The use of occupation as intervention is a central tenet of occupational therapy. As stated by Smallfield and Karges (2009), “The philosophy of occupational therapy includes the premise that meaningful activity is essential to occupational therapy intervention because occupation is the power of intervention” (p. 411). One definition of occupation-based intervention (OBI) may be found in the Occupational Therapy Practice Framework (OTPF) of the American Occupational Therapy Association (AOTA), which serves as the guiding document in the United States for entry-level occupational therapy training and clinical practice (AOTA, 2002, 2008, 2014). The second edition of the OTPF defined an OBI as follows:
A type of occupational therapy intervention—a client-centered intervention in which the occupational therapy practitioner and client collaboratively select and design activities that have specific relevance or meaning to the client and support the client's interests, needs, health, and participation in daily life. (AOTA, p. 672)
The inclusion of OBI within the OTPF is one example of the historical prominence of this practice within occupational therapy. However, the most recent edition of the OTPF did not include a definition of OBI, occupation-based practice (OBP), or occupation-based activity (AOTA, 2014). This change may be seen as removing a focus on the value of such a defining intervention lexicon from the profession's guiding documents in the United States.
Several authors have defined OBP as the practice of the use of OBI (Earley, Herlache, & Skelton, 2010; Peterson, Parker, & Urish, 2007; Skubik-Peplaski, Carrico, Nichols, Chelette, & Sawakai, 2012). As articulated by AOTA in the second and third editions of the OTPF, “the Framework was developed to articulate occupational therapy's contribution to promoting health and participation . . . through engagement in occupation” (AOTA, 2008, p. 625; AOTA, 2014, p. S6). Thus, OBP, or the use of occupation for therapeutic intervention, is the basis of occupational therapy. The literature also shows scientific and biological support for the use of occupation. Engagement in occupation has been shown to have positive neurological effects (Gutman & Schindler, 2007), meet basic psychological needs (Eakman, 2013), and enhance quality of life (Tyszka & Farber, 2010).
Understanding Occupation-Based Practice
The authors reviewed the literature on OBP published between 2008 and 2013. They found several gaps, specifically, how occupational therapy practitioners in the United States engage in OBP and use OBI as a part of daily practice. A qualitative study by Estes and Pierce (2012) reported that pediatric occupational therapists in the United States indicated that engaging in OBP affected their personal identity and was influenced by their entry-level education. They also reported that OBP was more satisfying and rewarding as well as more effective and individualized compared with other treatment modalities. Yet, the practice of OBP was perceived as more difficult in medical-based environments because of practical considerations and cultural forces. Specifically, Gillen (2013) raised concern that therapists face constraints because of the practitioner's role, the culture of the setting, the expectations of other professions, and legislation. Gillen (2013) noted a shortage of practitioners who embrace the contemporary paradigm of occupation. They described solutions through a framework of evidence-based practice. Di Tommaso et al. (2016) found that therapists in mental health settings in Australia valued OBP but did not see the need to use it as a means of intervention, just as the end goal. Participants reported that their entry-level education provided little training in applying occupation as a part of practice (Di Tommaso et al., 2016). As part of a qualitative study of OBP in mental health settings in Australia, Ashby, Grey, Ryan, and James (2015) expressed concern that OBP can become marginalized in some workplaces. Occupational therapists employed in these settings require support from professional organizations to implement strategies to maintain OBP (Ashby et al., 2015).
One issue in understanding the practice patterns of therapists who use OBP has been the absence of a common definition of OBI as part of day-to-day practice or in descriptive research. Various terms are used interchangeably with OBI, such as task-specific activities/occupations (Arbesman & Mosley, 2012), therapeutic occupations (Earley et al., 2010), occupation-based activities (Earley et al., 2010; Hermann et al., 2010), occupation-centered activities (Copley, Rodger, Graham, & Hannay, 2011; Gray, 1998), and client-centered activities (Arbesman & Mosley, 2012). The limited research in this area and the contributing factors are being used to define and measure occupation and OBP, resulting in diversity and limited consistency. A secondary consequence of the limited scholarship in this area is its effect on occupational therapy students who attempt to use OBP on clinical rotations, yet tend to adopt more therapeutic activities or preparatory tools modeled by their clinical educators and embodied by the clinic culture (Di Tommaso, Wicks, & Isbel, 2014). In the United Kingdom, occupational therapy students reported limited opportunities to engage in OBP while on clinical placements (Gillen, 2013).
This study investigated whether the use of OBI was influenced by therapists' demographic features and identified therapists' perceptions of factors that facilitate or prevent the use of OBI in the clinic. Because there is no universally accepted definition of OBI, we used the definition provided in the 2008 edition of the OTPF (AOTA, 2008).
This study was approved by the Human Subjects Committee at Idaho State University, Pocatello, Idaho.
What are the demographics of those therapists who report using occupation-based interventions?
What barriers and facilitators to the implementation of occupation-based interventions do therapists report?
This study used a cross-sectional survey (Portney & Watkins, 2015) of clinically practicing occupational therapists in the United States (Table A, available in the online version of the article).
Occupation Based Practice Survey
The survey was constructed on SurveyMonkey and included 18 closed- and open-ended questions. Of these, eight descriptive questions addressed OBP, nine questions addressed demographic characteristics (e.g., age, location, years of experience, degree), and one question was included to allow participants to enter an incentive drawing. Data collection began with a pilot review to assess and refine the clarity and comprehensiveness of the survey. Seven full- or part-time clinicians took part in the pilot study, and adjustments were made to the questions based on feedback from the pilot review. Specifically, the order of some questions was changed, the wording was adjusted to improve clarity, and more options for “other” and a comment section were added.
Potential participants included a stratified random sample of 1,000 occupational therapists generated by the AOTA member sampling database. The sampling process used by AOTA was not revealed at any time to the researchers. Of the 1,000 potential participants, a total of 121 therapists responded to the survey, for a response rate of 12.1%.
For study inclusion, participants were currently licensed as an occupational therapist in the United States and had been working with clients for at least 20 hours/week for the previous 6 months. Participants were excluded if they were not currently licensed as an occupational therapist within the United States, if their primary work setting was outside of the United States, or if they had no physical mailing address on record. Participants self-identified as meeting the inclusion criteria as a part of the screening/informed consent process; the criteria were not verified by the researcher.
This study was approved by the Human Subjects Committee at Idaho State University, Pocatello, Idaho. The researchers used the Dillman method (Dillman, Smyth, & Christian, 2014) to solicit survey responses. Initially, all participants were mailed a postcard that described the overall goal of the study and explained that a letter would follow with further details. An invitation letter was mailed to participants 7 days later containing the web address and an access code for the survey. A follow-up postcard was mailed 15 days after the letter to encourage participation before the close of the survey. The survey was open for 30 consecutive days. At the beginning of the survey, participants were asked to provide consent for participation.
The quantitative data generated from the survey were analyzed with measures of central tendency, frequency distribution, and Pearson product-moment correlation (Portney & Watkins, 2015). Three open-ended questions allowed participants to elaborate on their survey responses. The first two descriptive questions asked participants to report perceived barriers and facilitators to their ability to implement OBP in their current practice setting. The third question asked participants to comment on any other aspects of OBP or to suggest areas for further research.
Data were based on expanded descriptive statements and evaluated with qualitative analysis (Corbin & Strauss, 2014). Response data were exported from SurveyMonkey and organized in spreadsheets by question. Each statement was read, reread, and coded by two graduate research assistants in occupational therapy. The analysis generated 61 distinct categorical codes that were reviewed and aligned for intercoder agreement, with 97% accuracy after the first two reviews. Disagreements were presented to a third rater for resolution. The codes were converted to descriptive categories with qualitative analysis, based on the work of Corbin and Strauss (2014). The same raters developed conceptual categories with a reflective process of data analysis. Qualitative data were gathered and analyzed to ensure trustworthiness. The process included peer examination (external to the study), triangulation of raters (two primary, one secondary), and auditing of data analysis (Krefting, 1991). Implementation of these strategies ensured the credibility, transferability, and confirmability of the qualitative analysis (Krefting, 1991).
Because of the nature of the survey questions (Table A), the codes (e.g., time, motivation of the therapist, client perception) and qualitative themes (e.g., therapist, client, environment) were polarized toward exploration of perceived barriers and facilitators of OBI (Figure 1). The data did not capture the underlying social, environmental, cultural, and attitudinal factors that influenced participants' perceptions of the identified barriers and facilitators. Three subcategories emerged from the data as elements that facilitated OBP and barriers that prevented OBI.
Results and Discussion
The geographical distribution of participants is shown in Figure 2. Representation of the participants from the current study is similar to that of those reported by the AOTA (2015a) Salary and Workforce Survey ± 5% (standard error of the mean).
Regional distribution of respondents.
Participant demographic data are shown in Table 1, Table 2, and Table 3. The participants were primarily female (89%) and 51 to 55 years old (19.1%). More than one third of the participants had 21 or more years of experience as an occupational therapist, and half had earned a master's degree. These findings are similar to those reported in the 2015 AOTA Salary and Workforce Survey (AOTA, 2015a) in which 90.9% of the respondents were female and 19.8% were 50 to 59 years old.
Types of Intervention Used
Setting and Use of Occupation-Based Intervention
The findings for years of experience showed a bidirectional representation, with most respondents having either 5 years or fewer (24.8%) or 20 years or more (33.9%). Occupational therapists who have fewer than 5 years of experience may be more likely to maintain their professional membership in AOTA because increasing numbers of entry-level academic training programs use much of the AOTA member content as part of their coursework. Conversely, occupational therapists who have more than 20 years of experience may maintain membership as a mechanism to give back to the profession or assume leadership roles; in addition, they may be more financially able to maintain membership compared with less experienced practitioners.
The highest degree earned overall was at the master's level (50.1%), followed by the bachelor's level (36.9%) and the doctorate level (clinical or academic [6.0%]). These demographic findings seem to align with participants' use of the OTPF practice framework, which was first published in 2002. It may be hypothesized that the OTPF is used more predominantly among those who have earned a master's or clinical doctorate degree.
For employment setting, 26.4% of respondents reported working in a skilled nursing facility, with other (18.2%), hospital-based adult inpatient rehabilitation (16.5%), and home health (16.5%) following close behind. Of the participants who responded “other” (e.g., outpatient community-based program, geriatric day program, work/industry), five worked in an academic setting and may not meet the requirement for working with clients for at least 20 hours/week.
For the framework that guided practice interventions (Figure 3), 59.5% of participants selected the OTPF (AOTA, 2002, 2008), 15.7% indicated that they used the World Health Organization's International Classification of Functioning, Disability, and Health (2001), and 18.2% identified that they used the occupational therapy uniform terminology (Reed & Sanderson, 1999). Because participants could choose multiple frameworks, it was difficult to determine a direct relationship between practice framework and the prevalence of OBI.
Professional framework used.
Participants were also asked to identify models and frames of reference (Figure 4) that were applicable to their practice. The most frequently chosen models and frames of reference were rehabilitative (55.4%), biomechanical (50.4%), and the Model of Human Occupation (48.8%). The models and frames of reference that were rarely selected include the Ecology of Human Performance (5.8%), the Psychodynamic Model (9.9%), and Toglia's Dynamic Interactional Approach (5.8%).
Practice models and frames of reference used.
Table 1 shows the prevalence of each type of intervention reported by respondents. Definitions of preparatory, purposeful, and OBI type were provided within the survey and were based on the second edition of the OTPF (AOTA, 2008). Participants were asked to estimate what percentage of their interventions fit into each category. Overall, the average time spent using the various intervention types included 37% purposeful activities, 34% OBI, 28% preparatory, and 14% other (e.g., administrative time, teaching).
Of the 114 participants who provided information on the percentage of use of OBI, 108 reported some use of OBI, with percentages ranging from 5% to 75%, a mean of 35.4%, and a median of 30.3%.
Table 2 shows the distribution of the use of OBI in the primary settings identified by respondents. Skilled nursing facilities had the most participants, with OBI use reported an average of 34.7% of the time. Occupational therapists working in a pediatric outpatient setting reported the highest percentage of time using OBI, with more than 10 participants reporting 38.5%. Because of the low number of participants in many categories, it is difficult to draw conclusions from this preliminary data analysis on how setting influences the frequency of use of OBI.
The previous information was examined more closely to identify linear relationships. The Spearman rank correlation (Portney & Watkins, 2015, p. 827) was calculated with SPSS version 23.0 and did not show any relationships between the selected variables of OBP and years of experience, degree, or work setting, as shown in Table 3. However, regardless of the findings, the data used in the analysis did not meet the assumption of normality.
Environment. Elements of the theme of “environment,” which included the physical setting, the clinic culture, resources, demands, and temporal restraints, were identified as barriers to OBP. The perceived barrier of the environment was exemplified by one participant who indicated that the use of OBP was affected by “productivity levels.” Another participant stated that general practice was “easier to do point of services documentation during therapeutic exercise or therapeutic activities versus activities of daily living.” This may be interpreted as indicating that the simple nature of other intervention types (preparatory or purposeful activity) allows for documentation during treatment time, which is not possible with OBP. Finally, some participants noted environmental or cultural factors that impeded their use of OBP, including “lack of treatment space, limited time spent with clients, and difficulty with clients understanding discharge needs/barriers to independence.” Another respondent stated, “When treating older children to become more independent with meal prep, cooking, chores, etc., we do not have the space nor the equipment available to simulate these tasks.” Finally, a participant identified one barrier as the “narrow definition of occupational therapy = activities of daily living in adult physical disability settings and the lack of understanding of OBP from other disciplines.”
Therapist. The theme of “therapist” included participants' perceptions of their own abilities, beliefs, values, and practices. One participant self-identified as a barrier to OBP by noting “limits of my own imagination, time constraints.” Another respondent identified “increased effort required” for OBP as a barrier. Finally, a participant identified “lack of a common understanding of occupational-based practice” as a barrier.
Client. The theme of the “client” may be defined by characteristics (physical and psychosocial) of the client and support external to the client. In describing clients' views, one participant noted a discrepancy between:
“Clients' perception of what occupational therapy is and what they “should” be doing in therapy. Some clients or families feel that if they are not doing exercises then they are not having therapy. So we need to educate and help them to identify the occupations that are the issue. Once they identify those areas, they are more accepting of the focus on occupation.”
Another participant articulated the focus on the way that client preferences created barriers, stating, “Goals for children in the school setting are determined by curriculum demands and child development and not always determined based on students' preferred occupations.” Finally, a participant identified the client's preconceived idea of therapy as a barrier, noting difficulty with “patients buying into using ordinary household objects as therapeutic tools. Somehow rearranging books on shelves is a reaching activity in their minds, but moving cones on those same shelves is ‘therapy’. Sometimes the buy-in needs to come from other therapists in the clinic as well.”
Environment. Elements of the theme of “environment,” which included the physical setting and clinic culture, were identified as facilitators to OBP. As an example, one participant stated that “the environment of my rehab setting offers an activities of daily living suite where we can practice instrumental activities of daily living, such as cooking and home maintenance.”
Another participant identified as a facilitator “access to instrumental activities of daily living equipment (kitchen, garden, laundry room, a budget to purchase specific instrumental activities of daily living equipment).” Other participants reported that having the “support of administration and co-workers” as well as “continuing education” enabled OBP.
Therapist. The theme of “therapist” included respondents' perceptions of their own abilities, beliefs, values, and practices. One participant identified as a facilitator “my resourcefulness and the ability to modify items in order to fit them to the person and the occupation we are working on.” Another noted that “continuing education on the topic” of OBP enabled the use of this approach.
Client. The theme of “client” included physical and psychosocial characteristics of the client as well as support external to the client. One participant identified the frequency of using OBP, stating, “I do about 75% of my work in assisted living facilities. The staff in those facilities see the benefits and progress of occupational therapists working with their residents. Residents will feed off of each other when they see someone improve, and they are usually much more open to occupational therapy. And in many cases, occupational therapy becomes much better suited than physical therapy because they like the functionality of occupational therapy over physical therapy exercises.”
Other participants stated that OBP “may be a great motivator for clients” and “patients are becoming better advocates and more involved in setting goals.”
The goal of this study was to gain an understanding of the key demographics of occupational therapy professionals who self-identified as engaging in OBP and to discover the perceived barriers and facilitators to the implementation of OBI. Ultimately, a profile of participants who use OBI/OBP could not be generated, given the findings of correlational analysis. However, some factors were related to the possible profile of practitioners who use OBI/OBP. These primarily include exposure to various models of OBP, frames of reference, and interventions. The meaningful findings related to the respondents' perceptions of the barriers and facilitators to the use of OBI/OBP.
Barriers and facilitators were analyzed separately. The same three descriptive categories were identified as barriers and facilitators, with a different hierarchy, based on the frequency and strength of the 61 codes. The order of perceived barriers was environment, client, and therapist. The order of perceived facilitators was environment, therapist, and client. This is important information for scholars, educators, and clinicians to provide increased opportunities for OBI/OBP.
According to the AOTA Accreditation Council for Occupational Therapy Education Accreditation Standards and Interpretive Guide (2011) and the AOTA Blueprint for the Future of Entry-Level Education (AOTA, 2010), emphasis is placed on understanding the value and implementation of occupation as a part of the preventive and rehabilitative aspects of occupational therapy (Arbesman & Mosley, 2012). Within entry-level occupational therapy education in the United States, educational programs are required to instill the value of providing occupation as an intervention.
One strategy to support the role of the client as a facilitator is to encourage clinicians to refocus efforts on the 2015 AOTA distinct value statement as they advocate and communicate with their clients. This statement reads, “Occupational therapy's distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective” (AOTA, 2015b). Emphasizing the distinct value of occupational therapy may eliminate some aspects of the environment that are currently barriers (e.g., setting, culture, third-party payers).
The definition of OBI is presented in the second edition (AOTA, 2008) of the OTPF, yet it is not included in the third edition (AOTA, 2014). This change increases the distance between practice and maintaining the cornerstone of the physical therapy profession, which is using occupation both as part of the intervention and as the outcome (Skubik-Peplaski et al., 2012). The AOTA's 2017 Centennial Vision was created as a goal to strive toward “occupational therapy [as] a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs” (AOTA, 2008, p. 664). Without evidence to support the foundation of the profession, which is the use of occupation as an intervention, it is difficult to achieve the goal of being an evidence-based profession.
Limitations included a low response rate (12.1%), which led to a small sample size (n = 121). The population was based solely on existing AOTA members (at the time of the study), which limited the heterogeneity of the sample. In addition, some survey questions could have been interpreted in more than one way. Because all of the participants were members of AOTA and likely had a favorable view of OBP, self-selection bias was a potential limitation. Completion of the survey required Internet access, which may have prevented some people from responding. Participants were not notified of the closing date for the survey, which may have excluded those who intended to complete the survey but missed the closing date. The survey tool assisted in answering the research question, but the minimal specificity of some questions may have muted some of the respondents' views. Finally, the expanded descriptive data were treated as qualitative data but were missing the depth and breadth traditionally found with qualitative methods.
Recommendations for Future Research
The effect of the work environment on the ability to implement OBP/OBI requires further analysis because it emerged as both a barrier and a facilitator. Understanding therapists' perceptions of the environment may help them to adapt or work within reported constraints and increase advocacy for the resources needed to implement OBI.
Future research is needed to follow up with participants who provided contact information to explore individual views and definitions of OBP/OBI with traditional qualitative methods. In addition, future research can explore the use of OBP/OBI and analyze the practice patterns of occupational therapy practitioners in other countries.
Implications for Occupational Therapy Practice
The current findings may familiarize readers with the barriers and facilitators to OBI/OBP and enable further reflection to inform the return to the professional roots of occupational therapy. The study may help clinicians to advocate for more client time and realistic expectations for productivity, educate and reason clinically beyond activities of daily living in entry-level occupational therapy education and training, and encourage the development of policies and practices that discourage documentation during therapy sessions. Finally, professional development for OBP/OBI should be included in diverse settings for practitioners at all levels.
- Accreditation Council for Occupational Therapy Education. (2011). Accreditation standards and interpretive guide (Effective July 31, 2013)—December 2013 interpretive guide version. Retrieved from https://www.aota.org/~/media/Corporate/Files/EducationCareers/Accredit/Standards/2011-Standards-and-Interpretive-Guide.pdf
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Types of Intervention Used
Setting and Use of Occupation-Based Intervention
|Setting||Average reported OBI%||n|
|Skilled nursing facility||34.7||19|
|Variables||Correlation coefficient (r)|
|Years of experience and OBI%||−0.086|
|Degree and OBI%||0.179|
|Primary work setting and OBI%||0.065|
Occupation Based Practice Survey
What Practice Framework do you use? (More than one response is acceptable)
Uniform Terminology, 3rd Ed.
2008 Occupational Therapy Practice Framework: Domain and Process, 2nd ed.
2014 Occupational Therapy Practice Framework: Domain and Process, 3rd ed.
International Classification of Functioning, Disability, and Health (ICF)
I don't know
Other (please specify)
Which of the following intervention Models or Frames of Reference do you use? (mark all that apply)
Allen's Cognitive Levels
Cognitive Behavioral Therapy (CBT)
Ecology of Human Performance (EHP)
Model of Human Occupation (MOHO)
Neurodevelopmental Theory (NDT)
Occupational Adaptation (OA)
Person Environment Occupation (PEO)
Person Environment Occupational Performance (PEOP)
Proprioceptive Neuromuscular Facilitation (PNF)
Sensory Integration (SI)
Task Oriented Approach (TOA)
Toglia's Dynamic Interactional Approach
I don't know
Other (please specify)
The following definitions will help you answer the next question:
Preparatory methods: “Methods and techniques that prepare the client for occupational performance. Used in preparation for or concurrently with purposeful and occupation-based activities.” (AOTA, 2008, p.674)
Purposeful activity: “A goal directed behavior or activity within a therapeutically designed context that leads to an occupation or occupations. Specifically selected activities that allow the client to develop skills that enhance occupational engagement.” (AOTA, 2008, p.674)
Occupation based intervention: “A type of occupational therapy intervention—a client centered intervention in which the occupational therapy practitioner and client collaboratively select and design activities that have specific relevance or meaning to the client and support the client's interests, need, health, and participation in daily life.” (AOTA, 2008, p.672)
What percentage of interventions that you provide in your overall practice fit into the following categories? (total should equal 100%): Please enter whole numbers.
What types of client/patient populations do you use occupation-based interventions with?(select all that apply)
Other (please specify)
What do you see as the barriers to your ability to implement occupation-based practice in your current practice setting?
What do you see as facilitators to your ability to implement occupation-based practice in your current practice setting?
Are there any other aspects of occupation-based practice that you would like to comment on or make suggestions that we include as we move forward in our research?
In which setting are you CURRENTLY employed? (mark all that apply)
Hospital Based Adult Outpatient Rehabilitation
Hospital Based Adult Inpatient Rehabilitation
Hospital Based Pediatric Outpatient Rehabilitation
Hospital Based Pediatric Inpatient Rehabilitation
Private Practice Adult Outpatient
Private Practice Pediatric Outpatient
Skilled Nursing Facility
Long Term Acute Care
Based on the selections above, please indicate your current PRIMARY setting:
How many years of experience do you have in the setting chosen above?
How many years have you been working as an occupational therapist?
Please indicate your age in years:
What is your gender?
Please enter the PRIMARY state in which you practice.
Which is the highest level of OT Degree that you have earned?
Other (please specify)