THE OCCUPATIONAL PERSPECTIVE
Last updated: September, 2019
The content provided in this section is intended for interdisciplinary collaborators in order to help clarify the role of the occupational therapist in intervention with women's health topics.
Additionally, for practicing occupational therapists, the review of information is relevant and valuable in considering the current trajectory of our professional domain.
DEFINING THE OCCUPATIONAL PERSPECTIVE
While the term “occupational perspective” is utilized frequently within the respective literature of the field, there remains ambiguity in what this means. Njelesani, Tang, Jonsson, and Polatajko (2014) put forth what is perhaps the simplest definition of the term: a way of looking at or thinking about human doing. In short, occupational therapy is a profession of “action” and “doing” – these are the tools of assessment and intervention that should remain constant. Each individual client brings unique considerations in their definitions of what is meaningful and purposeful within the context of their own individualized life, but the lens of the occupational therapist is trained on the processes of actionable pursuit. Understanding that people are occupational beings and that the occurrence of occupational challenges greatly impacts their lives, yields power in the use of occupation as a therapeutic agent of change (Fisher, 2014).
THE SCIENCE OF OCCUPATION
Twenty-five years ago at the University of Southern California, a Ph.D. program in occupational science was introduced under the leadership of Elizabeth Yerxa, posing two fundamental questions: What are the biological, psychological, and sociocultural foundations for meaningful, purposeful activity? How does engagement in such activity promote health and well-being? (Frank, 2014, p. 77).
Occupational science is the systematic study of humans as occupational beings (Clark et al., 1991). Just as a physician assesses and establishes the overall health of an individual respective to the various systems of the body being in homeostasis; the psychiatrist evaluates by the cognitive and emotional processing of the mind; and the physical therapist appraises client function through musculostructural alignment, strength, and coordination; the occupational therapist too has a science by which they organize their perspective of assessment and intervention. The ‘Science of Occupation’ refers to the body of evidence-based literature that articulates and supports the use of occupation – doing, through engagement in meaningful activity – to impact measurable outcomes in an individual’s functional performance and/or quality of life.
THE OCCUPATIONAL THERAPY PRACTICE FRAMEWORK (OTPF)
The Occupational Therapy Practice Framework: Domain and Process 3rd ed. (herein referred to as ‘the OTPF’) is the official guiding document of practice within the profession of occupational therapy, as overseen by the American Occupational Therapy Association (AOTA). The OTPF outlines the current standards of practice and articulates the perspective of the occupational therapist in the promotion of health among persons, groups, and populations via the engagement and participation in occupations (AOTA, 2014). This document refers to itself as an ever-evolving document, which is subject to a 5-year review cycle to determine relevance and usefulness within the profession (AOTA, 2014).
Within its contents, domain is defined with regard to relevance and interplay of specific occupations, client factors, performance skills, performance patterns, as well as context and environment. It further outlines relevance to process, which is pertinent to the course of evaluation, intervention, and measurement of outcomes by the occupational therapy (OT) practitioner. All practicing OTs should be intimately familiar with the contents of this article, as well as how they are applicable to their specific domain of practice specialty.
The word occupation, which in and of itself may be confusing to those who are unfamiliar with the lexicon of the profession, refers to and is synonymous with “activities” – particularly the daily life activities that people engage upon that provide meaning and purpose (AOTA, 2014). In the realm of women’s health, the OTPF offers multiple elements that speak directly to the occupational needs and concerns of potential clients. Women’s health topics relative to the area of pelvic health have specific interplay with the more basic activities of daily living (BADLs) such as toileting and toilet hygiene, a well as engagement in sexual activity. These tasks are considered to be fundamental, enabling basic survival and wellbeing (AOTA, 2014).
While these, and other broader aspects of women’s health diagnoses or conditions, extend into the intricacies of instrumental activities of daily living (IADLs), which “support life within the home and community that often require more complex interactions than those used in ADLs” (AOTA, 2014, p. S19). Examples of such IADLs that can be severely impacted by complex women’s health topics include tasks such as caring for others, child rearing, communication management, health management and maintenance, and religious and spiritual activities and expression (AOTA, 2014).
Other categories of occupation that cannot be overlooked or minimized in the intervention of the whole person are relative to rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014). Each of these elements serves to define the value of occupation within an individual’s unique life, and should likewise be considered in the interplay of client factors, performance skills or patterns, and processing skills that are elicited by various conditions or experiences of health and wellbeing. As it has always been the prerogative of the occupational therapist, understanding how these activities interplay with such client factors, specifically when taken into consideration of the context and environment unique to the individual, makes the field of occupational therapy uniquely suited to designing a holistic and client-centered perspective for functional intervention.
AN ONGOING EVOLUTION OF THE OT PROFESSION
The profession of occupational therapy has evolved through multiple paradigm shifts since its time of inception. Rooted in the arts-and-crafts movement and moral treatment movement of the early 1900s, the profession emerged as a holistic intervention looking beyond medicine to the importance of ‘being productive’ to provide a sense of mental achievement. From a place of origin in mental health settings, much of the professional domain shifted to a medical rehabilitation model secondary to the increased demand for improved physical functioning of wounded soldiers following the era of World War II. Emphasis on science and theory within the profession were further underscored by amendments made to the Social Security Act and establishing Medicare and Medicaid in the 1960s (Lamb, 2017).
Visionaries of the profession, such as Wilma West, spoke of the imminent value in embracing change within professional expectations, that is our collective responsibility as practitioners and a collective profession to adapt to the evolving demands of society (Lamb, 2017). In the 1980s the field of occupational therapy took another transformative step toward the realm of education-related services, highlighting their contributions to the educational system within the country (Lamb, 2017).
At the turn of the millennium, not only is the profession of occupational therapy standing upon yet another paradigm shift, equally the entire healthcare model within the United States has been challenged to do the same. A series of publications by the Institute of Medicine beginning in 1999 served to shine a white-hot light on the flaws that exist within the current medical landscape. These reports outlined a need for improved quality outcomes, a greater emphasis on collaborative teamwork, and improved focus upon patient-centered care within the American healthcare system. With the system-wide changes that have been set into motion for our healthcare model in the past two decades, there is an anticipation of transformation ahead once again for the realm of occupational therapy propelling it into the future.
Michael Iwama (2013), a present-day leader in the field and one of many voices, speaks to the importance and potential that our profession has to offer in the sector of public health. In addition to these urgings, a health promotion frame of reference is increasingly emphasized to address the health of populations rather than simply at the individual level (Lamb, 2017; Scaffa, Reitz, & Pizzi, 2010). But perhaps more than anything, there is a call from above urging the masses of frontline OT practitioners to return to their roots of the profession, resuming an emphasis on occupation (Lamb, 2017). In the words of Amy Lamb, President of the American Occupational Therapy Association, “We must hold on to the core belief that quality occupational therapy practice is anchored in the meaningful, necessary, and familiar activities of everyday life. That is our distinct value, and to remain vital we must demonstrate this value every day” (2017, p. 3).
EMPHASIS ON OCCUPATION
As a majority of frontline OT practitioners are currently employed within a biomedical model of care, this call to ‘return to the roots of occupation’ may present with resistance or defensiveness regarding the quality of their present professional contributions. Examination of the most commonly billed data codes reveals that quality occupational intervention has been compromised by environmental pressures, largely a system that demands unrealistic productivity standards and an unavailability of true occupational medium utilization (Lamb, 2017). Therapeutic exercise and therapeutic activities are the most commonly billed codes within the OT profession, neither of which captures the true value of the occupational contribution, and only serves to endanger the profession by minimizing our most powerful contribution to quality patient-centered care (Lamb, 2017).
Occupation must remain central to interventions provided by OT practitioners. Fisher (2014) articulates the significance of placing occupation at the forefront of what we as professionals do, highlighting the difference between common lexicon such as occupation-centered, occupation-based, and occupation-focused – which are not synonymous, but rather a uniquely related taxonomy of terms. These terms are defined in Table 1.
Fisher (2014) further advocates that in order to achieve an occupation-centered perspective the first step is to shift away from a “bottom-up” lens that places body functions and person factors as the central tenet of intervention, and rather adopt an occupational lens. This can be achieved through the use of certain occupational therapy models of practice that are designed to bring occupation into the focal point of assessment and intention. Examples of such models that place occupation at the center of the evaluation and intervention process will be outlined in sections covering various complex topics in WH.
For occupational science and occupational therapy, it is occupation that is positioned in the center. A profession- specific-perspective.
To be based means to have something as a main ingredient or to be a fundamental part of something. For occupational scientists and occupational therapists, that base or foundation is occupation. A method of evaluation and intervention that involves engaging a person in occupation.
To be focused is to bring something into focus and to concentrate one’s attention on it. When we are occupation-focused, our attention is focused on occupation. The immediate focus is on evaluating and/or changing a person’s quality of occupational performance – the “here and now” – not on what might occur or develop in the future.
BALANCING A TOP-DOWN AND BOTTOM-UP PERSPECTIVE
Being that many OT practitioners are entrenched in a biomedical practice environment, complete abandonment of the “bottom-up” perspective is a convoluted request. This may not be entirely feasible, particularly as changes in perception and practice habits take time to transition. Gentry, Snyder, Barstow, and Hamson-Utley (2018) put forth the recommendation to utilize a Biopsychosocial Model within OT practice, that is inclusive of both a "top-down” and “bottom-up” approach to intervention. While a true “top-down," or occupationally-centered, frame of reference may be the ideal of the professional domain, as occupational therapists continue to practice in a biomedical sector of health care, emphasizing a model that allows for an increased balance of perspective is an ideal transitional tool. Utilization of such a model of intervention brings the biological focus to a client-centered and balanced perspective of care, unifying the value of intervention upon physical dysfunction, psychological, and sociocultural factors (Gentry, Snyder, Barstow, & Hamson-Utley, 2018).
Utilizing a biopsychosocial approach in OT practice has the ability to impact real and meaningful progress in clients’ outcomes of function, satisfaction, and overall quality of life (Gentry, Snyder, Barstow, & Hamson-Utley, 2018). This is achieved when awareness, identification, and inclusion of biopsychosocial factors are considered in creating a plan of care (Gentry, Snyder, Barstow, & Hamson-Utley, 2018).
As many of the women’s health topics discussed within this platform have dynamic interplay between physical and psychological function, the use of a biopsychosocial approach to intervention is considered ideal. While an occupationally-centered perspective is given precedence to the intervention strategies outlined, the bottom-up and top-down perspectives of assessment and intervention are considered in balance.
MAKING QUALITY OF LIFE AN OUTCOME PRIORITY
Pizzi and Richards (2017) put forth a compelling argument in favor of a paradigm shift within the profession of occupational therapy that places QOL and wellbeing at the forefront of determining a successful outcome of occupationally centered care at the individual, community, and population levels. Within their articulation, practitioners are urged to shift their priorities away from measures that target performance, and instead upon participation (Pizzi & Richards, 2019). This reiterates the foundation of which occupational therapy is rooted, one that views clients as occupational beings, with unique perspectives regarding QOL as determined by self-directed interactions within their lived experiences. Creating assessment and interventions that are centered around the client’s individualized experiences and perceptions of wellbeing and QOL as directed by their occupational profile represents one of the highest potential achievements in client-centered care that an occupational therapist could prioritize.
It is also put forth by Pizzi and Richards (2017) that a transition is needed from an identity as ‘rehabilitation specialists’ to that of occupational therapists defining themselves as ‘specialists in QOL, health promotion, and wellbeing’ through the utilization of occupation in the facilitation of healthy living. The authors share their recommendations for the use of the Environment—Health—Occupation—Well-Being Model (E-HOW) as a means to facilitate the transition of professional focus, represented in Figure 1 (Pizzi & Richards, 2017).
(Pizzi & Richards, 2017)
WHY THE NEED FOR THE OT PERSPECTIVE IN WOMEN’S HEALTH
The World Health Organization (WHO) has identified women’s health as an ‘urgent priority’ on a global scale (Davidson et al., 2011). Topics relevant to women’s health impact both the developed and the developing world, and have a considerable influence on the future generations of girls and women, families and communities (Davidson et al., 2011). Within the United States progress has been made through efforts of the National Institutes of Health (NIH) and in the creation of the Office for Research on Women’s Health (ORWH) to promote the agenda for research advancement pertaining to women’s health outcomes (Palmer & Sass, 2013). Current strategic planning for the promotion of women’s health research call for increased interdisciplinary collaboration and research efforts to represent the holistic nature of women’s health concerns (NIH, 2019).
Women’s health topics that are relevant to the Occupational Therapy Practice Framework: Domain and Process (OTPF) represent a wide variety of physical and psychosocial conditions, each with unique considerations relevant to client factors, performance skills, performance patterns, context, and environment. This makes the occupational therapist ideally qualified to create a client-centered and holistic intervention method from an occupation-centered model of care. Without research efforts to contribute occupational therapy’s professional voice and perspective to the conversation about women’s health advancement, our professional credibility will be diminished as a healthcare science with a rich knowledge base to promote health and wellness within this client population.
While the field of occupational therapy has begun efforts in representing women’s health topics in its research collection and evidence-based publication, many gaps exist in the current body of literature. Without a collection of research that translates women’s health topics into the language and perspective of an occupation-centered practice, the field of occupational therapy remains underrepresented as a contributor to the overall health outcomes of this client population.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.
Clark, F. A., Parham, D., Carlson, M. E., Frank, G., Jackson, J., Pierce, D., … Zemke, R. (1991). Occupational science: academic innovation in the service of occupational therapy’s future. American Journal of Occupational Therapy, 45(4), 300–310. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107500845&site=eds-live
Davidson, P. M., McGrath, S. J., Meleis, A. I., Stern, P., DiGiacomo, M., Dharmendra, T., … Anderson, D. (2011). The health of women and girls determines the health and well-being of our modern world: A white paper from the International Council on Women’s Health Issues. Health Care for Women International, 32(10), 870–886. https://doi-org.prx-usa.lirn.net/10.1080/07399332.2011.603872
Fisher, A. G. (2014). Occupation-centered, occupation-based, occupation-focused: Same, same or different? Scandinavian Journal of Occupational Therapy, 21, 96–107. https://doi.org.prx-usa.lirn.net/10.3109/11038128.2014.952912
Frank, G. (2014) Occupation for population health: An appreciation. Journal of Occupational Science, 21:1, 77-80, DOI: 10.1080/14427591.2014.891432
Gentry, K., Snyder, K., Barstow, B., & Hamson-Utley, J. (2018). The biopsychosocial model: Application to occupational therapy practice. The Open Journal of Occupational Therapy: Vol. 6: Iss. 4, Article 12. Available at: hDps://doi.org/10.15453/2168-6408.1412
Iwama, M. @ COT Annual Conference. (2013, July 2). Retrieved from https://www.youtube.com/watch?v=67PqinQ7qNM&feature=youtu.be
Lamb, A. J. (2017). Presidential Address, 2017—Unlocking the potential of everyday opportunities. American Journal of Occupational Therapy, 71, 7106140010. https://doi.org/10.5014/ajot.2017.716001
National Institute of Health. (2019). The 2019-2023 trans-NIH strategic plan for women’s health research. Retrieved from https://orwh.od.nih.gov/sites/orwh/files/docs/ORWH_Strategic_Plan_2019_02_21_19_V2_508C.pdf
Njelesani, J., Tang, A., Jonsson, H., & Polatajko, H. (2014). Articulating an Occupational Perspective. Journal of Occupational Science, 21(2), 226. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=edo&AN=ejs32848016&site=eds-live
Pizzi, M. A., & Richards, L. G. (2017). Guest Editorial—Promoting health, well-being, and quality of life in occupational therapy: A commitment to a paradigm shift for the next 100 years. American Journal of Occupational Therapy, 71, 7104170010. https://doi.org/10.5014/ajot.2017.028456
Palmer, J. R., & Sass, S. (2013). Chapter 8: Progress in women’s health research. Women and Health, 107–117. https://doi.org/10.1016/B978-0-12-384978-6.00008-X
Scaffa, M. E., Reitz, S. M., & Pizzi, M. A. (2010). Occupational therapy in the promotion of health and wellness. Philadelphia, PA: F. A. Davis Company.