This article discusses the historical development of occupational therapy in Norway. The historical context behind the development of a profession can provide an understanding of how to plan for the future based on experiences of the past. Historical context refers to the social, religious, economic, cultural, and political conditions that exist in a certain time and place (Collins et al., 1999). We present some short contextual information about Norway.
Norway is a Nordic country in Europe. As of September 2019, it was home to a population of 5,356,769 (Statistics Norway, 2019). Of this population, 765,108 individuals immigrated from other countries (mostly Poland, Lithuania, Sweden, and Somalia), and 71.5% of all Norwegians are registered in the Norwegian Christian Lutheran Church. Although it was once a nation of modest means, during the 1980s, the economy changed, with the discovery of oil and gas in the North Sea (Nielsen, 2008). Norway has four seasons, with great differences (between −51.2°C and 34.6°C) among winter, spring, summer, and autumn. Norway has an indigenous population, the Sami people, who have their own culture and languages and the Sami Parliament.
Norway is considered one of the most developed democracies in the world. It is described as a welfare state because it offers free health care and education for all citizens, including free higher education (Lindahl & Squires, 2011). The Norwegian welfare state is founded on the principles of the Nordic model. The Nordic model began to gain attention in the Nordic countries after World War II and provided a platform for rebuilding the countries. The Nordic model includes a comprehensive welfare state and collective bargaining, and a high percentage of the workforce is unionized. This model also includes systematic and regular “three-part collaboration and dialogue” among government representatives, employee organizations, and employer and professional associations (Kristensen, 2019; Lindahl & Squires, 2011; Storeng et al., 2006). In the Nordic countries, professional associations are also trade unions. Ergoterapeutene, the Norwegian Association of Occupational Therapists, meets with central politicians, ministers, decision makers, and employer organizations to lobby, discuss, and agree on common issues. Because of this welfare system, nearly all occupational therapists work in the public welfare and health services.
The occupational therapy profession in Norway was created by establishment of the welfare state model by the social democratic government. After World War II, there was a need to rebuild the country and mobilize workforce reserves, defined as persons with disabilities and married women (Midré, 1990). The state took responsibility for ensuring that Norway's citizens would have access to free education, health services, and income in the form of social security if they were unable to work. It also meant that all citizens would contribute to the common good through direct or indirect taxes. In the 1950s, the goal of social democracy was to allow everyone to participate in society (Birkeland, 1997), and it was considered unethical for people not to take part in the tasks of society unless they had good reasons. This policy demanded some degree of conformity from all individuals in the interest of security and the common welfare (Midré, 1990).
This article provides a descriptive and historical overview of the development of occupational therapy in Norway, based on primary, secondary, and original literature sources and government documents. This long, complex, and winding history describes the development of occupational therapy in Norway from 1952 to the present.
1950 to 1980: At the Intersection Between an Activity and a Medical Perspective
Establishment of Occupational Therapy in Norway
In 1949, a plan for occupational therapy education was introduced by Statens Kvinnelige Industriskole (the State Female Industrial School), which educated women in different handicrafts, but was rejected by the Ministry of Finance (Munthe, 1962). A committee of pioneers in occupational therapy and representatives from the Norwegian Directorate of Health discussed the matter, and this meeting resulted in the first undergraduate occupational therapy program, which began in Oslo in 1952 (Raastad et al., 2013). The next year, the Norwegian government passed a resolution that defined the need for vocational rehabilitation and included a role for occupational therapists (Governmental Resolution No. 48, 1953). This resolution influenced the role and mission of occupational therapy in the early years.
In this first period, occupational therapists worked in sanatoriums and institutions to provide treatment, vocational training, and rehabilitation for individuals with tuberculosis, polio, mental health problems, and epilepsy as well as children with disabilities and elderly persons (Raastad et al., 2013). Initially, the therapeutic use of crafts was a hallmark of the occupational therapy profession in Norway (Horghagen et al., 2007; Ness, 2002; Nilsskog, 1991). The use of craft activities in Norway was rooted in a social democratic understanding that everyone should participate in society and that craft activities were important for all. Arts and crafts activities were based on ideas from the Arts and Crafts movement (Stein & Cutler, 2002) and the Norwegian Crafts organization (Sundt, 1975). Sundt (1975) saw arts and crafts activities as an opportunity for low-income people to earn money, which is in line with Dickie and Frank's (1996) international study of how the production and sale of crafts formed the main activity and income for many contemporary families worldwide. The use of craft activities also was anchored in the first Norwegian law on the treatment of people with mental illness that was passed in 1848 (Winge, 1917). Herman Wedel Major, an idealistic physician, emphasized the importance of treatment through participation in everyday activities and craft production, according to therapeutic reasoning (Winge, 1917). The Norwegian pioneers in occupational therapy identified problems with the use of craft activities: Were craft activities therapy, or just an activity to pass the time in boring institutions? In addition, some pioneers recognized that weaving activities were seen as a necessity for the institution's income rather than an activity that strictly met patients' treatment needs (Horghagen et al., 2007).
At the time, most occupational therapists were young women, and they were few. These pioneers in occupational therapy offered professional reasoning with the use of meaningful activities in rehabilitation, and these ideas were not always in line with accepted medical reasoning. The occupational therapists worked in institutions with a hierarchy in which physicians and nurses were in charge, and the occupational therapists had to compromise their ideals to meet the expectations placed on them (Horghagen et al., 2007; Raastad et al., 2013). The occupational therapists did not always feel free to criticize the medical perspectives of doctors and nurses, or to talk about their professional reflections and arguments about the therapeutic use of activities.
Establishment of the Norwegian Association of Occupational Therapists
The Norwegian Association of Occupational Therapists was established in 1952 and became a member of the World Federation of Occupational Therapists (WFOT) in 1958. This membership challenged, inspired, and influenced the occupational therapy profession in Norway. The vice president of WFOT visited Norway in 1954, providing information on standards and challenging Norwegian occupational therapists to develop therapeutic use of occupations (Nilsskog, 1991).
In 1974, the second occupational therapy program was established in Trondheim, located in the middle of Norway. At the same time, occupational therapy programs expanded from 2 years of training to 3 years of education (Viken, 2006). In 1975, the Norwegian law on approval of health personnel granted official authorization to the occupational therapy profession. The same law protected the name of the occupational therapy profession with the title “ergoterapeut.”
1980 to 2010: In the Context of Holistic and Dynamic Models
Deinstitutionalization of Large Hospitals and Institutions
Beginning in the 1970s and 1980s, health and social services moved toward deinstitutionalization of large hospitals and institutions, especially for persons with mental and cognitive health challenges (Tøssebro, 2019). Special schools for disabled children were closed because all children by law now had the right to attend local schools. In 1988, the national government turned over responsibility for nursing homes to municipalities. With this reform, local municipalities became employers of occupational therapists who worked in nursing homes. This period also saw rapid growth in the number of occupational therapists in primary health care (Ytrehus, 1994). Occupational therapists began to work outside of institutions, where they met persons in need of services in their own environments.
Home Modification and Assistive Technology
In 1994, assistive technology became regulated and was offered as a right to all citizens of Norway (Ministry of Labour and Social Affairs, 2017). This reform gave occupational therapists a central role, in collaboration with citizens, in finding the best equipment and technology to assist with participation in home, work, and education. The first county center for assistive technology was established in Telemark in 1979. By 1995, all 19 counties had their own county center, where occupational therapists and other professionals provided assistive technology and supervision to their municipalities.
The government's priority of providing free access to assistive devices led to more occupational therapy positions, but it also narrowed the public view of the profession as primarily concerned with home modification and assistive technology (Stigen, 2018). Tuntland (1998) found that, by 1998, occupational therapists were often working alone in municipalities and were not using their full range of knowledge and skills.
A Stronger Occupational Perspective and Paradigm
Revision of the WFOT minimum standards for the education of occupational therapists (Hocking & Ness, 2002) represented a paradigm shift from a medical focus to an occupational focus for occupational therapy education worldwide. These standards were used to develop educational programs in Norway. In contrast with cause-and-effect theories, an awareness of dynamic models was developed. Occupational therapy programs in Norway began to teach occupational therapy models, such as the Model of Human Occupation (Kielhofner, 2002), the Canadian Model of Occupational Performance (Law et al., 1990), and the Kawa model (Iwama et al., 2009). During these years, all occupational therapy programs established agreements with different European and Nordic programs and became members of the European Network of Occupational Therapy in Higher Education. These networks led to opportunities for exchange of students and faculty members and collaboration on research and publications, supported by the Nordic Council, European Union programs, and national research funding.
During this time, the profession increased in national and international influence, resulting in a stronger occupational perspective and paradigm. The establishment of occupational science (Jackson et al., 1998; Wilcock, 1998, 2006; Yerxa, 1990) influenced Norwegian occupational therapists to revitalize the occupational perspective and increased awareness of the profession's core knowledge and competencies. Occupational science led to increased awareness of environmental and cultural influences as well as a focus on knowledge of occupational balance/imbalance, occupational justice/injustice, and conceptual knowledge about the concepts of occupation and activity.
Health Promotion and Human Rights
The World Health Organization (WHO), with its focus on health promotion and human rights (Whiteford & Hocking, 2012), and the International Classification of Functioning, Disability and Health (WHO, 2001) also influenced the profession to be more aware of participation and inclusion (Ness, 1999). Revision of the WFOT minimum standards for the education of occupational therapists in 2016 also increased awareness of human rights and equality (WFOT, 2016).
Many occupational therapists started to expand occupational therapy in new directions. During these years, occupational therapists became specialists, started postgraduate education, or completed master's degree programs (Ness & Horghagen, 2017).
2010 to 2019: A Focus on Participation and Inclusion
Expansion of the Role of Occupational Therapist
Occupational therapists in Norway have broad and versatile competencies. They work in hospitals, institutions, and health services and in a variety of positions, services, and agencies. Most occupational therapists work within the municipal health service, especially with rehabilitation, habilitation, and palliative services. Many work in hospitals in the field of mental and somatic health care, in rehabilitation centers, in the Norwegian Labor and Welfare Organization (Nav), within assistive technology centers, and in supported employment, housing, occupational health services, kindergartens, and schools (Asbjørnslett et al., 2015; Bonsaksen et al., 2016; Elvrum et al., 2018; Kjeken, 2011; Magnus, 2001; Sveen et al., 2016; Taule et al., 2015).
Toward a Knowledge-Based Practice
A survey of Norwegian occupational therapists reported the 10 most commonly used assessment tools in municipality services (Dolva et al., 2015). These included: (a) the Canadian Occupational Performance Measure; (b) the Mini-Mental State Examination; (c) different screening tools for dementia used in municipalities; (d) the Index of Activities of Daily Living developed at Sunnaas Rehabilitation Hospital in Norway; (e) the Interest Checklist (Model of Human Occupation); (f) the Barthel Index for Activities of Daily Living; (g) the Occupational Questionnaire; (h) the Rivermead Behavioral Memory Test; (i) the Assessment of Motor and Process Skills; and (j) Goal Attainment Scaling. These findings suggest that occupational therapy is embracing knowledge-based practice, understood as an integration of the client's preferences, the therapist's experience, and evidence-based research (Dolva et al., 2015; Tuntland, 2009). Despite the wide variety of assessments used by occupational therapists in Norway, certain factors inhibit the application of assessment in occupational therapy practice (Stigen et al., 2019). In addition, Stigen et al. (2019) suggested that dilemmas related to choosing assessments include choosing tools that are not easy to manage and choosing tools based on the level of impairment instead of occupation. Knowledge-based practice may be facilitated by strengthening the knowledge and skills of occupational therapists in performing formal assessments (Horghagen et al., 2015).
Kinn and Aas (2009) conducted a study of perceptions of practice among Norwegian occupational therapists. They found that therapists working in diverse health care settings considered themselves facilitators of their clients' potential to manage everyday life occupations. This view is in line with knowledge-based practice because it is person centered and based on initiating occupational therapy according to the client's preferences. Nevertheless, some Norwegian occupational therapists face a conflict when attempting to meet leaders' and colleagues' expectations of their responsibilities.
Approximately 88% of community-based occupational therapists in Norway work with assistive technology and report that they spend 51% of their time with assistive technology (Bonsaksen et al., 2020). Gramstad and Nilsen (2016) studied 48 community-based occupational therapists in Norway who reported that their expertise was particularly linked to assistive devices. Another study by Gramstad and Nilsen (2017) identified assistive technology as one of the top research priorities among community-based occupational therapists.
Two Reforms That Open New Roles for Occupational Therapists
Recently, the development of occupational therapy has been influenced by demographic changes in Norway, with growing numbers of elderly people, persons with mental health challenges, and disabled people without regular work, in addition to persistent social inequality. Political initiatives and the economy play an important role in the participation and inclusion of all members of a society. Two major reforms in Norway, one in 2008 and the other in 2009, led to significant changes for occupational therapists.
The first reform was the new Nav, which is responsible for the coordination of state pensions, social welfare, employment, vocational rehabilitation, and assistive devices (Ministry of Labour and Social Affairs, 2009). Many occupational therapists began working within Nav throughout the country, with an emphasis on providing suitable work modifications and assistance to employees with disabilities (Jakobsen, 2009). During this period, the municipalities also were given broader responsibility for citizens' health through implementation of the Coordination Reform (Ministry of Health Care Services, 2009). This second reform stressed the importance of managing long-term chronic conditions effectively through new community-based services, improved primary health care, and better coordination between the health care and social and welfare sectors. The municipalities in Norway were given new tasks, and the scope of responsibility for citizens' health was expanded (Lillefjell et al., 2018; Stigen et al., 2019). The Coordination Reform led to an increasing number of occupational therapists in the local communities and municipalities to support people in managing everyday life activities. Some therapists were employed to coordinate the transition between specialist and municipality services.
Development of the Role and Required Tasks for Occupational Therapists
Contemporary challenges faced by practitioners include the discrepancy between occupational therapists' service deliverables in Norwegian municipalities and the wide range of tasks that occupational therapists are expected to provide (Aas & Grotle, 2007; Arntzen et al., 2019). The precise role and required tasks for occupational therapists must be further negotiated and restructured to meet future challenges. A recent study of occupational therapists working in municipalities who provided assessments of clients with cognitive impairments concluded that the therapists face several conflicts in their practice (Stigen et al., 2019). Occupational therapists value an occupation-based approach to intervention, but for the assessment process, they use impairment-based screening tools, even if they question the usefulness of the results.
The Ministry of Health and Care Services supported a project initiated by the Norwegian Association of Occupational Therapists to implement reablement in Norway (2011–2015), with funding included in the national state budget. This project is in line with the Coordination Reform. Reablement is an interdisciplinary person- and occupation-centered approach that supports individuals in achieving their goals through participation in daily activities, home modifications, and the use of assistive devices as well as through leveraging social networks (Tuntland & Ness, 2014). Associations of nurses and physiotherapists have joined the project as well as the employer organization for Norwegian municipalities known as KS (Kommunesektorens Organisasjon [the Norwegian Association of Local and Regional Authorities]). Occupational therapists play a central role in implementing reablement, as motivators or leaders of health teams (Hjelle et al., 2017; Jakobsen & Vik, 2019; Tuntland et al., 2019; Vik et al., 2008). This reablement project illustrates the three-part collaboration in the Nordic model.
Legislation of Occupational Therapy Services in Municipalities Beginning in 2020
In 2015, the Norwegian Parliament mandated that all municipalities in Norway have occupational therapists, starting in 2020. This is a milestone in the history of occupational therapy in Norway. Recently, there has been a 20% increase in the number of occupational therapists in the municipalities (Statistics Norway, 2019). Today, approximately 2,600 occupational therapists work in municipalities in Norway, representing more than half of all occupational therapists in the country (Statistics Norway, 2019). A variety of demographic, technological, and political factors (Hagen, 2011), along with the profession's development of reablement as well as scientific and empirical knowledge about how to enable people to participate in everyday life activities, contributed to the increase in the number of occupational therapists working in the municipalities (Tuntland & Ness, 2014; Tuntland et al., 2019). Despite this 20% increase (Statistics Norway 2019), however, 80 of 424 Norwegian municipalities had no occupational therapists in 2019, and coverage varied from none to 12 per 10,000 inhabitants (Statistics Norway, 2019). It is estimated that the number of occupational therapists in community-based health services will need to triple to meet upcoming health care needs and satisfy the new mandate (Hagen, 2011). A shortage of practitioners may pose a challenge in the years to come.
Bachelor's and Master's Degree Education in Occupational Therapy and Occupational Science in Norway
In preparation for the health and welfare reforms described earlier, the government identified a need for more occupational therapists and supported the establishment of four new training programs in the cities of Tromsø (1990), Bergen (1993), Sandnes (2001), and Gjøvik (2013). In 2019, Norway had six occupational therapy educational programs.
In Norway, the entry-level degree for occupational therapists is the bachelor's degree, which requires 3 years of study. The Ministry of Education and Research in Norway (Ministry of Education, 2012–2013) regulates graduate courses through national curriculum regulations established for each profession (Advisory Board for Higher Education, 1998). Contemporary course regulations have divided the curriculum for occupational therapy into four main themes: (a) occupational therapy—foundation and development (60 European credits); (b) occupational therapy—professional practice (150 European credits); (c) biomedical science (anatomy, physiology, and pathology; 60 European credits); and (d) human and social sciences (anthropology, psychology, and sociology; 90 European credits).
The national regulations are undergoing revision in response to criticism that the curricula have not adapted to contemporary challenges in society. The national regulations are described as learning outcomes and will be implemented in the six occupational therapy educational institutions beginning in autumn 2020. Learning outcomes are organized within the following themes: (a) activity and participation in everyday life; (b) professional practice of occupational therapy; (c) rehabilitation, habilitation, and treatment; (d) adaptations, technology, and facilitation; (e) inclusion, participation, and belonging; and (f) innovation, professional development, and management.
Master's degree programs in different areas are available to occupational therapists, but only Oslo Metropolitan University offers a master's degree in occupational therapy. The Norwegian University of Science and Technology offers a master's degree in occupational science. Most occupational therapy programs offer postgraduate courses at the master's level in specialties such as welfare technology, assistive living, knowledge-based practice, health, and work participation.
No doctoral programs in occupational therapy or occupational science are offered in Norway, but other doctoral programs are open to occupational therapists. The first occupational therapist received a Norwegian doctorate in 2004, and now 40 occupational therapists (38 women and 2 men) have earned a Norwegian doctorate.
Role of the Norwegian Association of Occupational Therapists
The Norwegian Association of Occupational Therapists, Ergoterapeutene, and its members have participated in international collaborations, meetings, and congresses arranged by the WFOT since 1958. In 1986, Ergoterapeutene became a member of the Council of Occupational Therapists for the European countries. International networking at annual meetings of the presidents of the Nordic occupational therapy associations allowed expression of mutual support and discussion of development. Ergoterapeutene has arranged national congresses every fourth year since 1997.
Some milestones for the association include:
1989—Adopted Norwegian ethical guidelines for occupational therapists (revised 2017).
1998—Defined seven areas for occupational therapy specialization: children's health, the health of the elderly, mental health, somatic health, generic health, public health, and work health (since 2015 at the master's level).
2011—Published the core competencies for Norwegian occupational therapy (revised 2017) (Norsk Ergoterapeutforbund, 2017b).
Since 1958, the association has published the magazine Ergoterapeuten, which contains scientific articles as well as eyewitness reporting and information from the association. The magazine has open access and follows the principles of universal design. Since 1994, the association has collaborated with the Nordic occupational therapy associations in the publication of the Scandinavian Journal of Occupational Therapy, which has been a catalyst for elevating the academic level of occupational therapy education and research in the Nordic countries.
In recent years, the Norwegian Association of Occupational Therapists has systematically addressed the major health and welfare challenges in Norway. The association has methodically developed its policy strategy based on its vision of “activity and participation for all” (Norsk Ergoterapeutforbund, 2017a, 2017b). Ergoterapeutene has searched for opportunities to demonstrate how occupational therapists can help to meet Norway's health and welfare needs. In meetings with politicians, the association has argued for the role of occupational therapy in these reforms. Ergoterapeutene also has developed close links and collaboration with associations for persons with disabilities to work toward common goals.
We live in a time of constant change. This article describes how the occupational therapy profession has developed in Norway since its start in 1952.
Occupational therapy in Norway has developed through both professional and academic progress and under the Nordic welfare model. Norwegian researchers and faculty members have been powerful forces in the development of the profession by including new international research, occupational therapy models, and perspectives from occupational science, such as occupational justice and occupational balance.
The Norwegian Association of Occupational Therapists, Ergoterapeutene, has reached milestone achievements, such as the implementation of reablement as part of the services provided in the municipalities, securing free assistive technology for all, and advocating for the acceptance of occupational therapists as experts within work inclusion and workplace assessment. By repeating the same message, the association has influenced political decisions, gained recognition, and ensured that occupational therapy is legally required within all municipalities. This development has been possible because of the Nordic model, including the three-part collaboration that promotes dialogue to find the best solutions.
Occupational therapists, educators, and researchers must constantly ask the questions: What is our role in solving the national health and welfare challenges? How can occupational therapy be a solution for the future welfare state?
Norwegian occupational therapists are in the process of moving from a medical and impairment perspective to a model that embraces activity, participation, and inclusion. This paradigm shift has allowed occupational therapists to enter new areas of health promotion, work inclusion, and primary health care.
The Coordination Reform and the Nav reform have increased the need for occupational therapists. Most citizens are now expected to master everyday life, school, and work in their local environment. This paradigm shift has provided an opportunity for leadership in occupational therapy. There is majority political agreement on the main health and welfare challenges in Norway: demographic changes include a larger proportion of elderly people, social inequality, work participation, a growing number of mental health problems, and increases in substance abuse, musculoskeletal disorders, and noncommunicable diseases. Despite reforms, many people who experience these challenges cannot participate in education and work. As occupational therapists, we must collaborate with others to create a diverse society in which everyone experiences belonging and inclusion.
In the future, we may face challenges that we cannot anticipate today, such as increased migration, new diseases as a result of climate change, viruses, economic downturns, or a threat of war. The core of occupational therapy nonetheless must remain firm to ensure meaningful occupation and social participation through cooperation with a community- and person-centered approach. Occupational therapists will face challenges in assisting the population in adapting for an inclusive, sustainable, and age-friendly environment to ensure activity and participation for all citizens.
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