational Therapy Education, 2017). Because professional practice must reflect the larger society (Cruess et al., 2004), educational standards for occupational therapy in China must address Chinese beliefs, values, knowledge, and models for service delivery. Establishment of Chinese-specific educational standards will support the development of quality educational programs that graduate occupational therapists who are prepared to deliver high-quality care. Once educational standards are established, an association would be responsible for working with the government to establish an accreditation system to ensure that educational programs meet minimum requirements.

Even though the WFOT standards (World Federation of Occupational Therapists, 2016b) provide latitude for culturally relevant education in occupational therapy, they do not specifically address traditional Chinese values and beliefs. Human occupations stem from societal values, habits, and norms. To promote a people-centered practice, it is important for Chinese educational standards to incorporate common Chinese cultural and philosophical assumptions. Compared with those from Western countries, people in China perceive higher societal demands for interdependence (Huang, Yao, Abela, Leibovitch, & Liu, 2013; Minkov et al., 2017). Because of this collectivist mind-set, persons consider themselves an extension of an in-group and often favor in-group goals over personal goals. It is also common in Chinese society to view the sick and elderly as needing pampering and “look[ing] after” (Jones & Skinner, 2013). Consequently, family or local community members consider it their duty and a community obligation to complete daily routines for the sick or elderly (Fang et al., 2017). Chinese people highly value community involvement, whereas people in Western countries typically value individual independence and privacy (Minkov et al., 2017; Oyserman, Coon, & Kemmelmeier, 2002). Further, occupational therapists must consider common Chinese attitudes differentiating leisure and recreational activities from work and productive activities. Many commonly performed domestic and work-related tasks are defined as leisure and recreational activities by Chinese people (Walker & Wang, 2008). For example, Walker and Wang (2008) reported that a high percentage of Chinese residing in Canada perceived cooking, cleaning, and shopping as leisure activities, whereas the researchers defined these activities as unpaid work. Occupational therapists who are educated in China must adopt the values of Chinese society and not those of Western culture and must learn to consider these contextual factors when assessing clients and planning interventions.

Establishing Practice Standards

The establishment of practice standards is one of the most important responsibilities of a professional association. Practice standards delineate minimum requirements for performance and quality of care for occupational therapists across all settings. Employers, clients, peers, and the public use these practice standards to assess the appropriateness and quality of services received (American Occupational Therapy Association, 2015b). Occupational therapists are considered incompetent if they do not meet these standards for performance and quality of care.

Members of a profession should develop, continually monitor, and update their practice standards. Care provider agencies, consumers, and professionals in China can use these standards to assess the quality of occupational therapy. These practice standards should reflect best practices in China and establish a baseline for competent services. Finally, a professional association can provide input to legislators and consumers when establishing practice standards to assist in the formation of laws and policy further regulating professional practice (Akers, 1968; Clayton & Miller, 2017).

Challenges and Supporting Strategies

Of the many challenges facing Chinese occupational therapists who wish to see the establishment of a Chinese occupational therapy association, three are most pressing: (a) they must work within existing government structures to establish an association; (b) they must develop strategies to legitimize occupational therapy as a distinct health care service; and (c) they must ensure the cultural relevance of occupation-focused interventions.

Establishing an Occupational Therapy Association

The political culture and complex government structures of the People's Republic of China present a unique challenge for the establishment of a national occupational therapy association. Unlike the self-initiated and self-regulated professional associations in Western countries, most existing professional associations in China were established from the top down—by the government in response to societal needs (Zhuo, Purves, Li, & Huang, 2015). Thus, occupational therapists must first convince the government that there is a need for a professional occupational therapy association. A group of occupational therapists practicing in China has formed the Occupational Therapy Subcommittee under the Chinese Association of Rehabilitation Medicine (Chinese Association of Rehabilitation Medicine, n.d.). They work diligently to promote occupational therapy as a health care profession by defining its specific scope of services. The members of the Occupational Therapy Subcommittee work closely with the Chinese government and community stakeholders and have proposed the formation of a professional association to promote occupational therapy as a specific discipline. Through their work within this structure, these occupational therapists have the potential to obtain government support for the establishment of a Chinese occupational therapy association.

Simultaneously, occupational therapists at the local level should support the establishment of a Chinese association at the “grass roots” level (Zhuo et al., 2015). Today, there are an estimated 29 approved rehabilitation medicine associations at the provincial level in China (China Science Communication, n.d.). Occupational therapists can join these local associations and form occupational therapy subcommittees. Occupational therapists in the Guangdong province have used this method to form a subcommittee (Guangzhou Rehabilitation Center for People with Disability, 2011). As these subgroups form, it will be a challenge to set up independent groups under the medical subcommittees. However, once these subgroups are formed, they could unite, with government support, to form one national association.

Instituting and maintaining a Chinese occupational therapy association also would require financial support from members and other agencies. The costs associated with supporting the organization and any required membership fee might deter potentially interested occupational therapists from pursuing initiation (Deleskey, 2003). However, the long-term net benefits of establishing an occupational therapy association outweigh the costs. As a nonprofit organization, the Chinese occupational therapy association would promote the professional reputation of occupational therapy through program accreditations, credential oversight, and continued education of its members. Occupational therapists and the government should jointly support the establishment of an association. Although the government may have concerns that an association would create a professional monopoly, this would be a positive outcome for Chinese citizens. Educational and practice standards, along with a culturally relevant code of ethics, would ensure that occupational therapists are competent and are providing quality interventions, ensuring the safety and legitimacy of practice (Baerlocher & Detsky, 2009). The fostering of professionalization would guarantee professional competency (Carr-Saunders & Wilson, 1964; Penelope & Hinojosa, 2011) and protect citizens from unprofessional conduct.

Legitimizing the Profession of Occupational Therapy

In China, the public and most health care professionals are unfamiliar with the scope of services provided by occupational therapists (Li, 2015). Therefore, occupational therapists often must explain their practice and describe how it differs from nursing and other professions, such as physical therapy. They also must defend their role as skilled health care professionals and make distinctions between different rehabilitation professions. Creation of a Chinese occupational therapy association would legitimize occupational therapy as a profession by defining its domain of concern (areas of expertise) and the services that occupational therapists provide. Specifically, the activities and publications of a Chinese occupational therapy association would clarify the value of occupational therapy to the public. A better public understanding of occupational therapy will help to legitimize the profession in China.

Ensuring Culturally Relevant Occupational Interventions

Occupational therapy services in China focus on remedial activities and therapeutic exercises (Shi & Howe, 2016). These interventions are medically based and may not reflect occupations rooted in Chinese culture. Thus, Chinese occupational therapists must develop culturally centered documents and occupation-focused practices and not directly adopt Western documents and practices. For example, Chinese culture values productive and work skills over leisure and recreational activities (Ng, Howard, Wang, Su, & Zhang, 2014). These values may affect clients' priorities in setting goals during interventions. In addition, when focusing on activities that involve eating, occupational therapists should be sensitive to common regional foods and eating habits. Finally, occupational therapists must integrate occupation-focused interventions into existing practices of traditional Chinese medicine. For example, therapists in China may use tai chi to promote physical activities or may use acupuncture instead of transcutaneous electrical nerve stimulation to help patients relieve pain and discomfort.

Conclusion

The establishment of a Chinese occupational therapy association in the People's Republic of China is necessary to promote the profession of occupational therapy and guarantee the delivery of high-quality health care for all Chinese citizens. Critically, an association would support quality education, promote the competence of occupational therapists, and ensure that the profession meets the specific needs of the citizens of China. All occupational therapists in China, especially those in clinical settings, must engage with academics to persuade the central government to support the establishment of an occupational therapy association for the People's Republic of China. The WFOT could assist occupational therapists in the People's Republic of China in their efforts to meet with the central government to begin the long process of establishing a Chinese occupational therapy association. During this process, occupational therapists must explain the advantages of establishing a culturally specific occupational therapy knowledge base in China. Advancing occupational therapy practices that are consistent with Eastern beliefs, values, norms, and habits would provide a solid foundation to guide the evolution of occupational therapy toward a blending of Eastern and Western health care.

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Authors

Ms. Shi is a doctoral candidate, Dr. Howe is Associate Professor, Director of Post-Professional Programs, and Dr. Hinojosa is Professor Emeritus, Department of Occupational Therapy, Steinhardt School of Culture, Education, and Human Development, New York University, New York, New York. Mr. Wang is alumnus, Department of Politics, College of Arts and Science, New York University, New York, New York.

The authors have no relevant financial relationships to disclose.

The authors thank Hector W. H. Tsang, Professor and Associate Head of the Department of Rehabilitation Sciences at the Hong Kong Polytechnic University, Hong Kong, and Fengyi Kuo, DHS, OTR, CPRP, Kunming-LIH Sky City Rehabilitation Hospital, Kunming, Yunnan, China, for their input.

Address correspondence to Yun Shi, MA, Department of Occupational Therapy, Steinhardt School of Culture, Education, and Human Development, New York University, Pless Hall, 82 Washington Square East, 6th Floor, New York, NY 10003; e-mail: ys1433@nyu.edu.

Received: May 02, 2017
Accepted: November 03, 2017

10.3928/24761222-20180212-06

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