Experiences of occupation-based practice: An Australian phenomenological study of recently graduated occupational therapists

Abstract

Introduction

The call for occupational therapists to embrace occupation-based practice has increased in recent decades. Little is known about how occupational therapists perceive and implement occupation-based practice. This study aims to uncover the experiences of new and recent graduates using occupation in their practice.

Method

A phenomenological design guided the development of semi-structured interviews. New and recent Australian occupational therapy graduates were interviewed about their experiences of occupation in their practice. Interview transcripts formed the data and themes were developed by thematic analysis.

Findings

Eighteen occupational therapists were interviewed. Three main themes emerged from the data. Overall, graduates found it challenging to embrace occupation in their everyday practice, deciding it is more pressing to remediate impairments than to enable occupations. Some participants stated that occupation-based practice was unrealistic given the efficiency pressures of their practice environments. However, graduates felt that with more experience they would be able to implement occupation in their daily practice.

Conclusion

Recently graduated occupational therapists in Australia find it challenging to consistently implement occupation in their daily practice. Confidence to apply occupation-based skills is an important factor for implementing occupation in practice. Some recent graduates are choosing impairment-based techniques over occupation-based practice.

Keywords

Practice occupation occupational therapy qualitative research practice patterns

Introduction

The history of occupational therapy has been punctuated by two major paradigm shifts and currently the profession is endeavouring to transition to a third, the contemporary paradigm, as described by Kielhofner (Kielhofner, 2009a). In the first practice paradigm, occupation was at the core of practice, giving occupational therapy a unique foundation, distinct from other health professions at the time (Kielhofner, 2009a). The mechanistic paradigm was the second major shift, in which practice typically centred on biomechanical perspectives and impairment-based techniques (Kielhofner, 2009a). The shift towards the mechanistic paradigm eventuated as there was increasing pressure for practice to become empirically justified and align with the medical model (Wilding and Whiteford, 2009). Wilcock (2006) highlighted that practice shifts away from occupation have been detrimental to occupational therapy practice. However, Kielhofner believed that recently occupational therapists’ practice has begun to shift again and therapists are now practising within the contemporary paradigm (2009a). However, currently, there are few examples to illuminate that all therapists have embraced the contemporary paradigm (Molineux and Baptiste, 2011).

Occupation is the foundational perspective of the contemporary paradigm. Occupation, according to the World Federation of Occupational Therapists (2016), ‘refers to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do’. The contemporary paradigm consists of three main concepts: occupation is inextricably linked to health and wellbeing; humans can experience dysfunction in their occupations; and finally, occupation-based practice. The term occupation-based practice is described as occupation as the foundation within the assessment, intervention and evaluation phases of the occupational therapy process (Fisher, 2013). That is, a person’s occupations of choice ought to be utilised in these phases and a client can expect to engage in occupation as part of their interactions with an occupational therapist. For example, a person engaging with occupational therapy services could expect to detail their favoured occupations and for these or other chosen occupations to be used as the basis of assessment to uncover occupational issues. Then, therapy decisions will be centred on these occupations, or the client will be asked to perform or engage in these occupations as the therapy or intervention, rather than a component of the occupation being worked on via an exercise treatment programme, for example. Finally, the ‘success’ or evaluation of the occupational therapy service is also centred on occupation rather than components areas such as decreases in impairments.

However, at present it is unclear how occupational therapists use occupation within their daily practice, especially given the considerable paradigmatic changes the profession has had to navigate in recent decades (Kielhofner, 2009b). There is some contention about whether occupational therapists have shifted their practice into the contemporary paradigm. In the recent past, academics and leading occupational therapists have encouraged a ‘renaissance’ within occupational therapy, where occupational therapists again may make changes to practice to more closely align to the founding philosophies of the profession (Molineux, 2011; Whiteford et al., 2000: 61; Wood, 1998). This may indicate that there are still significant practice modifications required for occupational therapists to practise within this new paradigm.

The definition of occupational therapy from the World Federation of Occupational Therapists is: ‘occupational therapy is a client-centred health profession concerned with promoting health and wellbeing through occupation’ (2017: 4). One interpretation of this definition is that ‘through occupation’ might signal that occupational therapists must use occupation as the therapeutic modality in their practice. It has been argued that it is imperative for occupational therapists to align their practice to the founding philosophy of the profession and embrace occupation-based practice (Fisher, 2013; Molineux, 2004; Reilly, 1962). However, it is still unclear whether Australian occupational therapists value occupation in practice and how they perceive their use of occupation in practice. Despite this study investigating the Australian perspective of occupation-based practice, as the authors are situated in the Australian context, research into this topic is relevant for international contexts given the importance of the topic to all occupational therapists.

Literature review

A comprehensive search of the literature using electronic databases CINAHL, Scopus and Medline was conducted. A search of Australian, and international peer reviewed research was conducted. The search was conducted using combinations of terms including ‘occupation’, ‘occupational therapy’, ‘occupation-based practice’, ‘occupation-focused practice’, ‘practice patterns’, ‘perception’, ‘experience’ and ‘graduates’. The literature was dominated by opinion pieces, commentary or keynote addresses. Few original research papers were uncovered that specifically addressed new and recent graduates’ experiences of using occupation in practice.

Despite the call for occupational therapists to embrace occupation-based practice, Fisher remarked, ‘our unique focus on occupation is not always obvious in practice’ (Fisher, 1998: 512). Lack of an occupational focus in occupational therapy practice was evident in a study of child and adolescent mental health clinicians in the United Kingdom (Fortune, 2000). Fortune found that some therapists chose to be a ‘gap filler and all-rounder’, potentially due to positive feedback and favourable recognition from other health practitioners (2000: 229). Fortune stated that often therapists made practice decisions that were not congruent with occupational therapy’s central paradigm (2000). An audit of occupational therapists working in mental health and learning disability settings discovered that occupational therapists found it challenging to complete occupation-based assessments when they had other generic case manager responsibilities (Parkinson et al., 2009). These scenarios combined could significantly impact on the profession’s identity and value within the broader healthcare environment.

Some occupational therapy research has recently focused on the implementation of occupational approaches in acute hospital settings (Britton et al., 2016; Di Tommaso et al., 2016; Wilding and Whiteford, 2008). In particular, Wilding and Whiteford’s action research study in an Australian hospital found that when occupational therapists more explicitly included occupation in their practice they experienced increased confidence, professional connection and motivation to achieve occupation-based practice (Wilding and Whiteford, 2008, 2009). However, Britton et al. (2016) found pragmatic and environmental constraints of acute hospitals had an impact on occupational therapists’ clinical reasoning, resulting in a practice that was mainly focused on discharge planning.

Despite the many complex barriers to occupation-based practice, it is unclear whether occupational therapists still aspire to use occupation in practice. New graduates may face even greater challenges to implementing occupation in their practice due to the significant power relationships and hierarchical structures they have to overcome (Di Tommaso et al., 2016). However, new and recent occupational therapy graduates could be well placed to apply their recent university education into practice. New and recently graduated occupational therapists who have been educated in World Federation of Occupational Therapists’ (WFOT) accredited university programmes in Australia should have been exposed to the ‘occupation for health’ philosophy (Wilcock, 2006) and occupation-based practice. This is due to the WFOT’s Revised Minimum Standards for the Education of Occupational Therapists (2002) guidelines, which encourage university educators and programmes to include content with a focus on occupation. As new graduates have been the most recent therapists to have exposure to the latest theoretical concepts at university, it could be argued that they are well placed to support the implementation of occupation-based practice. Gillen and Greber (2014) have called for therapists to learn from students about the application of occupation in practice.

It remains unclear whether an occupation focus during tertiary education translates to being able to implement occupation-based practice. From the literature, it is uncertain whether new and recent graduates are able to implement occupation in their practice upon graduation or if they value occupation in their practice. To explore these unknowns, this study explored the perceptions of new and recent Australian graduates using occupation in their practice.

Considering this, research questions were formulated to uncover the perceptions of occupation in practice of new and recent graduates in Australia. The questions that underpinned the study were:

How do recently graduated occupational therapists think about occupation within occupational therapy? How do they describe the use of occupation in their daily practice?

Do recently graduated occupational therapists wish to or believe they can implement occupation-based practice in their work settings?

Do recently graduated occupational therapists feel sufficiently prepared to implement occupation-based practice upon graduating?

Method

As this study set out to gain a deeper understanding of graduates’ perceptions of occupation in practice, the use of qualitative methodology was appropriate. Phenomenology was used to underpin the data collection and analysis to uncover the participants’ experiences of occupation in their daily practice. Phenomenology is a philosophical perspective that assists researchers to explore, uncover and understand everyday experiences without presuming knowledge of those experiences (Crotty, 1998). That is, the researcher is open to what presents itself when participants describe a phenomenon. The use of phenomenology provided the opportunity to uncover the complexity and contextual nature of the participants’ perception of occupation in practice (Crotty, 1998; Denzin and Lincoln, 1994; Kinn and Aas, 2009). Phenomenology allows researchers to uncover a certain phenomenon from the participants’ perspective (Hesse-Biber and Leavy, 2006). Interviews are commonly used to uncover this contextual information from participants (Grbich, 1999). In-depth, one-on-one, semi-structured interviews allowed the first author to gain understandings about the topic for each of the graduates interviewed.

Ethical clearance was gained from the university’s Human Research Ethics Committee (number 14-156). Pseudonyms have been used throughout to ensure confidentiality and anonymity.

Recruitment

Occupational therapists who graduated from Australian occupational therapy university programmes between 2007 and 2014 were invited to volunteer for the study. An exploratory pilot study had been completed to test the suitability of the wide range of years since graduation, and the findings demonstrated little variation between the new and more experienced graduates in terms of their experiences of using occupation in practice (Di Tommaso et al., 2016). Participants were included who had attended either undergraduate or graduate-entry programmes. Finally, all participants were required to be registered occupational therapists and have work experience since graduating. The participants, however, were not required to hold a position where their job title was ‘occupational therapist’, allowing for the recruitment of people working in role-emerging settings.

As this study was designed to capture a wide variety of experiences from a diverse range of new and recent graduates around Australia, multiple phases of recruitment were implemented. Firstly, permission was granted to advertise for recruitment on the website of Occupational Therapy Australia (OTA), the national professional body for occupational therapists in Australia. OTA also published the study details in a monthly online newsletter distributed to all members nationally. The study was advertised in each state’s and territory’s respective OTA councils by email newsletter and on their websites. As is the case for many professional associations internationally, not all registered occupational therapists in Australia are members of OTA. Therefore, a more comprehensive recruitment strategy was needed.

Managers of occupational therapy departments in major health services around the country were asked to forward a recruitment email to their staff. The recruitment email contained the study information sheet and reply contact details for a consent form. The first advertising round recruited members of OTA, while the second round recruited staff of public hospitals and health services. The third advertising strategy recruited occupational therapists working in the private sector or role-emerging areas. An internet search for major private organisations, private practices and non-government organisations in all states and territories was utilised to recruit participants. Additionally, professional networks and social media through Facebook occupational therapy groups were used to advertise the study. This approach ensured that a wide variety of occupational therapists had the chance to volunteer for the study.

Data collection and analysis

After a thorough recruitment phase, 27 therapists volunteered to be interviewed for the study. One therapist did not meet the inclusion criteria due to her year of graduation being prior to 2007, leaving 26 potential participants. The therapists were purposively sampled for interviews based on their experiences post-graduation, with both the years of experience and current practice setting taken into consideration. In-depth interviews were conducted with new and recent graduates from a wide range of educational and practice backgrounds from around Australia. Once data saturation was reached, 18 new and recent graduates had been interviewed. Eleven interviews were completed over the telephone, and when geographical location allowed, the remaining interviews were completed face-to-face. Each interview completed ranged from one to two hours in duration to ensure adequate time to explore all experiences in sufficient detail. As is the nature of phenomenological interviews, a majority of open-ended questions were asked.

All participants in this study received an information sheet and signed a consent form to participate in the study. All participants consented to their interviews being audio-recorded. All interviews were transcribed verbatim and these transcripts formed the data. Transcripts were de-identified to ensure any identifying details were removed. After this, Braun and Clarke’s (2006) thematic analysis guide was used to build codes and then themes. This process ensured a systematic analysis of each transcript. Inductive codes were created for each transcript, thereby guaranteeing each transcript was able to elicit new codes and uncover new perspectives. After coding of all the transcripts, themes were developed by grouping codes together and an iterative refining process was completed.

Participants

Participants were interviewed from six Australian states and territories. Sixteen participants were female and two male. Graduates ranged from less than 1 year of working as an occupational therapist up to 7 years. Fourteen of 18 graduates completed undergraduate pre-registration education programmes, and four were from graduate-entry programmes. Half of the graduates in this study were employed by publicly funded government healthcare services and most of these worked in an acute inpatient hospital. No participants who volunteered to take part in the study were, in the authors’ opinions, from role-emerging practice areas. Many of the participants worked in regional areas around Australia. See Table 1 for further information.

Table 1.

Participant demographic data.

Pseudonym	Years since graduation	Locality	Practice area
Adam	6	Metropolitan	Acute: aged care
Alicia	4	Rural	Acute: private hospital
Anne	1	Metropolitan	Acute: public inpatient hospital
Chloe	7	Rural	Private practice
Danielle	6	Metropolitan	Acute: public inpatient hospital
Eliza	1	Regional	Acute: public inpatient hospital
Grace	2	Regional	Community: aged care
Jenny	4	Regional	NGO: paediatrics
Joanne	2	Regional	Acute: public inpatient & paediatrics
Julie	7	Regional	Acute: public mental health
Kaitlyn	4	Regional	Private practice
Kim	1	Regional	Acute: private hospital
Laura	4	Metropolitan	Community: aged care & community: public outpatient rehabilitation
Melanie	7	Regional	Acute: private rehabilitation
Rachel	<1	Metropolitan	Acute: public inpatient hospital
Sally	1	Regional	Acute: public inpatient hospital
Sarah	5	Regional	Acute: public inpatient hospital
Tim	7	Regional	Acute: private hospital

NGO: non-governmental organisation.

Trustworthiness and credibility

The research team were all involved in the design and development of the study. This process continued throughout but especially in the data collection and analysis phase. After five interviews were completed, the research team reviewed the de-identified transcripts to ensure that the information required was captured, and no additional information was required. A systematic process of data analysis was completed for every transcript. Use of Braun and Clarke’s (2006) guide to thematic analysis ensured a consistent approach when inductively building themes from the data set. The first author was responsible for completing the thematic analysis. Themes were checked for credibility and deemed to be appropriate by the rest of the authors of this paper. A member-checking process was undertaken where all the participants were sent their raw transcripts for checking and to ensure that their interview was represented accurately within the transcript.

As is important in all qualitative research, the first author engaged in a process of reflection and ensured that all assumptions and bias were acknowledged (Yin, 2011). A reflexive journal was maintained throughout the data collection and analysis process to ensure that all decisions and reflections were recorded (Watt, 2007).

Findings

After completing a thorough and systematic data analysis, three main themes emerged from the data. They were: Enacting occupation-based practice; Occupation is a luxury; and Experience: ‘It’s more of a confidence thing’.

Enacting occupation-based practice

During the interviews, participants described their daily practice in many different ways. Despite all participants stating that they strive to assist their clients to return to occupation or to complete their daily occupations during their time in the service, few participants could articulate how they used occupation in their practice. When describing occupation-focused practice or occupation-based practice (used interchangeably by the participants) in their work, there was little reference to occupation in therapy sessions. For example, when detailing scenarios about her occupation-based therapy sessions, Kim described a typical therapy session as ‘using Theraputty, it might be for fine motor, it might be beading or using paperclips or tweezers and marbles and for them relating it to opening containers in the kitchen or something like that’. In this example the use of occupation was not explicit in the intervention, and as Kim described it was up to the client to make links to daily occupational tasks when in the kitchen.

Sally offered this example of occupation-based practice:

I guess really if I thought about it more at this point… I would probably be doing some of that bottom up kind of approach and those specific biomechanical kind of things, I’m still doing it with the focus of occupation in mind, but the occupation isn’t your interventional therapy, and maybe that is OK, I don’t really know.

Sally admitted that describing how she used occupation in practice was extremely difficult and that she had given the concept little thought since graduating.

When describing their therapy sessions, many participants chose to describe upper limb rehabilitation sessions. It is important to note that all participants in this study were from traditional occupational therapy settings. Tim, a hand therapist, provided insight into his practice, in which he commenced his therapy with:

A bit of an assessment of their range of movement and swelling and sensation, whatever their issue might be, and get some objective measure on that. And then usually from there I’ll be able to update their home exercise programme and send them away with that to do for the next week.

He further described that usually his sessions contain ‘passive ranging activities and some active ranging activities and there might be some strengthening as well. So not particularly activity-based, they might be just exercise-based’. For Tim, having a process to follow for a majority of clients was beneficial given the frequency of similar diagnoses and injuries that were being treated in the hand therapy clinic.

Tim was not the only participant to admit that using occupation was not explicit in their practice, as Laura exclaims: ‘we are discharge planners. I’m a discharge clearer, that’s what I am’. Laura highlighted that in her role on the acute surgical wards of a large metropolitan hospital, no focus on occupation is required and therefore it is not important to her or her colleagues. Rachel also offered her take on the state of occupation-based practice in hospitals: ‘we’re not quite as focused on probably what we should be [occupation], or we do become the one-stop shop [for discharge planning]… rather than the role that we were taught through [university]’.

Despite some participants favouring impairment-based techniques, some participants still saw the value in employing occupation-based practice. As Eliza offered:

Using occupation as therapy is probably good because they’re, technically, doing those tasks, so there’s a point to it, and they can sort of see a point to it, rather than, you know, just moving a cone or whatever it might be, if they’re actually doing something that they do at home anyway, I think, yeah, it could work. And when there’s enough time to implement it, is probably where the issue would arise.

Despite a perception that occupation-based practice would take up more time than other therapy modalities, Eliza described the value that clients could gain when occupational therapists used the occupations of their choice in therapy, as it would enable the clients to see meaning and purpose in the sessions. However, it seems from the responses from the participants, occupation in practice is not utilised, nor central to the daily practice of the new and recently graduated occupational therapists in this study.

Occupation is a luxury

Seventeen out of 18 participants indicated that occupational therapists needed to remediate impairments (cognitive, physical or emotional) before they could start occupation-based interventions. The remaining participant worked in a mental health setting where clients with chronic mental health conditions were commonly seen. In short, clients could not participate in occupation-based interventions until they had overcome all their limitations prior to participation in occupations. However, as most of the participants in the study worked in a hospital setting, when their clients overcame impairments or could safely live with their impairments, clients were then ready for discharge from the service. So occupation was thought of as a luxury in an occupational therapist’s practice; something that could not be implemented unless a therapist had spare time.

There was an overall acceptance by each participant that if other occupational therapists were able to implement occupation-based interventions or work on little more than self-care or basic safety needs, that these therapists were wasting time, not managing their priorities or caseload well, and were perceived as not being able to handle the pressures and realities of practice. Alicia voiced her team’s collective frustration when another team member prioritised occupation-based practice: ‘it’s frustrating for the department because [we] need to get through our wait list and all of those really high priority clients’. Another participant expressed her disbelief that focusing on occupations was allowed by the managers in her workplace: ‘I think it does happen like I’ve heard of… different therapists who can work on [occupation]… they somehow justify working on these goals that seem quite low on the list of priorities’. Therefore, occupation was not always favoured in practice by the participants. Tim stated: ‘I don’t know it’s realistic to be occupation-focused’. He later went on to clarify that he did not think therapists could be occupation-based in their work and be perceived as successful by other occupational therapists. Melanie felt that completing occupation-based practice was menial and perceived implementing occupation as a lower level skill than impairment-based practice. She suggested that occupational interventions might be able to be included in practice by ‘delegating a lot of those what might be perceived lower skilled or lower priority tasks to [therapy assistants] who can perform those kind of therapies at a slower pace or with supervision’.

Successfully managing the priorities of their caseloads was important, particularly for the new graduates. This was a common topic of conversation during the interviews, providing insight as to why occupation was rarely used in their practice. As Kaitlyn stated, ‘for someone who’s just had a hip replacement to have a goal of getting back to lawn bowls is just not high enough on the list for us to focus on’. Jane offered further insights into the choices recent graduates face, stating that ‘[occupation is] not going to be the priority, the priority is going to be is how are you coping with your 25 clients that you have’. Further highlighting the choices and pressures on graduates, Danielle said that the setting also has an effect on why occupation cannot be used in practice. She stated that occupation is a luxury in the hospital setting and she highlighted the pressures of working in this environment as an occupational therapist. She commented:

I think it’s been a choice somewhere along the line, I mean certainly from an acute [occupational therapy] perspective I don’t think that we work the way [occupational therapy] in general would work, we fit into that acute hospital ‘get people out of bed setting’ and we very much mould to that, I think that’s something that’s forced upon us because we want that OT role there and we think we do have a role there, but we do have to conform to the setting as well, we can’t win it all.

In order to be perceived as successful and competent, it seems the new and recent graduates in this study felt the need to sacrifice occupation and an occupational perspective during their practice and in their clinical reasoning. Using occupation in practice was seen by this cohort as peripheral and wasting time, and was therefore abandoned by most participants.

Experience: ‘it’s more of a confidence thing’

A common theme throughout all the interviews was participants felt that with more experience they would be able to become more occupation-based in practice. They felt that, with time, their practice would be less about learning the protocols and expectations of the workplace, becoming more automatic in clinical reasoning and increasing their knowledge about common diagnoses, and that their attention would turn to applying occupation in practice. As Eliza stated:

I think it’s probably more because I have a job and I have a role and so I try and just sit myself within that role with almost no scope within my brain to think about, you know, what else I could be doing…

Jane also alluded to this in her interview:

You are not thinking about occupation, you are just thinking, ‘how do I get through what I am expected to do?’ So you really just ok how do I meet the goals that I am meant to be doing? How do I meet my key performance indicators as a therapist? Not, ‘am I being true to occupation’. I think that comes later, once you get through the first couple of years where you just going ‘I don’t know how to do this – how do I be an [occupational therapist]?’ Then I think you can start to go back and look at evidence and things and try and bring that kind of thinking back into it. But I think to start with ‘how do I get through the day?’

One participant, Sally, was also cautious of this, even though she cited time and experience as the tools to make her practice more occupational. She claimed:

That’s when I said you know that you can’t necessarily always rely on a senior [therapist], but I do have in my head that you know that there might be a therapist that’s been out for 40 years and has been doing the same thing for 40 years and maybe that’s not what the evidence and the research says now or that’s not what they learnt at [university] is going to be very different to what I learnt at [university]. So I think there is certainly the potential that there are therapists out there that have been doing things for a long time that aren’t as occupation-focused as they could be.

Therefore, despite gaining experience and potentially moving to a more senior role, experience may not be the key to improving occupation-based practice.

Some participants conceded that with more experience, they perceived that they would feel more efficient at managing a caseload, and this might give the illusion of more time. As Danielle commented:

So I think there's a degree of experience in there, definitely. I think that they've got the basics well and truly, and they can do [the basics of practice] quite efficiently. So maybe they've got a sense of having more time.

Having more experience was cited by one participant as being able to adequately manage all the constraints against being able to implement occupation-based practice. Spending less time focusing on the constraints and demands that are placed on health professions in current practice may also be a by-product of greater experience. Anna stated:

Experience, I really think as a new graduate your mind is so busy with what things do I have to do and documentation and time management and communication and that kind of thing that sometimes there is so much going on in your mind that, although you want to be as occupation-focused as you possibly can, sometimes there are just those constraints there, so I think that with experience I hope that some of those other things become a bit more second nature and I can focus more of my skills on therapy.

From this it is unclear whether gaining more practical experience as an occupational therapist will allow a therapist to become occupation-based in the future if they wish.

Discussion and implications

This study has revealed that for new and recently graduated Australian occupational therapists, impairment-based techniques are more central to decision-making and intervention planning than occupation-based practice. Although the graduates felt occupation was a consideration for practice, the graduates did not feel that implementing occupation in practice was desirable or realistic due to external pressures, including from other occupational therapists. It seems from this study that graduates believe that they need more experience as occupational therapists prior to being able to consistently implement occupation-based practice.

In recent times, there has been an increase in the number of published articles about theory–practice and research–practice gaps and knowledge translation specific to occupational therapy (Cramm and White, 2011; Fänge and Ivanoff 2009; Warner and Townsend, 2012). Implementing theory into practice is often compounded by contextual influences commonly discussed in the literature. As a majority of the participants in this study work in acute settings, it is important to acknowledge some of the perceived institutional challenges. The medical model of health care is often held in opposition to the contemporary paradigm or cited as a barrier to enacting occupation-based practice (Kielhofner, 2009a, 2009b; Wilding and Whiteford, 2008). Further impacts on occupational therapy are the blurring of professional identity and over-reliance on interdisciplinary practice models. Fortune (2000) presented the notion that occupational therapy’s professional identity was under threat, as therapists could be perceived as ‘gap fillers’ without any professionally articulated model for practice. Such a perspective is troubling, as a study found that knowledge of occupational therapy was poor in health professionals such as nurses and medical practitioners (Jamnadas et al., 2001). Systemic barriers such as the focus on medical management as a priority, and the discharge-focused nature of traditional healthcare, could affect uptake of even the most basic of changes to practice or interventions (Novak and McIntyre, 2010). Furthermore, Britton et al. (2016) and Wilding and Whiteford (2009) described time constraints and the difficulty of deviating from accepted standards of practice as other challenges. It was evident from the interviews that these were common barriers for new and recent graduates. For them, there was pressure to practise in a manner that was accepted and expected by other senior members of the profession, but also the multidisciplinary team. These findings highlight that this is an important issue to be aware of to make sustained practice change in the future. It is unclear from the findings of this study whether therapists would still be able to be occupation-based in practice despite the barriers if they specifically chose to move their practice to be in line with the contemporary paradigm.

Occupation-based practice: a choice

This study has highlighted that not only do occupational therapists find it challenging to implement occupation-based practice, but even when in situations where occupation may be used, therapists were choosing impairment-based techniques. Therapists perceived that occupation is a luxury in practice and only to be implemented if there was time after remediating impairments. Some therapists decided not to implement occupation due to their perception of occupation not being valued by other occupational therapists in practice. This finding is interesting as research and commentaries have focused on strategies for therapists to become more centred on the founding philosophy of the profession (Fortune, 2000; Gillen and Greber, 2014; Wilding and Whiteford, 2008). However, it may be that not all therapists aspire to become occupation-centred. Nor do strategies to become occupation-centred specifically focus on the new and recent graduate population, potentially assuming that their recent education has adequately prepared graduates to use occupation in practice. However, this study has also highlighted that there are specific barriers to occupation-centred practice for new and recent graduates. Therefore, future research and practice change processes should take into account the perceptions of other therapists as a potential barrier to change.

Twinley and Morris (2014) questioned whether occupational therapists in the United Kingdom are aligning their practice to be occupation-based, highlighting along with this study’s findings that internationally, implementing occupation-based practice is still not central to practice. Gillen and Greber (2014) outlined strategies for therapists to more overtly choose to implement occupation in their practice. Their opinion piece, coupled with the graduates’ perspectives in this study, suggests that implementing occupation-based practice is a choice for therapists to make on a daily basis. Whilst Wilding and Whiteford’s (2008) action research study found that enabling clients to engage in occupation was motivating and satisfying for occupational therapists, this study found that new and recent graduates felt that impairment-based practice still delivered a sense of fulfilment for client and therapist. This finding could highlight why there has been limited uptake of occupation-based practice as advocated by Kielhofner (2009a) and Fisher (2013).

Occupation: not yet accepted?

Findings from this research add to the profession’s understanding of the barriers for occupation-based practice from the perspective of new and recent graduates. Some barriers to occupation-based practice are documented in the literature, such as the dominance of the medical model (Gillen and Greber, 2014; Wilding and Whiteford, 2007). However, this study has also highlighted that it is not only external issues or biomedical or healthcare system factors that inhibit occupation-based practice. At present, from the perspective of new graduates, other occupational therapists are discouraging the use of occupation in practice.

Occupational therapists making a choice to practice in an occupation-based manner is not new to the debate within the literature. Authors such as Gillen and Greber (2014) and Molineux (2011) have asserted that occupation-based practice requires therapists to make a deliberate choice about their style of practice. However, in the recent past more debate around the inclusion of occupation as the main requirement of an occupational therapist’s practice has intensified. An opinion piece by Gustafsson et al. (2014) advocated for our knowledge of the contemporary paradigm to be considered, alongside other paradigms such as evidence-based practice, and for therapists to exercise professional reasoning to balance two (at times incongruous) perspectives. Joosten (2015) proposed another perspective whereby occupational therapists must not solely focus on evidence within the discipline of occupational therapy and expand into broader related knowledge to inform practice. In reference to occupation-based practice, Joosten suggested that rather than concern for ‘occupational therapists using techniques not unique to occupational therapy or providing intervention that does not meet a very narrow interpretation of being occupation based’, the most pressing concern for the profession is that therapists are not aligning practice to conceptual practice models (2015: 220). Other occupational therapists’ views on the incongruence of other related knowledge paradigms and the contemporary paradigm is unclear from the literature. Such viewpoints highlight that the need to implement occupation-based practice requires more discussion and debate before the profession can be unified on this issue. Findings from this study add to this discussion in the literature. Interviewing graduates uncovered that occupation does not feature prominently in everyday practice decisions and that aspects of client-centred practice and impairment-based techniques are valued over occupation. Furthermore, interviews revealed that related knowledge paradigms are seen as incongruous with the contemporary paradigm and occupation-based practice. Machingura and Lloyd (2017) recently published an editorial questioning occupational therapy leaders and their advocacy for practice change into the contemporary paradigm. Machingura and Lloyd (2017) stated that occupational therapists traditionally have not questioned the direction of the profession and they criticised some for ‘abandoning well-researched approaches [evidence-based practice] in their quest for contemporary practice’ (Machingura and Lloyd, 2017: 3). Their editorial reveals there is still criticism from within the profession of the sole use of occupation-based practice. Findings from this study align with the perspective that occupation as the central tenet of the profession is not widely accepted in practice.

Implications for practice

This study revealed experiences of new and recent occupational therapy graduates implementing occupation-based practice. It appears that graduates believe they require more practice experience and confidence to begin to use occupation in practice. However, this study has highlighted that negative perceptions from other occupational therapists were a barrier to implementing occupation in practice. Therefore, occupational therapists should evaluate their own beliefs and perspectives of occupation-based practice. Furthermore, therapists in senior positions or those responsible for the supervision of new graduates must be mindful of allowing new graduates to build their skills and confidence to effectively and consistently implement occupation-based practice.

Study limitations

Although these findings may be applicable and interesting to occupational therapy, caution should be used generalising the findings to other international settings. This study was conducted in the Australian practice context and mainly highlighted the experiences of working in acute inpatient settings and traditional roles. Therefore, it may be difficult to generalise these findings to other practice settings. Due to the requirement for this study to only recruit participants who volunteered and signed a written consent form, volunteer bias could not be eliminated. Therapists may have volunteered if they had a stronger connection to or interest in occupation-based practice, or not, than other occupational therapists.

Conclusion

Occupational therapists in this study often chose not to implement occupation in practice, favouring impairment-based techniques as their first preference for therapy. Graduates perceived that with increased experience and confidence, their practice would become increasingly occupation-based in nature. Further research should be conducted to gain international perspectives of new and recent graduates and the value they place on occupation within occupational therapy.

Key findings

New and recent occupational therapy graduates perceive occupation as peripheral to practice, favouring impairment-based techniques.

Graduates believe that with increased practice experience and confidence they may choose to implement occupation-based practice.

What the study has added

New and recent occupational therapy graduates are choosing not to implement occupation-based practice as their preferred treatment modality, preferring to implement impairment-based techniques in the first instance.

Footnotes

Research ethics

Ethical approval was obtained from the University of Canberra’s Human Research Ethics Committee (Approval number: 14-156) in 2014.

Consent

All participants provided written informed consent to be interviewed for the study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and publication of the article.

Funding

The authors received no financial support for the research, authorship and publication of the article.

Contributorship

Amelia Di Tommaso, Stephen Isbel, Alison Wicks and Jennie Scarvell were all responsible for the development of the research. All authors reviewed the findings and provided input and feedback for trustworthiness and rigour. All authors reviewed, edited and approved the final manuscript. Amelia Di Tommaso completed all recruitment, data collection and data analysis, and wrote the first draft of the manuscript.

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