Practice Project, that examined the situation of occupational therapists practis- ..... EDUCATION. Diploma OT. 19. 22. Degree OT. 77. 66. Masters. 10. Doctorate.
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CATHERINE LYSACK • ROBYN STADNYK, • MARGO PATERSON • KERRYELLEN MCLEOD • LAURA KREFTING
KEY WORDS Community occupational therapy Curriculum design Fieldwork education, occupational therapy
Professional expertise of occupational therapists in community prcctice: Results of an Ontario survey
ABSTRACT
This paper presents findings of a study, The Community
Practice Project, that examined the situation of occupational therapists practising in community based settings in the province of Ontario, Canada in 1992. In addition to providing a profile of the typical community based therapist, the Catherine L. Lysack, M.Sc.,O.T.(C)
is a graduate student in the Department of Community Health Sciences, University of Manitoba, 750 Bannatyne Avenue, Winnipeg, Manitoba R3E OW3
study considered issues relating to: the principal roles in places of employment; specific job skills and areas of professional expertise utilized in the community; and how well occupational therapists' formal training prepared them for their
community oriented roles and tasks. Results indicate that great opportunities
Robin Stadroyk, M.Sc., 0.T.(C) is an
exist and job satisfaction is high in community settings. Nonetheless, therapists feel inadequately prepared for the new role of consultant and its concomitant
Assistant Professor, Division of Occupa-
skills in a field that has re-oriented itself toward the client and is increasingly
tional Therapy, School of Rehabilitation
focused on health promotion and disability prevention.
Therapy, Queen's University, Kingston, Ontario, and a Research Associate, Home Care Program, Kingston, Frontenac and Lennox & Addington Teaching Health Unit Margo Paterson, M.Sc., 0.T.(C) is an Occupational Therapy Fieldwork Coordinator & Lecturer in the Division of Occupational Therapy, School of Rehabilitation Therapy, Queen's University, Kingston, Ontario
RÉSUMÉ
Cet exposé présente les résultats d'une étude sur un projet
de pratique communautaire qui s'est penché sur la situation des ergothérapeutes oeuvrant en milieu communautaire dans la province de l'Ontario, au Canada en 1992. En plus de donner le profil type de l'ergothérapeute en milieu communautaire, l'étude prend en considération des questions se rapportant aux rôles principaux exercés en milieu de travail, aux qualifications professionnelles requises et aux domaines d'expertise professionnelle utilisée en milieu communautaire et combien la formation initiale des ergothérapeutes
Kerryellen McLeod, M.H.Sc., 0.T.(C) is an Assistant Professor, in the School of Occupational Therapy, University of New England, Biddeford, Maine
les prépare exercer des rôles et des tâches en milieu communautaire avec succès. Les résultats démontrent qu'il existe de nombreuses possibilités de travail dans ce domaine et que la satisfaction qu'on en retire est grande. Néanmoins, les ergothérapeutes ne se sentent pas suffisamment préparés pour
Laura Krefting, Ph.D., 0.T.(C) is a Consultant at the PPRBM Prof. Dr. Soeharso CBR Centre, Colomadu, SOLO, Indonesia 51716
138
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assumer le rôle de consultants avec ce qu'il comporte d'exigences dans un domaine qui s'est réorienté vers le client et qui porte de plus en plus sur la promotion et la prévention en matière de santé.
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Traditionally occupational therapy has been based primarily in hospitals, rehabilitation centres and related institutions. Nevertheless, one must acknowledge that the profession has never been fully institutionalized and that a tradition of community practice (albeit small) has existed since the early days of this century. Building on this history in the community, considerable growth can be seen in the last ten years in the areas of school therapy (Dunn, 1988; MagillEvans & Madill, 1990; Royeen & Marsh, 1988), home care programmes, private practice (Bridle & Hawkes, 1990; Devereaux, 1991; Dutton, 1986), as well as less traditional roles areas such as in government and industry (Baum, 1985; Townsend, 1988). Roles in consultation and primary prevention/health promotion have also been developed (Dyck, 1993; Hurff, Lowe, Ho & Hoffman, 1990; Jaffe, 1986; Jaffe & Epstein, 1992; Madill, Townsend, & Schultz, 1989). In Canada, the Ontario provincial government has clearly stated its change in health policy direction through the Evans and Spasoff Reports (Ministry of Health, 1987) and the document From Vision to Action (1989). This later docurnent and others have identified the need for a reorientation of coursework and fieldwork in all health professions toward community health care (SilerWells, 1988). The need for occupational therapy students to learn about this movement to community practice has been emphasized for several years in the occupational therapy literature (Benzing, 1986; Strickland, 1989, 1991). In conjunction with this re-orientation to community based practice, there is a shortage of rehabilitation professionals generally. The critical human resource shortage in rehabilitation has been a long standing problem in Ontario and was identified as a specific issue in the document Achieving the Vision: Health Human Resources (1991) which recommended increasing the training capacity for rehabilitation professionals. Numerous other studies have also documented the critical shortage of rehabilitation professionals (Ministry of Health, 1989; Mirkopoulos & Quinn, 1989; Salvatori, Williams, Polatajko & MacKinnon, 1992). Rehabilitation professionals have begun to assume new roles in the community and in the private sector and occupational therapists appear to be quite satisfied in these job settings. However, it has not been determined whether the community roles and skills have been adequately addressed in existing professional training. Neither has it been determined what forms, methods, time requirements and sites for educating community practitioners are most appropriate. The resulting situation may be contributing to inadequately trained personnel and disincentives to employment in these areas. One might also expect the ultimate effect of this dissatisfaction to be attrition from the profes-
sion, employment in other fields, and/or the erosion of occupational therapy roles by other professionals more adequately prepared to practice in the community arena. The shortage of therapists generally, and the focus on community practice, coupled with limited knowledge of the educational requirements of these new practitioners prompted the study on which this paper reports. The Community Practice Project (CPP) studied occupational therapists in community practice in the province of Ontario in 1992. At the time of this study, all authors were members of the Division of Occupational Therapy, School of Rehabilitation Therapy at Queen's University in Kingston, Ontario. The ultimate purpose of the CPP was to increase the human resource base of competent community practitioners. The specific airns of the study were to: 1) survey community therapists regarding perceptions around community therapy and educational preparation for it; 2) develop and evaluate a multidisciplinary course for undergraduate rehabilitation therapy (occupational therapy and physical therapy) students; and 3) develop and evaluate training rnaterials for community fieldwork supervisors enhancing their ability to prepare students for community practice. Funding for the study was provided by the Ministry of Health for Ontario and therefore the study addressed Ontario needs specifically, although it may also highlight issues for other regions. The need for a study of community therapists was also stimulated by occupational therapy clinicians and academicians. The Occupational Therapy Division at Queen's University was undergoing revision of its curriculum at the time of this study. It was therefore determined that a survey of practicing community based occupational therapists would contribute important data to the planning of coursework in community practice. This paper reports on the occupational therapy findings of the CPP. Fieldwork and curriculum implications have been reported elsewhere (Paterson et al., 1993). The study also included a sample of 200 physical therapists. Results of the physical therapy sample have also been presented elsewhere (Lawless & Tata, 1993). Definition of Community Practice
Community occupational therapy services have been defined as those 1) labelled as community services by therapists themselves; 2) that are client related, consultative, educational or coordinating in nature; 3) offering approximately 75% or more services outside a building designated an institution; and 4) based in a public building, clinic, or home setting (Townsend, 1988). The Health Care Systems Committee (Ministry of Health, 1989) has expanded this concept to focus on individuals' independence and AOÛT 1995 • 139
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Table 1 Sampling Strategy
CAOT Employer Category
Population of Ontario
Community Therapists' Sample Size
N=552 Community Agency Private Practice Regional Government School Board Retail, Business
Insurance Company
CPP2
337 121 38 26 24 6
n=200 50 69 38 13 24 6
iCAOT, 1992. 2Community Practice Project (CPP)
local needs, as these have a direct impact on health. However, the definition of community practice is not easily elucidated. In addition to the criteria outlined above by Townsend (1988), employment in the community is often further defined by the therapist's role or the specific job setting. Further confusion is generated when terms such as community care and health promotion are used to distinguish between types of comniunity occupational therapists. In this study, the authors included all such individuals in their discussion of community therapists. The eligilDility criteria for inclusion in this study was established using the employment categories of the 1991 membership of the Canadian Association of Occupational Therapists (CAOT) (CAOT, 1991 & 1992). Study participants also had a role in determining the definition of community practice as they had the option of non-participation if they did not classify their own employment status as community based. In the end, examples of the sort of work in which community occupational therapists were involved included home care, sales representatives with home health care companies, health/ergonomics educators with manufacturers, insurance workers, case coordinators for the Arthritis Society, and therapists in the school system. Methodology The CPP survey was originally developed by fourth-year occupational therapy and physical therapy students working as a team at Queen's University, in Kingston (Harvey, 1991; Stone, 1991). Revisions were incorporated into the study version of the survey by the authors. The final result was a 27-item survey with a combination of fixed response and open-ended questions. This version was critiqued by an instrument expert. Mailing labels were obtained from CAOT for the 552 Ontario members who met the eligibility criteria. In order to obtain a diversity of practice 140
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settings, the sampling was weighted to increase the proportional representation of therapists practising in areas such as industry, retail, private practice, school boards, etc. (See Table 1). Surveys were sent to a sample of 200 occupational therapists. Data rnanagement and analyses for the study were facilitated by StatPac Gold (Walonick, 1988).
Results Of the 200 surveys mailed out, 130 (65%) were returned. Not all of the 130 participants responded to every question, thus the total number of responses varies slightly from item to item. Survey responses were of both a quantitative and qualitative nature. The findings provided an overview of the characteristics of respondents as well as a deeper understanding of the principal roles, specific job skills and areas of professional expertise utilized in the community and how well formal occupational therapy training prepared therapists for their community oriented roles and tasks. Descriptive comments were provided by 87 (67%) of respondents which added valuable insight into specific experiences of community practice, and therapists' suggestions for change. Characteristics of Respondents Table 2 provides an overview of CPP survey respondents in comparison with all Ontario occupational therapists with respect to gender, age and education. Twenty-five percent of respondents possessed other degrees or post-occupational therapy degree education as follows: clinical specialties (44%), occupational therapy related degrees (44%), and unrelated degrees (28%). The majority (72%) of the respondents were employed in one paid job although 22% reported employment in two. Fifty-four percent of respondents had been in their present job for less than five years. Table 3 provides a comparison between CPP survey respondents and Ontario occupational therapists with respect to their principal employment roles in the community. The disparate profiles reflect the deliberate over sampling of less traditional community practice therapists in the CPP category. Of interest is the finding that 11% of Ontario therapists describe their principal job roles as consultants/educators (CAOT, 1992) as compared with 85% of the CPP respondents. The clinician roles were similar between groups. Finally, 8% of Ontario therapists reported management roles as compared to 30% of CPP survey respondents. Private practice is an expanding area for rehabilitation professionals and occupational therapy is no exception. Results indicate that 36% of respondents were self-employed. This figure differs greatly from the 5% reported in 1992 by Ontario therapists generally (CAOT, 1992). The majority of CPP respondents re-
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Table 2
Table 3
Respondent Profile
Principle Roles in Community Employment
% CPP2
CATEGORY
ONTARIO OTs' (;ENDFR Female Male
% CPP2
CATEGORY ONTARIO OTs'
RESPONDENTS
RESPONDENTS
JnB SETTIN(I 96 4
99 1
Community, Home School, School Board Psychiatric Hospitals
AGE
13 4 9
48 16 9
30 22 14 14
31 33 12 20 2
11 64 8
85 75 30
87 1 0 22
17 45 14 0
Insurance Companies
20 - 29 30 - 39 40 - 49 50 +
21 44 23 12
CASELOAD Ad ult Mixed Geriatric
EDUCATION Diploma OT Degree OT Masters Doctorate
Pediatric
19 77
22 66 10 2
Adolescent
ROLE3 Consultant, Educator Clinician
'CAOT, 1992. 2Conimuniiy Practice Project (CRP) — Comparison data not available.
ceived their referrals from physicians i.e. family physicians (68%) and other physicians (57%). Still, other sources of referral were significant: other health professionals (61%), occupational therapists (41%), physical therapists (39%), self-referral (36%) and insurance companies (30%). Finally, CPP respondents reported that their greatest source of income was in the form of salary (65%), followed by direct billing (13%) and government funding (10%).
Administrator, Manager
EMPLOYER OT Health Ad m in istrator Home Care Supervisor Other
'CAOT, 1992. 2Community Practice Project (CPR) 3Respondents could check more than one category, while CAOT data were mutually exclusive categories.
Job Skills Necessary in the Community Occupational therapists use a variety of job skills in the community. In this study, job skills vvere defined as those behavioural activities that new graduates are expected to be able to perform. Job skills identified by respondents as most necessary included: written and verbal communication (98%); networking (94%); client assessment (93%); consulting (92%); client education/ treatment (89%); charting (83%); staff education/ inservices (79%); and individual counselling (76%). Formal professional training only prepared therapists for these job skills to a certain degree. Therapists were most prepared in: client assessment (80%); charting (67%); written communication (67%); verbal communication (65%); and use of treatment modalities (62%). Job skills in which therapists believed they were least prepared were networking and consulting. Sur-
vey results were dramatic in this respect. Although 94% of therapists required networking skills in their present jobs, only 16% felt their formal training prepared them to use these skills. Likewise, 92% of therapists require consulting skills while only 21% felt adequately prepared to do so. Therapists suggested that to become proficient in the community, they needed to improve their knowledge in two major areas. First, the therapist's role must shift to one of case manager or consultant where skills in networking are vital. As one therapist wrote: It is important that health practitioners develop the attitude that we are partners with the community facilities and thus respect their values, knowledge and expertise. Furthermore, we must also learn how to use and supervise AOOT 1995 • 141
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Table Necessary Community Job Skills Poorly Prepared for by Undergraduate Education
JOB SKILL NECESSARY
PREPARED
DIFFERENCE*
Networking
94
16
78
Consulting
92
21
71
Inservices
79
33
46
Administration
53
16
37
Teaching
89
57
32
Individual Counselling
76
46
30
Staff Education,
counselling is a necessary job skill that is being under utilized, or it is a job skill that is not as relevant in current community practice as it is thought to be by occupational therapy educators. Further analysis of this finding is required before a complete understanding of its significance can be gained. The second surprising result related to the job skills of managing volunteers. Interestingly, 24% of therapists indicated volunteer management was a necessary skill but only 3% felt prepared to use this skill. Fiftyseven percent felt this skill was not relevant in their job. Again, further investigation will be necessary to determine the importance of including this skill in undergraduate preparation or leaving its development to post-graduate employment experience.
Patient Education,
*The table above displays necessary community job skills where the difference between the present use of the skill and the degree to which therapists felt prepared to use these skills differed by greater than 30%.
volunteers and paraprofessionals ... in all of these tasks, interpersonal skills and communication skills are essential! Second, specific new skills must be learned. Of particular importance are home and environmental assessments (including vocation and ergonomic assessments) where "knowledge of community resources (accessing financial resources for home modification, assistive devices and equipment) becomes imperative." The formal undergraduate curriculum also left several other job skills poorly addressed. These skills included administration, sales/promotion, and medical/legal assessment. (See Table 4) Although a relatively small proportion of respondents identified a need for business administration and management skills, those who did actually provided the second greatest source of descriptive comments (25%) in the survey. Their requests for further information were very specific and included: private practice guidelines (i.e. practice standards, ethics, billing); quality assurance information; cost-effectiveness of various treatment regimes; and general financial management. Finally, in the area of job skills two surprising results were obtained. First, only one of all job skills listed was prepared for to a greater extent than was considered necessary for respondents' present jobs. This skill was group counselling: 32% of therapists were prepared to use this skill but only 25% indicated they were currently doing so. Forty-eight percent indicated that group counselling was not currently a relevant job skill. One might conclude then that either group 142
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Professional Expertise Used in the Community
Occupational therapists in the community require professional expertise. For purposes of this study, professional expertise was defined as high level professional functioning acquired after knowledge and attitudes have developed with occupational therapy experience in the field. Survey respondents reported that their most frequent demands on professional expertise involved: community resources (90%), selfdirected learning (89%); clinical reasoning (85%); client centred approach to practice (84%); advocacy (75%); health promotion/disease prevention (75%) and programme evaluation (68%). Formal professional training of therapists does not always parallel that required by community employment situations. Therapists felt most prepared for clinical reasoning, a client centred approach to practice and in health promotion/disease prevention. However, they considered that they were not as well prepared for private practice, health care legislation and multicultural practice issues. Community development and client advocacy issues were also identified as areas of inadequate preparation. (See Table 5) It appears that community employment situations demand expertise for which therapists are inadequately prepared. Interestingly, several areas of expertise identified as necessary in the community were also targeted as areas requiring increased knowledge. The most important areas were knowledge of community resources, client advocacy and multicultural practice issues. (See Table 6). One therapist suggested that a 'real world education' was more necessary than many other areas of professional expertise. She went on to say that: Since students accepted into university occupational therapy programmes are primarily privileged, white, middle-class females, it would be advisable for them to be as seasoned as possible in multicultural issues, poverty, abuse, women's issues, etc. It is a
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Table 5
Table 6
Areas of Professional Expertise Idenitifed by CPP Respondents as
Necessary Areas of Professional Expertise poorly
Prepared for by Undergraduate Training
prepared for by undergraduate training
AREAS OF EXPERTISE
PERCENT*
Clinical Reasoning
64
Self-directed Learning
51
CO M munity Resources
90
30
60
Client Centred Approach to Practice
45
Advocacy
75
16
59
Health Promotion, Disease Prevention
37
Client Advocacy Issues
16
Multicultural Practice Issues
57
10
47
Community Development
13
Health Care
Multicultural Practice Issues
10
55
9
46
68
29
39
89
51
38
Disease Prevention
75
37
38
Community Development
49
13
36
PROFESSIONAL EXPERTISE
Health Care Legislation
9
Private Practice Issues
8
*Percent of all therapists identifying each area of professional expertise as necessary in the community.
Legislation
Prograrnme Evaluation Self-directed Learning
tough, raw world out there and some preparation regarding how to be effective when dealing with all this would be valuable. Similar comments were provided by another respondent: Practice in the community requires ... the maturity to handle many unusual situations, (nothing like it is in the book), confidence in your own decision making ability, but enough courage to admit that you don't know it all ... flexibility, a sense of humour, and the ability to work unsupervised or with minirnal input from others. Still, its a great place to be! The fact that even greater emphasis should be paid to a client-centred approach and health promotion/ disease prevention was evident in the fact that the greatest number of respondents' comments (30%) were received on this topic. Therapists claimed that "the relationship of theory and philosophy to practice must be upgraded," and that there exists "a need for knowledge about alternative and more relevant models of service delivery." The orientation of practice toward the client/consumer should also include "an increased awareness and respect for the rights of clients" and "education of the professional to assist in the empowerment of people with disabilities." Also neglected were caregiver issues. Occupational therapists need to learn how to be innovative with what is available in a patient's home and community; client centred practice is good to a point but caregivers must be involved in the choices made. Finally, in regard to the perceived lack of profes-
% NECESSARY % PREPARED % DIFFERENCE*
Health Promotion
* The table above displays necessary areas of community professioanl expertise where the difference between the prsent use of the expertise and the degree to which therapists felt prepared to use the espertise differd by greater than 35%.
sional expertise in health promotion/disability prevention, therapists recognized but felt inadequately prepared for the re-orientation away from curing medical illness to improving function. Preparation for Community Practice Approximately equal numbers of occupational therapy respondents indicated that their educational training had increased their awareness of community career opportunities such as those in which they were currently employed (530/0 aware versus 43°/0 unaware). Survey results very clearly indicated however (690/0 agreed or strongly agreed) that therapists have opportunities for growth and promotion in their jobs. Perhaps these opportunities contribute to job satisfaction, as 90% of community occupational therapists stated they were satisfied or very satisfied with their current jobs. Despite the apparent enthusiasm for community settings however, therapists indicated there is a need for better preparation for community practice (85% either agreed or strongly agreed that continued education was necessary to meet the needs of their current AOÛT 1995 * 143
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community job). The high levels of job satisfaction reported despite a perceived lack of professional preparation was an unexpected, albeit positive, study finding. Further study of the role of continuing education will be necessaiy to determine the correlation between perceived competence and job satisfaction in community practice. In response to their perceived limited professional training, respondents did seek out further education and training to prepare themselves better for community jobs. Interestingly however, this education was primarily related to skills in clinical competency (78%), administration/management (29%), and technology currency (18%). The education sought out was least likely to be in the area of consultation or government/ agency legislation/policy. This is a significant study finding because specific job skills and professional expertise very closely related to these areas were identified earlier in the survey as being very important to therapists in the community. It may be that the continuing education obtained is a function of the training courses available rather than the training courses needed. If this is indeed the case, every effort should be made to make continuing education timely and relevant instead of only expedient. Over 25% of written comments addressed the relationship between quality fieldvvork placements in the community and future success in community practice. These data were particularly important given the purpose of the survey. The majority of respondents stated one community placement should be mandatory in undergraduate education. It was further suggested that therapists involved in community roles should be actively pursued for their contributions to the undergraduate curricula. Several respondents encouraged clinical supervision of occupational therapy students by other health professionals as a viable option for increased exposure to community practice. They stated that nurses, social workers and counsellors, for example, were often quite capable of supervising occupational therajoy students and providing a valuable learning experience in the community. Clearly fieldwork is important for it reinforces the concepts introduced in the classroom and facilitates the integration of theory and practice.
Discussion Role of Comnlunity TheraFDists The CPP survey results emphasized community therapists' roles as consultants and educators. The role of the consultant in community practice has been discussed extensiv'ely (Dunn, 1988; Dutton, 1986; Jaffe & Epstein, 1992) but it is clear that preparation for these roles should be deliberate at the undergraduate level. Consultative practice enables therapists to use their expertise efficiently by sharing it with community 144 • AUGUST 1995
members i.e. community workers, community groups, family members, so that therapeutic intervention can occur in the setting, relationship and manner most relevant to the client. As well as learning the skills related to consultative practice, students must learn to value this type of practice as an exciting, dynamic way to interact with their community. It is also important to note that most of the therapists in our sample did not report directly to an occupational therapist, but rather to someone of another discipline. While there has been marked concern in Canada about therapists reporting to non-therapists (Kuretsky, 1992), it would appear that reporting to a non-therapist is a fact of life for most community practitioners. Therefore we must prepare students to be confident in their skills and expertise as occupational therapists, so that they may work effectively and thereby promote their profession. The prevalence of reporting to non-therapists has implications for fieldwork in the Canadian context. Barriers exist to the use of clinical placements in vvhich students report to non-occupational therapists, or in which no occupational therapist currently works. This results in a bias against community placements, an issue which is being addressed by CAOT's Fieldwork Accreditation Task Force report tabled in March 1995. In order to provide students with valuable community experience, fieldwork coordinators have to be very resourceful and develop innovative methods of fieldwork supervision such as those described by Backman (1994). An example of this is Queen's University- use of academic staff to provide supervision for community fieldwork experiences.
Job Skills and Professional Expertise Study participants identified four main areas of skill and expertise as important for community practice. The first area of expertise is client-centred practice. It is paramount to community practice. The influence of environment and social roles on occupational performance in the community cannot be overstated. The appreciation of client-centred practice however, represents expertise vvhich must be developed through the entire occupational therapy curriculum. A specialized area of professional expertise within client-centred practice is that of culture. Multiculturalism was identified by more than half the sample as a necessary area of expertise. Certainly, recent government documents have underscored the need for community care and support to be provided in a culturally sensitive manner (Ministry of Health, Ministry of Community and Social Services, & Ministry of Citizenship, 1993; Ministry of Health, 1987). Occupational therapy literature on this topic is also increasing (Dyck, 1992, 1993). Krefting (1991) outlines a model which considers the influence of culture at the individual, family, community, and
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regional levels. The second area is clinical reasoning and selfdirected learning. These are the processes by which the therapists approach their work in the community. Clinical reasoning may be defined as critical thinking and problem-solving in a clinical setting. It is crucial for community therapists, given that they often work very independently. This may be one reason why many comtnunity agencies are reluctant to hire inexperienced therapists. Yet there has been extensive research to show that clinical reasoning can be developed in occupational therapy students (Neistadt, 1992). Self-directed learning is defined as operationalizing adult learning principles by focusing learning on the interaction between an individual and a situation within a social context. The goal of such an approach is collaborative, participatory, and problem-centred learning (Brunt & Scott, 1986; D'A Slevin & Larey, 1991; Jennet, 1992; Knowles, 1975; Pine & Horne, 1969). Since the therapists who were surveyed indicated that this was an important area of expertise, then ideally, students should develop this style of learning as part of their education. In other words, if the goal of occupational therapy education is the development of intellectual and attitudinal attributes resulting in a therapist who has the capacity for self-directed learning and clinical reasoning, then the curriculum must articulate these expectations to students and provide a climate for their development, both in fieldwork and classwork. The third skill area identified by therapists is knowledge of community resources and advocacy. Expertise in these areas facilitates networking. The relevance of these areas to community practice is supported by Hurff et. al. (1990) and Benzing (1986). It is important that students be exposed to these areas of expertise if they are to recognize the interdependence of the role they play with the roles of other health care and social service providers, as well as advocacy groups. It is important that students learn how to advocate and lobby in an effective yet sensitive manner. Finally, it must be noted that advocacy proficiency demands prior subskills such as educating people effectively and communicating clearly, whether in writing, speaking, or record-keeping. The final area of expertise identified by therapists relates to specialized knowledge areas such as health promotion. This is a highly topical issue in our health care system as evidenced by government documents and our own professional organization (CAOT, 1993; Epp, 1986; Ministry of Health, 1992). Health promotion is a viable model of health and social care to which occupational therapy can contribute (CAOT, 1993; Dyck, 1993; Edwards, 1990). Expertise in health promotion enables therapists to function as interdependent, responsive members of their community. In conclusion, the areas of expertise identified by
therapists show the need for both independence and interdependence in the effective community practitioner. They must be able to learn and problem solve in a relatively independent fashion, but must interact, plan, assess, treat and consult in an interactive fashion. Fieldwork and Continuing Education Fieldwork expertise was identified by CPP respondents as a requirement to reinforce the academic curricula and to help students feel comfortable in these settings. While Queen's University has offered community fieldwork ill settings such as community agencies and schools for several years, students' evaluations provided evidence of the need for clearer educational objectives. The results of the CPP study were used to create objective-based learning modules with topics such as: the individual in the community; community resources; the community environment; and social and health care systems. Careful consideration was paid to individual learning styles, the adult learning approach and the self-directed learning model. Clearly, therapists already involved in community practice have indicated areas for continuing education which are not available in currently-offered courses. Better and higher quality continuing education and professional support were identified in the survey as necessary to improve morale and prevent stress and burn-out. One therapist commented: I found that educational opportunities are minimal for community occupational therapists. Most of the training courses are designed for hospital/clinic staff. Another handicap of this job is we can't watch colleagues in order to learn. Since so many occupational therapy schools across the country are adopting community practice courses in their curricula, perhaps they could lead the way in this education by offering course materials in a format which is more accessible to the community practitioner (e.g.distance learning, 2-day intensive workshop, etc.). Study Strengths and Limitations There are several limitations to the interpretation of data collected in this survey. They relate to the sampling technique, information collected, and survey focus. First, the primary purpose of the CPP survey was to collect information for curriculum development in community practice by an occupational therapy undergraduate programme. Because of this, a purposive sampling technique was used to encourage as wide a range of responses as possible, with regard to skills and professional expertise information. Therefore the results of this suivey cannot be safely used for other purposes. For example, the profile of community therapists obtained for this study is descriptive of the AOOT 1995 • 145
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respondents only and cannot be generalized to all Ontario occupational therapists. Furthermore, given that the majority of respondents would most likely have been educated in Ontario, study conclusions may not be applicable to other regions of the country. Still, survey results can be used to indicate the variety of personal characteristics, work attributes, and roles which characterize community practice in Ontario. Second, no inforrnation was collected regarding respondents' year of graduation, school of undergraduate occupational therapy training, or type and number of community fieldwork placements. Therefore, survey findings cannot be used to evaluate the effectiveness of specific university educational programmes. In addition, the influence of work experience on the data provided by respondents cannot be ascertained. Nevertheless, the results can be used to target job skills and areas of professional expertise which are identified by a broad range of community therapists as necessary in their current work. For example, study findings were very clear that the majority of community therapists felt most unprepared in the areas of consultation, networking and advocacy, and also with respect to multiculturalism and health promotion. Undergraduate education programmes have some justification in examining their coursework and fieldwork training in light of these findings. Third, the focus of the CPP survey was on the link betvveen educational preparedness and job skills or professional expertise. The assumptions and limitations inherent in this focus must be considered. For example, it is not clear whether we can effectively address all concerns identified by respondents through undergraduate education of a clinically inexperienced audience. Furthermore, continuing/professional education may also pose difficulties as market demands, accessibility, and resources (such as time and money) of both presenters and participants continues to be limited. Finally, while it has been assumed that undergraduate and continuing education are the most pragmatic ways to address the learning needs of present and future community therapists, life and work experience, mentoring, observation, and other methods of learning may also play an important role. Finally, the authors wish to emphasize that the CPP survey was developed using thinking that was current in late 1991 and early 1992. In 1995, community practice is a more dynamic area of professional practice than ever. The need for knowledge and skills for community practice are exploding as occupational therapists grasp the broad scope of opportunities which are emerging with health and social reform. The strength of the Community Practice Project is its contribution as one of the first attempts to determine the levels of preparedness for community practice and identify the educational challenges that remain. 146 * AUGUST 1995
Conclusion The aim of the Community Practice Project (CPP) survey was to gather information on the perceptions of community therapists with respect to their preparation for practice in the community. Study findings were used to inform the development of undergraduate curriculum and fieldwork. A profile of specific job skills, principal roles, and areas of professional expertise were identified. One of the most significant survey findings was that networking and consultant roles were high priority arJas that need to be better addressed in new curriculum and reinforced by fieldwork experiences. On the whole, CPP respondents were very positive about their choice to work in the community. In the words of one respondent: I think the scope of our training provides us with the tools to step into jobs in areas not traditionally specific to occupational therapy. More and more of these jobs are being taken on by us, but the potential is even greater. We have a unique opportunity to seize. I for one am happy I have carved out the niche I have and established a very satisfying career. This study may contribute to a better understanding of the requirements necessary for the preparation of successful community occupational therapists. These new data may ultimately increase the human resource base of community practitioners. Perhaps this knowledge may also be applicable in the education of more effective institutional practitioners as well. Acknowledgements
Parts of this paper were presented at the CAN-AM Conference in Boston, July 1994, and at the CAOT Conference in Regina, June 1993. The authors gratefully acknowledge that preparation of this manuscript was supported by a grant from the Ontario Ministry of Health, Health Human Resources Planning Division. The authors also wish to thank the anonymous reviewers for their helpful comments and suggestions on this paper. Finally, the authors wish to acknowledge their colleagues on the Community Practice Project (CPP) Steering Committee with whom much was accomplished: Steve Lawless, Elizabeth Tata and Tracey Livingstone. References Backman, C. (1994). Looking forward to innovative fieldwork options. Canadian Journalof Occupational Therapy, 61, 7-10. Baum, C. (1985). Growth, renewal and challenge: An important era for occupational therapy. American Journal of Occupational Therapy, 3_9, 778-784. Benzing, P. (1986). Community networking: Definition, process, and implications for occupational therapy and physical therapy. Physical and Occupational Therapy in Geriatrics, 4(4),
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