Abstract
All levels of human engagement are imbued with creativity, which can be observed in many areas of a person’s life. In addition, creativity has been recognized as an important aspect of occupational therapy theory and practice since the beginnings of the profession. However, few studies have explored creativity in the context of occupational therapy process and client-centered practice (Ernst & Moore, 2013; Hickey, 2016; Madsen, 2007; Schmid, 2004).
Creativity has often been described as the creation of something new—an intentional development of novel and useful products and ideas by individuals or groups of people (Amabile, 1988; Corazza, 2016; Runco & Jaeger, 2012; Weisberg, 2015). It facilitates problem solving, flexibility, self-expression, and health maintenance (Runco, 2004). The concept pertains to solutions and innovations that can be either extraordinary or simple, but they always contain a degree of originality (Corazza, 2016; Mirowsky & Ross, 2003). Creativity enables people to reach their goals, including realizing their highest potential, and contributes to growth, meaning, and change (Kurkinen, 2014). Different descriptions of creativity imply that it is a complex phenomenon, being difficult to define and understood in different ways by different people (Weisberg, 2015).
In occupational therapy literature, the concept of creativity usually appears in two distinct functions: (1) as a therapeutic tool or modality (Leenerts & Evetts, 2016; Müllersdorf & Ivarsson, 2016) and (2) in the context of an occupational therapy practitioner’s own creativity, including clinical reasoning and cognition (Ernst & Moore, 2013; Robertson & Griffiths, 2012).
The use of creative techniques in occupational therapy peaked in the 1960s and 1970s; however, later, expressions of creativity became less popular. Nonetheless, creativity never disappeared from occupational therapy’s practice and discourse (Hickey, 2016; Reed & Sanderson, 1999). In fact, occupational therapy practitioners have often distinguished themselves as professionals who are inherently very creative. Some scholars believe that this personal characteristic has enabled them to individualize their interventions, contributing to the client-centered nature of their work (Madsen, 2007). Kielhofner (2008) points out that, to motivate clients to participate in activities and occupations that are important to their lives, therapists often need to be creative. In contemporary practice, creativity has been described as a part of a therapist’s implicit knowledge base that is used when implementing a client-centered approach (Merritt & Boogaerts, 2014).
Although the connection between occupational therapy and creativity appears evident, studies of creativity among occupational therapy practitioners are extremely rare. Ernst and Moore (2013) argued that little is known about the perception of creativity in occupational therapy and the experience that clients and therapists have with it. Robertson and Griffiths (2012) referred to occupational therapists as problem solvers and called for more research that would deepen the understanding of the therapist’s focus on the client’s problems.
The purpose of our study was to further the understanding of client-centeredness in the context of an occupational therapist’s creativity. More specifically, we were interested to know whether the client’s uniqueness was the key motivator of creativity in the occupational therapy process.
Method
This quantitative study was a part of a mixed-methods study of creativity within occupational therapy that followed an exploratory sequential design (Creswell, 2013). The initial qualitative exploratory phase included focus group interviews with experienced occupational therapists and guided the development of an assessment instrument (Oven, 2016; Oven & Lobe, 2018). On the basis of the categories that emerged from the qualitative analysis, we developed the Creativity in Occupational Therapy Questionnaire (COTQ), which was used in this study.
The main hypothesis of our study was that the client’s uniqueness is the most important motivator of creativity in the process of occupational therapy. Although we acknowledge that different factors contribute to an occupational therapist’s creativity, the specific hypothesis that we tested in the process of this quantitative study was as follows: Clients and their characteristics are more important to the creativity of an occupational therapist than the occupational therapist’s personality.
To fulfill the aim of this study, we mainly focused on the COTQ’s section on the occupational therapist’s attitude toward the client and the influence the client has on the therapist’s creativity (see Cluster 4 in subsequent COTQ description).
Participants
Table 1 shows participant characteristics. Most of the participants were women (93%) between ages 22 and 58 yr (mean [M] = 38.5, standard deviation [SD] = 10.5). The highest percentage of participants worked in care of older adults (30%), followed by mental health (20.3%), inpatient rehabilitation (14.5%), pediatrics (12.1%), and neurology (8.7%). Some (14.5%) also indicated that they worked in other areas, including vocational rehabilitation, work with homeless people, work with children with special needs, and work with prisoners. The mean number of years that participants had worked was 14.4 (SD = 11.0), and the mean number of years in present employment was 12.2 (SD = 10.6).
Participant Characteristics
Note. Percentages may not total 100 because of rounding. M = mean; SD = standard deviation.
Assessment Instrument
The COTQ was used in an online survey of occupational therapists. It contained five clusters of questions, or items (in the form of statements):
Attitude toward creativity (15 items; sample statement: “Routine usually inhibits creativity.”)
Attitude toward work and feelings related to work environment (13 items; sample statement: “I have all the necessary equipment and resources to perform my work.”)
Creativity in the occupational therapy process (14 items; sample statement: “Creativity is important in all phases of the occupational therapy process.”)
Attitude toward clients and their influence on the therapist’s creativity (12 items; sample statement: “Creativity helps me build trust and rapport with the client.”)
Factors that influence creativity, either as facilitators or as inhibitors of the process (29 items; sample statement: “Praise from co-workers encourages my creativity.”).
All items were closed-ended, and participants responded to them using a 5-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree. In addition, participants were asked demographic questions about their age, gender, area of work, work experience, and level of education.
To check its clarity and reliability, we pretested the questionnaire in a pilot study that included 12 occupational therapists working in different fields, randomly chosen on the basis of their electronic addresses (Oven, 2016). Reliability was checked for all five clusters of items, and Cronbach’s α for the 83 items was .90, which shows that the instrument can be considered highly reliable (Field, 2009).
Data Collection and Sample
Using an online survey enabled us to have a bigger sample, gave participants more autonomy, reduced time and costs, and aided the data analysis (Lozar Manfreda & Vehovar, 2008). Our initial aim was to reach all occupational therapists working in Slovenia at the time of the study, which was estimated at 500 therapists (Šuc et al., 2014). The online survey was sent to all electronic addresses, obtained from the Association of Occupational Therapists of Slovenia and the Faculty of Health Sciences Ljubljana, where occupational therapists are educated. We also encouraged recipients to forward the survey to their colleagues who might not have received it. Participation was voluntary and anonymous, and no incentives were provided. The online survey was available between April 19 and May 16, 2016. Before the data collection, permission was obtained from the National Medical Ethics Committee (No. 0120–135/2015–2 KME 100/06/15).
Of the 267 occupational therapists who began to complete the questionnaire, 250 (90.6%) completed it partially, and 203 (80.2%) completed it in full. Therefore, data were obtained from between 203 and 250 participants for each question (questions included in the analysis did not have a common number of total answers). In addition, the survey included more than 40% of the population of Slovenian occupational therapists.
Data Analysis
Descriptive statistics were applied to the sample and individual variables. Before conducting further analysis, normal data distribution was checked. It was established that data were normally distributed. Because our questionnaire was divided into different clusters, factor analysis, using the principal axis factoring method, was applied to reduce the number of variables. The factor analysis followed a three-step process described by Bastič (2006): (1) calculating initial factor loadings, (2) factor rotation, and (3) calculating factor scores.
Our research hypothesis was tested using the stepwise regression method to check whether there was a correlation between the dependent variable (creativity) and the two independent variables (the client’s uniqueness and the occupational therapist’s personality). Pearson’s correlation coefficient was used to measure the strength of the linear relationship between paired data (Ferligoj et al., 2011). All analyses were conducted using IBM SPSS Statistics (Version 23; IBM Corp., Armonk, NY).
Results
Analysis of Answers
According to COTQ scoring, most of the participants expressed satisfaction with their work (M = 4.2, SD = 0.7) and felt that creativity contributed to their overall work satisfaction (M = 4.4, SD = 0.7). They experienced their work as interesting and dynamic (M = 4.2, SD = 0.7), and creative problem solving was perceived as a positive challenge (M = 4.2, SD = 0.7). For most therapists, creativity at work was more important than routine work (M = 4.0, SD = 0.9).
Occupational therapists included in the study felt that clients’ specific characteristics and difficulties triggered and encouraged their creativity (M = 4.2, SD = 0.8). A statement referring to the client as the most important reason for an occupational therapist’s creativity received strong support (M = 4.0, SD = 0.9). More than a third (39.9%) of the participants agreed with that statement, and another third (31.7%) strongly agreed. In addition, participants confirmed that creativity enabled occupational therapists to seek unique solutions for each individual client (M = 4.3, SD = 0.7). More than half (56.4%) of the participants agreed, and a third (30.3%) strongly agreed, that creativity helped them implement a client-centered approach in practice (M = 4.2, SD = 0.7).
Creativity facilitated trust building and contributed to a therapeutic relationship (M = 3.9, SD = 0.8) and also motivated the client to participate in the treatment process (M = 4.1, SD = 0.8). Most occupational therapists also agreed that clients’ feedback motivated their creativity (M = 4.3, SD = 0.7). In the participants’ opinion, their personal characteristics also encouraged creativity (M = 4.3, SD = 0.6). Table 2 presents the results of the statistical analysis for Cluster 4 of the COTQ (“Attitude toward clients and their influence on the therapist’s creativity”).
COTQ Cluster 4 Items and Scores
Note. COTQ = Creativity in Occupational Therapy Questionnaire; M = mean; SD = standard deviation.
Hypothesis Testing
Our hypothesis was that the client was more important to the creativity of an occupational therapist than the therapist’s personality. Table 3 shows that the stepwise regression method used produced two regression models. The first model included the client’s uniqueness as the independent variable, which explained 68.8% of variability in the dependent variable. The second model added the occupational therapist’s personality as an independent variable, which explained another 5.6% of variability in the dependent variable. Therefore, combining both independent variables explained 74.4% of variability in the dependent variable (i.e., creativity in the occupational therapy process).
Regression Models
Note. SE = standard error.
Independent variable: client’s uniqueness.
Independent variables: client’s uniqueness and therapist’s personality.
For the rest of the analysis, the second regression model was used to test the study’s hypothesis. The regression model was statistically significant, F(2, 195) = 283.43, p = .000. Table 4 shows that both the client’s uniqueness (B = .574, p = .000) and the occupational therapist’s personality (B = .388, p = .000) had a statistically significant influence on creativity in the occupational therapy process. However, the client’s influence was greater; therefore, we can confirm our hypothesis that clients and their characteristics are more important to the creativity of an occupational therapist than the occupational therapist’s personality.
Second Regression Model
Note. Significant p values are in bold. SE = standard deviation; — = not applicable.
Discussion
This study aimed to increase the understanding of creativity within client-centered occupational therapy practices. It explored how an occupational therapist’s creativity relates to the individual client, predicted to be the most important factor in the creative process.
At the essence of a client-centered approach is a partnership between the occupational therapy practitioner and the client (Sumsion, 2000), which enables the client’s active involvement, decision sharing, and freedom of choice (Law, 1998) as well as consideration for his or her interests, priorities, and personal autonomy (Levack, 2009) and integrity (Kassberg & Skär, 2008). By using this approach, an occupational therapist can also offer a holistic intervention that increases the success and efficacy of the intervention (Tonga et al., 2015).
Our study offered evidence that creativity facilitates a client-centered approach. This phenomenon had previously been observed by Merritt and Boogaerts (2014), who stated that creativity plays a role in developing and maintaining client-centeredness. When practicing creatively, the relationship between a client and a therapist can be relaxed, which enables personal development and learning. Moreover, clients do not wish their therapists to simply follow an established formula. Instead, they expect to participate in activities that are relevant to them (Rebeiro, 2000). This viewpoint reverberates with the concept of creativity and creative adaptations that take place in occupational therapy practice to meet the client’s needs, as shown in our study.
Another finding of our study was that occupational therapists perceived the client’s problems as a challenge and that the client’s specific characteristics encouraged and supported their creativity. It is likely that occupational therapy practitioners have a high degree of interest to problem solve and find the search for solutions exciting. Mayer (2001) believed that if a person finds a problem interesting, the process of problem solving gets initiated. In contrast, the process is usually postponed if there is less personal interest. We could also argue that creativity enables occupational therapy practitioners to search for the most appropriate solution for each individual client, increasing the satisfaction for everybody involved. The link between creativity and life satisfaction has previously been proposed, for example, in the context of the flow experience (Csikszentmihalyi, 1997; McHugh, 2016).
Client Feedback
Client’s satisfaction appears to encourage creativity. Feedback received from clients and family members is often very valuable. Conti and colleagues (2001) found that positive feedback supports creativity, whereas Keenan (2015) suggested that regular feedback increases personal satisfaction. Obtaining information and regular feedback from the client should, therefore, be encouraged.
Previous studies confirmed the notion that client feedback is important to the work process and can have a positive influence on relationship building and collaboration (Bachelor, 2013; Oanes et al., 2015). Nonetheless, there have not been many studies that explored the influence that client feedback has on the therapist’s work (Oanes et al., 2015). Our study contributed to this body of knowledge by demonstrating the relevance of feedback to creativity and client-centeredness. Oanes et al. (2015) also pointed out that the way feedback gets processed depends on the therapists’ personal characteristics, including their flexibility, openness, and readiness for change, which relates to the factor of personality explored in this study.
Relationship Building
A client-centered approach is important for relationship building and can be seen as a foundation for a successful intervention. Most of our participants believed that creativity assisted in forming a therapeutic relationship based on trust, which had already been reported by Merritt and Boogaerts (2014). Van Veldhoven (2000) also argued that creativity plays an important role in designing a good relationship. Occupational therapists included in our study believed that creativity increased the client’s motivation for participation. Inner motivation could, therefore, be viewed as an important factor for both the client and the therapist’s creativity. It is likely that by using a client-centered approach imbued with creativity, the therapist can draw the client in and motivate him or her toward active participation.
Limitations
The study’s approach has several limitations. It is possible that participants completing the online survey did not share in their understanding of the concept of creativity. Schmid (2004) found that the word creativity is seldom used by occupational therapists; more often, it is replaced with other nouns, such as innovation, change, and problem solving. Our participants’ replies might, therefore, refer to different concepts. In addition, the questionnaire was designed as a self-assessment tool that produced subjective opinions and evaluations; therefore, it might not represent the objective situation. To deepen the understanding of creativity in the occupational therapy process and increase objectivity, it would be advisable to also observe occupational therapy practitioners during their work.
Our data collection method had limitations that are specific to online surveys. For instance, some participants did not complete the questionnaire in full, which could also be attributed to the length of the COTQ. In addition, we are planning to translate the questionnaire and implement it in other geographical locations, which would increase the generalizability of the findings.
Implications for Occupational Therapy Practice
The COTQ is a novel assessment tool that incorporates different factors that can contribute to creativity within the occupational therapy process. It recognizes the role of client-centered practice and provides suggestions on how to support this practice in daily interactions with the client. The findings of this study have the following implications for occupational therapy practice:
Creativity can facilitate a client-centered therapy approach and should be supported during occupational therapy education, clinical practice, and organization of work.
Feedback from clients and family members should be encouraged because it increases motivation and therapeutic relationship building.
The COTQ could be used in future longitudinal studies of creativity and for educational purposes.
Conclusion
To the best of our knowledge, this was the first study of creativity in occupational therapy in Slovenia. It focused predominantly on the role of the client. We acknowledge that there are other factors that also contribute to creativity, which have not been presented in this article. Future longitudinal studies of occupational therapy practitioners’ creativity could improve our understanding of the importance of this concept for occupational therapy practice, especially in the current fast-paced practice climate, which is subjected to constant change and requires strong commitment and skill from practitioners to remain client centered.
Footnotes
Acknowledgments
We thank Susan Bazyk, professor of occupational therapy at Cleveland State University, for reviewing this article and providing us with constructive feedback and encouragement.