Experiences of occupational therapy education: contexts, communities and social occupational therapy

Experiências de formação em terapia ocupacional: contextos, comunidades e terapia ocupacional social

Abstract

Over the past decades, the profession of occupational therapy has increased its focus on the wellbeing of society as a whole in response to growing inequality. In addition, guidelines for occupational therapy student education have also been revised to ensure that occupational therapists graduate with an appreciation of and ability to work with diverse populations of people in multiple contexts, beyond a biomedical focus on health and impairment. As a result, occupational therapy educators have been challenged to create curricula that meet the profession’s social responsibility by preparing students to practice with communities and populations in a contextualised way. To contribute to this discussion and foster dialogue about what this may look like in occupational therapy programs, we present examples of curricula from three courses in two undergraduate occupational therapy programs in Australia and Brazil: “Understanding the Context of Occupation” and “Occupation, Health and Participation - Communities and Populations”, at Griffith University, Australia; and the course “Social Occupational Therapy”, at the Federal University of Sao Carlos, Brazil. The courses include topics such as: working in micro to macro contexts, working with communities and populations, collective occupation, politics and advocacy, social justice, occupational justice, social security and others. With differences across the programs, based on their geographical and institutional contexts, as well as their socio-historical and cultural contexts, the examples provide some ideas for educators about preparing students to work in a contextualised way with communities and populations.

Keywords:
Education; Occupational Therapy/Trends; Social Environment; Professional Role

Resumo

Nas últimas décadas, a área de terapia ocupacional ampliou seu enfoque em dimensões sociais em resposta ao crescente patamar de desigualdade. Além disso, as diretrizes para a formação de terapeutas ocupacionais também foram revisadas para garantir que os profissionais se graduem com uma sensibilidade e capacidade de trabalhar com populações diversas e em múltiplos contextos, para além de um foco biomédico em saúde e deficiência. Como resultado, os educadores em terapia ocupacional têm sido desafiados a criar currículos que abordem a responsabilidade social, preparando os alunos para atuarem com comunidades e populações de forma contextualizada. Para contribuir com essa discussão e dialogar sobre como poderiam ser programas em terapia ocupacional, apresentamos exemplos de currículos de três cursos em dois programas de terapia ocupacional, um na Austrália e um no Brasil, são eles: “Entendendo o contexto da ocupação” e “Ocupação, saúde e participação - comunidades e populações”, na Griffith University, Austrália; e o curso “Terapia Ocupacional Social”, da Universidade Federal de São Carlos, Brasil. Os cursos incluem tópicos como: trabalhar do micro ao macro contextos, trabalhar com comunidades e populações, ocupação coletiva, política e defesa de direitos, justiça social, justiça ocupacional, seguridade social e outros. Com diferenças entre o programas, com base em seus contextos geográficos e institucionais, bem como em seus contextos sócio-históricos e culturais, os exemplos fornecem algumas ideias para educadores sobre como preparar os alunos para trabalhar de maneira contextualizada com comunidades e populações.

Palavras-chave:
Formação; Terapia Ocupacional/Tendências; Meio Social; Papel Profissional

1 Introduction

The education of occupational therapists has been changing around the world, with a push for new-graduates to emerge with a strong sense of social responsibility, responsiveness to contextual determinants of occupational performance and engagement, and the ability to apply this knowledge to promote social justice, occupational justice (Townsend & Marval, 2013; Sakellariou & Pollard, 2013), and citizenship (Lopes, 2016). This has been clearly reflected in the World Federation of Occupational Therapists’ (WFOT) “Revised Minimum Standards for the Education of Occupational Therapists” (World Federation of Occupational Therapists, 2016). The document articulates the need for entry-level practitioners to have skills to work across micro and macro levels with individuals, communities and populations, and with a human rights focus that spans these diverse areas of practice. In order to do so, the WFOT recognises the need for students to be imbued with not just technical skills but the “soft skills” essential to the kind of emerging practice that is needed to respond to the challenges of the 21^st century. Such skills include communication, political awareness, critical thinking, awareness to change, and interpersonal skills (Fortune et al., 2013 as cited in World Federation of Occupational Therapists, 2016). Whilst these revised standards highlight the relevance of macro contextual factors such as globalization and citizenship to occupational therapy, less clear is how to approach or teach these topics in occupational therapy education.

Promisingly, a few scholars within the profession have shared their insights and experiences from designing and delivering curricula that promote the aforementioned theoretical concepts. Throughout these insights, the need to incorporate clients’ lived realities is frequently cited (Lopes, 1997; Fleming-Castaldy, 2015). Some report attempting to achieve this through practice education placements (Pollard & Sakellariou, 2014) or experiential outings into local communities (Aldrich et al., 2016). Another key feature is the integration of local and global perspectives, provided through international readings, international student collaborations, and class discussion of local and global issues (Aldrich et al., 2016; Huot et al., 2018). Unsurprisingly, scholars stress the importance of interactive classes that involve group discussion and debate in order to develop skills in critical reflection and analysis (Crawford et al., 2017; Lopes et al., 2012a). Whilst it is encouraging to note the insights shared by these scholars, it is suggested that more work is needed to continue to develop pedagogical strategies that effectively promote the exploration of macro level contextual factors within occupational therapy curricula.

It is our hope that this paper will provide new contributions to this discussion by presenting the teaching and learning experiences of similar content at two universities. The courses “Understanding the Context of Occupation” and “Occupation, Health and Participation - Communities and Populations” at Griffith University, Australia; and the course “Social Occupational Therapy”, at Federal University of Sao Carlos, Brazil, are presented with the central goal of providing some insights into how these occupational therapy courses are integrating the exploration of contextual factors from the macro to the micro into occupational therapy education. It is hoped that presenting our experiences may promote the integration of such curricula in other occupational therapy programs as well as stimulate further dialogue about this aspect of contemporary occupational therapy education.

2 Teaching Context

2.1 Griffith University: Australian experience

The Bachelor of Occupational Therapy program at Griffith University was established in 2014. The program is a four-year, full time, undergraduate degree (Griffith University, 2017). The program’s underpinning philosophy is informed by occupational science and is firmly grounded in a contemporary view of occupational therapy, which maintains an occupational perspective of humans and health as the defining feature of the professional paradigm (Kielhofner, 2009). This perspective has helped inform a growing recognition of the contribution of occupational therapy to areas outside of traditional health and social care, with individuals, groups, or even whole communities, who do not have a biomedical diagnosis (Townsend & Polatajko, 2007; Whiteford & Hocking, 2012) but who experience occupational issues due to structural barriers within society. It is this strong occupation focus that is the hallmark of the Griffith University occupational therapy programs (Griffith University, 2017).

The program has a number of educational and operational principles that underpin the curriculum including a focus on ensuring students have the ability to apply their occupational therapy knowledge, skills, and attitudes in any setting. To achieve this, the program is not divided into small discrete units nor are courses divided into lifespan stages or diagnostic groups as it is believed that such approaches may encourage students to prioritise a bottom-up impairment level perspective which is not aligned to the profession’s contemporary paradigm (Kielhofner, 2009). Instead, these practice characteristics (i.e. diagnostic groups, impairments, lifespan stages) are integrated across the occupational therapy courses, along with an increasing focus on social structures and determinants of health. Consistent across all occupational therapy courses is an explicit and intentional focus on occupation as our profession’s unique subject, knowledge of which is believed to be essential for effective practice, reasoning, and professional identity (Hooper et al., 2014). Such approaches to curriculum design are based on the program aim to enable students to become occupation centred, theory driven, evidence based, and client centred occupational therapists, able to practice in current, emerging and future settings and roles, to enhance the health and wellbeing of individuals, communities and populations through occupation (Griffith University, 2017).

2.1.1 Understanding the context of occupation

This second-year course was designed to bridge occupational therapy specific courses with courses taught outside of the program discipline, particularly those in public health and social theory. Students’ first year occupational therapy courses introduce them to the micro level environments that contribute to occupational performance and engagement for individuals. This second year course aims at extending their understanding to the meso and macro level contextual factors present within society at local, national, and international levels, and the impact of these on occupational therapy, and occupational performance and engagement for not just individuals but communities and populations. To do this, rather than naming and exploring specific social theorists and theories (for instance Dewey, Bourdieu, Freire, Gramsci and Foucault) these are implicitly interwoven into the course through the use of occupational science literature. Such an approach intentionally aligns with Griffith’s program design of maintaining a focus on occupation within occupational therapy specific courses, whilst integrating perspectives and theories from outside the program discipline.

The course starts by introducing the concept of social justice and social change, and from this moves on to discussing human rights, occupational justice and occupational rights (Arnold & Rybski, 2009). Broader perspectives of occupational performance and engagement, such as a transactional perspective of occupation (Cutchin & Dickie, 2013; Dickie et al., 2006; Lavalley, 2017), critical occupational therapy perspectives (Hammell, 2006, 2015a; Hammell & Iwama, 2012; Gerlach, 2015) and a capabilities approach to occupational therapy practice (Bailliard, 2016; Hammell, 2015b) are then introduced and subsequently the contexts (social, cultural, physical, institutional) are explored, from the micro to the macro, in order for students to understand the situatedness (Galvaan, 2015; Madsen & Josephsson, 2017) of occupational performance and engagement. Students are introduced to neoliberalism as an all-pervasive ideology (Ganti, 2014), capitalism as an economic system, and the Protestant work ethic (Kantartzis & Molineux, 2012), and are guided through a process of understanding how these aspects of Western society (and their historical development) interact with other contextual factors to impact occupational performance and engagement and occupational therapy practice (Kantartzis & Molineux, 2012; Hammell, 2010). Students are first guided in critically reflecting on how these concepts impact their own occupational performance and engagement as well as how they may impact occupational performance and engagement for marginalized groups within society, such as refugees and asylum seekers, Australia’s First Nations People, disabled people, women, people of cultural and racial diversity, and people living in poverty. The former is achieved through guided and critical self-reflection in small tutorial groups, and the latter is achieved through the integration of relevant occupational therapy case studies and practice examples drawn from professional experiences of academic staff, as well as from the literature (Galvaan, 2012; Swain & French, 2010; Rudman, 2005, 2012; Malfitano et al., 2014; Gerlach, 2015). The aim is that as students understand the influence of the meso and macro contexts on occupational performance and engagement, they then also begin to see occupational therapy’s contribution in responding to issues not just at an individual (and often biomedical) level but at a societal and structural level (Pollard & Sakellariou, 2009; Hocking & Mace, 2017; Wilding & Whiteford, 2009).

A key assessment in the course requires students to apply their knowledge of the complexity and situtatedness (Galvaan, 2015; Madsen & Josephsson, 2017) of occupation to analyse an occupational justice issue within a marginalised community in Western Sydney as represented in a television documentary (Australian Broadcasting Corporation, 2012). Students are provided with additional resources (e.g. government reports) in order to analyse how the various social, cultural, institutional and physical contexts, from a macro to a micro level, have, over time, interacted to create situations of occupational injustice for this community.

The course ends by guiding students through a process of critical reflection on their own positioning within society, with specific reference to their privilege and power (as compared to the marginalised community previously discussed), and the impact this may have on their future practice with clients, many of whom may be marginalised or oppressed in one form or another. The aim is to assist students to develop a sense of cultural humility (which is explicitly explored), as well as reflect on ways they may be able to modify their therapeutic practice to create client-centred relationships based on genuine respect and power-sharing (Hammell, 2013; Bailliard, 2016), skills essential for all occupational therapy practice.

2.1.2 Occupation, health and participation: communities and populations

Twelve months after completing “Understanding the Context of Occupation”, third year students undertake the course “Occupation, Health and Participation - Communities and Populations”. This course uses and builds upon the knowledge gained in the first and second years of the program, most notably “Understanding the Context of Occupation” and also courses in public health which include content on conducting needs assessments for major public health issues. The ethos behind the course is to allow students to gain knowledge, skills, and attitudes essential for work in settings where clients are not individuals, but groups of people brought together by shared values or contexts.

Although it is common for courses with a focus on working with communities and populations to utilise a community development approach, “Occupation, Health and Participation - Communities and Populations” continues to follow the broader Griffith occupational therapy program in using a specific occupational therapy process to guide practice, namely, the Canadian Practice Process Framework (CPPF) (Craik et al., 2013). The CPPF was designed to be an evidence-based and client-centred framework that can be applied in a diverse range of practice contexts. Through consistent use of the CPPF throughout the entire program, students are taught that they can use the same decision making processes and structures with individuals, communities or populations (Craik et al., 2013).

The course runs over twelve weeks and is structured into four modules: Community and Collective Occupations, Assessment Skills for Communities and Populations, Working with Communities and Populations, and Leadership and Emerging Occupational Therapy Practice. Students spend time reviewing and understanding collective occupations, what constitutes a community or a population, how shared ideals can create social change, and how to be ‘client centred’ when working with groups, communities and populations (Kantartzis, 2017; Ramugondo & Kronenberg, 2015). Over the course of the semester, students actively practise implementing skills and knowledge for authentic and sustainable change addressing occupational issues within communities or populations. Students work through the occupational therapy process, justify their decision-making using evidence, and are guided by principles of power sharing, equity, empowerment, justice, and occupational therapy theory. Assessment skills are taught by completing focus groups, learning about survey design, understanding the principles of authentic community consultation, and through building on previous knowledge of needs assessments. Occupational therapy approaches that students learn about and develop are preparing for and running groups and developing and delivering change proposals based on identified occupational issues.

The Leadership and Emerging Occupational Therapy Practice module is based on examining and appreciating the unique skills that occupational therapists can bring to established community development work. Students also investigate future and emerging areas of practice in a wide variety of contexts. A key discussion in this module is how occupational therapists can position themselves to have greater influence in non-traditional settings beyond healthcare to develop a profile as leaders in social and political spaces and advocate for the occupational rights of people around the world. Each module allows students to gain knowledge of and practise implementing skills an occupational therapist will need when working with communities and populations.

To embed the knowledge gained throughout the course, a key assessment item requires students to compare and contrast an occupational therapy specific process (such as the CPPF) with community development frameworks to gain a picture of what working with communities and populations can look like without the specific lens of occupation, as is often required when working in role-emerging settings. Students are also required to consider the implications for client-centred practice when working with groups and communities. During their critique and appraisal students often highlight the individualistic nature of many texts and resources which detail client-centred practice, and propose that the profession provide alternative definitions to be more inclusive of working in community spaces.

Students in this course are exposed to real life scenarios and case studies where they can think broadly about the impact and role of occupational therapists in addressing occupational issues. To ensure alignment with the WFOT’s (World Federation of Occupational Therapists, 2016) “Revised Minimum Standards for the Education of Occupational Therapists”, local, national and international examples of community-based occupational therapy are explored. In addition to guest speakers and case studies developed with therapists in the field, students apply their occupational perspective to current news and media articles in order to explore potential roles occupational therapists might have when working with communities and populations.

2.2 Federal University of Sao Carlos: Brazilian experience

The undergraduate course in occupational therapy at the Federal University of Sao Carlos started in 1978. The program is five years long, and the curriculum is organized into five thematic topics which, when combined, express the program’s philosophy. The underpinning themes of the curriculum are: a) occupational therapy: b) theory and professional reasoning for individuals, activities, everyday life and contexts; c) practices in occupational therapy; d) occupational therapy theoretical and methodological references; e) and occupational therapy and research. Integrated throughout the whole program, through various courses, are topics such as: State, social politics, citizenship, culture, territory, context, diversity, power, and others. Students are encouraged to understand context not only as a factor affecting occupation and occupational therapy practice, but as a site for intervention (Universidade Federal de São Carlos, 2015).

In the Brazilian context the concept of everyday life is used interchangeably with occupation. Therefore one of the goals of the occupational therapist is to work through everyday life to try to promote social participation and social inclusion. Based on one Brazilian definition, the role of occupational therapy in society is

[…] to act in the health, education or/and social fields with the goal of promoting emancipation and autonomy for those who, temporarily or definitively, have difficulties related to inclusion and social participation. The reasons for these difficulties might be physical, sensory, mental, psychological and/or social (Universidade de São Paulo, 1997).

Subsequently, a diverse range of occupational therapy actions (we refrain from using the term intervention or treatment which are not always relevant – Malfitano et al., 2014) are identified, and as a result occupational therapy has relevance and applicability to many different population groups.

2.2.1 Social occupational therapy

At the Federal University of Sao Carlos the field of social occupational therapy has been developing since 1998 through the Metuia Project (a research project developing teaching, research and University-community engaged actions), led by Professor Roseli Esquerdo Lopes. Projects in partnership with communities have been used to teach students about the social field and professional actions in occupational therapy (Lopes et al., 2012a). Initially, projects developed in the social field were offered as placement sites to occupational therapy students. In parallel, informal study groups were offered outside of standard classes for students with a special interest in this field. Later, an elective course in social occupational therapy was offered, and simultaneously, aspects of social occupational therapy were gradually inserted into different courses within the program. In 2016, the curriculum of Federal University of Sao Carlos officially included “Social Occupational Therapy” as a compulsory course to students in their third year of the program.

Social occupational therapy has developed in Brazil as a specific field to deal with social inequalities. It refers to political and ethical professional actions that target individuals, groups or systems to enable justice and social rights for people who are disadvantaged by social conditions (Barros et al., 2005). It is concerned with

[…] social issues such as poverty, homelessness, immigration, drug use, unemployment, under-employment, culturally marginalized groups, prostitution, discrimination against transsexual people, incarceration, and other important issues, which demand professional responses (Malfitano & Lopes, 2018, p. 21).

The course is dedicated to prepare students to develop the skills and theoretical knowledge base to work in the social field. In line with the pedagogical and political aim of the program (Universidade Federal de São Carlos, 2015), the goals of the course are: to raise awareness of the social field among students, particularly community work; to discuss the social dimension of human doing; to define social occupational therapy as a specific field in occupational therapy; to define social occupational therapy as having different perspectives compared to the health field; to discuss occupational therapy action outside of clinical settings; to discuss social inequalities, values, and the occupational therapy role in society; and to learn about social technologies and resources in occupational therapy (Universidade Federal de São Carlos, 2015).

The topics provide students with exposure to and understanding of their ethical responsibilities within the social field, while simultaneously preparing them for practice. The topics are: a) Prejudice and stigma and the influence of these on practice; b) Social question, as presented by Robert Castel (2003), social security and social support networks, which together form the basis of society; c) Rights, social policies and citizenship in the capitalist society; d) Social occupational therapy: history and theoretical background; e) Welfare; f) Education; g) Health and Life Medicalization, as presented by Illich (1974); h) Social security; i) Justice; j) Culture (including the different social markers); and k) Experiences in Social Occupational Therapy. The course is organized in four blocks. The first block, composed by the topics “a”, “b” and “c”, is related to social theory and adopts a socio-historic approach to understanding society and inequalities including their relevance to occupational therapy practice. This block is approached as an introduction, based on authors like Erving Goffman (2009), Robert Castel (2003), Paulo Freire (1970) and T. H. Marshall (1950), and explores the relevance of each topic to occupational therapy (Lopes, 2016; Lopes & Malfitano, 2017). The second block examines the history of social occupational therapy in Brazil highlighting its development and challenges (topic d) (Lopes et al., 2015). The third block uncovers different fields of the social context to discuss its general constitution, principles and possible actions in occupational therapy. For example, Education is presented as a site within the social field. Education is analysed in terms of history, law, and occupational therapy actions in schools and at the political level (for example the inclusion of children with disability or actions to integrate all students in the school environment) to highlight the relevance of social occupational therapy to Education. Each site (topics e – j) is explored in a similar fashion (Almeida et al., 2012; Lopes et al., 2012b, 2019; Bregalda & Lopes, 2016; Morais & Malfitano, 2016; Dorneles & Lopes, 2016). The last block is dedicated to analysing experiences in social occupational therapy, discussing how to deliver the work (item k) (Lopes et al., 2014).

The content is delivered in the form of pre-readings, group discussions, reflections and seminars. Students choose a field of practice, such as Education, Welfare, Justice, Health, or Culture; and present its context through a social occupational therapy approach. At the end of the course, they present an assessment based on the analysis of an article related to their chosen practice field. They discuss why this subject is related to the social field, what occupational therapy actions have been or should be applied, and how a social occupational therapy approach might be different. The course is intended to prepare the future professionals to practice with individuals, communities and populations with a critical understanding of context and social inequalities.

3 Conclusion

Occupational therapy education needs to incorporate not only technical and individual-based occupational therapy interventions but have an equal emphasis on social approaches that provide students with an understanding of future-focused role-emerging skills to work with individuals, groups, communities, and populations. Time needs to be spent designing and delivering curricula that develop students’ knowledge, skills, and attitudes to work in diverse contexts from the macro to the micro. This requires the ability to critically analyse contexts and their impact on occupational performance and engagement, or everyday life, as well as skills to work in partnership with people to develop contextually relevant occupational therapy approaches that address collective perspectives. The need for students to have such knowledge, skills and attitudes is clearly reflected in the WFOT’s Minimum Standards for the Education of Occupational Therapists (World Federation of Occupational Therapists, 2016).

The need for international discussion and learning from shared experiences is paramount to enhance and develop scholarship in this field, promote global perspectives, and protect against ethnocentrism. In developing this article and discussing examples of educational approaches in Brazil and Australia, it was clear that there was much to learn from each other, despite each context being quite different. More specifically, the Australian educators benefited immensely from learning about the practice of social occupational therapy in Brazil, and how content related to this practice is taught. For them, a challenging aspect of developing courses in this field was the limited literature and examples to provide guidance or insight into how occupational therapy programs may be teaching this material to students. Our intention is to contribute towards filling this gap. From a Brazilian perspective, engaging in dialogical approaches related to teaching about contexts and communities, and the application of international models of practice in occupational therapy, was a beneficial means for southern theoretical perspectives and practices to be part of this international dialogue.

This article has provided some examples of how such curricula is delivered in two different countries. We acknowledge that there are no right or wrong approaches to designing curriculum in this field, and much depends on local and historical contexts and perspectives. These examples are not intended to be prescriptive nor do we claim them to be best practice. Our intention is to contribute to an international discussion and potentially foster a community of practice for educators to share and learn from different experiences of occupational therapy education in this area around the world.

• How to cite: Irvine-Brown, L., Di Tommaso, A., Malfitano, A. P. S., & Molineux, M. (2020). Experiences of occupational therapy education: contexts, communities and social occupational therapy. Cadernos Brasileiros de Terapia Ocupacional. Ahead of Print. https://doi.org/10.4322/2526-8910.ctoARF1931
• Funding Source Sao Paulo Research Foundation (FAPESP) - Grant 2017/22484-0.

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Publication Dates

• Publication in this collection
  2 Mar 2020
• Date of issue
  Jan-Mar 2020

History

• Received
  16 Apr 2019
• Reviewed
  23 June 2019
• Accepted
  20 Aug 2019